The United States Department of Health and Human Services recently sought advice from patients, clinicians and public health experts on addiction treatments supported by “rigorous, empirical evidence of effectiveness”.
Health and Human Services endorses medications to address opioid addiction, but there are actually no medications to address addiction to stimulants such as cocaine and methamphetamine.
Three decades of pharmaceutical testing have come up empty, and with half of all fatal overdoses in the US now involving stimulants, and with standard counselling frequently falling short, we have a pressing need for new and effective interventions.
The answer may come from a proven non-medical remedy.
A Stanford team’s examination of 157 clinical trials of treatments for cocaine, including both psychotherapy and medications, found little clinical benefit with one notable exception: contingency management, a programme that leverages motivational incentives, or “carrots”, to help shift an addict’s behaviour.
According to the Stanford analysis, these methods more than doubled the odds of someone testing negative for cocaine.
Methamphetamine – despite its reputation as being more addictive than cocaine and certainly more damaging to the brain – was shown to be similarly responsive to contingency management.
Vouchers and cash
In a typical scenario, a participant who provides a negative drug test receives a reward – a “reinforcer” – such as vouchers, small amounts of cash or the opportunity to draw from a prize bowl.
Reward schedules are sometimes arranged so that each subsequent reinforcer is slightly larger than the last.
If a drug test is returned positive, the value of the reward for that person is reset to a lower value.
Data suggest that the effects of contingency management programmes are fortified when administered together with cognitive behavioural therapy or counselling.
A review of 50 clinical studies of patients addicted to stimulants found that a reward system combined with a community reinforcement approach – where therapists encourage patients to extract gratification from their families and jobs as substitutes for the gratifications of drug use – reduced cocaine-positive drug tests by more than a third when compared with rewards alone.
Although contingency management has been studied in the context of stimulant addiction for more than 30 years, it wasn’t applied at scale until 2011, when the Department of Veterans Affairs (VA) developed a programme that’s now administered in more than 110 VA medical centres.
Patients in these programmes could receive vouchers for US$1 (RM4.08), US$20 (RM82) or US$100 (RM401) that are redeemable in VA-run shops and canteen services.
On average, participants received around US$200 (RM817) in coupons over 12 weeks.
Fewer deaths
From July 2018 through December 2020, stimulant-addicted patients in the Veterans Health Administration who received rewards were 41% less likely to die within a year versus a well-matched comparison group that was not part of a contingency management programme.
Starting in 2021, states could apply for waivers that allow Medicaid funds to underwrite contingency management vouchers as part of their pilot programmes.
California was the first to jump in, launching a 24-week outpatient programme in 2023.
An interim evaluation found that the testing programme reached about a quarter of all California Medi-Cal members who were in outpatient treatment for stimulant use.
These programmes proved to be successful, as 75% to 95% of their drug tests came up negative for stimulants over 24 weeks.
As of early 2025, Delaware, Hawaii, Montana and Washington have also been approved for Medicaid waivers to experiment with rewards as intervention.
Meanwhile, according to the National Academy of State Health Policy, Michigan, Vermont, Virginia and Arizona’s Maricopa County have started contingency management programmes with opioid settlement funds.
An analysis by the Washington State Institute for Public Policy found that programmes offering total rewards of more than US$500 (RM2,043) had a 78% chance of generating benefits that exceeded costs.
Primary treatment
These optimistic results have led the American Society of Addiction Medicine and the American Academy of Addiction Psychiatry to name contingency management as the frontline treatment for stimulant-use disorder.
In January 2025, the Biden administration raised the cumulative cap on federal grants from the Substance Abuse and Mental Health Services Administration for rewards to US$750 (RM3,064) from US$75 (RM306) per patient per year, provided that these awards are issued as gift cards or services rather than as cash.
Some believe we shouldn’t be using tax dollars to “pay” those who use drugs to do what most of us do every day.
Others worry that incentives may quash someone’s internal motivation to quit, or that patients will relapse once an incentive-based treatment ends.
Ideally, patients will eventually internalise the desire to stay off drugs because the rewards of recovery are more motivating than material incentives.
As one woman with a methamphetamine problem who participated in a rewards programme in Portland, Maine, told The New York Times: “I feel like being sober is payment enough, not waking up sick is payment enough, being trusted is payment enough.”
However, the systematic data on the sustained effects of contingency management are mixed.
Pros and cons
Some evidence suggests that rewards lead to better long-term outcomes than other treatments, even after the incentives end.
One study found that the effects may ebb over time, but are more durable than changes seen from traditional treatments.
A 2023 report from the Office of the Assistant Secretary for Planning and Evaluation, part of Health and Human Services, concluded that the reward approach “is among the most effective treatments for promoting lengthier periods of abstinence during treatment, which is associated with a greater likelihood for long-term abstinence following treatment”.
Steps can be taken to prevent fraud and abuse by patients.
Some programmes in California have engaged tech companies to block debit card purchases related to gambling, tobacco, alcohol or firearms and some programmes use mouth swabs to prevent substitution of a friend’s urine sample for one’s own.
We recognise that both clinicians and the general public have misgivings about “bribing” addicts to stop using drugs.
To date, contingency management is the only treatment that yields consistently positive outcomes in combating the heavy abuse of stimulants and its devastating toll on mental and physical well-being.
The strategy may challenge traditional views on who deserves public funds, but we urge the public and politicians to bite the utilitarian bullet.
They should support generous funding for incentives to help addicted individuals regain control of their lives and become productive workers, citizens and family members. – Los Angeles Times/Tribune News Service
Sally Satel is a senior fellow at the American Enterprise Institute and medical director of a methadone clinic in Washington, United States, and David Farabee is professor emeritus at the UCLA Department of Psychiatry & Biobehavioral Sciences.
