When it comes to treating methamphetamine addiction, the use of behavioral incentives is settled science. Offering financial rewards, like gift cards, to people who demonstrate that they’ve reduced or stopped their meth use, is highly effective: Studies show that contingency management, as it is known, can promote abstinence from drugs, increase utilization of health care services, and even reduce high-risk sexual behavior.
But despite spiking meth overdose rates and the Biden administration’s expressions of support for high-quality addiction treatment, contingency management has failed to gain traction. Instead, it has been held back by politics: namely, a longstanding $75 annual cap for contingency management services funded by select federal programs.
This year, frustration with the Biden administration has spilled into public view, culminating in a failed advocacy effort to raise the cap, and the president’s top domestic policy official appearing to acknowledge that decisions about the government’s drug crisis response are being made amid a highly charged political atmosphere.
“I understand their political concerns, but sometimes you just have to bite the bullet,” said Sarah Wattenberg, the director of quality and addiction services at the National Association for Behavioral Healthcare. “You have to decide: Too many people are dying, and we need to act now. And this is the only thing we have for stimulant use disorder.”
Increased enthusiasm surrounding contingency management, and the Biden administration’s refusal to raise the reimbursement cap, comes amid a fast-worsening crisis of stimulant use. Meth and cocaine are seen as part of a “fourth wave” of the current U.S. drug crisis, which has morphed from prescription opioids to heroin to fentanyl and, now, to opioid use mixed with stimulants. Over 36,000 Americans died from overdoses involving psychostimulants like meth in 2023, according to the Centers for Disease Control and Prevention.
Though there are multiple highly effective medications used to treat opioid addiction, there is no such option when it comes to meth or cocaine. Increasingly, addiction treatment providers, as well as state governments and local public health groups, are turning to contingency management.
It is a naturally controversial approach. In essence, contingency management amounts to paying people not to use drugs — a concept that could easily anger the Biden administration’s critics, especially those most opposed to federal agencies’ recent embrace of harm reduction strategies.
But offering material incentives to help reduce harmful behavior is simply the recognition of basic brain chemistry, said David Gastfriend, an addiction psychiatrist and the chief medical officer at DynamiCare, among the leading companies offering contingency management services.
“There’s nothing improper about using money to do that if you’re monitoring those behaviors and setting behavioral targets, scientifically, to promote awareness of health,” Gastfriend said in an interview. “It’s the same way we raise children. It’s the same way we train house pets. It’s the same way we incentivize employees to learn new skills to become better at their job.”
Currently, however, a main source of funding for contingency management has capped annual reimbursement for the service at $75 — less than $3 per week over a typical distribution period of six months. Research and real-world data show that contingency management is most effective when the financial incentive is far larger. In West Virginia, patients receiving roughly $100 per month were more than twice as likely to submit drug tests proving their abstinence than in a New Jersey program capped at $75 per year, according to a recent DynamiCare white paper.
As a result, many programs around the country are offering treatment they acknowledge is subpar. Others, hoping to offer larger sums, have sought other government funding streams or even donations to help build out their programs.
As the stimulant use crisis has grown worse, the advocacy push surrounding federal funding for contingency management has intensified. In recent years, the main focus has been the $75 cap put in place by the Substance Abuse and Mental Health Services Administration, which oversees several major grant programs that states use to fund addiction treatment services.
Advocates lobbying to increase the cap include the National Council for Mental Wellbeing, private companies like DynamiCare, and Wattenberg’s coalition, which among others includes Westley Clark, the former top addiction treatment official at SAMHSA.
“The SAMHSA cap of $75 is far below an evidence-based amount,” Wattenberg said. “It’s disappointing, and while I understand there are political considerations … we are doing nothing to implement the most effective practice, and that’s inexcusable.”
Besides being ineffective, the groups say, offering insufficient reimbursement could lead to misleading evidence for contingency management’s opponents.
Advocates are pushing for a larger sum: $599, or roughly $100 per month for a six-month period. This amount, too, is a product of federal policy — the level of a taxable event by the Internal Revenue Service. Amounts of $600 or more could require patients in the throes of meth addiction to fill out complex tax paperwork as a condition of receiving their financial reward.
Many drug policy experts have charged SAMHSA with dragging its feet on the only known effective option for treating stimulant addiction. Those criticisms intensified earlier this year, when the agency left its $75 cap in place for a new round of grant awards through its popular State Opioid Response program.
“I think politics plays a role, and perception plays a role,” said Rob Kent, an addiction policy consultant who served until 2023 as general counsel to the White House Office of National Drug Control Policy. “We can’t ignore the fact that we’re in the middle of elections for national offices, and will be people who view it differently.”
