While there is growing hope that the end of the COVID-19 pandemic is in sight, America’s other health crisis — the drug overdose epidemic — is intensifying. In the 12 months leading up to August 2020, the Centers for Disease Control and Prevention estimated there were over 88,000 overdose deaths, enough to fill the Washington Football Team’s stadium with spillover into the parking lot. Not only does this tragic statistic reflect the most overdose deaths recorded in a 12-month span in American history, but it also represents countless tears shed for the children, siblings, friends and parents whose lives were cut short by the disease of addiction.
Ending this crisis will require using every evidence-based tool at our disposal.
One such intervention that works is called contingency management, which was recently highlighted in the Office of National Drug Control Policy’s Year One Drug Policy Priorities statement. The approach, grounded in nearly a century of research on operant conditioning, involves providing small, tangible incentives that reinforce positive behaviors. In addiction treatment, contingency management can be used to encourage behaviors associated with healthy outcomes, such as keeping appointments and abstaining from drug use. Addiction treatment professionals in both inpatient and outpatient settings can either offer prize incentives or vouchers that can be exchanged for something like groceries, gas or a movie ticket. Whether patients are eligible for a small reward is determined by objective criteria such as attending regular meetings, testing negative for drug use or meeting other goals.
According to the National Institute on Drug Abuse, part of the National Institutes of Health, contingency management can be highly effective at promoting abstinence from drugs. One meta-analysis of 30 studies found that contingency management “generated significantly better outcomes than did control treatments,” a conclusion that was confirmed by another meta-analysis using more recent literature in 2014. Randomized controlled trials, the gold standard for scientific and medical research, have shown that contingency management is effective at promoting abstinence time and time again. While contingency management approaches are effective for patients with a variety of substance use disorders, including opioid use disorder, research shows it is especially useful for those living with stimulant use disorder – a type of SUD for which there is currently no Food and Drug Administration-approved medication for treatment.
As a strong body of evidence demonstrates, contingency management can be an effective tool when used as part of a comprehensive approach to treatment. Unfortunately, contingency management is almost never available to patients who could benefit from it, largely due to federal rules meant to prevent bribery and patient steering in health care.
Even though contingency management is recognized by NIDA, ONDCP, the Substance Abuse and Mental Health Services Administration, the Department of Veterans Affairs, and the FDA as providing therapeutic merit, its use is broadly considered to potentially violate the federal Anti-Kickback Statute, which prohibits payments to induce or reward patient referrals for care. Contingency management may also run afoul of the Eliminating Kickbacks in Recovery Act of 2018, which prohibits payments for referrals to recovery homes or SUD treatment facilities. While a 2008 Department of Health and Human Services advisory opinion found that one contingency management program did not offer impermissible inducements, its analysis and findings cannot be applied to other programs. Instead, contingency management programs need to be evaluated on a case-by-case basis. This potential legal risk prevents many treatment professionals from implementing contingency management.
In order to fully align coverage policy with science, the federal government should create safe harbors for validated contingency management protocols under the Anti-Kickback Statute and the Eliminating Kickbacks in Recovery Act so that addiction treatment professionals don’t have to ask for a lengthy, inefficient review on a case-by-case basis. The safe harbors should specify appropriate guardrails for contingency management programs to ensure they are offered with fidelity to evidence-based protocols and avoid the potential for fraud and abuse. By doing so, policymakers have the opportunity to help advance one of ONDCP’s top priorities: expanding access to evidence-based treatment. With these changes, the federal government can safely empower providers to combat America’s drug overdose epidemic using a science-backed approach.
With 450,000 lives lost due to opioid overdoses alone since 1999 — and no end in sight — isn’t it time we break down the barriers to treatments that we know work? Treatment providers should be empowered to offer every evidence-based approach we have, including contingency management, to patients with SUD. With appropriate safeguards in place, contingency management can save countless lives.
Dr. Nzinga Harrison is the chief medical officer and co-founder of Eleanor Health, a value-based provider of comprehensive outpatient addiction treatment.
Charles Ingoglia, MSW, is the president and CEO of the National Council for Mental Wellbeing.
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