Contingency Management for Adults with Substance Use Disorder: Evidence Roundup

Blog
Hadley Fitzgerald and Megan Lisch, Center for Health Care Strategies
One person handing a card to another.

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. 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.

What do contingency management programs look like in practice?

The following sources offer insights on CM implementation in various health care programs and settings.

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.