Lift the contingency management limit
Recommendation
The Administration should move without delay to lift the Contingency Management limit of $75 per patient per year.
Background/summary
Contingency Management is a highly effective approach to treat individuals with substance use disorders (SUDs). It provides small tangible reinforcements such as prizes, vouchers, or small amounts of money to motivate and sustain objectively measured positive changes in behavior (e.g., abstinence or decreased drug use). In addition, it takes advantage of the brain’s reward response – the same response that fuels substance use. While Contingency Management treats many SUDs, there is a particularly urgent need to increase its use to treat stimulant use disorder, which lacks other proven effective treatments. One meta-analysis[1][2] found that Contingency Management “has an extraordinarily strong evidence base and is a demonstrably cost-effective technique that has been used for decades to promote abstinence from benzodiazepines, cocaine, tobacco, opiates, alcohol, marijuana, and methamphetamine.” Yet, adoption has been limited due to concerns that laws meant to prohibit kickbacks might inadvertently snare providers and payers utilizing this evidence-based treatment.[3]
Thankfully, the Office of the Inspector General of the U.S. Department of Health and Human Services (HHS) issued an opinion[4] in 2022 that allayed these concerns and has also approved raising the $75 limit per patient per year for Contingency Management. Unfortunately, the Substance Abuse and Mental Health Services Administration (SAMHSA), which must approve any increase, has not yet done so. As a result, Contingency Management continues to be underutilized despite the availability of flexible State Opioid Response Grants to help fight the opioid and stimulant epidemics. States that use these funds for Contingency Management are forced to do so at a level far below what the evidence suggests is effective.
citations
1. Sterling M McPherson, Ekaterina Burduli, Crystal Lederhos Smith, Jalene Herron, Oladunni Oluwoye, Katherine Hirchak, Michael F Orr, Michael G McDonell, and John M Roll. A review of contingency management for the treatment of substance-use disorders: adaptation for underserved populations, use of experimental technologies, and personalized optimization strategies. National Institutes of Health, National Library of Medicine, National Center for Biotechnology Information. Last Accessed August 13, 2018.
2. Pfund, R. A., Ginley, M. K., Boness, C. L., Rash, C. J., Zajac, K., & Witkiewitz, K. Contingency management for drug use disorders: Meta-analysis and application of Tolin’s criteria. American Psychological Association. Last Accessed 2022.
3. Health Affairs. Contingency Management: A Highly Effective Treatment For Substance Use Disorders And The Legal Barriers That Stand In Its Way. March 11, 2020.
4. U.S. Department of Health and Human Services, The Office of Inspector General. Re: OIG Advisory Opinion No. 22-04. Last Accessed March 2, 2022.