A26 EZ RE K THE WASHINGTON POST.SUNDAY, APRIL 3 , 2022
the opinions essay
10 patients for a tiny “demonstration”
trial in which they could earn rewards if
they stopped using benzos. Before the
intervention, nine of the 10 patients had
tested positive for benzos. After three
months — during which time partici-
pants were tested twice a week and re-
warded with modest prizes for benzo-free
urine — seven of the 10 patients had
clearly reduced their use. “Wow,” Stitzer
recalled thinking. “We’re on to something
here.”
Stitzer’s research is at the foundation
of a field that has generated scores of
reports about contingency manage-
ment’s efficacy. The work has produced
many insights: It has shown that the
“fishbowl” approach (drawing for prizes)
and the “voucher” approach (earning
fixed amounts over time) both work. It
has shown that contingency manage-
ment is effective across different racial
and ethnic groups and income levels.
And it has shown that CM can have
positive spillover effects. During a 2013
randomized trial of people with stimu-
lant dependence and serious mental ill-
ness, not only was the CM group 2.4
times more likely to submit a stimulant-
negative urine sample, but those receiv-
ing CM also had fewer psychiatric symp-
toms and hospitalizations.
The data are more mixed on CM’s
lasting effects. In some studies — includ-
ing Stitzer’s early trials — patients started
using again when the incentives went
away. But a recent analysis found that CM
had better long-term benefits than other
approaches. As with many treatments, it
helps to avoid an abrupt end to support.
One review concluded that the best long-
term results came when CM was paired
with the “community reinforcement ap-
proach,” which deliberately assists peo-
ple in building rewarding social lives, to
carry them along after a program ends.
In other words, contingency manage-
ment is not a panacea. But a massive body
of research tells us that it is the best tool
we have to help people abstain from
stimulant use.
Yet today, if you’re trying to quit stimu-
lants and want access to the treatment,
odds are your health provider won’t offer
it to you — unless you’re a veteran.
In 2010, the Department of Veterans
Affairs commissioned an evaluation of its
behavioral health-care services and found
that only 1 percent of its patients had
access to contingency management, even
though the treatment had robust scientific
credentials. Determined to change this, it
appointed Dominick D ePhilippis, a gre-
garious clinical psychologist from Brook-
lyn, to implement and oversee an ambi-
tious operation that included trainings for
VA providers in the basics of CM.
Over a decade after VA began pouring
resources into contingency manage-
ment, more than 5,000 patients have
gone through its programs, according to
DePhilippis, with impressive results:
Ninety-two percent of participants’ sam-
ples come back free of the target sub-
stance. In short, VA has shown that CM’s
usefulness isn’t a fantasy.
W
ith so many people in the United
States battling addiction, why is
a tested, effective treatment still
barely used?
The biggest obstacles to contingency
management’s wider adoption turn out
to be a complicated mix of regulatory and
THE OPINIONS ESSAY FROM A25 bureaucratic hurdles. The good news is
that if we want to expand access — to offer
evidence-backed care to more Americans
— the federal government could take two
actions now to give CM the recognition
and push it deserves.
First — and this will sound ridiculous-
ly basic — CM needs a billing code.
Billing codes are how providers get paid,
and CM doesn’t have one. If providers
can’t bill for a service, they can’t get
reimbursed, which makes them less like-
ly to offer it at all. And while it’s possible
to pay for CM without a code — through
private grants, for instance — it
shouldn’t take that much effort to pay
for such a well-researched therapy. (Con-
sider that individual and group psycho-
therapy for addiction both have billing
codes, and that contingency manage-
ment has been shown to increase absti-
nence more effectively than therapy.)
The Centers for Medicare and Medic-
aid Services should create a code to pave
the way for greater CM availability — not
only for the privately insured but also for
those on government health insurance,
who tend to be lower-income and face
more hurdles to overcoming addiction.
Second, the Biden administration —
which named expansion of CM a year-one
priority — should move more boldly to
clear up regulatory confusion that has
discouraged states and clinics from offer-
ing full-throated contingency manage-
ment.
In a significant development, the
watchdog arm of the Department of
Health and Human Services did recently
sign off on a specific third-party CM pro-
vider — DynamiCare Health, a private
telehealth company with established
safeguards against fraud whose services
are offered through a phone-based app.
This was a big deal: Any entity partnering
with DynamiCare can now skirt the
dreaded regulatory confusion that has
long deterred many states from offering
full-fledged CM.
But states that choose not to work with
a third-party provider must still navigate
a complicated regulatory landscape. The
Biden administration can and should do
more to help states seamlessly expand
their CM programs.
One simple move would be for the
federal Substance Abuse and Mental
Health Services Administration (SAMH-
SA), which funds treatment programs
across the country, to lift its absurdly low
$75-per-year restrictions on CM rewards.