A major perceived driver of SAMHSA’s reluctance to raise its cap is fear of political backlash. One controversy looms particularly large: right-wing criticism in 2022 of the agency providing funding for “safer smoking kits,” with the aim of helping to prevent flesh wounds and infectious disease among people who smoke meth, fentanyl, or other drugs. One right-wing outlet soon reported that the kits would include pipes, prompting several news cycles about the Biden administration’s efforts to fund the purchase of new “crack pipes.”
Republican lawmakers rushed to condemn the program. Soon after, health secretary Xavier Becerra and Rahul Gupta, Biden’s drug policy chief, released a statement clarifying that federal dollars would not be used for pipes in smoking kits. Sens. Joe Manchin (D-W.Va.) and Marco Rubio (R-Fla.) later introduced legislation banning federal funding for the distribution of pipes or drug paraphernalia.
Mainstream forms of treatment and harm reduction also remain stigmatized or controversial. Medications like methadone and buprenorphine are often derided as “swapping one drug for another.” Supervised consumption sites and syringe exchange are criticized as enabling drug use — even though research shows that all three approaches help reduce rates of death and disease.
One top Biden aide recently appeared to confirm that the administration is sensitive to perception on hot-button drug policy issues. At a recent Capitol Hill event hosted by the National Council for Mental Wellbeing, Neera Tanden, the chair of the White House Domestic Policy Council, was asked about contingency management, and ongoing efforts to raise the reimbursement cap. Her reply, according to two sources present: That in today’s highly charged political environment, things get blown out of proportion.
In a subsequent statement to STAT, Tanden emphasized that the Biden administration’s response to the overdose epidemic is driven by the best available scientific evidence. But she stopped short of a full-throated endorsement of contingency management, calling instead for further research.
“In order to save lives and keep communities safe, we continue to pursue evidence-based approaches including expanding access to treatment for substance use disorder and life-saving overdose reversal medication, while also advancing research into promising treatments like contingency management,” she said. “The Administration will continue to follow the scientific evidence, and partner with advocates, industry, and bipartisan members of Congress to save lives.”
It is unclear whether SAMHSA intends to eventually raise its funding cap, either in November following the presidential election or next year, should Vice President Kamala Harris defeat former President Donald Trump.
A SAMHSA spokesman declined to comment, citing the agency’s ongoing review of the cap.
Other arms of the federal government, however, have already endorsed contingency management, and acknowledged that a $75 annual cap poses a significant obstacle.
One recent report from the Department of Health and Human Services noted that research shows contingency management is most effective when incentive levels are between $100 and $200 per month, and listed the $75 cap as among several “major barriers” to successful implementation.
And while some legal experts have expressed concern that rewards to patients could run afoul of federal anti-kickback statutes, the HHS inspector general in 2020 issued a notice pledging not to pursue enforcement actions for “nominal” payments.
Perhaps most significantly, the Centers for Medicare and Medicaid Services — a federal agency run by Biden appointees — has quietly approved waivers for state Medicaid programs to implement contingency management programs and participants a maximum of roughly $600 per year. These states run the gamut politically: They include California, Montana, and Washington. West Virginia has also run a demonstration program using a $600 cap, awarding $100 per month over a six-month period.
Each program has taken care to avoid the perception of simply paying people.
“Some folks twist it and say, ‘You’re giving drug users money,’ which is completely false: Nobody’s getting money,” Kent said. “They might get an electronic benefits card that’s restricted so you can’t use it to buy alcohol or tobacco. Safeguards have been put into place. But some folks view it as enabling, and that takes on a whole different dynamic when people pitch it that way.”
States that have implemented reimbursement at lower levels have seen markedly less success than those awarding closer to $100 per month.
New Jersey’s program, which relies on SAMHSA funding, awards a maximum of $75 per year. Compared to West Virginia’s program, patients were half as likely to submit drug tests showing they were abstinent, and completed half as many units of a behavioral health course offered in the DynamiCare app, according to a company white paper. And in West Virginia, nearly two-thirds of patients who enrolled in the program remained engaged six months later — a rate far higher than in New Jersey.
The results, Gastfriend said, reinforce what a large body of research already shows: That contingency management is the only option available to treat meth addiction, and it only works if the financial incentives are substantial.
“We don’t have any other choice but to introduce this,” he said. “And it doesn’t work if you don’t have enough money available to induce the patient to focus on changing their behavior.”
STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.