Recently, leading national organizations, including the Addiction Policy Forum, ASAM, and the National Council on Mental Wellbeing, called on the White House to lift the federal cap on contingency management (CM) funding. Currently, a $75 annual limit restricts the incentives that can be offered to individuals through federal grant-funded programs. This cap not only contradicts decades of scientific evidence but also significantly hinders the potential impact of innovations designed to improve recovery outcomes.
Contingency management is a proven behavioral therapy that rewards positive actions, such as attending treatment sessions or maintaining drug-free urine tests (Bolívar et al., 2021; Petry, 2012). Studies have consistently demonstrated CM’s effectiveness across multiple substance use disorders, including cocaine, methamphetamine, alcohol, and opioid use. the Advisory Opinion from HHS-OIG (back in 2022!) sees incentives of up to $599 per patient annually as appropriate and an amount that does not raise concerns about fraud or undue influence. Yet two years later, the $75 cap remains and dramatically undercuts the ability to incentivize meaningful behavior change.
Innovations in Contingency Management
Numerous startups and programs have integrated CM into their approaches, ranging from digital health platforms offering gift card rewards to apps that gamify treatment engagement. Notably, reSET and reSET-O, the first FDA-approved digital health apps for substance use disorder (SUD), incorporated contingency management as a key feature. These groundbreaking apps provided patients with incentives for completing modules and engaging with treatment. (In September 2024, the app was purchased by PursueCare; its original creator, Pear Therapeutics, filed for bankruptcy in 2023.)
Innovations like these demonstrate the transformative potential of digital CM tools, yet the current funding restrictions create a significant barrier to their success. When rewards are too small to meaningfully motivate behavior change, both patients and programs struggle to achieve the desired outcomes.
Lifting the funding cap would open the door to further innovation, allowing developers to create more robust CM systems that integrate seamlessly into broader treatment plans. This change could also enable programs to serve more patients, support longer treatment engagement, and ultimately contribute to better recovery outcomes.
Arguments Against Contingency Management
Despite its strong evidence base, contingency management has faced criticism and challenges that limit its broader adoption. Some of the key arguments against CM and counterpoints to these concerns include:
Perception of Paying People to "Do The Right Thing": Critics argue that providing monetary or tangible rewards for behaviors like substance-free tests or achieve treatment goals feels like “paying people to do the right thing,” which some view as unethical or counterproductive.
Response: CM does not replace intrinsic motivation but complements it. Research shows that small, external incentives can jumpstart behavior change, helping individuals build momentum in early recovery when intrinsic motivation is often weakest (Predergast et al., 2006). Over time, positive behaviors and improved outcomes become self-reinforcing, reducing reliance on external rewards.
Potential for Misuse of Rewards: Some express concern that individuals might misuse the incentives, such as spending gift cards on substances rather than essentials.
Response: Programs can mitigate this risk by offering non-cash rewards, such as vouchers for groceries, clothing, or other necessities. Digital CM platforms can also track and limit spending categories to ensure incentives are used appropriately. Perhaps most importantly, the assumption of misuse is stigmatizing towards the individual and can interfere with sense of self-efficacy.
Cost Effectiveness: Some policymakers question whether CM is a cost-effective approach compared to other treatment options.
Response: CM has repeatedly demonstrated cost-effectiveness in clinical trials, leading to better treatment engagement, reduced use, lower rates of return to use, and fewer hospitalizations (Coughlin et al., 2023). These outcomes significantly offset the cost of incentives, making CM a valuable component of a comprehensive treatment plan.
Concerns About Sustainability: Critics worry about the long-term sustainability of funding for CM programs, particularly if higher incentives are introduced.
Response: Allowing higher incentives can improve outcomes, potentially attracting additional funding from private and public sources. Moreover, integrating CM into digital platforms can reduce administrative costs and improve scalability, enhancing sustainability. Finally, the upfront increased expense will likely lead to long-term financial savings, and, more importantly, the saving of lives.
A Call for Action and Innovation
The current $75 cap on contingency management incentives stifles the potential of evidence-based solutions to address the addiction epidemic. By lifting the cap, we can empower innovators, researchers, and treatment providers to harness CM's full potential, creating scalable solutions that drive real change. This shift would enable more individuals to benefit from recovery-focused incentives and further solidify CM as a critical tool in the fight against substance use disorders.
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