Guest Editorial: Remove Arbitrary Barrier to Evidence-based Treatment for Stimulant Use Disorder
Although the current overdose crisis in the US is almost universally referred to as the “opioid” or “fentanyl crisis”1,2, the overdose death rate associated with psychomotor stimulants, including methamphetamine and cocaine, has also dramatically increased in recent years. A recent report using CDC data documented a “50-fold increase in the methamphetamine mortality rate” from 1999-2021.3 Of the 32,353 total methamphetamine-associated deaths in 2021, 61.2% included fentanyl, meaning that 38.2% — or 12, 617 deaths — did not involve fentanyl. Other CDC data also indicated a tripling of cocaine-related deaths, with and without fentanyl.4 Thus, it would be a misrepresentation of the 2023 overdose crisis to be viewed as exclusively an opioid or fentanyl crisis.5
The rates of stimulant-related overdose deaths were substantially different according to race/ethnicity. Increases in methamphetamine-related overdose deaths among American Indian/Alaska Native (AI/AN) increased over eightfold between 2010 and 2019.6 Among Black individuals, overdose death rates associated with methamphetamine alone and in combination with opioids were found to have increased tenfold (compared to 3-fold among White individuals) over this period. 7
There is only one treatment with robust evidence of efficacy for treating individuals with cocaine and methamphetamine use disorder–contingency management (CM), a behavioral approach based on basic principles of positive reinforcement. (There are no FDA-approved medications for treating stimulant use disorder [StimUD]). The evidence for CM as a treatment for StimUD is supported by over three decades of NIH-sponsored research.8,9,10 The evidence from these decades of research suggests that incentives at the level of $100-200 per month is most effective. At this full-value level, incentives have a 77% likelihood of producing benefits that exceed the costs – beginning in the first year.11 However, federal policy continues to pose serious obstacles to the implementation of CM.12,13
The Motivational Incentives Policy Group (MIPG) has recently facilitated an important change in federal policy emanating from the US Department of Health and Human Services Office of the Inspector General (OIG). Between 2008 and 2020, the OIG had been a perceived obstacle to implementing CM: it had suggested that providers could be investigated for fraud and abuse simply by implementing CM. However, in December 2020, a new OIG Final Rule reassured providers that CM use is not prohibited.14 The Final Rule permits CM if providers use appropriate safeguards are used to prevent fraud and abuse.
Serious obstacles to implementation remain, nevertheless.
It was erroneously believed that the OIG required that the amount that could be used for incentives be limited to $75 and that only non-monetary rewards were acceptable. This erroneous belief is reflected in the current HHS policy that puts a $75 limit on the total per-patient amount that can be used in incentives in CM protocols. Specifically, SAMHSA and HRSA state this restriction in their 2022 and 2023 RFPs. CM for treating StimUD cannot be done in line with the vast published research with a $75 per patient incentive limit.
The now arbitrary $75 ceiling is forcing some states to produce requests for proposals (RFPs) with a $75 ceiling on incentives. The evidence shows that the $75 ceiling is ineffective. Adhering to this limit wastes federal dollars and jeopardizes clinical and scientific integrity, undermining the implementation of CM for StimUD as an evidence-based practice. This practice ensures that CM will fail. Although HHS, Assistant Secretary for Planning and Evaluation, Substance Abuse and Mental Health Services Administration, and other agencies have the authority to reverse the misperception about the $75 limit, no action is evident.
If effective, evidence-based treatment for individuals who use psychostimulants is not available; these individuals will continue to be at very high risk for overdose death. HHS agencies must remove the language from their grant portfolios that reflect a $75 limit on incentives and instead align the language with the scientific evidence.
This issue is described in more detail in Rawson et al., 2023.
Richard Rawson, PhD
For the Motivational Incentives Policy Group
H. Westley Clark, MD, JD
Mady Chalk, PhD
Tyler Erath, PhD
Erin McCrady, JD
Carol McDaid, BA
Sarah Wattenberg, PhD
Members of the Motivational Incentives Policy Group, a stakeholder coalition concerned about the growing problem of stimulant (methamphetamine and cocaine) misuse, overdose and addiction, and expanding the implementation of contingency management behavioral therapy.
For more on this, please see Contingency Management for Stimulant Use Disorder: Progress, Challenges, and Recommendations in the Journal of Ambulatory Care Management.