Abstract
Introduction:
Stimulant-associated harms are increasing in the U.S. Contingency management (CM) is the most effective available stimulant use disorder (StUD) treatment; guidelines recommend CM in conjunction with other psychosocial treatments. Unfortunately, there are barriers to CM provision, and it is unclear to what extent recommended StUD treatment is available in substance use treatment facilities. We examined provision of recommended StUD treatment reported by U.S. treatment facilities and associated facility characteristics.
Methods:
We used 2024 National Substance Use and Mental Health Services Survey (N-SUMHSS) data. Outcomes included facility report of frequent use of CM/motivational incentives (CM/MI) for non-opioid substances, and CM/MI plus other recommended treatments (cognitive behavioral therapy [CBT], community reinforcement approach [CRA], or Matrix Model [MM]). We estimated associations between facility characteristics and outcomes using multivariable logistic regression models.
Results:
Less than half of facilities reported frequent use of recommended StUD treatment (42% CM/MI, 41% CM/MI+CBT, 8% CM/MI+CRA, 25% CM/MI+MM). In general, reported provision of CM/MI alone or in combination with other treatment was positively associated with state licensure/certification, accepting state-financed insurance, offering opioid agonist treatment, and higher state percent rural population (except CM/MI+CRA), and negatively associated with primarily providing substance use services (vs. mental health and substance use services), private non-profit ownership (vs. private for-profit), accepting Medicare or Medicaid, cash/self-pay only, and higher state-level stimulant-involved overdose mortality rate.
Conclusion:
Increasing the availability of recommended StUD treatments, especially CM, is crucial in U.S. substance use facilities. These exploratory findings can inform future research to help policymakers and administrators improve access.
Keywords: stimulant, stimulant use disorder, treatment, contingency management, policy, National Substance Use and Mental Health Services Survey
INTRODUCTION
The majority of U.S. overdose deaths in recent years involved stimulants (59% of overdose deaths January 2021-June 2024) (Tanz et al., 2025). In 2024, over 4.2 million U.S. residents had stimulant use disorder (StUD) (Substance Abuse and Mental Health Services Administration, 2025a). Ensuring the availability of effective StUD treatment is essential to countering the increasing harms of stimulant use.
Contingency management (CM) is an evidence-based behavioral therapy in which abstinence from substances (or other health-promoting behaviors) is reinforced with incentives (financial or otherwise) (U.S Department of Health and Human Services, 2023). CM is the most effective treatment currently available for StUD and is considered first-line treatment (Kampman, 2026; U.S Department of Health and Human Services, 2023). Clinical guidelines for StUD recommend CM as the primary component of the treatment plan in conjunction with other psychosocial treatments (American Society of Addiction Medicine/American Academy of Addiction Psychiatry, 2024). Unfortunately, CM provision is limited by multiple barriers, including U.S. policy-related barriers (e.g., lack of clarity around the federal Anti-Kickback Statute which seeks to prevent profit motives from improperly influencing provider behavior), lack of public and private payers that reimburse for CM, implementation barriers (e.g., lack of training in CM/behavioral interventions, required staffing), and stigma (U.S Department of Health and Human Services, 2023).
It is unclear to what extent recommended StUD treatment is available in substance use treatment facilities, as well as what factors might support or hinder availability. This exploratory analysis examined self-reported provision of recommended treatment for StUD in U.S. treatment facilities and associated facility characteristics.
METHODS
Data source and study sample
This study used publicly available data from the 2024 National Substance Use and Mental Health Services Survey (N-SUMHSS). The N-SUMHSS is administered yearly to U.S. substance use and mental health treatment facilities and gathers facility-level reporting of available services and other facility characteristics (Substance Abuse and Mental Health Services Administration, 2025b).
Facilities were included in the study sample if they reported providing outpatient substance use treatment services and answered the survey item asking about frequently used substance use treatment services (question A10) (Substance Abuse and Mental Health Services Administration, 2021). Facilities were excluded if they provided services exclusively to incarcerated people or were operated by the Veterans Health Administration, Department of Defense, or Indian Health Service, as these facilities serve specific populations and are subject to unique system-wide regulations and/or implementation efforts. Details of sample inclusion/exclusion are included in Appendix A. This study was determined to be non-human subjects research by the University of Washington Human Subjects Division.
Measures
The N-SUMHSS asked “Which of the following clinical/therapeutic approaches listed below are used frequently at this facility?” (question A10), followed by a list of approaches and an option for none of the above; respondents answered separately for services provided for opioid use disorder versus other substance use disorders (Substance Abuse and Mental Health Services Administration, 2021). To capture provision of CM for StUD, our outcome of interest was reporting frequent use of “contingency management/motivational incentives” (CM/MI) for other (non-opioid) substances. We additionally examined whether facilities reported frequent CM/MI use and frequent use of another recommended psychosocial treatment for non-opioid substances, including cognitive behavioral therapy (CBT), community reinforcement approach (CRA) with vouchers, or the Matrix Model (MM), in line with clinical guidelines (American Society of Addiction Medicine/American Academy of Addiction Psychiatry, 2024).
