Lessons Learned from Statewide Contingency Management Rollouts Addressing Stimulant Use in the Northwestern United States

Headline

Contingency management program implementation in two states offers lessons for addressing stimulant use disorder.

Background

States can support the implementation of contingency management, an evidence-based behavioral therapy often used for addressing substance use disorders, through a variety of funding sources, including the federal State Opioid Response (SOR) grants, offered by the U.S. Substance Abuse and Mental Health Services Administration. This article explores lessons from statewide contingency management pilots in Montana and Washington State, which were partially funded by SOR grants. Both rollouts focused on addressing stimulant use disorder and trained providers in implementing contingency management programs with fidelity to evidence-based treatment protocols that complied with federal regulations. The article shares the composition of programs launched in each state and describes the success and challenges encountered during and after implementation.

Findings

Across both states, 154 providers from 35 sites were trained in contingency management and 17 of these sites subsequently implemented a contingency management program for stimulant use disorder. Most of these programs were located at federally qualified health centers, offered other substance use disorder treatments, and were in suburban areas or small towns. Four implementation lessons were identified:

1. Funding: The sites overcame a common barrier to adopting contingency management by being provided with funds from the state for higher-value incentives. These incentives, often exceeding the SOR grant limit, have been proven to be more effective at promoting stimulant abstinence than lower-value incentives. The states also offered funding or Medicaid billing guidance for the frequent urine screens required by contingency management, which might otherwise be restricted by annual caps.
2. Logistical fit: Sites that could accommodate frequent outpatient visits were more likely to successfully implement contingency management following evidence-based protocols compared to sites without that capacity (e.g., jails, inpatient hospitals, emergency departments).
3. Philosophical fit: Some providers found it challenging to adhere to the model for several reasons: they wanted to distribute incentives more freely, believed their harm reduction approach conflicted with contingency management, and expected abstinence from all substances rather than just one.
4.  Adaptation vs. fidelity: While contingency management is ideally implemented with strict adherence to the model, sites still achieved success by making site-specific adaptations requested by providers and patients. For instance, a rural Washington State provider collaborated with the authors to modify contingency management for telehealth.

Policy/Program Takeaways

States are pivotal in promoting the adoption of contingency management to address substance use disorders. States should consider all federal contingency management funding sources, including SOR grants and Section 1115 Medicaid waivers, which as of February 2025 have been approved in several states, including the states studied in this article.