A time-tested behavioral intervention brings new momentum to substance use treatment

More than half of U.S. overdose deaths now involve stimulants, pointing to the urgent need for effective treatment for stimulant use disorder. Deaths involving of U.S. overdose deaths now involve cocaine, methamphetamine, and other stimulants nearly quadrupled between 2015 and 2022 (“Drug Overdose Deaths: Facts and Figures,” National Institute on Drug Abuse, 2024opens in new window).

In response, support is converging around contingency management (CM), a behavioral approach that provides rewards, such as gift cards, for negative drug tests and other recovery milestones. CM, which has been found effective in more than 100 studies conducted over several decades, complements rather than replaces counseling and other interventions for stimulant use disorder. The approach aligns with broadly shared goals in substance use treatment, including recovery, accountability, and efficient use of public funds.

“We don’t have any FDA [Food and Drug Administration]–approved medications for the treatment of stimulant use disorder, but what we do have is almost 40 years of evidence on the efficacy of contingency management,” said psychologist Thomas Freese, PhD, director of the University of California, Los Angeles, Integrated Substance Use and Addiction Programs, who is leading California’s CM pilot, the Recovery Incentives Program.

CM is not only backed by experimental findings—it also works in the real world. Among nearly 3,000 Veterans Health Administration patients with stimulant use disorder, those who received CM were 41% less likely to die within a year than those who did not (Coughlin, L. N., et al., The American Journal of Psychiatry, Vol. 182, No. 11, 2025opens in new window).

The mounting evidence has led top organizations and agencies to back the treatment. In 2024, the American Society of Addiction Medicine and the American Academy of Addiction Psychiatry released clinical practice guidelines naming CM as the frontline treatment for stimulant use disorder (Journal of Addiction Medicine, Vol. 18, No. 1S, 2024opens in new window). Soon after, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) increased the cap on federal funds that can be used for incentives. CM programs can now provide rewards worth up to $750 per person per year—up from $75, a limit that was not supported by experimental evidence (Petry, N. M., et al., Addiction, Vol. 99, No. 3, 2004opens in new window).

CM is a psychology success story, said psychologist Michael McDonell, PhD, a professor at Washington State University’s Elson S. Floyd College of Medicine who has studied the intervention for nearly 2 decades. It was created, assessed, and advocated for by psychologists, with key support from APA. With SAMHSA’s policy change and pilot programs underway in several states, more people with stimulant use disorder can start to reap the benefits.

“The momentum in the field has shifted from developing interventions to implementing them in real-world settings,” said Jesse Dallery, PhD, a professor of psychology at the University of Florida who studies digital delivery of CM. “We know CM works. Now, it’s a matter of reaching as many people as possible.”

Part of CM’s power is in its simplicity. Typically, participants visit a clinic twice a week for urine drug testing. If their test is negative, they immediately earn a reward—either a gift card or a chance to draw from a prize pool, with rewards of varying values. The intervention usually lasts between 12 and 24 weeks and may be paired with counseling or other approaches.

At least seven systematic reviews and meta-analyses, based on numerous randomized controlled trials, show that CM is the most effective intervention available for stimulant use disorder (Bentzley, B.S., et al., JAMA Network Open, Vol. 4, No. 5, 2021opens in new window; Brown, H.D., & DeFulio, A., Drug and Alcohol Dependence, Vol. 216, 2020opens in new window; De Crescenzo, F., et al., PLOS Medicine, Vol. 15, No. 12, 2018opens in new window).

CM works better than cognitive behavioral therapy and other behavioral approaches. It helps when paired with counseling, but also as a stand-alone intervention. And it is also cost-effective: An analysis by the Washington State Institute for Public Policy found that CM programs offering total rewards over $500 had a 78% chance of generating benefits that exceeded their costs (“Contingency Management [Higher Cost] for Substance Use Disorders, Washington State Institute for Public Policy,” 2024opens in new window). Evidence also suggests that CM leads to better long-term outcomes than other treatments even after incentives end (Ginley, M.K., et al., Journal of Consulting and Clinical Psychology, Vol. 89, No. 1, 2021opens in new window).

In addition to its benefits for patients, CM may also offer a buffer against burnout for addiction treatment providers. Qualitative data suggest that CM can boost staff morale and strengthen relationships among team members as they see patients make meaningful progress (Oluwoye, O., et al., Psychology of Addictive Behaviors, Vol. 34, No. 1, 2020; Kellogg, S. H., et al., Journal of Substance Abuse Treatment, Vol. 28, No. 1, 2005opens in new window).

“We’ve also heard anecdotally that substance use counselors in CM pilot programs are much more excited about coming to work each day, because they’ve finally got something that works,” said Scott Barstow, the senior director of congressional and federal affairs for APA Services, APA’s companion organization.

