Richard A. Rawson, Ph.D., is Professor Emeritus at the UCLA Department of Psychiatry and a Research Professor at the Vermont Center for Behavior and Health at the University of Vermont. He received a Ph.D. in experimental psychology from the University of Vermont in 1974. Dr. Rawson conducted numerous clinical trials on pharmacological and psychosocial/behavioral addiction treatments for the treatment of individuals with cocaine and methamphetamine disorders. He has represented the US at numerous international meetings on methamphetamine. He has led addiction research and training projects for the United Nations, the World Health Organization and the U.S. State Department, exporting science-based knowledge to many parts of the world. He currently is providing consultation on treatment of stimulant use disorder to 8 US states and several international projects. Dr. Rawson has published 3 books, 40 book chapters, and over 250 peer-reviewed articles and has conducted at least a zillion workshops, paper presentations, and training sessions.
Having created the Matrix Model and having conducted research on stimulant use disorder for years, why do you think contingency management should now be the mainstream treatment for individuals with stimulant use disorder?
It’s simple. I’m interested to see CM become used in real-world treatment programs because CM works. It is a powerful treatment intervention that can help people reduce their use of cocaine and meth, and for many, it can be a major step in the development of a long-term addiction recovery.
In the 1980s, when people addicted to cocaine and methamphetamine began to seek treatment, we really had no idea how to think about treatment. There was no standard of care. In fact, we didn’t understand that people could actually get addicted to cocaine and meth. There were no textbooks to describe treatment; we learned about stimulant addiction from the patients we treated. In fact, when people started treatment at Matrix, we asked them to sign a consent form which clearly stated that there was no established treatment for individuals addicted to stimulants and that we would be learning from them as we did our best to provide help.
The Matrix Model was the attempt that my colleagues and I made to organize the knowledge available at that time into a framework of treatment that we could systematically deliver to patients. We manualized Matrix in a set of materials with funds from NIDA. Using that manual, we treated thousands of people for stimulant use disorder (StimUD) in the Southern California clinics of the Matrix Institute. SAMHSA adopted the Matrix Model, and we evaluated it in a large study with almost 1,000 participants. The study results were positive, and we felt we had made a useful contribution.
However, I became aware of Steve Higgins’ work with contingency management (CM) in the mid-1990s and visited him at the University of Vermont to learn more about the approach. I felt that the very positive results he was reporting in his published research must be attributable to some unique qualities of the situation in Vermont. Maybe people were not using much cocaine, maybe the cocaine was not very potent, maybe the individuals in his studies were somehow less disadvantaged…I was skeptical of the CM research because the results were so good
I applied for and got a grant from NIDA to compare CM to cognitive behavioral therapy (CBT), the primary therapeutic component in the Matrix Model. The study was a randomized clinical trial, the gold standard in research. One group of addicted individuals were randomly assigned to receive CM, a second group received CBT, and a third group received CM+CBT. All treatments were administered three times per week for 16 weeks. I was quite sure that CBT would be as effective as CM and convinced that the combination of CM and CBT would get the best results.
The results were remarkable and very clear. Participants randomly assigned to the CBT group provided 15 stimulant-negative urine test results over the 16 weeks of treatment, while participants assigned to the CM group provided, on average, 28 stimulant-negative results. That was almost twice as many negative tests. An even bigger surprise was that those in the CM+CBT condition also provided 28 stimulant-negative results. There was no added benefit to adding CBT to CM. CM produced an outcome that was far superior to CBT.
My own experience conducting this study convinced me that CM should become a mainstream treatment for people who want to reduce/stop their cocaine/meth use.
What are the key elements of CM?
Quick definition: Contingency management employs the systematic delivery of positive reinforcement for desired behaviors incompatible with drug use. Incentives can be “earned” for submission of cocaine/methamphetamine-free urine samples or for completion of other goal behaviors.
Key elements of CM:
- Clearly define a single, measurable goal behavior
- Frequently measure the goal behavior (2-3 times per week)
- Provide tangible, desired reinforcers immediately after behavior is observed
- Ensure the reinforcer amount is adequate and supported by published research
- Withhold incentive when behavior is not observed while maintaining a supportive attitude
- Comply with fraud prevention guardrails per SAMHSA guidelines
These are the set of “key elements” that we can easily define. However, another very important element is the “humanity” and compassion and the non-judgmental support of the staff who deliver CM. Individuals in CM treatment develop very positive and powerful relationships with the staff members who deliver the CM program. Well trained staff who can use motivational interviewing skills and encourage patients are a big part of the positive effect of CM.
Now that you’ve guided several of Maine’s CM pilot sites over the past 2 years, what stands out about their efforts?
