In 2023, the opioid epidemic is still with us, with overdose fatalities increasing every year, and recent data suggest that contingency management for people on medication for opioid use disorder (MOUD) may help to decrease polysubstance use, particularly co-occurring opioid and stimulant misuse.
Experts on the opioid crisis now indicate we’re in the fourth wave or phase of the crisis, which began in the late 1990s. The fourth wave is characterized by mental health problems and treatment access issues related to the COVID-19 pandemic. In addition, wave four/phase four inlcudes increasing polysubstance misuse, with methamphetamine and the presence of fentanyl in various illicit drugs exacerbating the problem by both increasing overdose fatalities and complicating the assessment, treatment, and recovery process.
To learn more about the opioid crisis in general, please navigate to the blog section of our website and review the articles in this category:
To learn about the latest approaches receiving federal funding and the new innovative approaches we’re implementing nationwide, please read this article:
This article will focus and a study published in the Journal of the American Medical Association called Contingency Management for Patients Receiving Medication for Opioid Use Disorder. The study examined the effect of a drug use prevention/reduction/abstinence approach called – as the title implies – contingency management. Researchers reviewed data on contingency management for various drugs, but prioritized analysis on psychostimulants such as methamphetamine. These drugs currently present a significant challenge: they’re associated with increasing overdose death, and – unlike alcohol or opioid use disorder (AUD/OUD), there are currently no medications available to treat stimulant use disorder.
What is Contingency Management?
Here’s how mental health and addiction treatment experts define contingency management:
“Contingency management (CM) is a behavioral therapy, based on operant conditioning principles, that provides tangible reinforcers for evidence of behavior change. In the case of substance use disorders, it most often involves delivery of monetary-based reinforcers for submission of drug negative urine samples.”
Three decades of research on contingency management confirm the following:
- It improves treatment outcomes for people with substance use disorder (SUD)
- It’s safe to implement simultaneously with psychotherapy or pharmacotherapy
- It works for various SUDs
- Pre-existing conditions don’t impact effectiveness
- It works for a wide variety of patients, regardless of demographic or personal characteristics
However, there’s significant resistance to implementing a CM approach to SUD treatment among policymakers, treatment providers, and insurance companies, including Medicare/Medicaid. The arguments against CM revolve around resistance to paying people not to do drugs and concern that patients will divert money paid to abstain from one drug to purchase other drugs. We won’t get into the reasons for/against or discuss the theoretical pros and cons of contingency management in this article: instead, we’ll review evidence from the study above. The study has a relatively narrow focus and prioritizes the following research goal:
“The overarching aim of this systematic review and meta-analysis is to provide a timely and comprehensive review of contingency management’s efficacy in addressing the public health crisis of psychomotor stimulant use and other common clinical challenges among patients receiving MOUD.”
In other words, the researchers wanted to know whether reimbursing patients with opioid use disorder (OUD) in treatment with medications for opioid use disorder (MOUD) decreased polysubstance use, specifically polysubstance use including stimulants like methamphetamine.
Contingency Management and Polysubstance Use While on MOUD
To answer their research question and determine the effectiveness of contingency management on drug use among people on MOUD, the study team analyzed information from 74 clinical trials including data on 10,444 adult patients currently in treatment for opioid use disorder with MOUD.
Here’s what they found.
- Contingency management associated with medium-large effect size on abstinence, compared to control groups
- Contingency management associated with small-medium effect size on abstinence, compared to control groups
Illicit Opioid Use:
- Contingency management associated with a medium-large effect size on abstinence, compared to control groups
- Contingency management associated with a medium-large effect size on increased abstinence, compared to control groups
- Contingency management associated with a small-medium effect size on increasing therapy attendance, compared to control groups
- Contingency management associated with a medium-large effect size, compared with control groups
After collecting and analyzing the data to yield those results, researcher combined all the evidence on abstinence and treatment adherence to identify any big-picture, general trends in the data. Here’s what they found.
Combined Data, Abstinence:
- Contingency management associated with significant increased abstinence, compared to control groups
Combined Data, Treatment Adherence:
- Contingency management associated with increased treatment adherence, compared to control groups
At first glance, this evidence looks overwhelmingly positive. It indicates contingency management may have an important place in SUD treatment moving forward. We’ll discuss these results further, below.
Can Contingency Management Really Work?
The data answer that question with a simple, affirmative “Yes.”
However, perhaps a better question might be:
Contingency management works, but is it an approach we want to pursue?
The answer to that is unclear. It should be obvious: if it works, use it. But there are things to think about, here. For instance, is it sustainable to pay people – indefinitely – to not use drugs? This question is relevant because additional data shows that when providers remove the reinforcement or reward – e.g., the money – the positive effects fade quickly.
That’s something to consider, with very real financial implications. At first blush, ongoing, open-ended contingency management doesn’t seem like a sustainable approach.
However, that fact notwithstanding, we need to consider something else, as elucidated by the study authors:
“…contingency management is the only intervention that has reliably increased abstinence from psychomotor stimulants in randomized clinical trials across more than 30 years of research.”
That’s a powerful argument in favor of finding a realistic way to incorporate contingency management into our long-term approach to SUD treatment. Psychomotor stimulants are a primary driver of the current fourth wave of the overdose fatality crisis. Overdose deaths involving fentanyl-laced methamphetamine are on the rise. With contingency management emerging as an effective approach to increasing abstinence, an expansion of the role of CM is logical.
If we truly want to take an all-of-the-above approach to mitigating harm caused by the opioid and overdose crisis, then we need to consider CM. Further, we need to understand the reasons – beyond cash in pocket – it may be an effective approach for reducing psychomotor stimulant misuse. Stimulant misuse carries a significant risk of serious health complications, including fatal overdose. If it reduces harm, we need to find out why. Then we can learn more about how we to leverage the why to help more people in need.