Bridging the Gap: Reaching the 98% Without Access to Evidence-Based Substance Use Disorder Treatment
December 16, 2025
A 2025 study published in the American Journal of Psychiatry revealed something remarkable: veterans with stimulant use disorder who received recovery incentive programs had a 41% lower likelihood of dying compared to those who received standard care. The research, which examined the entire Veterans Health Administration database, didn’t just show improved substance use outcomes. It demonstrated a significant reduction in mortality. While this study focused on stimulant use disorder, recovery incentive programs have demonstrated effectiveness across substance use disorders, including for opioid use disorder where they improve treatment adherence and reduce concurrent substance use.
At a recent discussion hosted by the National Council for Mental Wellbeing, Dr. Lara Coughlin, clinical psychologist and associate professor at the University of Michigan who contributed to that landmark study, put the implementation gap in stark terms. Despite decades of evidence and this life-saving potential, she noted, only about 2% of people with stimulant use disorder currently receive recovery incentive programs as part of their treatment.
This gap between evidence and practice represents one of the most urgent challenges in addiction care today. The discussion brought together leading experts to explore not just why recovery incentive programs work, but how digital tools are finally making it possible to bridge this gap and bring evidence-based care to scale.
The Evidence Base Is Compelling & Strong
Recovery incentive programs, also known as contingency management, involve providing immediate, tangible rewards for behaviors that support recovery, such as attending appointments or testing negative for substance use. The approach is deceptively simple: catch people doing well and reinforce those moments with positive feedback and meaningful incentives.
The science supporting this approach has grown increasingly robust over the past decade. A 2018 meta-analysis of 50 clinical trials involving 7,000 participants found that contingency management and community reinforcement approaches were the most effective interventions for substance use disorder, both short- and long-term, with benefits persisting even after programs ended. A 2020 systematic review of 44 studies confirmed strong evidence for the approach, particularly when combined with cognitive-behavioral therapy. And a 2021 JAMA Psychiatry study demonstrated that contingency management significantly improved outcomes for patients receiving medication-assisted treatment for opioid use disorder, helping them maintain treatment adherence and achieve abstinence from concurrent substance use.
But it’s the mortality findings that demand attention. Dr. Lara Coughlin, clinical psychologist and associate professor at the University of Michigan who contributed to the 2025 study, emphasized the significance: “This is exciting. It not only improves the substance use outcomes, but also confers benefits around death.”
For stimulant use disorder specifically, where medication-assisted treatment options remain limited, recovery incentive programs represent the most effective intervention available. And yet, the vast majority of people who could benefit never receive it.
Real-World Results Are Proving the Research Right
The disconnect between research efficacy and clinical implementation has long plagued healthcare, with myths about contingency management often overshadowing the evidence. But two organizations are demonstrating that recovery incentive programs work just as well in real-world settings as they do in controlled trials.
At Cascadia Health in Portland, Dr. Tracy Nguyen, Senior Medical Director of Addiction and Recovery Services, has been offering recovery incentives for methamphetamine use across four clinics. After more than a year of implementation, the results mirror what research predicted: less frequent substance use, reduced cravings, improved overall health, better sleep, and increased protective behaviors. Participants became more connected to people who support their recovery and attended more services and community meetings.
“It absolutely works in real life. It is working and helping people,” Nguyen said, dispelling the persistent myth that these programs only succeed in controlled research environments.
At Sun River Health across New York’s Hudson Valley, Crystal Marr, Associate Vice President of Substance Use Disorder services, saw similar outcomes when the organization rolled out recovery incentives in primary care settings. The retention data tells a compelling story: in one quarter, treatment retention reached 98% among patients receiving recovery incentives, compared with 73%-80% among those who were not.
“It’s been a wonderful experience that has really improved retention rates, and it works,” Marr said.
Both organizations credit digital platforms as essential to their success, and as the key to finally scaling what research has proven effective.
Digital Delivery Solves the Implementation Barrier
For years, one of the primary obstacles to widespread adoption of recovery incentive programs was the operational challenge of delivering immediate rewards. True contingency management requires specific components: clearly defining a behavior, measuring it frequently, providing tangible incentives immediately after the behavior is observed, and maintaining consistency across all interactions.
Confronting Stigma Head-On
Perhaps the most persistent barrier to broader adoption isn’t operational. It’s ideological. The perception that recovery incentive programs “reward people for doing the wrong thing” continues to limit access to an intervention that saves lives.
All three panelists identified stigma as the root cause of this misconception and the primary obstacle standing between evidence and implementation.
“I think this all goes back to stigma,” Marr said. “It is a treatment modality to strengthen a person’s recovery from substances. The goal is full recovery, but how a person gets there is like looking at how someone gets to recovery in diabetes management or asthma management. It’s not a straight line.”
The concern about misuse -that patients will spend rewards on drugs or alcohol- reveals this underlying stigma most clearly. Both Nguyen and Marr pointed out that after more than a year of implementation, neither organization has encountered this problem. Digital platforms include safeguards, such as restricting purchases at the merchant level so cards cannot be used at liquor stores or for lottery tickets, but the real issue runs deeper.
