Should contingency management protocols and dissemination practices be modified to accommodate rising stimulant use and harm reduction frameworks?

Gabriela Kattan Khazanov; James R McKay; Richard Rawson

doi:10.1111/add.16497

Should contingency management protocols and dissemination practices be modified to accommodate rising stimulant use and harm reduction frameworks?

Addiction. 2024 Apr 16. doi: 10.1111/add.16497. Online ahead of print.

Authors

Gabriela Kattan Khazanov^{1

2}, James R McKay^{1

2}, Richard Rawson^{3

4}

Affiliations

¹ Center of Excellence for Substance Addiction Treatment and Education, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
² University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
³ University of California Geffen School of Medicine, Los Angeles, CA, USA.
⁴ University of Vermont Center for Behavioral Health, Burlington, VT, USA.

PMID: 38627885
DOI: 10.1111/add.16497

Abstract

Background: Stimulant-related overdoses have increased dramatically, with almost 50% of overdoses in the United States now involving stimulants. Additionally, harm-reduction approaches are increasingly seen as key to reducing the negative impact of substance use. Contingency management (CM), the provision of financial incentives for abstinence, is the most effective treatment for stimulant use disorder, but historically has not been widely implemented. Many recent, large-scale implementation efforts have relied upon foundational CM protocols that may not sufficiently account for recent increases in the prevalence and lethality of stimulant use nor the growing preference for harm reduction versus abstinence-only frameworks.

Argument: We argue the need to (1) consider whether and how CM protocols might be modified to address rising stimulant use and harm reduction frameworks and (2) make CM widely accessible so that it can reduce population-level stimulant use while ensuring that it is delivered with fidelity to its basic principles. Proposed changes include changing CM reinforcement schedules to emphasize treatment engagement and reductions in use in addition to abstinence, changing guidelines on the duration of and re-engagement in CM, investing in research on virtual CM, incentivizing providers and health systems to deliver CM, making it easier to purchase and use point-of-care drug screens, using direct-to-consumer marketing to increase demand for CM and adapting CM to the community in which it is being implemented.

Conclusions: Our proposed modifications to contingency management (CM) protocols and accessibility may more effectively address rising stimulant use and align CM more closely with harm-reduction frameworks. Given the urgent need to reduce overdose deaths, developing and testing modified CM protocols may need to rely upon methods other than randomized controlled trials. Efforts to disseminate CM widely to reduce population-level stimulant use must be balanced with the need to maintain fidelity to CM's basic principles.

Keywords: Contingency management; financial incentives; harm reduction; overdose; reinforcement; stimulants; virtual.

© 2024 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.