Other facility characteristics examined included treatment focus (mental health and substance use or primarily substance use), ownership (private for-profit, private non-profit, or other [including state government, local/county/community government, tribal government, federal government]), state licensure/certification, national organization accreditation (including The Joint Commission, Commission on Accreditation of Rehabilitation Facilities, Council on Accreditation, National Committee for Quality Assurance, or the Health Care Facilities Accreditation Program) (Busch et al., 2025), whether the facility accepted Medicare, Medicaid, state-financed insurance (other than Medicaid), private insurance, or was cash/self-pay only (Gannon & Warnock, 2025), and whether the facility offered opioid agonist treatment (methadone or buprenorphine) for opioid use disorder (Busch et al., 2025). We obtained 2024 state-level stimulant-involved overdose mortality rates from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (WONDER) system (Centers for Disease Control and Prevention, National Center for Health Statistics, 2026), split into quartiles (Busch et al., 2025). We obtained state percent rural population from the 2020 U.S. Census (U.S. Census Bureau, 2020), also split into quartiles. Details of measure definitions are included in Appendix B.
Analyses
We described the study sample with respect to all outcomes and facility characteristics. We then estimated associations between each facility characteristic and each outcome using multivariable logistic regression models with standard errors clustered by state. We fit one model for each outcome, including all facility characteristics as independent variables. Analyses were conducted in Stata version 18 (StataCorp, 2023).
RESULTS
Sample description
The study sample included 13,169 facilities (Appendix A). The majority (62%) provided both mental health and substance use services; 38% provided primarily substance use services (Appendix C, Supplemental Table C1). 45% had private for-profit ownership, 47% private non-profit, and 8% other. Most were state licensed/certified (86%), accredited by a national organization (60%), accepted Medicare (58%), Medicaid (82%), state-financed insurance (55%) or private insurance (81%), and offered opioid agonist treatment (57%).
Frequent use of recommended StUD treatments and associated facility characteristics
42% of facilities reported frequent use of CM/MI; 41% CM/MI+CBT, 8% CM/MI+CRA, and 25% CM/MI+MM (Appendix C, Supplemental Table C1).
Positive associations:
Regression model estimates are presented in Table 1. State licensure/certification was positively associated with CM/MI, CM/MI+CBT and CM/MI+MM. Accepting state-financed insurance was positively associated with CM/MI, CM/MI+CBT, CM/MI+CRA and CM/MI+MM. Offering opioid agonist treatment was positively associated with CM/MI, CM/MI+CBT, CM/MI+CRA and CM/MI+MM. Higher state percent rural population was positively associated with CM/MI (second vs. first quartile), CM/MI+CBT (second vs. first quartile) and CM/MI+MM (second and fourth vs. first quartile).
Table 1.
Associations between facility characteristics and frequent use of recommended StUD treatments
| CM/MI | CM/MI + CBT | CM/MI + CRA | CM/MI + MM | |
|---|---|---|---|---|
| aOR (95% CI) | aOR (95% CI) | aOR (95% CI) | aOR (95% CI) | |
| Treatment focus | ||||
| Mental health and SUD (ref) | -- | -- | -- | -- |
| Primarily SUD | 0.78 (0.69–0.89)*** | 0.77 (0.68–0.87)*** | 0.75 (0.61–0.94)* | 0.91 (0.79–1.06) |
| Ownership status | ||||
| Private for-profit (ref) | -- | -- | -- | -- |
| Private non-profit | 0.82 (0.71–0.96)* | 0.83 (0.71–0.97)* | 0.69 (0.54–0.88)** | 0.77 (0.62–0.96)* |
