Contingency management is an addiction treatment that works.

Odds are you’ve never heard of it, though.

Contingency management, usually called CM, rewards people to avoid the behaviors they’re trying to quit. That means someone in a CM program visits a clinic a couple of times a week for a urine test; if it’s drug-negative, they immediately get a gift card or prize. If the test is drug-positive, they get encouraging words to keep trying.

CM rewires reward pathways in the brain that have been hijacked by drug use. It’s simple and effective, with decades of evidence and studies to back it up.

“It’s a powerful tool for changing behaviors related to day-to-day struggles,” says Michael McDonell, professor at the Washington State University Elson S. Floyd College of Medicine and a leading CM researcher.

Michael McDonell sitting at a table listening to a person
Michael McDonell (Courtesy Elson S. Floyd College of Medicine)

While CM has been shown to be effective in treating multiple addictions, it’s one of the only treatments available for addiction to stimulants, such as methamphetamine and cocaine.

So why isn’t it widely used?

Partly because of federal restrictions around monetary incentives in health care. And partly because it hasn’t been covered by Medicaid, the state-federal insurance program under which most people with addiction receive care.

Based on the success of WSU-led pilot programs, however, Washington last year became the second state to provide a waiver allowing CM to be offered as treatment to Medicaid-covered patients. The goal is to expand CM to 90 sites in the state over five years, McDonell says.

Expansion will include innovation.

A pilot project in Seattle, for example, will bring testing to residents in supportive housing facilities. It will make CM more convenient for the people who are participating. And reducing substance abuse in a communal living situation could improve life for everyone at that location.

CM can’t become a widespread treatment option without action from the federal government. But with the state of Washington agreeing to cover contingency management under Medicaid, CM might be at a tipping point.

“It’s frustrating to think that there’s all this great science that’s gone into developing this intervention and it works so well, but very few people have access to it,” McDonell says. “There’s so much interest from states and cities because they don’t want people to keep dying from drug overdoses. They’re looking to CM as part of that solution.”


Read more

Substance use and addiction  (Feature Part 1)

Understanding pain  (Feature Part 3)

How to talk about substance use  (Feature Part 4)