This is important because data suggest
that such low reward levels aren’t very
effective. Running CM pilot programs
with too-low rewards would be like run-
ning a vaccine trial with doses at less than
half the strength of what experts suggest
would offer adequate protection — and
then, even worse, grounding future policy
on the results of that flimsy pilot.
As more states and clinics launch
programs with funding from SAMHSA,
they should be free to offer rewards at
levels that actually work. And SAMHSA
should attach useful strings to the fund-
ing, such as requiring programs to ad-
here to evidence-based protocols and to
continually assess outcomes.
These recommendations are not to
suggest that CM’s broader adoption de-
pends on the government’s efforts alone.
The public — those of us who are open to
behavioral interventions, and who be-
lieve in getting people the best possible
care — has a role to play, too.
First, we need to demonstrate pa-
tience. If all goes well — if more states and
providers begin offering contingency
management — you will probably hear a
lot more about the treatment in coming
years. But something will almost certain-
ly go wrong. Maybe you’ll read about
unscrupulous or ineffective providers, or
an individual who made poor choices
with their rewards. Or maybe you’ll know
people who try CM and then relapse.
It might be tempting to condemn the
treatment outright. Instead, we should
ask tough but fair questions: Did the
program adhere to what studies have
shown are the most effective protocols?
What kinds of safeguards were in place to
prevent fraud? Did people receive suffi-
cient support after they’d graduated from
the program? Taking time to learn from
those questions will help ensure that
people are consistently offered a gold
standard of care.
Second, the public needs to demon-
strate impatience — the right kind. Pa-
tient and family advocacy matter. It’s
time to start asking direct questions of
providers: Do you offer contingency man-
agement? If so, does your version match
what the evidence shows is effective? If
not, what exactly do y ou offer, and what is
the proof that it works?
It’s important to be realistic about
what widespread CM can achieve. Addic-
tion programs have their limits, and most
Americans wrestling with substance
abuse don’t seek formal treatment. In
addition, because many people battling
addiction have other pressing threats to
their well-being — homelessness, for ex-
ample — any approach that can’t attend to
these other needs might not yield success.
But CM just might change the lives of
an untold number of Americans. And
they should have the chance to find out
whether it works for them.
When I last spoke with Anileah Bus-
well, in mid-March, she had been sober
for 11 months and two days. She had
graduated from her CM program in Feb-
ruary and enrolled in a data analytics
course. Her daughter, she said, was
“crawling like a maniac.”
CM hasn’t been a silver bullet for
Buswell. So many things steadied her
along the way, including the affordable-
housing initiative that helped her land
her own apartment and the residential
program where she was staying when her
daughter was born. But contingency
management has played a pivotal role.
And she says she’s grateful for the regi-
men that has allowed her to find her
bearings and proud of the life she’s build-
ing with her daughter and boyfriend, who
has also been sober for months, thanks to
other treatments and supports.
Buswell’s meth-free streak has won her
several gift cards, one of which she used
to buy cleaning supplies and toilet paper
for her new apartment. During one of our
conversations, she was tidying up the
place while we spoke — her daughter had
eaten her first-ever freeze pop that day
and had made a mess.
“I like it,” Buswell said about finally
having her own nest. “It’s small. But it’s a
good place to start.”Emefa Addo Agawu is a Post Opinions fellow.Contingency management
is not a panacea. But a
massive body of research
tells us that it is the best
tool we have to help people
abstain from stimulant use.
TONY LUONG FOR THE WASHINGTON POSTAnileah Buswell holds
her daughter at their
home in Nashua, N.H.Stimulant-related deaths in the United States
Methamphetamine overdoses are behind many
stimulant-related deaths in the country.2015 2016 20172018 2019 2020 20215,00010,00015,00020,00025,00030,388Provisional data as of March 25, 2022.Source: Centers for Disease Control and PreventionContingency management increased abstinence
Source: “Comparative efficacy and acceptability of psychosocial interventions for
individuals with cocaine and amphetamine addiction,” De Crescenzo et al. (2018)12-step program aloneContingency management + 12-step programContingency management aloneContingency management + community reinforcement approachCognitive behavioral therapy alone
1.17 *Compared with the control groupPeople in contingency management programs were more likely to be
abstinent at the end of the treatment than those in other programs.Cost comparison
Note: All costs for 2019.
Sources: Health Care Cost and Utilization Project (ER visit); ValuePenguin
(ambulance ride); Federal Bureau of Prisons (prison costs); author’s calculationsTypical cost for two weeks in prisonTypical cost of one ambulance rideAverage cost of one stimulant-related ER visitMaximum rewards for a typical
contingency management program$600$5 70$1,211$1,360THE WASHINGTON POST2.84 times more likely*2.21.821.35