Because they involve monetary incentives, CM programs include a number of ethical safeguards to protect against fraud and to avoid offering rewards large enough to pressure participants. Caps on the total amount a participant can earn lower the risk of abuse, while the use of vouchers or gift cards instead of cash reduces the chance that incentives are resold or used for unintended purposes. Detailed logs and documentation help track participant eligibility and the delivery of rewards. Programs are also audited periodically to verify that they comply with ethical and legal standards (Clark, H.W., & Davis, M., Preventive Medicine, Vol. 176, 2023opens in new window).

Real-world rollouts of CM are further strengthening the intervention’s evidence base. In addition to the 41% drop in mortality among veterans who received CM, California’s Recovery Incentives Program has shown promising early results. Freese and his team have reached nearly 10,000 patients at 111 sites across the state and are now compiling their first outcomes report.

“We’re seeing in the rollout that it’s working as the research suggests,” Freese said. “People are coming in, engaging with the program, testing negative, and making changes we don’t see with the other available treatments for stimulant use disorder.”

SAMHSA’s policy change also gives CM a big boost, because states can now use State Opioid Response and Tribal Opioid Response grants to administer CM with payouts of up to $750 per person per year. A handful of states have found other ways to support the programs: California, Washington, and Montana have gained permission to use Center for Medicare and Medicaid Services (CMS) funds for CM through what is known as a Section 1115 waiveropens in new window, while Vermont, Connecticut, and Michigan are using funds from opioid litigation settlements to administer CM.

Most of the progress so far involves federally sponsored health care, such as primary-care offices and community clinics supported by CMS. The next frontier is securing coverage for CM by private insurers.

Researchers have already shown that CM smartphone interventions can work (Dallery, J., et al., Perspectives on Behavior Science, Vol. 42, 2019opens in new window; DeFulio, A., et al., Frontiers in Psychiatry, Vol. 12, 2021opens in new window). To verify participants are not using substances, these apps use a combination of methods, including photos of home drug tests, mail-in tests, data from wearable sensors, and random check-ins. Several companies, including Affect Therapeutics and DynamiCare Health, now deliver digital CM programs through their platforms, allowing thousands of patients to access them through insurance networks.

As CM continues to roll out, researchers are exploring questions that can further boost its real-world impact (Rawson, R. A., et al., Preventive Medicine, Vol. 176, 2023). For example: Do voucher-based systems and prize-based systems work equally well? What is the ideal magnitude for incentives? How frequently should participants be tested, and how long should treatment last?

Researchers are also exploring how CM can be culturally adapted for specific populations. McDonell and his colleague Katherine Hirchak, PhD, of Washington State University, have partnered with several American Indian and Alaska Native communities, finding that programs were highly effective when administered by members of the partnering communities (JAMA Psychiatry, Vol. 78, No. 6, 2021opens in new window; Addiction, Vol. 116, No. 6, 2021opens in new window).

Beyond its utility for stimulant use disorder, evidence suggests that CM may be useful for incentivizing a range of health behaviors. Stephen Higgins, PhD, a professor of psychology at the University of Vermont, and others have shown in randomized controlled trials and meta-analyses that CM is more effective than counseling in preventing smoking during pregnancy and that it can be done through a smartphone app (Preventive Medicineopens in new window, Vol. 165, Part B, 2022opens in new window; Kurti, A. N., et al., JAMA Network Open, Vol. 5, No. 5, 2022opens in new window; Notley, C., et al., Cochrane Database of Systematic Reviews, 2025opens in new window). That evidence led the United Kingdom to implement CM for perinatal smoking cessation nationwide (“National Smoke-Free Pregnancy Incentive Scheme,” National Health Service England, 2024opens in new window).

In Florida, Dallery is conducting a large clinical trial of smartphone-based CM to help patients at underserved primary-care clinics quit smoking. With funding from the Patient-Centered Outcomes Research Institute, he and his team are comparing three interventions: CM plus acceptance and commitment therapy (ACT); ACT alone; and referral to the Florida Quitline, the current standard of care.

Separately, McDonell led four randomized controlled trials showing CM is just as effective for treating alcohol use disorder as it is with stimulants (JAMA Psychiatry, Vol. 78, No. 6, 2021opens in new window). Further studies find that CM enhances medication adherence in opioid use disorder, reduces human immunodeficiency virus (HIV) risk behaviors, and more.

The past year’s progress reflects one measured step forward, Barstow said, and plenty of work lies ahead. But there’s no denying that CM could be a major asset in the overdose crisis.

“I don’t know that I’ve been involved in a program that looks so positive in terms of its impact, its efficacy, and its acceptability,” said Freese, of California’s pilot. “Our job now is to implement this right and keep seeking ways to reach the hardest-hit populations.”