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Guest Editorial 鈥� Contingency Management Saves Lives: From Evidence to Action

By Lara Coughlin, PhD, and Allison Lin, MD, DFASAM

With helpful feedback from Devin C. Tomlinson, PhD, Lan Zhang, PhD, H. Myra Kim, ScD, MPH, Gabriela Khazanov, PhD, James R. McKay, PhD, and Dominick DePhilippis, PhD

For decades, contingency management (CM) has been the gold standard behavioral treatment for stimulant use disorder (StUD). More than 100 clinical trials show that CM consistently reduces stimulant use. Yet until now, there has been little real-world evidence that CM improves the outcome that matters most: survival. Our recent study of Veterans Health Administration patients provides the first evidence that CM is associated with reduced mortality among people with StUD. Veterans who received CM were 41% less likely to die in the year after treatment initiation compared to matched peers who did not.1 In a moment when stimulant-related deaths are surging nationwide, this is powerful confirmation that CM is not only effective2-5—it is lifesaving.

Communities are desperate for options

Stimulants now play a role in roughly half of all overdose deaths in the United States.6 Yet, unlike opioid use disorder, there are no FDA-approved medications to treat StUD.7 And outside of CM, few behavioral options demonstrate strong, consistent benefit for stimulant use; across head-to-head reviews and meta-analyses, CM is the most effective treatment for StUD.8-11 As clinicians, many of us feel powerless in the face of this epidemic. CM offers both us and our patients hope. It is straightforward, grounded in behavioral science, and saves lives.

What CM looks like (and what it doesn’t)

At its core, CM involves providing tangible rewards (often reloadable debit or gift cards) to reinforce treatment goals such as stimulant-negative drug screens or attendance at treatment sessions. The process is simple, structured, and transparent. As shown in recent studies, CM can be feasibly integrated into usual substance use disorder outpatient settings.12 And, frankly, it just works.

Still, myths persist. Here are some of the most common, and why they don’t hold up:

Myth: “We’re just paying people to do what they should do anyway.”

Fact: Incentives serve as reinforcers to strengthen a patient’s own health-related behaviors, just like therapy and other treatments. This is entirely consistent with evidence-based behavioral science. Importantly, CM helps counterbalance the powerful reinforcing effects of drug use by making recovery-oriented behaviors immediately rewarding.13 In doing so, CM helps patients fight against the cravings and decision-making biases that are hallmarks of addiction.14,15 Supporting these behaviors is in the best interest of patients, health systems, and society.

Myth: “The effects don’t last once incentives stop.”

Fact: CM produces immediate reductions in substance use, which is lifesaving in itself.1 Critically, benefits persist after incentives end: a meta-analysis found sustained abstinence effects up to 1 year post treatment, with outcomes comparable to or greater than other psychosocial interventions. Moreover, periods of not using substances are linked to improved health, greater treatment engagement, and better chances of long-term recovery.2

Myth: “CM is too expensive.”

Fact: Because incentive magnitude matters, CM programs should budget for effective levels of reinforcement (not token amounts). The review by Rash et al recommends benchmarks (eg, ~$128/week) for medium-to-large—effect CM protocols.16 Although this may sound substantial, it is in line with the cost of many standard behavioral health treatments. For example, medications for opioid use disorder (MOUD) such as buprenorphine typically cost ~$500 or more a month.17-19 Viewed in this context, CM incentive budgets are modest and offset by reductions in health care use, justice involvement, and mortality.20

Myth: “People might use the incentives to buy substances.”

Fact: Research also shows that recipients of cash-equivalent incentives do not increase substance use compared to those receiving non-cash rewards. Cash recipients often use their funds for essential personal items (eg, utilities, groceries).21 Qualitative work also finds that participants value flexibility and autonomy with cash-based reinforcers, consistent with allocating funds to basic needs.22 Importantly, CM incentives are only earned when target behaviors are objectively verified (eg, stimulant-negative tests); if someone uses substances, they do not receive subsequent incentives (and may reset escalation) until they meet the contingency again.23,24

Myth: “Providing incentives undermines a person’s internal motivation to quit.”

