Contingency management has proven to be one of the most effective treatments for patients addicted to stimulants such as meth and cocaine. The practice — which rewards patients with money or prizes for hitting certain treatment milestones — has been shown to improve retention and abstinence rates.
However, stigma and lack of reimbursement prevent many substance use disorder (SUD) treatment providers from offering the incentive-based practice.
For providers who decide to take the plunge, they must consider a number of factors if they want their contingency management programs to be successful, experts say.
Chiefly among those factors are regulations, according to Eric Gastfriend, CEO of DynamiCare Health, a technology platform that specializes in contingency management for SUD.
“[Contingency management] is acceptable to the regulators when it’s practiced correctly — but that means it has to be clinically sound [and] use an evidence-based protocol,” Gastfriend told Behavioral Health Business. “It can’t be used as a way to advertise the program or incentivize patients to pick one program over another.”
Headquartered in Boston, DynamiCare partners with addiction treatment providers and other health care organizations to reward SUD patients for hitting certain positive treatment milestones. If patients achieve those set goals, they’re rewarded with financial deposits on a smart debit card, which can’t be used for cash withdrawals, bars or liquor stores.
When rolling out a contingency management program, Gastfriend said providers have to make sure their protocols are clearly outlined and well-documented. That means there must be a record explaining why a patient earned a specific amount of money, when the money was deposited and what goal was achieved.
Kristin Muhlner, CEO of Affect Therapeutics, echoed Gastfriend’s call to be mindful of regulations, advising providers to thoroughly examine the research and rules surrounding contingency management before rolling out a program of their own.
Affect is a year-old digital SUD treatment provider whose aim is to make contingency management affordable, scalable and auditable.
It is currently still in its pilot phase, but once Affect goes to market — which it hopes to do later this year — it will provide patients with a six-month intensive episode of care and an open-ended maintenance period. Patients will receive access to a digital therapeutic app, as well as an assignment to a dedicated care advocate, addiction counselor and psychiatrist. All the while, every aspect of the program is incentivized with contingency management.
In addition to considering regulatory factors, Muhlner said it’s important for providers to ensure their contingency management programs celebrate patients’ successes.
“For us, what that has meant is implementing contingency management incentives, but also implementing, in our app, core aspects of game design theory, which are meant to drive people back to engage with the program,” Muhlner told BHB. “And there are things that I think clinicians can do to make people feel really motivated and to make them feel celebrated in their success and not make them feel judged when things don’t work.”
Prizes are also important. They have to be large enough and distributed quickly enough to be worthwhile to patients, Muhlner said. Gastfriend agreed.
“If you’re doing small prizes that are worth less than $75 for a few months, that’s unlikely to be effective and it’s not really [contingency management],” he said. “If you have long delays, … like a week delay between the patient staying sober and earning reward, that’s not very effective. It really should be as immediate as possible.”
All that said, implementing contingency management is worth the time, effort and cost it takes to put into effect, according to Shawn Ryan, president and chief medical officer at BrightView Health, one of the few SUD treatment providers currently offering contingency management.
He recommends providers take advantage of grants and alternative payment models to help them finance the roll out of contingency management offerings.
“If you want your patients to have the best chance of recovery, it should be part of your program, period,” Ryan told BHB. “Go to the insurance companies and [regulators] and ask them: ‘Why not? We know this works. It’s well researched. We need every tool in the toolbox.’”
“We’ve got really strong tailwinds as it relates to the regulatory climate here — and a lot of evidence,” she said. “Each state is going to have to take some perspective on how to implement this and how to regulate these programs — because obviously there is an opportunity for bad actors to do inappropriate things, but I think we’re delighted with where things are headed, and the fact that we’re seeing support at the highest levels for it.”
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