September is National Recovery Month, an important reminder that while we have come a long way in reducing the burdens associated with substance use disorders (SUD), the U.S. is still in the midst of a nationwide overdose epidemic. The epidemic is also rapidly changing and affects individuals from all backgrounds and walks of life. Importantly, the substances typically involved in overdoses are also changing and while most overdose deaths still involve the use of opioids, the increasing use of psychostimulants has added to the complexity of the epidemic. Given this reality, states are eagerly seeking alternatives to treat beneficiaries with stimulant use disorders who are enrolled in Medicaid, the largest single source of coverage for SUD services in the country. With California taking the lead, various states are particularly looking at one of the most promising evidence-based interventions to address misuse of stimulants: contingency management.
Stimulant Use Disorder and Overdose
Though synthetic opioids continue to be involved in much of the recent increase in overdose deaths, the number of deaths involving psychostimulants is also significantly increasing. Psychostimulants include drugs like methamphetamine and cocaine. According to a National Institute for Health Care Management (NIHCM) 2019 research, “cocaine and methamphetamine are each now involved in more [overdose] deaths than either prescription opioids or heroin.” Stimulant related overdose can cause psychiatric, cardiopulmonary, and neurological symptoms that can lead to coma and death. The combination of stimulants and synthetic opioids or polysubstance use, has become one of the main drivers in what is considered the “fourth wave” of the opioid epidemic. In addition, substances like methamphetamine have a high purity and potency with a relatively low cost, making them highly desirable and relatively easy to access. In California, overdose deaths increased by 22% in the past year and deaths associated with methamphetamine use have quadrupled in the last 10 years. Further, only 17.8% of those accessing publicly funded treatment for substance use disorder in the U.S. are doing so for cocaine or other stimulants.
Contingency Management
There are clinical challenges associated with treating stimulant use disorder including high dropout rates. One meta-analysis of in-person psychosocial SUD treatment found that the average dropout rate was 30.4% and dropout rates were highest in studies targeting cocaine, methamphetamines, and major stimulants. Currently, there are no Food and Drug Association (FDA)- approved medications to treat stimulant use disorders though there are promising psychosocial interventions. One of the most promising psychosocial interventions for stimulant use disorder is contingency management. Contingency management is the systematic delivery of positive reinforcement for desired behaviors through incentives. In the case of stimulant use disorder, incentives are provided in the form of vouchers or gift cards for the submission of stimulant-free urine samples or attendance at treatment sessions. In most contingency management programs, the value of the positive reinforcement increases as participants complete the targeted behavior in consecutive visits. If a participant does not fulfill the desired behavior, the value of the positive reinforcement is typically reset to the original starting amount.
Several studies have shown the effectiveness of contingency management in treating stimulant disorder. One meta-analysis measured different treatments for cocaine use disorder and found that contingency management programs were significantly associated with reduction in cocaine use among adults. Another study found that for treating methamphetamine use disorder, contingency management showed the strongest evidence, although cognitive behavioral therapy alone or with contingency management was also effective. A third meta-analysis reviewed contingency management for methamphetamine use disorder and found a range of benefits for this method. Contingency management reduced methamphetamine use in 26 of the 27 studies, and indicated longer retention in treatment, more therapy sessions attended, higher use of other services, among other benefits.
Medi-Cal Contingency Management Pilot: The Recovery Incentives Program
In January 2022, California became the first state to receive approval from the Centers for Medicare and Medicaid Services (CMS) to implement a contingency management pilot program for Medicaid enrollees. This pilot program, officially named Recovery Incentives Program, will be rolled out in two phases, with the first phase set to begin between the fall of 2022 and March 2024. During the first phase, counties currently participating in the Drug Medi-Cal Organized Delivery System (DMC-ODS), California’s Medi-Cal program for SUD services, have the option of participating in the contingency management pilot. Currently, the Department of Health Care Services (DHCS) has approved 24 counties for participation.
Interventions as part of the pilot program will consist of a 24 week course with the option of continued recovery support services after program completion. Participants can also receive additional support during their participation like counseling, medication assisted treatment (MAT), patient education, peer support, withdrawal management, and recovery services. The incentives for this program are gift cards for retail stores, grocery stores, and gas stations, although no cannabis, tobacco, alcohol, or lottery tickets are allowed as purchases.
During weeks 1 through 12 of the program participants will be asked to visit their contingency management provider or testing site to provide a urine sample that is tested for the presence of stimulants. If the test is negative for stimulants, the participant receives an incentive starting at $10 for the first week and increasing by $1.50 per week for each subsequent negative test. The maximum possible incentive for this period of the program is $438. During weeks 13 to 24, participants visit their provider or testing site once a week. In weeks 13 to 18, participants receive $15 for each negative urine test and in weeks 19 to 23 participants receive $10 per negative urine test. In week 24, participants can receive a final incentive of $21 for a negative urine test. A participant can receive a maximum total of $599 if they do not miss any visits and consistently test negative for stimulants.
Conclusion
California’s launch of a contingency management pilot will help address the unmet health needs of individuals who use stimulants and may reduce the number of overdose deaths involving these substances. Other states, including Montana, West Virginia, and Washington, are currently considering similar pilots. The adoption of contingency management in additional states and across other health insurance programs will be key to our continuing fight against the overdose epidemic.