What is the root of that fear? It’s stigma. We need to learn to trust people more. People who use drugs benefit a lot from us saying we trust you
Dr. Tracy Nguyen, Senior Medical Director of Addiction and Recovery Services, Cascadia Health
The evidence supports this trust. Coughlin cited multiple studies showing that people who receive recovery incentives have equal or greater internal motivation to change compared to those who don’t, and that external rewards strengthen rather than replace internal motivation. Follow-up studies conducted six to nine months after rewards end show that participants maintain outcomes as good or better a year later.
Nguyen observed this pattern firsthand. Recovery incentives help people build initial engagement with medication-assisted treatment programs during a critical period when many might otherwise give up. “Even if the reward is extrinsic at the beginning, I do see that, over time, it becomes intrinsic; people keep showing up,” she said. “It doesn’t feel like people are showing up just to get the reward; the reward is an added benefit.”
Marr described the neurological reality behind this observation. “Contingency management helps support and retrain the pathways in their brains,” she said. Through treatment and connection, the internal desire for full recovery grows, creating the sustaining quality of life people are striving for.
Understanding recovery incentives as a treatment modality rather than a reward system fundamentally changes the conversation. These programs help people fight against cravings and decision-making biases created by substance use disorder. They provide structure during a vulnerable period and reinforce the neural pathways that support recovery behaviors.
Coughlin returned to the evidence-practice gap, noting that although contingency management works better than any other available intervention for stimulant use disorder, only 2% of people with stimulant use disorder receive it. Stigma, not lack of evidence, drives this disconnect.
Without digital tools, this was difficult to execute with fidelity, particularly across multiple sites or in telehealth settings. Staff had to manually track behaviors, calculate reward schedules, and figure out how to deliver something tangible to patients quickly enough for it to function as an effective reinforcement.
Digital platforms have transformed this challenge. Nguyen explained that she couldn’t see a way to maintain fidelity to the recovery incentive model without digital delivery, particularly as Cascadia Health provides both telehealth and in-person services across four sites. Now, staff simply mark appointments as completed in the CHESS Health dashboard, and patients receive immediate notifications that rewards have been sent to their reloadable Visa cards.
“Without digital tools, it was harder to figure out how to deliver that immediate reward,” Nguyen said. The digital dashboard allows staff to deliver rewards immediately, regardless of location, while maintaining the consistency and frequency that makes the intervention effective.
At Sun River Health, Connections, the patient-facing peer-backed recovery support app which includes some elements customized specifically for their organization, allows patients to participate seamlessly while administrators work behind the scenes to onboard staff and deliver rewards. This infrastructure makes it possible to integrate recovery incentives into primary care settings where they can reach people earlier in their journey.
The digital approach solves another critical challenge: scalability. Programs that once required significant manual tracking and coordination can now expand across multiple sites and care settings without losing the elements that make them effective.
Financing Models Are Emerging
The practical challenge of funding recovery incentive programs has become more manageable as policy support expands and organizations demonstrate return on investment.
In 2025, SAMHSA (the Substance Abuse and Mental Health Services Administration) increased the cap on incentives from $75 to $750, a significant policy shift that reflects growing recognition of these programs’ value. Organizations are accessing funding through multiple channels: SAMHSA State Opioid Response and Tribal Opioid Response funds, opioid settlement funds, state and private grants, and foundations. Some states are pursuing 1115 waivers to the Centers for Medicare and Medicaid Services to enable the use of Medicaid funds.
At Cascadia Health, a SAMHSA grant funded the digital platform while a local care organization funded the rewards. The year-long pilot produced compelling enough results that Nguyen expects sustained funding moving forward. “Looking at the results, we think we will get sustained funding, as this impacts our whole community and health system. We are showing the return on investment,” she said.
Sun River Health used opioid settlement funds initially and is now working to incorporate the model into its budget through value-based care system models. “It is a wonderful investment,” Marr said.
Both organizations emphasized that funding both digital platforms and rewards requires a long-term plan, but the outcomes justify the investment. Improved retention, reduced mortality, better overall health, and increased engagement with care all demonstrate value. As more programs demonstrate these results, the business case for recovery incentive programs becomes increasingly clear.
Bridging the Gap for the Remaining 98%
The evidence is unequivocal: recovery incentive programs save lives. Digital tools have solved the implementation challenges that once made these programs difficult to scale. Funding mechanisms are expanding. Organizations that have implemented these programs report outcomes that mirror research findings. What remains is a collective commitment to reaching the 98% currently without access. This means confronting stigma directly, educating stakeholders about the science of addiction and recovery, and recognizing that substance use disorder treatment should look more like the management of other chronic conditions. Meeting people where they are and providing the support they need to sustain recovery.
The gap is solvable. With growing policy support, digital infrastructure that makes implementation feasible, and real-world programs demonstrating success across different care settings, recovery incentive programs are positioned to reach far more of the people who need them. People with opioid use disorder benefit from enhanced medication-assisted treatment and improved retention. For those with stimulant use disorder, where no medications exist, contingency management represents the most effective intervention available.
For the 98% of people with opioid use or stimulant use disorder currently unable to access this evidence-based, life-saving intervention, that expansion cannot come soon enough.
