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The Department of Health and Human Services recently sought advice from patients, clinicians and public health experts on addiction treatments supported by “rigorous, empirical evidence of effectiveness.” Health and Human Services endorses medications to address opioid addiction, but there are actually no medications to address addiction to stimulants such as cocaine and methamphetamine.
Three decades of pharmaceutical testing have come up empty, and with half of all fatal overdoses in the U.S. now involving stimulants, and with standard counseling frequently falling short, we have a pressing need for new and effective interventions.
The answer may come from a proven nonmedical remedy. A Stanford team’s examination of 157 clinical trials of treatments for cocaine, including both psychotherapy and medications, found little clinical benefit with one notable exception: contingency management, a program that leverages motivational incentives, or “carrots,” to help shift an addict’s behavior. According to the Stanford analysis, these methods more than doubled the odds of someone testing negative for cocaine.
Methamphetamine — despite its reputation as being more addictive than cocaine and certainly more damaging to the brain — was shown to be similarly responsive to contingency management.
In a typical scenario, a participant who provides a negative drug test receives a reward — a “reinforcer” — such as vouchers, small amounts of cash or the opportunity to draw from a prize bowl. Reward schedules are sometimes arranged so that each subsequent reinforcer is slightly larger than the last. If a drug test is returned positive, the value of the reward for that person is reset to a lower value.
Data suggest that the effects of contingency management programs are fortified when administered together with cognitive behavioral therapy or counseling. A review of 50 clinical studies of patients addicted to stimulants found that a reward system combined with a community reinforcement approach — where therapists encourage patients to extract gratification from their families and jobs as substitutes for the gratifications of drug use — reduced cocaine-positive drug tests by more than a third when compared with rewards alone.
Although contingency management has been studied in the context of stimulant addiction for more than 30 years, it wasn’t applied at scale until 2011, when the Department of Veterans Affairs developed a program that’s now administered in more than 110 VA medical centers.
Patients in these programs could receive vouchers for $1, $20 or $100 that are redeemable in VA-run shops and canteen services. On average, participants received around $200 in coupons over 12 weeks. From July 2018 through December 2020, stimulant-addicted patients in the Veterans Health Administration who received rewards were 41% less likely to die within a year versus a well-matched comparison group that was not part of a contingency management program.
Starting in 2021, states could apply for waivers that allow Medicaid funds to underwrite contingency management vouchers as part of their pilot programs. California was the first to jump in, launching a 24-week outpatient program in 2023. An interim evaluation found that the testing program reached about a quarter of all California Medi-Cal members who were in outpatient treatment for stimulant use. These programs proved to be successful, as 75% to 95% of their drug tests came up negative for stimulants over 24 weeks.
As of early 2025, Delaware, Hawaii, Montana and Washington have also been approved for Medicaid waivers to experiment with rewards as intervention. Meanwhile, according to the National Academy of State Health Policy, Michigan, Vermont, Virginia and Arizona’s Maricopa County have started contingency management programs with opioid settlement funds.
An analysis by the Washington State Institute for Public Policy found that programs offering total rewards of more than $500 had a 78% chance of generating benefits that exceeded costs.
These optimistic results have led the American Society of Addiction Medicine and the American Academy of Addiction Psychiatry to name contingency management as the frontline treatment for stimulant-use disorder. In January 2025, the Biden administration raised the cumulative cap on federal grants from the Substance Abuse and Mental Health Services Administration for rewards to $750 from $75 per patient per year, provided that these awards are issued as gift cards or services rather than as cash.
Some believe we shouldn’t be using tax dollars to “pay” those who use drugs to do what most of us do every day. Others worry that incentives may quash someone’s internal motivation to quit, or that patients will relapse once an incentive-based treatment ends. Ideally, patients will eventually internalize the desire to stay off drugs because the rewards of recovery are more motivating than material incentives.
