Five States Are Now Paying People to Stay Sober. It's Working.

There is no FDA-approved medication for methamphetamine use disorder. No pill, no injection, no patch. For the roughly 2.5 million Americans who use methamphetamine, the pharmacological toolkit that has transformed opioid treatment over the last two decades simply doesn’t exist. What does exist, with a larger and more consistent evidence base than almost any other behavioral intervention in addiction medicine, is contingency management: giving people tangible financial rewards when they test negative for their target substance.

The logic is behavioral — reinforce the behavior you want. The evidence is unusually strong: multiple meta-analyses, effect sizes that hold across populations and settings, a Washington State Institute for Public Policy analysis finding that CM programs offering more than $500 in total incentives have a 78% chance of generating benefits that exceed their costs. Among all psychosocial interventions for stimulant use disorder, contingency management has the most consistent empirical support.

Until recently, Medicaid — the primary payer for low-income Americans with substance use disorders — couldn’t fund it. The legal tangle around paying Medicaid beneficiaries cash-adjacent incentives, combined with federal anti-inducement provisions, kept CM out of most public-payer coverage. That’s been changing.

CMS has now approved Medicaid contingency management programs in five states: California, Delaware, Hawaii, Montana, and Washington. California’s Recovery Incentives Program — the first to launch as a formal Medicaid benefit — offers eligible members between $596 and $1,092 in financial incentives over the course of enrollment, depending on the duration and frequency of negative test results. Delaware extends CM services to pregnant and postpartum members for up to 64 weeks. Montana runs a 12-week program.

The January 2025 SAMHSA advisory allowing grantees to provide incentives up to $750 per patient per year removed another layer of the federal barrier.

What this means practically: the treatment gap for stimulant use disorder — which currently has no equivalent to buprenorphine for OUD — now has a first-line evidence-based option in five states. For a person with methamphetamine use disorder enrolled in Medicaid in California, there is now a structured path to paid participation in treatment that didn’t exist three years ago.

The question of why it’s still only five states is partly bureaucratic, partly political. Paying people to do things that are already their “responsibility” — staying sober, showing up for care — triggers a cultural resistance that has nothing to do with the evidence. That resistance has kept effective treatment unavailable for millions of people in 45 states where it could be deployed tomorrow, given political will.

The five-state picture is progress. It is not enough.

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Related: Treatment & Recovery coverage · Stimulants