Following years of advocacy by psychologists, researchers, APA Advocacy staff, and members of the behavioral health community, the Substance Abuse and Mental Health Services Administration (SAMHSA) has announced that it will allow contingency management incentives of up to $750 per patient per year, up from the previous limit of $75. The announcement will enable grant recipients in SAMHSA programs that allow use of contingency management, including the $1.4 billion State Opioid Response and $63 million Tribal Opioid Response programs, to begin delivering evidence-based contingency management (CM) services. Although the Centers for Medicare and Medicaid Services has already approved waivers to five state Medicaid programsopens in new window—California, Delaware, Montana, Washington, and Hawaii—for implementing contingency management, SAMHSA’s announcement will significantly ease the path for furthering such programs.
As APA CEO Arthur C. Evans, Jr., PhD, stated in APA’s press release on the announcement, “Make no mistake, this change will save lives and protect families.”
Decades of behavioral and translational research have demonstrated the effectiveness of contingency management in treating a variety of substance use disorders (SUDs) in diverse populations. Importantly, contingency management is effective in treating people with stimulant use disorders and is considered the “gold standard” of care. Unlike opioid use disorders, there are no medications approved for treatment of cocaine, methamphetamine, or prescription stimulant use disorders. The U.S. is experiencing a “fourth wave” of the drug overdose crisis in which co-involvement of stimulants and fentanyl is becoming the single largest category of deaths. SAMHSA estimates that more than 4 million Americans meet diagnostic criteria for a stimulant use disorder.
Contingency management can be used alongside other forms of treatment for the broad range of substance use disorders, because of its effectiveness in incentivizing patient behaviors (such as abstinence, treatment attendance, and medication adherence) that are conducive to recovery. As stated in SAMHSA’s advisory, “CM consistently produces positive effects across many types of SUDs and other health conditions.”
SAMHSA’s advisory includes a wide range of requirements and conditions for the provision of CM using agency funding, which track those described in a 2023 report to Congressopens in new window by the U.S. Department of Health and Human Services. Grantees proposing to implement CM interventions as part of their SAMHSA grant award will be required to:
- Use either prize-based or voucher-based protocols for incentives, without the use of cash or cash equivalents, and with restrictions against the purchase of weapons, intoxicants, tobacco, lottery tickets, or pornographic materials using vouchers or gift cards.
- Use an evidence-based protocol for CM to incentivize abstinence, SUD treatment attendance, or medication adherence behaviors, with a minimum treatment duration of 12 weeks. CM interventions targeting abstinence as an incentivized behavior must conduct rapid point of care testing in person using an FDA-approved test, with incentives provided immediately following verification of the incentivized behavior.
- Refrain from recruiting patients into the clinical environment specifically for such treatment, or with the promise of incentives resulting from involvement in CM.
- Ensure that both assessments of whether incentivized behaviors are achieved and the provision of incentives be conducted by a health care practitioner authorized to provide SUD treatment services in that state.
- Designate one or more individuals to act as “champions” for CM implementation within the office or facility offering CM, and ensure that staff who will implement, administer, or supervise CM interventions participate in CM-specific training delivered by an advanced degree holder who is experienced in the implementation of evidence-based CM.
APA has long advocated to expand access to contingency management. Over the past Congress, APA Advocacy staff organized and participated in coalition meetings to discuss the importance of removing barriers to implementation of contingency management with congressional offices, other substance use stakeholder organizations, and multiple staff within the U.S. Department of Health and Human Services. In May 2024, APA Services joined several other organizations in a letter to U.S. Department of Health and Human Services (PDF, 60KB)opens in new window Secretary Xavier Becerra, Assistant Secretary for Mental Health and Substance Use Miriam Delphin-Rittmon, PhD, and Office of National Drug Control Policy Director Rahul Gupta, MD, urging lifting of the $75 cap on CM use within SAMHSA’s substance use grant programs.
APA applauds Assistant Secretary Delphin-Rittmon for taking this critical step forward in establishing access to evidence-based contingency management, and we will continue working to cement and build upon this progress. Further work will be needed at both the federal and state level to expand awareness of and support for contingency management among policymakers, consumers, and the general public to train providers, and to build capacity among treatment programs.
For more information contact Scott Barstow with APA’s Advocacy office.