Contingency management (CM) is an evidenced-based, psychosocial treatment that uses incentives to reinforce positive recovery behaviors in individuals with substance use disorders (SUDs). Frequently combined with other SUD treatment approaches, CM is demonstrated to promote abstinence, boost treatment engagement, and increase adherence to medication. It can also aid in the prevention, diagnosis, and management of hepatitis, HIV, and tuberculosis. It is a particularly effective treatment for cannabis or stimulant use disorders, neither of which have Food & Drug Administration-approved medication treatment. It also has the potential to be lifesaving in light of the steep rise of stimulant-related overdoses, including fentanyl-laced stimulant overdoses.
How does contingency management work?
CM can be delivered in any SUD treatment setting, but is most commonly provided on an outpatient basis, and increasingly via telehealth. It is often used alongside other treatments approaches such as cognitive behavioral therapy (CBT) and medications for opioid use disorder (MOUD) or alcohol use disorder. Participants of CM programs work with trained clinicians to identify a target behavior to measure over time and reinforce with incentives. These target behaviors are often abstinence, treatment attendance, or medication adherence. The overall goal is to foster long-term behavioral changes in individuals following their participation in the program.
Participants earn incentives on a fixed schedule in the form of vouchers or prizes (e.g., toiletries, gift certificates, movie passes). For each indicator of a positive behavior, such as a negative drug test or a specific treatment attendance milestone, participants are awarded incentives. In the prize-based approach, the program participant would draw a prize from a fishbowl. In the voucher-based approach, the participant would receive a voucher for an item or service. Incentives are most effective when awarded promptly and in escalating amounts for each demonstrated, consecutive positive behavior. Research also indicates that outcomes improve when incentives are of higher value or awarded more frequently. For negative behavior, CM programs withhold incentives or re-set them to the original value. Duration of CM may vary depending on the specific goals of the treatment program.
What is the regulatory and funding landscape surrounding contingency management?
There are specific policy barriers and opportunities related to CM. Prospective CM providers may worry about violating federal and state anti-kickback and beneficiary inducement laws, which restrict giving incentives to patients or influencing their choice of treatment programs. In 2020, the U.S. Department of Health and Human Services’ Office of Inspector General issued new regulations, stating that the legality of CM programs would be analyzed on a case-by-case basis. Notably, the Department of Veterans Affairs has been able to operate outside of these restrictions, and has widely implemented and studied CM since 2011.
Historically, Substance Abuse and Mental Health Services Administration (SAMHSA) regulations limited CM incentives to $75 per individual per year, far below the levels found to be most effective. However, updated SAMHSA guidance published in January 2025 increased this limit to $750 per individual per year for programs operating under SAMHSA funding. This change presents a significant opportunity for states and tribal territories to pursue CM programs through State Opioid Response (SOR) and Tribal Opioid Response (TOR) grants.
Additionally, states interested in using Medicaid funding for CM can pursue approval through a Section 1115 demonstration waiver. In December 2021, the Centers for Medicare & Medicaid Services approved the first CM waiver for California for eligible individuals enrolled in the Medi-Cal Recovery Incentives Program in participating counties. Since then, four additional state waivers have been approved (Delaware, Hawaii, Montana, Washington) and two states (Michigan and Rhode Island) have waivers pending approval. These waivers vary in eligibility, program length, and incentive amounts, but all support individuals with stimulant use disorder, with some states also approving use for opioid and alcohol use disorder treatment.
What is the evidence on contingency management?
A substantial body of evidence published on CM interventions highlights its effectiveness in increasing abstinence, improving treatment adherence, and promoting overall health and well-being.
- Randomized Controlled Trial of Contingency Management for Stimulant Use in Community Mental Health Patients with Serious Mental Illness – This 2013 study analyzed patients with stimulant use disorder and serious mental illness, comparing their participation in treatment with or without CM. Those in the CM program were 2.4 times more likely to have a negative urine test during treatment and exhibited lower levels of other substance use and psychiatric hospitalization.
- Effect of Prize-Based Incentives on Outcomes in Stimulant Abusers in Outpatient Psychosocial Treatment Programs: A National Drug Abuse Treatment Clinical Trials Network Study – This 2005 study of a multistate network of CM programs showed increased length of treatment, submission of stimulant and alcohol-free urine samples, and rates of continuous abstinence following CM treatment.
- Contingency Management Interventions for HIV, Tuberculosis, and Hepatitis Control Among Individuals with Substance Use Disorders: A Systematized Review – This review of 23 studies demonstrates how CM can be a valuable intervention for boosting adherence for preventive services, diagnostic tests, and treatments for HIV, tuberculosis, and hepatitis among people with SUD.
- Contingency Management for Patients Receiving Medication for Opioid Use Disorder: A Systematic Review and Meta-Analysis – This review shows that CM is improves overall treatment outcomes for people receiving medication for opioid use disorder (MOUD) and is effective in reducing substance use for various types of substances.
- Long-term Efficacy of Contingency Management Treatment Based on Objective Indicators of Abstinence from Illicit Substance Use up to 1 Year Following Treatment: A Meta-Analysis – This analysis of almost two dozen randomized trials shows long-term benefits in reducing substance use, including that CM significantly improves the likelihood of abstinence from drug use up to one year following treatment.
What do contingency management programs look like in practice?
The following sources offer insights on CM implementation in various health care programs and settings.
- Lessons Learned from Statewide Contingency Management Rollouts Addressing Stimulant Use in the Northwestern United States – This review of CM pilot programs in Montana and Washington details the process used to train providers and implement treatment services leveraging SOR funding.
- Substance Use Disorder Program Offers New Approach to Stimulant Addiction Treatment – This blog post highlights Boston Medical Center’s Stimulant Treatment and Recovery Team (START) program, which began in June 2021. It outlines the program’s clinical guidelines for implementing contingency management in a similar setting.
- Budget Impact Tool for Implementing Contingency Management for Co-Occurring Alcohol Use Disorders and Serious Mental Illness – Providers interested in establishing or enhancing CM programs can use this tool to estimate upfront and ongoing costs associated with implementation. Although it was created for community mental health centers to budget for CM in treating individuals with alcohol use disorders and co-occurring serious mental illness, it can be customized for various treatment settings and patient needs
Share Your Contingency Management Resources and Tools
Do you have a resource or emerging best practice related to CM programs? Share your experience with the Playbook. We are interested in growing our library of evidence and implementation best practices to help those in the field strengthen and build successful CM programs in communities across the nation.