Importantly, CM is particularly effective in treating people with stimulant use disorders (SAMHSA, 2021a). In the absence of any U.S. Food and Drug Administration (FDA)-approved medications to treat stimulant use disorders, CM is considered a primary and potentially life-saving intervention for the over 4 million people who meet diagnostic criteria for a stimulant use disorder (a substance use disorder involving cocaine, methamphetamine, or prescription stimulants [SAMHSA, 2024]).

CM is equally effective among those with concurrent stimulant and opioid use disorder, as well as in promoting abstinence from cannabis use (SAMHSA, 2021a). Among those with concurrent stimulant and opioid misuse, CM might focus on the use of stimulants, or be used to promote treatment adherence among those receiving medications for opioid use disorder (MOUD). CM has been shown to reduce use of other drugs and to improve treatment attendance and medication adherence among people receiving MOUD (Bolivar et al., 2021). Compared to other approaches, CM produces significantly better adherence to prevention, diagnosis, and medical interventions for hepatitis, HIV, and tuberculosis. In this way, CM consistently produces positive effects across many types of SUDs and other health conditions (Haug et al., 2006; Herrmann et al., 2017).

Based on informal feedback from SAMHSA grant awardees, the widespread implementation of CM interventions funded in whole or in part by SAMHSA grants has been limited by concerns regarding the federal anti-kickback statute and the belief that certain guidance published by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) imposed a CM incentive value cap of $75 per patient, per year. HHS-OIG has clarified its views on this point in guidance.*

Previous SAMHSA Notice of Funding Opportunities limited per patient, per year CM incentive valuesto $75. SAMHSA has determined that a higher per patient, per year incentive value can be offered by grant programs that include CM activities, provided that those activities meet the conditions set forth in this advisory document, which mirror those found in the HHS Report to Congress on Contingency Management for the Treatment of Substance Use Disorders. Within this framework, providers have
the flexibility to implement evidence-based CM services that provide effective and life-saving treatment, so long as in doing so, providers demonstrate fidelity to existing evidence-based models of CM. This requirement ensures that grantees use federal funds for permissible purposes and that patients are receiving equitable and evidence-based care.

Other considerations and requirements discussed in this document include:

• ●  Evidence-based models of CM, their structure, and potential per patient cost;
• ●  Ramifications for the clinical setting, including the benefits of offering CM in conjunction with other interventions, population-focused service design, education, and information resources; and
• ●  Guardrails that must be observed in implementing CM interventions. * See 85 Fed. Reg. 77,684, 77,791-92 (Dec. 2, 2020), available at https://www.federalregister.gov/documents/2020/ 12/02/2020-26072/medicare-and-state-health-care-programs-fraud-and-abuse-revisions-to-safe-harbors-under-the. Although the highest allowed value permitted by this guidance—$750 per patient, per year—would fall outside the safe harbor specified by the current regulation ($605 per patient, per year for 2025), see https://oig.hhs.gov/compliance/safe-harbor-regulations/annual-inflation- updates/, the preamble of the regulation clarifies that “if a contingency management incentive that implicates the Federal anti- kickback statute, Beneficiary Inducements CMP, or both does not satisfy an existing safe harbor or exception (as applicable), that does not mean that such incentive automatically violates the statutes and is illegal.” (Id. at 77,792).