Early recovery from addiction to opioids and stimulants is physically and mentally demanding, and involves a long road to recovery.

“During the early stages of addiction recovery there is typically not much that is positive for patients,” says behavioral health counselor Carla J. Rash, Ph.D. of UConn School of Medicine. “But Contingency Management is an effective, behavioral tool bringing some early-on positivity to a patient’s addiction recovery treatment plan until the positive benefits of their medication and body’s natural recovery kicks-in.”

While nationally under-used and under-resourced, the behavioral therapy known as Contingency Management (CM) has been shown to be the most effective, first-line addiction recovery tool for stimulants like cocaine and methamphetamine. For substance abuse with opioids, such as heroin and prescription painkillers, CM can be used effectively as an adjunct to first-line medication treatments.

Rash adds, “Essentially, by offering incentives through Contingency Management vouchers and prizes, we are saying to them that if they are doing the hard work of recovery, we want to encourage and positively reward those efforts. I have seen CM have such an enormous impact on so many patients’ lives.”

Reported for the first time, in JAMA Psychiatry on July 2, lead author Rash of UConn and co-researchers at the University of Vermont School of Medicine and Washington State University Medicine examined the published literature on 112 CM protocols reinforcing reductions in stimulant and/or opioid use. As a result of the study review, the researchers were able to pinpoint the most effective and evidence-based incentive dosage levels (i.e., magnitude) to use during CM care, adjusting it for present-day inflation levels.

The collaborative research team recommends the use of a weekly CM incentive standard of sufficient magnitude of $128 per week for vouchers or $55 per week for prizes over 12 weeks or longer to effectively reduce stimulant and/or opioid use.

For example, these estimates would equate to about $1,536 in CM incentive costs for voucher awards and $660 for prize awards over a typical 12-week protocol. Interestingly, the study authors share the context that in comparison this cost of using evidence-based magnitude CM incentive levels would be comparable or be less-costly weekly for example than first-line opioid use disorder treatments such as methadone ($126/week), buprenorphine ($115/week), and injectable naltrexone ($271/week). Plus, CM is typically a time-limited therapy.

“Our new study findings are important because it highlights the right ‘dosage’ or magnitude of Contingency Management,” says Rash.

To put the research team’s new recommended incentive dollar amounts in perspective, the federal oversight agency of The Substance Abuse and Mental Health Services Administration (SAMHSA) only this year increased its longstanding funding coverage of CM incentives from $75 per patient, per year to $750 per patient, per year.

“Our new JAMA Psychiatry study shows that the current federal CM incentive amounts are still too low to support evidence-based protocols. An effective CM dosage is essential for policy makers and health care providers alike to consider when implementing this intervention,” stresses Rash.

Rash adds, “Strong guardrails are necessary for the use of CM. Clinicians and researchers should not make up their own protocols for CM as ineffective protocols may be damaging.”

Career Mission to Bring Effective Contingency Management to More People

“To patients and families, Contingency Management is an effective tool for you or your loved one and can truly help bridge a person to success during the early stages of addiction recovery,” says Rash. “We are working hard to bring greater access to this most effective treatment to more people.”

In 2007 Rash first started as a post-doctoral fellow at the School of Medicine.

“I got into Contingency Management for addiction recovery when I was a grad student. I was interested in learning all about addiction therapies and wanting to work on what really was the most effective option,” says Rash.

At the time it was early-on in the Contingency Management field, but Rash was hooked on learning absolutely everything about it.

“I wanted to learn more about CM, make it more accessible, and even more effective,” she says. Advancing CM quickly became her career goal.

Rash quickly got her first CM-focused grant application funded by the National Institutes of Health and chose to stay at UConn to grow her CM research and career.

Fast forward to today, nearly two decades later, her CM research remains NIH-funded. She serves UConn as an associate professor in the Department of Medicine at the UConn School of Medicine and the Pat and Jim Calhoun Cardiology Center’s Behavioral Cardiovascular Prevention Division at UConn Health.

Rash’s ongoing research tries to better understand the most effective way to motivate treatment initiation and minimize relapse in addictions, especially the use of Contingency Management interventions. Her work is also funded by the Robert Wood Johnson Foundation (RWJF) and SAMHSA.

“We have come a long way in getting CM out to the clinical realm,” says Rash who was honored to work with her mentor, the late Dr. Nancy Petry, on the first and largest national clinical CM program Petry started in 2011 for the Veterans Administration. The extraordinarily successful program is still ongoing. Also, a few states have started their own CM programs with the biggest in California.