How incentives could better treat stimulant use disorder

Are gift cards and cash one way to help ease the drug overdose crisis?

The number of overdose deaths in the United States has doubled since 2015, exceeding 106,000 deaths in 2023. Although the overdose crisis is commonly referred to as the “opioid” overdose crisis, by 2021 approximately 50 percent of overdose-death toxicology reports showed evidence of recent use of cocaine or methamphetamine. This emergence of stimulants is often referred to as the “fourth wave” of the overdose crisis.

Although research has been underway for more than three decades to develop medications for people addicted to cocaine and methamphetamine, to date, none have been approved by the U.S. Food and Drug Administration. However, one group of Penn researchers advocates building on the success of a national program in the VA and efforts in California to increase access to a treatment called contingency management.

Contingency management (CM) is a form of behavioral economics developed in the 1990s that focuses on incentivizing behavior for patients, such as receiving a prize or a cash reward, when they prove through biological testing that they have not used stimulants.

The concept is as simple as it appears to be powerful: Pay for a desired outcome. Researchers at Penn regularly pursue incentives for everything from smoking cessation to improving patient services in a health care setting.

Building on early successes

While seemingly simple in principle, incentivizing someone to stop misusing stimulants can, in practice, be both misunderstood and difficult to manage.

Gabriela Khazanov, PhD, a research associate with the Penn Center for Mental Health and associate fellow with the Leonard Davis Institute for Health Economics, and James McKay, PhD, a professor of Psychology in Psychiatry, recently published a viewpoint in the journal Addiction making the case that researchers and clinicians should consider updating CM protocols and dissemination practices.

“These are recommendations that should be considered alongside guardrails to ensure that CM is being delivered with fidelity to its basic principles,” Khazanov noted. This is an attempt to adapt CM to our current situation, as stimulant use is rising at a rate faster than current CM protocols can keep up.”

Specifically, they recommend adaptations that include equal parts bureaucracy and technology: requiring Medicaid and private insurers to bill for CM services, using federal or state funds to pay for incentives, encouraging longer durations of CM (California uses a 24-week protocol instead of a more typical 12-week protocol), reconsidering guidelines for when patients can repeat CM or re-engage following periods of drug use, and modifying protocols to prioritize engaging and retaining patients in treatment.

Overcoming barriers & looking forward

While CM has been in place for some time, the practice has come with some questions.

“There have been concerns that CM is ‘paying patients for something they should be doing anyway’ but the fact is that incentivizing abstinence is effective and acceptable to patients and providers,” McKay said. The next step, according to McKay, should be to further refine CM protocols and improve access to the treatment so that it has the potential to reduce population-level stimulant use.

Another more tangible roadblock to expanding the use of CM is a current $75 cap on the use of federal funds for CM incentives. The cap requires Medicaid and other federal agencies funding health care services to go through a process in each state to request a waiver to provide higher incentives that are consistent with evidence-based recommendations. Either lifting the cap and/or developing parameters for a CM safe harbor policy would allow clinics providing CM to do so without needing to worry about triggering a Medicaid fraud investigation.

According to Richard Rawson, PhD, research professor at the University of Vermont, who collaborated with McKay and Khazanov on this work, it’s also not clear if money that is earned by patients during CM treatment is considered taxable income. “For some patients who receive government support for housing and food, and/or Medicaid, receiving taxable income can jeopardize eligibility for these benefits. Guidance from the Internal Revenue Service on if and how CM would be taxed would add clarity,” Rawson added.

The future of CM for stimulant use disorder

Looking ahead, the next phases of CM for stimulant use disorder are likely to include robust research, including expanding into virtual options for CM, using direct-to-consumer marketing to educate on the benefits of CM and generate demand from both patients and providers, as well as adapting CM to being culturally responsive—that is, shaping the intervention to a community’s values and preferences while retaining its core elements.

However, the concept of CM for stimulant use disorder is one that appears to be gaining newfound momentum, with enough data to show its impact while still being open to refinement.

“It's a pretty unique treatment without a perfect analogue,” Khazanov said. “It's a simple concept that, when implemented correctly, is highly effective, enjoyable for providers and patients, and has the capacity to transform lives.”