On December 29, 2021, California became the first state to receive federal approval to cover the contingency management approach to drug use through Medicaid. Contingency management (CM) programs give financial rewards to participants for negative drug tests, or in some cases for reducing drug use. The California Department of Health Care Services (DHCS) will now run a statewide pilot program for people with substance use disorder (SUD).
The program will focus on stimulants like cocaine and methamphetamine, although people with multiple addictions can also participate. On January 1, the state began asking counties to implement the program. The state is providing $58.5 million for the pilot, of which $26.7 million is federal funding. Each patient will receive a maximum of $599 over six months, and patients will also be offered follow-up recovery services.
According to the National Institute on Drug Abuse (NIDA), “overdose deaths involving methamphetamine nearly tripled from 2015 to 2019 among people ages 18-64.” This is especially concerning because while opioid use disorder has FDA-approved medicines like methadone and buprenorphine, no such treatments exist for meth or cocaine.
In July 2021, California Governor Gavin Newsom signed a state budget that funded the CM pilot program to run between July 2022-March 2024. Separately, a bill passed the legislature that would have permanently covered CM under the state’s Medi-Cal program. But Newsom vetoed that legislation, saying it was “premature” and that the state should evaluate the pilot first.
He also announced the state would seek federal approval to implement the CM pilot program. The program was approved by the federal Centers for Medicare & Medicaid Services (CMS) last month under an “1115 waiver,” as Alcoholism & Drug Abuse Weekly reported, and is part of a larger overhaul of the state’s Medicaid program. Under this waiver, California already provides comprehensive SUD treatment to Medicaid patients through its “Drug Medi-Cal Organized Delivery System” (DMC-ODS) program, launched in 2015.
Medicaid programs don’t provide for CM on a large scale, because of state and federal rules that prohibit financial “kickbacks” for treatment.
Through DMC-ODS, California expanded access to medications for opioid use disorder, case management and recovery services. Currently, 37 out of 58 counties across the state voluntarily participate in DMC-ODS, meaning any of them could participate in the CM pilot. (Other counties would need to opt in to DMC-ODS to do so.)
The CM approach is controversial, and faces many government barriers. Medicaid programs don’t provide for it on a large scale, because of state and federal rules that prohibit financial “kickbacks” for treatment. CMS rules normally restrict any financial incentives to patients to a maximum of $75 a year.
“These caps are not consistent with the science,” noted Alcoholism & Drug Abuse Weekly, with larger rewards shown to be more effective.
The federal government’s position on CM has been somewhat unclear. Both NIDA and the Substance Abuse and Mental Health Services Administration (SAMHSA) describe CM as effective. In 2020 under President Trump, however, the Department of Health and Human Services (HHS) refused to relax rules and expand CM through CMS. But the Biden administration has set a priority to “Identify and address policy barriers related to contingency management interventions … for stimulant use disorder.”
The San Francisco AIDS Foundation offers a program called “PROP” that employs CM for LGBTQ cocaine and meth users. People participate for 12 weeks, and can earn up to $330 total for providing “non-reactive urine tests for stimulants.” Participants who continue using drugs still benefit from the program’s support.
In 2011, the federal Veterans Health Administration (VHA) began offering CM to homeless veterans with SUD. The most common drugs used by participants are cannabis and stimulants. The VHA offers them the chance to draw from a “prize bowl” for Veteran Canteen Service vouchers and other small rewards if they prove they are abstinent, or are attending group therapy sessions. A 2018 study of this program showed that “on average, patients attended more than half their scheduled CM sessions” and that over 91 percent of drug tests were negative.
One criticism of CM is that benefits don’t continue indefinitely. A 2014 study found that after stopping prize benefits, CM patients were unlikely to remain abstinent six months later. In contrast, a 2018 study found that 12 months after CM patients stopped receiving benefits, they were still more likely to be abstinent compared to those who used other treatments.
“Having a non-judgmental group of people made me feel comfortable no matter what shape I was in.”
CM gives patients more than just rewards—the programs are also intended to create a supportive environment for people who use drugs.
According to the San Francisco AIDS Foundation, one evaluation found that a majority of a sample of its CM participants reduced their stimulant use, and remained abstinent for an average of nearly four months after the program ended. But participants also reported lifestyle improvements including better physical and mental health, safer sex and meth-use practices, and taking their HIV or PrEP medications as prescribed.
“Having a non-judgmental group of people made me feel comfortable no matter what shape I was in,” said one participant.