Methamphetamine and cocaine addictions are among the most difficult substance use disorders to treat. Both drugs are highly addictive, and there are no medications specifically approved to treat addictions to these stimulants.
There is, however, a behavioural treatment with decades of evidence behind it: known as “contingency management,” this method rewards people for abstaining from drug use, attending therapy or both.
Yet in Canada, contingency management remains largely confined to a few programs, research trials and philanthropic initiatives.
“Contingency management has been associated with improved outcomes in terms of substance use, abstinence,” said Dr. Didier Jutras-Aswad, a professor and addiction psychiatrist at the Centre hospitalier de l’Université de Montréal.
“It can also increase retention, attendance to treatment, and just engagement in care.
“But we have a long history of contingency management with a poor uptake. … [T]hat intervention is not being made available.”
Stimulant addiction
Stimulants are drugs such as cocaine, crack and methamphetamine that speed up activity in the brain and central nervous system, producing an intense surge of dopamine.
Stimulant use is widespread in Canada.
In 2025, nearly 970,000 Canadians reported using cocaine in the previous year, and about 314,000 reported using illegal amphetamines or methamphetamine. More than 100,000 of the Canadians who use stimulants are estimated to be at high risk of dependence.
“Many, many communities across Canada are suffering from [methamphetamine use disorder], and decision-makers hear about it quite a lot,” said Jutras-Aswad.
Contingency management has been studied and used in addiction treatment for five decades, most notably in the United States, but also in the United Kingdom and Australia.
In the 1990s, it was a common method for treating cocaine dependence. More recently, at least eight U.S. states have sought federal approval to use contingency management to treat methamphetamine use disorder.
In contingency management programs, users are given small rewards — such as vouchers, gift cards or cash — for showing drug-free test results or engaging in therapy. With cash payments, rewards typically start around $20, and can rise to as much as $100 if users maintain their abstinence.
Decades of randomized trials and meta-analyses have found that contingency management can be effective at increasing abstinence and improving treatment attendance.
A 2021–22 randomized trial in Calgary and Edmonton, co-led by University of Calgary addiction researcher David Hodgins, delivered contingency management remotely after the pandemic began. It improved treatment engagement but had less effect on substance use than researchers had expected.
“[I]n the time period we were looking at, it didn’t have huge effects on substance use,” said Hodgins.
“What we found was that it did, in fact, improve treatment engagement,” he said, noting participants were more likely to attend virtual and group therapy, or outpatient addiction treatment sessions.
Barriers to adoption
Yet despite the evidence of its effectiveness, contingency management is not widely used in Canada.
A 2023 study co-authored by Hodgins found that nearly two-thirds of 290 Canadian addiction-treatment providers were unfamiliar with contingency management. The providers represented 103 programs across all 10 provinces.
“Most were not familiar with CM and reported largely neutral attitudes toward it,” the researchers wrote.
Canadian Affairs reached out to all 10 provincial health authorities about the availability of contingency management. Just two — Alberta and Saskatchewan — said they make contingency management available in some of their publicly funded addiction services.
“Contingency management is an evidence-based behavioral intervention that uses structured positive reinforcement to encourage behaviors that support recovery,” a spokesperson for Recovery Alberta, the province’s mental health and addiction agency, told Canadian Affairs.
Three provinces — Ontario, B.C. and Nova Scotia — have limited programs through hospitals, research projects or philanthropic initiatives. Quebec’s use is currently limited to Jutras-Aswad’s clinical trial.
Newfoundland and Labrador and P.E.I. said they do not offer contingency management, while Manitoba and New Brunswick did not respond to multiple requests for comment.
Sources say there may be a number of reasons for the limited uptake.
Administering contingency management can present practical and ethical challenges. Participants can substitute someone else’s drug-free urine sample or spend their rewards on drugs.
Jutras-Aswad says the requirement to provide “clean” urine samples can also carry a stigma for patients, who may experience the testing as a form of surveillance or judgment.
The effects of a program tend to be strongest while incentives are being offered (although some research has found benefits that persist after payments stop).
Some clinicians also see payments as a form of bribery.
“It’s been seen by some as a shortcut in treatment … [where] you just provide something for someone for them to change their behaviour, but you’re not doing the ‘real work’,” said Jutras-Awad.
Funding is another barrier. “There’s no budget line for that type of intervention,” said Jutras-Aswad.
Hodgins says shifting budgets can be difficult, particularly when managers face criticism for “paying people to do what they should do anyways.”
In Hodgins’ national survey, lack of training was the most commonly cited implementation barrier.
“I’d say that a lot of [barriers] could be overcome by proper education,” Jutras-Aswad said.
New Canadian trial
A new Canadian trial is now testing whether contingency management can work without making drug-free urine tests the price of entry.
Jutras-Awad is leading a trial across four sites in — Vancouver, Toronto, Montreal and Charlottetown — for people with methamphetamine use disorder.
Participants are randomized to four groups combining standard care, contingency management and either an ADHD medication or placebo.
In the two contingency management groups, participants are rewarded over four months for engaging in care, such as attending appointments and participating in therapy, rather than providing drug-free urine tests.
The rewards start at $20 per visit and increase by $10 each consecutive week, reaching more than $100 per session.
The trial is still underway, so Jutras-Awad cannot yet comment on the results. But he is optimistic.
“If the trial shows … more engagement [with treatment] and methamphetamine use reduction in a Canadian context, that could speak to our policymakers,” he said.
For his part, Hodgins says contingency management delivers enough benefits to justify its cost.
A Canadian study found that a standard, 12-week contingency management program that rewarded negative urine tests cost about $250-$300 per participant in prizes and testing. By contrast, people with untreated substance use disorders cost the health-care system substantially more, a Canadian study has shown.
Similarly, recent economic modeling in the United States found contingency management for methamphetamine use disorder was highly cost-effective when broader social costs were factored in.
“[It is] cost-effective,” said Hodgins. “So in the long term, it actually saves money to the system because people have better outcomes.”
