Mutual-help linkage and contingency management for stimulant relapse (MEQ)

(i) Definitions. Mutual-help programmes are peer-led, usually free, voluntary recovery supports (AA/NA, SMART Recovery, etc.) outside professional case notes. Contingency management is systematic delivery of tangible reinforcers contingent on objectively verified target behaviours (e.g. methamphetamine-negative urine). Twelve-step facilitation is a professional therapy that aims to engage AA/NA — it is not the fellowship itself.^[1][2][6]

(ii) 12-week plan. Medical/psychiatric risk screen; thrice-weekly urine (or oral fluid) CM with immediate voucher or prize reinforcement for negative tests, escalating rewards for consecutive negatives, reset after positive, approximately 8–12 weeks intensive phase; re-engage CBT/MI; intensive referral to SMART Recovery (or other secular mutual-help) with scheduled first meeting and follow-up — not a pamphlet; partner/family education; sleep, nutrition, employment supports. Cite Roll multi-site methamphetamine CM and broader CM meta-analyses.^[2][3][5]

(iii) Ethics of “paying to stay clean.” CM is not bribery: it is evidence-based operant treatment that rearranges contingencies so abstinence can compete with immediate drug reward. Meta-analyses support efficacy; effects are often large among psychosocial options for abstinence during treatment (Dutra). Frame as time-limited clinical tool with maintenance planning, not unconditional cash.^[2][4]

(iv) Failure modes. Delayed rewards; no objective verification; punitive discharge for one positive; no escalation/reset design; no aftercare when CM ends; ignoring transport barriers to thrice-weekly testing; forcing AA language after clear refusal.^[2][6]

(v) Suicidality override. Pause incentive focus as the organising frame; urgent risk assessment, safety plan, consider higher intensity/inpatient care, involve supports; continue alliance and substance plan once safe.^[6]