Between 2003 and 2022, drug overdose deaths in the United States drastically increased by 366%. The major culprit for the increase in narcotic-related mortality were opioids, a class of drugs including heroin, fentanyl, and oxycodone. In recent years, because of more effective treatment options and the availability of opioid overdose-reversal drugs such as Narcan, opioid overdose deaths have started to decline, including a 24% decrease between 2023 and 2024. This decline represents 27,000 fewer overdose deaths.
In recent years, however, stimulant overdose deaths have started to increase even as opioid overdoses flatlined and started to decline. Stimulants chiefly include cocaine and methamphetamine. Cocaine overdose deaths per 100,000 people increased by 661% between 2010 and 2023, while overdose deaths of psychostimulants (which include methamphetamine),increased by 1,325% per 100,000 people between 2008 and 2023. Treatment for individuals with stimulant use disorder is much more limited than for individuals with opioid use disorder. For example, there is no FDA-approved overdose reversal treatment for stimulants, in contrast to Narcan for opioid overdoses. At this time, there are zero FDA-approved pharmaceutical drugs on the market to treat stimulant use disorder.
Currently, one of the most effective treatments for individuals with stimulant use disorder is contingency management. Contingency management is a treatment that uses incentives (frequently financial) to assist people with stimulant use disorder by paying them for remaining abstinent and for adhering to medication or treatment regimens.
While contingency management trials were historically underfunded, these programs are still effective. For example, contingency management programs operated by the Department of Veterans Affairs showed strongly positive results in helping veterans with stimulant use disorder cease substance use and to stay connected to other treatment resources.
While contingency management programs have a robust history of coverage for veterans, they do not for Medicaid members. Medicaid, the joint federal and state public insurance program that predominantly covers low-income and disabled Americans, provides coverage to roughly one-quarter of Americans. However in 2020, Medicaid members constituted 48% of overdose deaths. In 2019,1.7% of Medicaid members had a diagnosis of substance use disorder, representing millions of Americans.
Section 1115 of the Social Security Act allows states to innovate within their state’s Medicaid program, subject to agreement with the federal government and meeting certain budgetary and programmatic requirements. In 2021, the federal Centers for Medicare and Medicaid Services (CMS)approved the first state 1115 Waiver Demonstration with a contingency management program. Currently, CMS has approved five Medicaid contingency management programs in California, Delaware, Hawaii, Montana, and Washington. Two other states, Michigan and Rhode Island, have submitted applications to CMS for authority to implement these programs in their states but are awaiting CMS action.
Programmatically, the five Medicaid contingency management demonstrations differ in scope. For eligible Medicaid members, members can receive contingency management financial incentives for as short as 12 weeks (Montana) to 24 weeks. Delaware extends contingency management services to pregnant and postpartum members with certain types of substance use disorder for as long as 64 weeks. The financial incentives differ from state to state, with members avoiding substance use eligible between $596 and $1,092 in financial incentives over the course of a member’s enrollment in a contingency management program.
While many Medicaid contingency management programs are in their infancy, initial results are available from California’s first-in-the-nation program. The Interim Evaluation Report from California’s 1115 Waiver Demonstration describes an enrollment of 8,500 members across 100 sites. Among members enrolled, there was a higher retention in other drug treatment programs, improved access to care, reduced emergency department visits, and a reduction in overdose deaths. Results were mixed regarding health equity goals and in reducing hospital readmissions among enrolled members.
While more data is needed, early indicators are that Medicaid coverage for contingency management programs will help to reduce overdose deaths and provide more effective treatment for Medicaid members with stimulant use disorder.