WASHINGTON, D.C. – Senator Peter Welch (D-Vt.) and Reps. David Trone (D-MD-06), Lisa McClain (R-MI-09), Ann Kuster (D-NH-02), and Brian Fitzpatrick (R-PA-01) today led a bipartisan, bicameral letter to U.S. Department of Health and Human Services Secretary Xavier Becerra and Office of National Drug Control Policy Director Dr. Rahul Gupta requesting information on the Biden Administration’s efforts to expand access to contingency management services, one of the only evidence-based treatments for stimulant use disorder. The letter was also signed by Senator Ed Markey (D-Mass.) and Reps. Adam Schiff (D-CA-30), Becca Balint (VT-AL), Terri Sewell (D-AL-07), and Barbara Lee (D-CA-12).
“As you know, illicit drug use is escalating and growing in complexity. Stimulant use, alone and in combination with fentanyl, is a significant contributing element of this changing crisis,” wrote the lawmakers. “There are no FDA-approved medications for the treatment of stimulant use disorder. However, contingency management is a highly effective and underused behavioral intervention that reduces stimulant use. It is one of the most researched interventions in substance use disorder treatment, with decades of research and peer-reviewed literature validating the effective use of contingency management.”
Recognizing the need to offer treatment to individuals with stimulant use disorder, HHS has permitted the use of grant funds for contingency management, but the amount of funds allowed for the treatment is inconsistent with prevailing evidence. On this restriction of funds for contingency management programs, the lawmakers wrote: “This restriction leads states to implement a non-evidence-based practice that could result in poor outcomes and undermine public faith in the CM, while jeopardizing clinical and scientific integrity.”
A November 7, 2023, HHS Report echoes the call for examining and issuing guidance or other clarifications that explain permissible contingency management activities. The lawmakers called for more urgency in addressing this issue: “Our communities, however, do not have years to wait to access evidence-based contingency management services. As the overdose crisis worsens, we must do more to expand access to contingency management now.”
According to the National Institutes of Health, overdose is the leading cause of death for Americans aged 18-45, and drug overdose deaths increasingly involve stimulants such as cocaine and methamphetamines. Recent research found a 50-fold increase in the methamphetamine mortality rate in 2021. That year, stimulants alone or in combination with fentanyl were detected in 47.1% of overdose deaths.
Senator Welch has convened experts, first responders, and policy leaders in Vermont to address the escalating drug and overdose crisis, including hosting a roundtable with HHS Secretary Becerra during his first week in office. He has worked with his colleagues across the aisle to develop and introduce legislation to combat the evolving crisis. Last week, Senator Welch’s bipartisan Testing, Rapid Analysis, and Narcotic Quality (TRANQ) Research Act passed both chambers of Congress and will soon become law. The bill takes steps to address the deadly rise in illicit use of Xylazine, or Tranq – a harmful animal tranquilizer – and other novel synthetic drugs that have become increasingly common in the illicit drug supply in Vermont and across the country.
The full text of the letter can be found here and below:
Dear Secretary Becerra and Director Gupta,
As you know, illicit drug use is escalating and growing in complexity. Stimulant use, alone and in combination with fentanyl, is a significant contributing element of this changing crisis. We write to request information regarding the efforts taking place at the Department of Health and Human Services (HHS) and the Office of National Drug Control Policy (ONDCP) to expand access to contingency management (CM) services—the only evidence-based treatment available to treat stimulant use disorder.
According to the NIH, overdose is the leading cause of death for Americans aged 18-45, and drug overdose deaths increasingly involve stimulants such as cocaine and methamphetamines. Recent research found a 50-fold increase in the methamphetamine mortality rate in 2021. That year, stimulants alone or in combination with fentanyl were detected in 47.1% of overdose deaths.
There are no FDA-approved medications for the treatment of stimulant use disorder. However, CM is a highly effective and underused behavioral intervention that reduces stimulant use. It is one of the most researched interventions in SUD treatment, with decades of research and peer-reviewed literature validating the effective use of CM. The intervention uses positive reinforcement, including financial incentives, to encourage abstinence from stimulant use.
Recognizing the need to offer treatment to individuals with stimulant use disorder, HHS has permitted the use of grant funds to provide financial incentives. Despite a rule from the Office of the Inspector General that permits CM financial incentives, with appropriate safeguards and no specified dollar limit, the amount of HHS grant funds for incentives has been restricted to a total of $75.00 for an individual participating in CM. There is no research to support incentives at this low level of funding—meaning that HHS dollars may not be supporting effective CM protocols.
Further, this restriction leads states to implement a non-evidence-based practice that could result in poor outcomes and undermine public faith in the CM, while jeopardizing clinical and scientific integrity.
We were pleased to see a provision included in the 2023 Consolidated Appropriations Act requiring HHS OIG to review adding a safe harbor to federal anti-kickback statutes for evidence-based CM by December 2024 and recommendations to Congress by 2025 for improving access to CM.7 A November 7, 2023, HHS Report, Contingency Management for the Treatment of Substance Use Disorders: Enhancing Access, Quality, and Program Integrity for an Evidence-Based Intervention, echoes the call for examining and issuing guidance or other clarifications that explain permissible CM activities under potentially applicable federal fraud and abuse laws to ensure maximum access to CM.
Our communities, however, do not have years to wait to access evidence-based CM services. As the overdose crisis worsens, we must do more to expand access to CM now. Therefore, we request a briefing on this topic and answers to the following questions no later than January 12, 2024:
- What existing authorities are available to the Administration to increase the $75 incentive limit within the Substance Abuse and Mental Health Services Administration State Opioid Response grant without congressional action?
- Which federal substance use disorder and overdose prevention programs can currently be used to support CM interventions?
- What specific actions have HHS and ONDCP taken to-date to encourage the uptake of evidence-based CM services, and what additional actions—if any—does the Administration plan to take and in what timeframe?
Sincerely,
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