Incentive Strategies for Treating Opioid Use Disorder

Opioid use and abuse is a major public health problem that affected more than 10 million people in the United States in the past year.¹ The Department of Health and Human Services declared opioid misuse a public health emergency in 2017, which spurred a national wide conversation about how to prevent future abuse. There was a series of state level legislation in North Carolina, Rhode Island, Florida, and other states that limited opioid prescription to try to prevent more opioid dependence. However, there are large groups of people who are already addicted and require medical assistance in stopping their opioid misuse, which has been less frequently discussed on a national scale. Typically, opioid use disorder is treated with long term maintenance therapy of a long-acting opioid like methadone or a partial agonist like buprenorphine. A major problem for many in treatment is concurrent drug abuse which reduces the efficacy of opioid use disorder treatment. Opioid users often use other drugs: of 16,000 patients entering opioid use disorder treatment in one study, 97% reported using other, non-opioid drugs in the month before they began treatment.² In a meta-analysis of 50 randomized clinical trials, researchers found incentive strategies were the only successful intervention in reduce concurrent stimulant use, which is important for the success of opioid use disorder treatment.³

Incentive strategies, also known as contingency management, “the prize method”, or “the carrot and stick method,” is based on operant conditioning, which posits that behavior is shaped by consequences. Researchers give or withhold rewards and negative consequences based on the patient’s behavior, teaching participants to associate their actions with different outcomes. For studies looking at concurrent stimulant and opioid disorder use, participants were treated with maintenance therapy for opioid use and given a daily earning if they abstained from stimulants, which associates abstinence with positive monetary gain. Out of 22 studies, on average, participants were given $14.51 per day over a course of 17.2 weeks, and receiving incentives was associated with increased abstinence at the end of treatment assessment. Similar studies that analyzed polysubstance use, illicit opioid use, and cigarette use all demonstrated increased abstinence at the end of the study when using incentive strategies, suggesting contingency management is a viable way to help participants reduce drug misuse.⁴

While contingency management works, there are barriers to its widespread use. A major barrier is the financial burden of the monetary payments to patients. Currently, Medicare and Medicaid Services do not permit Medicaid funds to be used for this method due to concern for potential fraud.⁴ There is a current lack of studies investigating if contingency management does increase risk for fraud, which will be an important consideration for potentially implementing contingency management on a larger scale in the future.

References

​​1. Substance Abuse and Mental Health Services Administration. 2019 NSDUH Annual National Report. Published September 11, 2020. https://www.samhsa.gov/data/report/2019-nsduh-annual-national-report

2. Cicero TJ, Ellis MS, Kasper ZA. Polysubstance Use: A Broader Understanding of Substance Use During the Opioid Crisis. Am J Public Health. 2020 Feb;110(2):244-250. doi: 10.2105/AJPH.2019.305412. Epub 2019 Dec 19. PMID: 31855487; PMCID: PMC6951387.

3. De Crescenzo F, Ciabattini M, D’Alò GL, De Giorgi R, Del Giovane C, Cassar C, Janiri L, Clark N, Ostacher MJ, Cipriani A. Comparative efficacy and acceptability of psychosocial interventions for individuals with cocaine and amphetamine addiction: A systematic review and network meta-analysis. PLoS Med. 2018 Dec 26;15(12):e1002715. doi: 10.1371/journal.pmed.1002715. PMID: 30586362; PMCID: PMC6306153.

4. Bolívar HA, Klemperer EM, Coleman SRM, DeSarno M, Skelly JM, Higgins ST. Contingency Management for Patients Receiving Medication for Opioid Use Disorder: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2021 Oct 1;78(10):1092-1102. doi: 10.1001/jamapsychiatry.2021.1969. PMID: 34347030; PMCID: PMC8340014.