I’ve really enjoyed working with the Maine CM pilot project. This project is being done for all the right reasons. This isn’t a project set up by a government committee or imposed by outside experts. The motivation and rationale for the Maine project are that a group of individuals from MaineHealth and Spurwink recognized the need to effectively address stimulant use and addiction in Portland and several other Maine communities. With the support of the Co-Occurring Collaborative Serving Maine, led by Kate Chichester, with great leadership from Eric Haram, the decision to implement CM was a true collaboration.
The Maine CM project (through ME SUD LC) has been an exercise in collaboration and a deep commitment to helping patients with many serious challenges, including stimulant use disorder. There is shared information and strategies for problem-solving. In my participation as an advisor to the project, I have been asked some really good questions about the details of contingency management. There is a real desire to tailor the CM protocols to meet the needs of the patients, while following the science on the use of CM. The anecdotes that project clinicians have reported from patients on CM are inspiring. The New York Times article on the CM program in Maine, especially Jamie’s story, that captured the real-life benefits that patients achieve through participating in well-structured CM programs.
What are the challenges with scaling up Contingency Management for stimulant use disorder?
In a word…….Funding,
For a long time, there was a resistance to the idea of CM. CM isn’t like any other addiction treatment. It’s not a medicine, and it’s not talk therapy, and it’s not residential care. Many people simply don’t understand the underlying rationale of CM. I had one MD say: “I didn’t go to medical school to hand out gift cards to Walmart”.
As cocaine and meth use have become increasingly connected to overdose deaths and the severe medical and psychiatric consequences of stimulant use, there is less resistance to the idea of CM. People have become more focused on “what works” specifically for stimulant use disorder. And CM really provides very meaningful help to people who are trying to reduce stimulant use and ultimately cease using stimulants.
Now that people are recognizing the usefulness of CM, they immediately run into a big obstacle……How to pay for CM? Money is needed for the incentives, for point-of-care urine testing supplies, and for staff time. How can we get CM funded?
Currently, the most widely used methods of financing CM are:
- Medicaid 1115 Waiver (e.g., California and several other states).
- SAMHSA funds (specifically limited to SOR and TOR funds as approved by SAMHSA).
- Opioid settlement funds (e.g., Vermont, Michigan, and other states) are likely the most available and accessible source of current funding.
- Philanthropic foundations.
From a practical perspective, #3, opioid settlement funds (OSF) are the most readily available funds. Every state allocates these funds differently. It takes some groundwork to understand how each state allocates its OSF, but we have found that many states (now at least eight) have viewed CM for StimUD as a good use of OSF. Notably, a relatively small amount of these funds can have a major public health impact when used to support CM programs for StUD.
What guardrails or cautions do you have for Maine providers?
SAMHSA has a set of “guardrails” to ensure that CM funds are properly used and accounted for and that providers use evidence-based protocols. Advertising CM is an especially sensitive area as Medicaid authorities do not allow advertising CM. Programs can advertise that they are using “new effective evidence-based treatment for StimUD” but they cannot say “come to our program and get gift cards.” The best advertising is word of mouth from enthusiastic patients to their stimulant-using associates.
Another caution is to use CM protocols that follow the research on CM. Use adequate amounts of incentives (CM with a limit of $75 maximum is not evidence-based CM). Not every use of incentives as part of a treatment program is actually formal, research-based CM.
Are there other states or communities that we could look toward that might be comparable to Maine?
The California Recovery Incentives program is the largest and most established use of CM outside the VA. Vermont is doing some interesting things with CM, including use of CM as part of drug court programs and a new project using CM for people with StimUD being released from prison. Washington State is using CM in a variety of clinical settings. Montana is using CM in communities with large rural areas.
These interesting “twists” on the use of CM have real potential for expanding the impact of CM. But the Maine project really gives others in Maine an excellent real-world demonstration of how people who use cocaine and methamphetamine can be engaged and retained in treatment and assisted to reduce/discontinue their stimulant use. What the Maine project is already doing is the most important first step. And the folks who have led this effort deserve a great deal of credit.
What keeps you engaged in this work even in ‘retirement’?
“Retirement is for quitters.” Just kidding. I am really happy to be back in New England after 40 years in Los Angeles. I was born and raised on a dairy farm in Vermont and as I grew up in the 50s and 60s, it seemed to me that farmers don’t retire, they just move slower. And they are my model.
I’m doing less than I did during my days at UCLA. I now participate in animal rescue, and I have daily chores and hay to move around and barns to clean, so I have plenty to do other than continuing my work in addiction. But CM for stimulant use disorder is a “right time, right place” deal. There has been 30+years of research showing that CM works. For the first time, public health leaders are interested in using this approach. Now is the wrong time for me to walk away, so I’ll stay involved.