More Carrot, Less Stick: HHS Approves Program to Help People Overcome Substance Use Challenges

Change is hard, but the consequences of inaction can be much more difficult. The nation’s overdose crisis provides an opportunity to embrace bold new strategies.

The White House Office of National Drug Control Policy has made fundamental changes in the federal response to the overdose crisis – embracing harm reduction, removing barriers to treatment and stopping the trafficking of illicit drugs.

The administration has little choice but to try new methods. More than 104,000 Americans died due to a drug overdose in the 12-month period ending in September 2021. And according to the 2020 National Survey on Drug Use and Health, 40.3 million people aged 12 or older had a substance use disorder within the past year. Meanwhile, more than four out of five Americans who need treatment for illicit drug use do not receive it.

Like the Office of National Drug Control Policy, we also know the status quo won’t work. So, the National Council joined with DynamiCare Health, Inc. to ask the Office of Inspector General (OIG) within the Department of Health and Human Services to render a decision regarding contingency management (CM), an evidence-based approach for treating substance use challenges. CM relies on providing financial incentives to reward healthy behavior, such as abstinence and treatment retention.

The Biden administration signaled approval of CM when it released its year one policy priorities, which included identifying and addressing “policy barriers related to contingency management interventions (motivational incentives) for stimulant use disorder.” But we were relieved when the OIG on March 2 issued a favorable advisory opinion that essentially permits the use of DynamiCare’s app-based CM program because this represents an endorsement of another bold new strategy to address our nation’s substance use crisis.

It was the first time the OIG issued a favorable opinion for a nationally accessible contingency management program that offers patients the full-value, direct monetary rewards that research has shown to be effective.

In other words, it’s a big, bold step.

CM also is a step in the right direction. That’s because positive reinforcement works. CM provides motivation. It rewards good behavior. There’s no reason that principle can’t be applied to those with a substance use challenge.

The Department of Veterans Affairs has relied on the contingency management to treat 5,600 vets over the last 10years, according to a story on NPR. California will begin a statewide CM program this summer.

Applying CM to substance use is simply a creative approach to a substance use crisis that requires new thinking and novel solutions.

While it sounds edgy and new, CM has been in use for years and studied in great detail. Those studies demonstrate the efficacy of CM, especially for those trying to overcome stimulants like cocaine or methamphetamines.

“Contingency management is considered especially valuable for treatment of people addicted to stimulants such as methamphetamine and cocaine because there are no proven medications for that disorder,” according to the Washington Post.

CM also makes sense because stimulants are responsible for an increasing number of overdose deaths. From 2019 to 2020, the rate of drug overdose deaths involving cocaine increased 22%, and the rate of drug overdose deaths involving psychostimulants with abuse potential (such as methamphetamine) increased 50%, according to the National Center for Health Statistics.

But resistance to CM remains among those who don’t believe we should pay people not to use drugs.

We have so many resources available to help communities fight the overdose crisis and prevent the deaths of those with a substance use challenge, and different people respond to different treatments and strategies. Perhaps CM can help some people who are willing to try a new strategy to overcome a substance use challenge.

Change is hard, but it’s so much more humane than refusing to help and risking even more overdose deaths.


Charles Ingoglia, MSW
(he/him/his) President and CEO
National Council for Mental Wellbeing
See bio