As one woman with a methamphetamine problem who participated in a rewards program in Portland, Maine, told the New York Times: “I feel like being sober is payment enough, not waking up sick is payment enough, being trusted is payment enough.”
However, the systematic data on the sustained effects of contingency management are mixed. Some evidence suggests that rewards lead to better long-term outcomes than other treatments, even after the incentives end. One study found that the effects of may ebb over time, but are more durable than changes seen from traditional treatments.
A 2023 report from the Office of the Assistant Secretary for Planning and Evaluation, part of Health and Human Services, concluded that the reward approach “is among the most effective treatments for promoting lengthier periods of abstinence during treatment, which is associated with a greater likelihood for long-term abstinence following treatment.”
Steps can be taken to prevent fraud and abuse by patients. Some programs in California have engaged tech companies to block debit card purchases related to gambling, tobacco, alcohol or firearms and some programs use mouth swabs to prevent substitution of a friend’s urine sample for one’s own.
We recognize that both clinicians and the general public have misgivings about “bribing” addicts to stop using drugs. To date, contingency management is the only treatment that yields consistently positive outcomes in combating the heavy abuse of stimulants and its devastating toll on mental and physical well-being.
The strategy may challenge traditional views on who deserves public funds, but we urge the public and politicians to bite the utilitarian bullet. They should support generous funding for incentives to help addicted individuals regain control of their lives and become productive workers, citizens and family members.
Sally Satel is a senior fellow at the American Enterprise Institute and medical director of a methadone clinic in Washington. David Farabee is professor emeritus at the UCLA Department of Psychiatry & Biobehavioral Sciences.
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Ideas expressed in the piece
The article contends that contingency management, which uses tangible rewards to reinforce drug-free tests and other recovery behaviors, is the only intervention that has consistently demonstrated strong, replicated effectiveness for stimulant use disorders where no FDA-approved medications exist[2][5][7]. It emphasizes that meta-analyses and clinical guidelines now identify contingency management as the frontline treatment for cocaine and methamphetamine addiction, outperforming other psychosocial approaches on measures of abstinence and treatment retention[2][6][7].
In support of this position, the article highlights large trials in which contingency management nearly doubled the odds of stimulant-negative urine tests and produced longer stretches of continuous abstinence compared with standard care, a pattern echoed in national clinical network studies and meta-analyses reporting the largest effect sizes among relapse-prevention interventions[1][6][7]. The piece suggests that pairing incentives with counseling or cognitive behavioral therapy, and with community reinforcement strategies that help patients find satisfaction in family and work, further strengthens outcomes by improving engagement and supporting broader life changes[3][4][7].
The article points to real-world implementation in the Veterans Health Administration, where thousands of patients with stimulant use disorder who received contingency management were roughly 40% less likely to die within a year than similar patients who did not receive incentives, illustrating that benefits extend beyond short-term abstinence to reduced mortality and improved overall health[2][9][11]. It notes that these findings have persuaded major professional bodies, including the American Society of Addiction Medicine and the American Academy of Addiction Psychiatry, to endorse contingency management as a primary, potentially life-saving intervention for stimulant use disorder[2][5].
The article further argues that incentive-based programs can be cost-effective, citing analyses indicating that higher-value reward structures (above about $500 per episode of care) have a strong likelihood of generating benefits that exceed costs by reducing drug use, criminal justice involvement and healthcare utilization[2][10][12]. It underscores that Medicaid waivers, state pilots and opioid settlement-funded initiatives are beginning to scale contingency management, with evaluations showing high rates of stimulant-negative tests and favorable cost–benefit ratios in outpatient programs[2][7][10].
While acknowledging that some studies find contingency management’s effects taper over time, the article stresses that systematic reviews and meta-analyses still show better long-term outcomes than many comparison treatments, with participants receiving incentives maintaining significantly higher odds of abstinence months after rewards end[6][8][14]. It notes that advisory reports from federal health agencies conclude that contingency management is among the most effective tools for producing longer periods of abstinence during treatment, which in turn are associated with a greater chance of sustained recovery[5][8].
