WSU researchers train clinics including two in Spokane to help people quit stimulant drugs

People wanting to quit stimulant drugs have few clinical options, except for an incentive-based approach shown effective through decades of Washington State University research.

Called contingency management, it’s a behavioral intervention that uses gift cards and small prizes to help motivate people to quit using stimulants such as methamphetamine and cocaine. Typically, clinic visits are twice weekly for at least 12 weeks, and participants must have weekly drug-free urine samples to gain rewards.

This intervention moved outside research walls and into clinics statewide just within the past three years, as WSU researchers provided contingency management training. The intervention is now at nine sites, starting in 2020 with the Spokane Teaching Health Clinic. An additional eight sites – including MultiCare Rockwood Clinic – were launched under a pilot program sponsored by the state Health Care Authority.

As of July, Washington became the second state in the U.S., after California, to allow contingency management under a waiver to be a Medicaid-funded benefit. With that waiver, the additional funding is expected to expand the contingency management pilot to about 90 sites in the next five years.

“The recent developments really are how to get a science-based intervention into real-world clinical settings, and that is some of the work our group has been doing – training and technical assistance,” said Michelle Peavy, research director of training at WSU’s PRISM, for Promoting Research Initiatives in Substance Use and Mental Health.

Contingency management often is offered at sites that also provide opioid-use disorder treatment medications and intervention. It isn’t unusual that people in treatment have taken both opioids and stimulant-type drugs, Peavy said.

However, researchers contend that treatment for stimulants requires a different approach.

Peavy said when stimulant drug use becomes a problem, people’s focuses often narrow to just the drugs’ reinforcing effects and away from other positive aspects of life, such as relationships and meaningful work.

“If a person has a stimulant use disorder, there aren’t many medication options that will help people cut down or quit using,” Peavy said. “Contingency management is a nonmedication, behaviorally based intervention.

“Stimulant use is very reinforcing – it produces effects on human brains that people really like and are looking for. People’s lives can revolve around stimulant substance use.”

Plus, behavior change for anyone is difficult and sometimes painful, Peavy added. “But contingency management provides these incentives, rewards for not using, which kind of rewires the brain toward a different kind of reward system.”

There have been some significant barriers to implementing this intervention, despite strong research behind it, said WSU assistant professor Sara Parent, who has done contingency management training at clinics. She works in Spokane in the Elson S. Floyd College of Medicine’s community and behavior health department.

“Contingency management has been around for decades, researched for decades, so it’s a very well-established, evidence-based practice, but it’s taken a really long time to get it out of the world of research to make it a widely disseminated and readily available treatment in clinical and office settings,” Parent said.

“Right now, there just is a real need for treatment for stimulant use disorder. Contingency management has been studied for a number of different substance use disorders. It’s effective to help people stop using alcohol and for smoking cessation.”

The approach uses positive reinforcement and “retraining brains,” she said.

Contingency management uses a voucher system to exchange for a retailer gift card or prize. If a participant’s urine test is positive for drug use, the person is encouraged to return and try again. If they have a clean test, the vouchers start off at $10 and incrementally increase, an approach that research showed to be more effective, Parent said.

A maximum amount at the end of the program is $528 per person, she said.

Parent added that WSU researchers knew they could help people quit stimulant drug use, but they did so under funding by research dollars. Until the HCA’s pilot work and now the Medicaid waiver option, the intervention at clinics and medical offices didn’t have such funding.

She said another roadblock was how to apply the intervention within federal regulations and anti-kickback statutes that restrict incentives of monetary value in health care. Slowly, contingency management found its way into Veteran’s Administration services and other models.

The Medicaid waiver does two things, she said. It creates a set of rules and regulations that a Medicaid program can follow to solve some regulatory questions. And it allows contingency management to be a billable service.

Peavy said she takes issue with a common misconception that the intervention simply pays people not to use drugs. Clinic workers are trained to work with people on positive behavior changes, and participants are motivated to get help.

“It’s very dismissive of people who benefit from the intervention, because it discounts the hard work it takes to change behavior,” Peavy said. “All of us, even if you don’t use substances, can appreciate that changing our habits or changing our behavior is difficult. We all benefit from positive reinforcement or wins along the way to reach our goals or change behavior.

“People don’t change the behavior of drug use for a gift card. They change because they want better lives and they want improved relationships. I really take issue with this idea that it’s bribery.”