| Othera | 0.91 (0.71–1.18) | 0.88 (0.67–1.15) | 0.85 (0.53–1.37) | 1.01 (0.74–1.38) |
| State licensed/certified | 1.43 (1.18–1.72)*** | 1.45 (1.20–1.75)*** | 1.34 (0.83–2.14) | 1.71 (1.26–2.32)** |
| National organization accredited | 1.02 (0.89–1.19) | 1.03 (0.89–1.19) | 0.91 (0.76–1.08) | 1.01 (0.85–1.21) |
| Accepts Medicare | 0.59 (0.49–0.69)*** | 0.60 (0.50–0.70)*** | 0.71 (0.57–0.88)** | 0.57 (0.46–0.71)*** |
| Accepts Medicaid | 0.74 (0.59–0.94)* | 0.74 (0.59–0.92)** | 1.09 (0.86–1.39) | 0.81 (0.62–1.07) |
| Accepts state-financed insurance | 1.23 (1.07–1.41)** | 1.22 (1.07–1.40)** | 1.40 (1.13–1.73)** | 1.45 (1.23–1.71)*** |
| Accepts private insurance | 0.99 (0.84–1.16) | 1.01 (0.86–1.19) | 0.86 (0.64–1.16) | 1.05 (0.86–1.30) |
| Cash/self-pay only | 0.39 (0.28–0.53)*** | 0.40 (0.29–0.55)*** | 0.53 (0.25–1.10) | 0.41 (0.25–0.68)*** |
| Offers opioid agonist treatment | 1.42 (1.23–1.63)*** | 1.41 (1.23–1.62)*** | 1.49 (1.22–1.82)*** | 1.31 (1.12–1.52)** |
| State stimulant-involved OD rateb | ||||
| 1st quartile (3.8–11.2) (ref) | -- | -- | -- | -- |
| 2nd quartile (11.4–14.5) | 0.76 (0.62–0.93)** | 0.76 (0.63–0.92)** | 0.74 (0.58–0.94)* | 0.92 (0.75–1.13) |
| 3rd quartile (14.6–18.6) | 0.80 (0.62–1.03) | 0.79 (0.62–1.00) | 1.16 (0.90–1.50) | 1.15 (0.91–1.45) |
| 4th quartile (19.6–38.6) | 0.70 (0.54–0.91)** | 0.72 (0.56–0.93)* | 1.21 (0.90–1.63) | 0.94 (0.68–1.30) |
| State percent rural populationc | ||||
| 1st quartile (0.0–13.7) (ref) | -- | -- | -- | -- |
| 2nd quartile (13.9–26.5) | 1.17 (1.02–1.35)* | 1.16 (1.01–1.33)* | 1.07 (0.89–1.30) | 1.26 (1.02–1.54)* |
| 3rd quartile (27.0–35.4) | 0.89 (0.72–1.10) | 0.88 (0.72–1.07) | 0.71 (0.56–0.90)** | 1.13 (0.91–1.40) |
| 4th quartile (36.8–64.9) | 1.12 (0.89–1.41) | 1.09 (0.86–1.37) | 0.72 (0.53–0.98)* | 1.60 (1.12–2.29)* |
CBT=cognitive behavioral therapy; CM/MI=contingency management/motivational incentives; CRA=community reinforcement approach; MM=Matrix Model; OD=overdose; StUD=stimulant use disorder
State, local/county/community, tribal, or federal government
Per 100,000 residents, age-adjusted, 2024
From 2020 Census
p<0.05,
p<0.01,
p<0.001
Negative associations:
Primarily providing substance use services (compared to both mental health and substance use services) was negatively associated with CM/MI, CM/MI+CBT and CM/MI+CRA. Private non-profit ownership (compared to private for-profit ownership) was negatively associated with CM/MI, CM/MI+CBT, CM/MI+CRA and CM/MI+MM. Accepting Medicare payment was negatively associated with CM/MI, CM/MI+CBT, CM/MI+CRA and CM/MI+MM. Accepting Medicaid payment was negatively associated with CM/MI and CM/MI+CBT. Being cash/self-pay only was negatively associated with CM/MI, CM/MI+CBT, and CM/MI+MM. Higher state stimulant-involved overdose mortality rate was negatively associated with CM/MI (second and fourth vs. first quartile), CM/MI+CBT (second and fourth vs. first quartile) and CM/MI+CRA (second vs. first quartile). Higher state percent rural population was negatively associated with CM/MI+CRA (third and fourth vs. first quartile).
DISCUSSION
Using 2024 N-SUMHSS data, this study found that less than half of U.S. substance use treatment facilities reported frequent use of recommended treatments for StUD. Frequent CBT use was reported by most facilities regardless of CM/MI provision, therefore it is unsurprising that findings for the CM/MI and CM/MI+CBT outcomes were similar. Clinical guidelines provide a stronger recommendation for CBT than for CRA or MM (American Society of Addiction Medicine/American Academy of Addiction Psychiatry, 2024), therefore it is perhaps also unsurprising that we found lower reported use of CM/MI+CRA and CM/MI+MM compared to CM/MI+CBT. Still, these findings underscore a pressing need to increase availability of CM.