The article addresses worries about fraud and misuse by emphasizing that programs can incorporate safeguards, such as biometric or supervised testing, mouth swabs to prevent sample substitution, and spending controls on debit cards to block purchases related to gambling, alcohol, tobacco or firearms[2][7][11]. It suggests that these operational details, combined with careful monitoring, can reduce abuse while preserving the core behavioral principle that timely, meaningful rewards encourage healthier choices[6][11].
Ultimately, the article urges policymakers and the public to accept a utilitarian framing: even if “paying” people with addiction to refrain from drug use feels counterintuitive, the weight of evidence shows that well-designed contingency management helps individuals regain control, lowers overdose risk, and improves their ability to function as workers, family members and community participants[2][6][9]. The piece argues that, given the scale of stimulant-related harms and the lack of effective medications, investing public funds in robust incentive programs is a pragmatic and ethically defensible response grounded in empirical results rather than moral judgment[5][7][12].
Different views on the topic
Critics highlight that contingency management remains controversial and underused in everyday practice despite decades of research, reflecting persistent discomfort among clinicians and the public with the idea of “paying” people who use drugs to do what others are expected to do without incentives[1][6][11]. Commentaries note that many mental health professionals are unfamiliar with these interventions or hesitant to implement them, viewing financial or material rewards as inconsistent with traditional therapeutic norms and potentially stigmatizing for patients[1][6].
Opposing viewpoints stress ethical and equity concerns about directing limited tax dollars toward monetary rewards for individuals with substance use disorders, particularly when other health and social services are underfunded[6][10][13]. Some policy analyses describe resistance from stakeholders who believe funds would be better spent on expanding counseling, housing support, employment programs, and medication treatment for opioid use disorder rather than on gift cards or vouchers tied to negative drug tests[6][10][13].
Skeptics also point to mixed evidence on long-term outcomes, arguing that contingency management may produce strong gains during treatment but more modest or nonsignificant advantages once incentives stop, especially at follow-ups approaching a year[4][10]. Reviews that find no persistent effect at the longest follow-up are cited to support the concern that behavior change might be contingent on continued rewards, raising questions about whether intrinsic motivation and stable recovery are truly being cultivated[4][10].
Some clinical research suggests that, while contingency management clearly improves abstinence and retention during the incentive period, cognitive behavioral therapy can yield comparable longer-term results, which leads critics to question whether resource-intensive reward systems are necessary or superior once treatment ends[3][4]. These observers argue that heavy reliance on external incentives risks overshadowing skill-building therapies that aim to help patients manage cravings, restructure thinking patterns and address underlying psychological issues[3][10].
Additional concerns focus on implementation challenges, including the potential for gaming the system, falsifying tests, or diverting rewards to harmful activities, especially when incentives are delivered as cash or broadly usable cards[6][10]. Some state and health-system reviews highlight the need for complex administrative safeguards, clear limits on incentive values and strict monitoring, and opponents worry that these requirements make contingency management difficult to scale fairly and consistently across diverse treatment settings[6][10].
Guideline committees and evidence reviews sometimes offer only cautious or “weak” recommendations for contingency management in amphetamine and methamphetamine use disorders, reflecting lingering uncertainty about optimal incentive size, duration and contingency conditions for these drugs[4][10]. Those who emphasize this cautious language argue that policymakers should avoid overreliance on a single behavioral intervention and instead support a balanced portfolio of approaches, including psychosocial therapies, peer recovery supports and ongoing research into pharmacological options[4][5][10].
Finally, some commentators and advocates within recovery communities worry that a focus on material rewards may conflict with core recovery values that emphasize mutual aid, personal responsibility and community-based support rather than financial incentives[6][11]. In this view, the central goal should be building social connection, purpose and self-directed change, and contingency management is seen as a tool that should be used sparingly, if at all, rather than as the default frontline strategy for stimulant addiction[6][11].
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