Paying for Sobriety: A Closer Look at Contingency Management

The Washington Post recently wrote a long-form editorial featuring DynamiCare that outlines the benefits and the hope that contingency management offers the field of addiction recovery. They even share the story of a young mother whose life was changed through contingency management based addiction care. You can find the full article at: the Washington Post.

Although by no means a new approach to addiction treatment, contingency management (CM) has only recently made headlines for its unique methodology and effectiveness in successfully treating substance use disorders. Despite the fact that the practice of CM has a track record of being one of the most successful approaches to addiction treatment, with evidence of effectiveness ranging from alcohol to methamphetamine addiction, the use of contingency management is still uncommon across almost all avenues of addiction treatment. There are a number of reasons for this, but it is perhaps most pertinent to fully define what constitutes contingency management. 

At its simplest, contingency management (abbreviated “CM”) is rewarding people for positive actions related to recovery. In many cases (though not always!) this can look like paying people to abstain from drug usage. In one popular model called “voucher-based” contingency management, patients begin their programs with small monetary rewards, such as $1, per drug-free urine screen. If abstinence is maintained, for every passing drug screen the monetary reward will also increase. This means that the longer a person is abstinent, the higher their reward will be. While many balk at the thought of receiving $1 as a prize, research shows that the programs that used a range of prizes still reached high rates of relative success. 

But why? What is it about this simple treatment model that makes it so much more effective than other models? As cliche as it sounds, the answer may just be in our biology. CM is based on a model of rewarding behavior called “operant conditioning,” which started out as a field of psychological research in animals. Researchers found that, when offered positive reinforcement, animals would adapt their behaviors far beyond what was expected of them. Those studying addiction began to wonder whether or not they could develop a treatment system based on this response to positive reinforcement that would inevitably compete with the brain’s desire to do drugs… and it worked. 

While people are of course more sophisticated than animals, this relatively simple concept has shown that it has the potential to make a real impact on the amassing drug crisis in America. Between April 2020 and April 2021 an estimated 100,000 people died from drug overdoses. In the last five years alone, the amount of overdose deaths has risen fivefold. 

With both methamphetamine and opioid overdose deaths on the rise, the search for alternative and more effective treatment options have turned the eyes of addiction specialists towards contingency management. Research has now shown that contingency management can be  more effective than other stand-alone treatments such as cognitive behavioral therapy or the 12-step approach, but one of the great aspects of CM is that it can be combined with any of these approaches to bring success rates even higher. It is because of this success that multiple states including Montana, California, and Oregon are now considering implementing CM programs at the state level. 

All things considered, it leaves the question as to why contingency management has not been more widely used before now. The answer to this question is complicated and as one might expect, has a lot to do with money and stigma. Historically, funding contingency management programs has been difficult. Not because they are overly expensive when compared to other treatment programs (in fact, they’re significantly more cost-effective), but because state and federal funding was largely unavailable. Many people do not want their tax dollars being paid into what they see as the hands of addicts. Other, more bureaucratic, hurdles that contingency management faces are relatively simple in the grand scheme of things. 

For one, contingency management does not yet have a universal billing code. The lack of standardized billing practices makes CM difficult for providers to implement because there is a fairly low chance that they will be reimbursed through private insurance, Medicaid, or Medicare. Second, the federal government would need to establish national precedence as well as internal structures to safely implement standardized CM practices and avoid fraud. While these are largely governmental fixes that are out of the hands of most providers and patients, there are other small things that have been and will continue to be done for those willing to put in the extra work to implement contingency management, including clever workarounds such as the digital CM platforming offered by DynamiCare. DynamiCare recently partnered with the National Council for Mental Well-being to receive an advisory opinion from the federal Dept. of Health & Human Services Office of the Inspector General (HHS-OIG), allowing for CM as an evidenced-based method of treatment that does not run afoul of current anti-kickback laws. This advisory opinion opens the door for other providers to do the same.

Addiction treatment is not one-size-fits-all, so it is incredibly valuable for providers to have one more tool in their toolbox in order to help patients. Given the research and the growing federal interest in contingency management based addiction treatment, it is worth understanding that there may be new and more effective options in addiction treatment and recovery. When you combine those options with other treatments already present in the field, the opportunities for successful recovery only grow. 

To learn more, we highly recommend the long-form editorial on this issue from the Washington Post, which highlights not only DynamiCare, but also our research partner Maxine Stitzer PhD from Johns Hopkins. You can find the full article at by clicking here