Facility-reported use of recommended StUD treatments in survey data may represent upper-bound estimates of actual treatment provision. Given the known limitations of self-reported data (e.g., social desirability bias, variability in how respondents interpret “frequent” use or what treatments entail), the actual routine provision of recommended StUD treatments is likely lower than what is reported here. Facilities that are better resourced may be both more likely to offer recommended treatments and more likely to recognize and report them in surveys. Conversely, clinics with more limited resources may be both less likely to offer recommended treatments and to classify their services as such in survey responses.
The associations with facility characteristics observed in this exploratory study can guide further research to inform policy and practice. Future research should seek to understand what training or other resources can support facilities in providing these treatments, and how needs may differ for facilities that are focused primarily or exclusively on substance use services compared to those that also provide other mental health care. The positive association between offering opioid agonist treatment and offering recommended StUD treatments suggests there may be shared organizational or system-level drivers of evidence-based practice adoption; this may also underlie the positive association with state licensure/certification. Future research should seek to identify and understand these drivers to support increased provision of evidence-based care across conditions.
Private non-profit facilities were less likely to report frequent use of recommended StUD treatments than private for-profit facilities, echoing prior research on MOUD provision (Busch et al., 2025). This pattern points to the need for research into potential funding limitations/restrictions that may differentially affect non-profit facilities. Similarly, the negative association between Medicare/Medicaid acceptance and frequent use of recommended StUD treatments may reflect policy barriers, including restrictions on Medicare/Medicaid reimbursement for CM incentive payments. Several states have received approval to use Medicaid funding for CM, which may help address this gap for Medicaid (Kaufman et al., 2025). More research is needed regarding how different state-financed insurance programs approach payment for CM and how this may support treatment provision. It is unclear why cash/self-pay only facilities were less likely to report frequent use of recommended StUD treatments, however these facilities made up a small proportion of the sample (4%).
Notably, higher state-level stimulant-involved overdose mortality was associated with lower reported use of recommended StUD treatments. This contrasts with prior research examining MOUD provision in N-SUMHSS data, which found greater reported treatment availability in states with higher opioid-involved overdose mortality (Busch et al., 2025). It is unclear why stimulant-related harms may not have translated into expanded evidence-based care in the same way that the opioid overdose crisis seemed to lead to expanded MOUD provision (Cerda et al., 2023). Possible explanations include lower awareness of stimulant-related harms, limited awareness that CM is first-line StUD treatment, or particularly challenging implementation barriers, including CM-specific policy and payment barriers. More research is needed to understand these patterns. Similarly, it is unclear why higher state percent rural population was positively associated with most outcomes but negatively associated with reporting frequent use of CM/MI+CRA. More research is needed to understand the barriers to/facilitators of providing different recommended StUD treatments in rural vs. urban communities.
This study has limitations. The actual provision of treatments may have been overestimated due to desirability bias or survey respondents’ misunderstanding of what the treatments entail, and individual respondents may have interpreted “frequent” use differently when answering on behalf of their facility. Survey responses do not indicate whether treatments were in fact delivered or delivered in line with evidence-based protocols; the wording of the CM-related item (“contingency management/motivational incentives”) may have captured practices do not truly constitute CM. Although CM is frequently used to treat StUD, the survey did not allow facilities to specify whether they used CM/MI for StUD vs. other non-opioid substances. Facility funding level was not available in the data. We were limited to state-level geographic variables (overdose rate and rurality), restricting their specificity. Finally, facilities that declined to respond to the survey or that declined to answer question A10 are not represented, potentially limiting generalizability.
CONCLUSION
This study of 2024 N-SUMHSS data found that less than half of U.S. substance use treatment facilities reported frequent use of recommended treatment for StUD, and treatment may be less available in areas where it is most needed (e.g., in states with higher rates of stimulant-involved overdose death). In general, reported provision of CM/MI alone or in combination with other treatment was positively associated with state licensure/certification, accepting state-financed insurance, offering opioid agonist treatment, and higher state percent rural population (except CM/MI+CRA), and negatively associated with primarily providing substance use services (vs. mental health and substance use services), private non-profit ownership (vs. private for-profit), accepting Medicare/Medicaid, cash/self-pay only, and higher state-level stimulant-involved overdose mortality rate. These exploratory findings can inform future research to help policymakers and administrators increase treatment availability.
Supplementary Material
HIGHLIGHTS.
We examined reported use of stimulant use disorder treatment in U.S. facilities.
Less than half of facilities reported frequent use of recommended treatment.
Frequent use of recommended treatment may be overestimated in survey data.
Associated facility characteristics can inform further research.
Funding:
This research was supported by the Brandeis-Harvard Center to Improve System Performance of Substance Use Disorder Treatment, funded by the National Institute on Drug Abuse (Grant No. P30 DA035772, MPIs: Reif and Huskamp). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
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Declaration of interest: The authors declare no conflicts of interest.
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