Fact: Decades of research disprove this concern. The so-called “overjustification effect” (the idea that external rewards reduce intrinsic motivation) has not been shown to undermine substance use treatment outcomes.25 In fact, CM also enhances engagement by providing immediate reinforcement for behaviors that align with a person’s recovery goals. Studies demonstrate that patients receiving CM show equal or greater intrinsic motivation for change compared to those in control conditions, and that incentives strengthen rather than replace personal investment in recovery.26-28 Moreover, meta-analytic evidence shows that CM’s benefits often persist well after incentives are removed, indicating that CM supports durable behavior change rather than transient compliance.2

Making CM available

Despite its effectiveness, CM remains underused, but the recent increase in incentive caps by the Substance Abuse and Mental Health Services Administration (SAMHSA) to an effective range provides new opportunity.24 So the question is, what do we need to do now? Here are some suggestions:

  1. Check your state’s Medicaid policy. Some states (California, Michigan, Washington, Montana) are piloting CM through Medicaid 1115 waivers. If your state isn’t, ask why not.
  2. Seek other funding streams. Programs may be able to leverage federal and state resources such as State Opioid Response Grants or opioid settlement funds.
  3. Advocate. We need the same powerful advocacy and policy work that has helped shift attitudes on MOUD. Clinicians and professional organizations can call on state agencies, payers, and health systems to prioritize CM, including securing coverage and reimbursement. Letters, testimony, and collaboration with advocacy groups make a difference. Learn more and .

The future of CM

Policy and advocacy must address structural obstacles, such as restrictive incentive caps, patchy payer coverage, and limited workforce capacity. Simultaneously, we must also reckon with patient-level barriers to participation. Traditional CM protocols commonly require twice-weekly clinic visits over several months, which many patients struggle to meet. As one CM provider put it, “They don’t want to come here twice a week to do the contingency management. That’s why we haven’t had a ton of people [in CM]. That’s always the reason. ‘I don’t wanna travel there two days a week.’”29 That kind of visit burden is not hypothetical: a recent feasibility study of CM reported transportation challenges and difficulty attending twice-weekly sessions as barriers to engagement.30 Telehealth and digital tools, by reducing the need for frequent travel and integrating incentives into patients’ daily lives, have tremendous potential to break down those access barriers. Hybrid and remote CM must minimize patient-level and structural barriers to engagement, stay true to the active ingredients rooted in behavioral science, and ensure high-quality treatment delivery.

A call to action

The takeaway is simple: CM saves lives. Our patients deserve access to the most effective treatment available for StUD. Clinicians can start by learning about CM, dispelling myths, and exploring funding options in their state. Health systems and policymakers can act by removing outdated barriers, such as restrictive incentive caps and rigid in-person models that prevent many from receiving this life-saving treatment.

The stimulant crisis will not abate on its own. We have an intervention that works. For half a century, through crack, meth, and today’s fentanyl-tainted polysubstance supply, we’ve watched the same cycle repeat while treatment access lags. The difference now is that we can act on evidence that CM saves lives. Now is the time to use it.

 

Lara N. Coughlin, PhD, is a clinical psychologist and associate professor in the Department of Psychiatry at the University of Michigan’s Addiction Center. Trained in behavioral economics, her work centers on expanding access to contingency management (CM) while maintaining strong fidelity to the science that makes CM effective. She co-directs the program with Dr. Allison Lin, bringing evidence-based addiction care into real-world settings through research and partnerships with health systems, community clinics, payers, and other partners.

Allison Lin, MD, MS, DFASAM, is an addiction psychiatrist and associate professor in the Department of Psychiatry at the University of Michigan, and a research scientist at VA Ann Arbor. Dr. Lin is director of the , immediate past president of the Michigan Society of Addiction Medicine, and co-directs with Dr. Coughlin Michigan Innovations in Addiction Care through Research & Education (). Her research focuses on improving treatment access and outcomes for patients with substance use disorders.

 

References

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