Using the Opioid Settlement Funds to Invest in Evidence-Based Treatment Methods

Many states have begun the process of allocating funds from the opioid settlements, and some of them have drafted their opioid remediation program ideas. Contingency management (CM), a type of therapy in which individuals are rewarded for positive behavioral changes, has yet to make an appearance on these lists – despite the fact that CM is proven effective in over 100 randomized controlled trials for the treatment of substance use disorders (SUD).

While some states are still working to form advisory committees to oversee the allocation of settlement funds, many states have their committees in place. Most states are basing their priorities on the settlement agreement itself, which lays out 121 core strategies and approved uses of the funding. The list of remediation uses includes approaches like expanding naloxone training for first responders, increasing access to medication-assisted treatment (MAT) to individuals who are uninsured or whose insurance doesn’t cover the service, expanding drug screening to postpartum women, funding additional community drug disposal and prevention programs, and more. These are likely strategies that each advisory committee will consider because they’re highly effective at expanding the prevention and support options for SUD or those with opioid use disorder (OUD). 

These remediation lists are significant, not just because it’s important to use the settlement funds wisely, but also because they have the potential to change countless lives for the better. Unfortunately, CM is absent from these lists, and it is the only evidence-based option that is proven to treat and support all forms of substance addiction – OUD included. 

Additionally, Johns Hopkins, Shatterproof, and the American Medical Association are encouraging all states and communities to adopt 5 main principles when considering how to utilize the opioid settlement funds. CM has the potential to meet all 5 of these criteria: 

Principle 1: Spend the money to save lives. CM has been shown to save lives and is the most underutilized evidence-based treatment in the field of SUD.

Principle 2: Use evidence to guide spending. Over 100 studies dating back nearly 50 years have proven that CM is an effective addiction intervention. It is considered to be the most effective psychosocial intervention in the field of SUD treatment.

Principle 3: Invest in youth prevention. CM is recognized by NIDA as an evidence-based approach to treating SUD in adolescents. When delivered via digital platforms, CM is even more adapted to the lifestyles and needs of young adults.

Principle 4: Focus on racial equity. Federal regulations regarding standard treatment have been known to leave minorities behind. CM is highly accessible to anyone who needs it and has been shown to be effective across a wide range of demographics.

Principle 5: Develop a fair and transparent process for deciding where to spend the funding. Each state’s opioid advisory committee needs to be able to make informed decisions about what to fund. The evidence is readily available from multiple independent studies on the efficacy of CM. The CM method is not tied to a specific company or provider, so there is no conflict of interest when recommending investment in CM through the use of opioid settlement funds.  

Advisory committee members are encouraged to consider these principles before making their final decisions regarding the allocation of funds. CM has the potential to meet each of these 5 principles; this is another reason why it needs to be on all remediation lists moving forward.

Up to 23 million Americans are living with a substance use disorder, and almost 75% of them report not receiving any form of treatment. Adding a treatment method to your state’s list of remediation uses that’s conducive to multiple lifestyles and an effective intervention for anything from opioids to methamphetamines would expand treatment options and provide help for millions of people. 

Despite evidence of its efficacy and its use across the country, less than 10% of treatment programs in the United States currently incorporate contingency management.

What is Contingency Management?

Contingency management (CM) uses positive reinforcement and operant conditioning to promote harm reduction and abstinence in people of all ages and all levels of addiction. CM rewards patients for staying sober and staying in treatment. For example, a CM program might reward patients with a gift card incentive of $5 for every negative urine screen weekly in the first month. In the next month, the rewards could move to every other week. The reward amounts can also increase. For example, as patients stay sober, their reward amounts can increase from $3 to $5, then $10. In this way, CM works to create motivation by putting control in the hands of the patient/member. It gives people living with addiction another option for treatment – one that encourages delayed gratification and facilitates a sense of self-control. 

CM helps individuals remain consistently abstinent for 12 months, the optimal amount of time indicated by research to increase the likelihood of long-term recovery success. Within that first year, patients will have the time to internalize healthy patterns and they will no longer need external motivators like rewards. While popular for use with opioids, CM works for all severity levels and types of SUD.

CM is Evidence-Based

There has been research geared toward examining the role of CM in addiction for six decades. Studies show that it’s not only efficacious in reinforcing abstinence but also in increasing adherence to medication and encouraging patients to attend treatment meetings and appointments. By helping patients remain abstinent, CM enables patients to take full advantage of other clinical treatment components. 

Studies also show that CM increases (and even doubles) abstinence rates across many forms of SUD including nicotine, marijuana, alcohol, opioids, methamphetamines, and even co-occurring disorders. Furthermore, in a meta-analysis conducted by PLOS Medicine, including CM during treatment was found to be more effective than standard treatment or other evidence-based approaches without CM – up to one year following the discontinuation of incentives.

CM is Scalable 

CM has the ability to impact patients on a large scale. It can be implemented as a standalone method of treatment, through a digital platform, or alongside other forms of addiction or mental health treatment. When delivered via a digital platform, CM can integrate cognitive behavioral therapy (CBT) into daily routine care, and outcomes analytics can be fully formed and easily accessible. This frees up additional time for the providers and staff so they’re able to help more patients. When the opioid settlement funds are used to implement CM, patients, providers, and support staff all benefit.

SAMHSA’s current guidelines for funding opportunities only allow for $75 to be used per year per patient. The staffing, training, tracking and other aspects related to the implementation of CM can be funded, but the funds going to the patients themselves are restricted. In order for CM to be effective, reward amounts should be hundreds of dollars per year. Because of this, CM hasn’t taken off the way that it should have. However, the $75 limit does not apply to opioid settlement funds, which are free to implement full-value CM. The abatement funds finally give CM the opportunity to be implemented effectively and make a real impact on treatment outcomes.

CM is Cost-Effective

For every dollar invested in a CM program, there are $39 in benefits back to the healthcare system, taxpayers, and society.  CM costs the same (or less) to deliver than most MAT programs, and it has also been shown to deliver a greater return on investment (ROI). For every $1 invested in CM, health plans see a savings of $5 in terms of down-the-line medical expenses (like ER visits). 

Here is Why CM Must be Included in the Remediation Lists from the Opioid Settlement Funds

Despite its continually proven efficacy, CM continues to be incredibly underutilized because of barriers like funding and logistical challenges to implementation. Even though it has been used across the country for over a decade in the Veterans Association, adolescent programs, and various probation and parole departments, challenges surrounding reimbursement have prevented a wider adoption by other providers – a barrier that opioid settlement funds can eliminate. 

It’s also important to remember that this is a treatment method that can help those managing many forms of dependence including alcohol, opioids, methamphetamines, benzodiazepines, nicotine, and more. 

DynamiCare’s digital therapeutic platform is leading the way for CM to help patients and providers at scale. Built-in analytics enable individual accountability and will report back to the patient’s care team. We are removing barriers to treatment such as cost, transportation, stigma, and access by providing patients with a platform that will engage them in CBT and in their recovery. 

DynamiCare's innovative work has been recognized through 4 NIH grants and a 2019 New York Times Good Tech Award. DynamiCare has been featured by various news outlets, including the NY Times, WSJ, Washington Post, Boston Globe, and CBS News. If you’d like more information on DynamiCare’s digital therapeutic platform which uses CM to promote accountability for those trying to stop using drugs or alcohol, or how to access funding for the implementation, you can learn more or contact us.