At the San Francisco AIDS Foundation, staff members Tyrone Clifford (left) and Rick Andrews (right) demonstrate how a contingency management visit typically begins, with a participant picking up a specimen cup for a urine sample. If the sample tests negative for meth or cocaine use, the participant has an incentive dollar amount added to their "bank" which can later be traded for a gift card. Christopher Artalejo-Price/San Francisco AIDS Foundation
When Billy Lemon was trying to kick his methamphetamine addiction, he went to a drug treatment program at the San Francisco AIDS Foundation three times a week and peed in a cup. If it tested negative for meth, he got paid about $7.
"For somebody who had not had any legitimate money – without committing felonies – that seemed like a cool thing," says Lemon, who was arrested three times for selling meth before starting recovery.
The payments were part of a formal addiction treatment called contingency management, which incentivizes drug users with money or gift cards to stay off drugs. At the end of 12 weeks, after all his drug tests came back negative for meth, Lemon received $330. But for him, it was about more than just the money. It was being told, good job.
"It was the first opportunity where I was like, I have self-worth, still. It's buried. This person sees it and is willing to give me seven dollars, just to take care of myself. That was very motivating," he says.
As overdoses and public health costs related to meth and cocaine continue to spiral in California, state officials are desperate for more effective treatment options and are pursuing legislation and appealing to federal regulators to make contingency management more widely available. Washington, Montana, and West Virginia are also exploring similar strategies.
Because studies show contingency management works. The principles of the treatment – positive reinforcement techniques, primarily – are used widely in weight loss, fitness programs, and in families, as parents coax their children into adopting good behaviors, rather than punishing them for poor behaviors.
Billy Lemon, 50, kicked his meth habit more than 9 years ago after taking part in a "contingency management" program for meth and cocaine users at the San Francisco AIDS Foundation. For every negative drug test, he earned a small amount of money. Lemon now runs the Castro Country Club, a recovery center in San Francisco. Beth LaBerge/KQED
Research shows contingency management is the most effective treatment for meth or cocaine addiction, especially when combined with other behavioral therapy. At the San Francisco AIDS Foundation, 63% of people who participated in the program in 2019 stopped using meth entirely, and another 19% reduced their use.
The Department of Veterans Affairs has relied on the therapy to treat 5,600 vets over the last 10 years. Of the 73,000 urine samples collected in the VA program, 92% tested negative for drugs, according to Dominick DePhilippis, a clinical psychologist at the Philadelphia Center for Substance Addiction Treatment & Education who helped launch the VA's program.
"Patients often come to treatment ambivalent about change. Why? Because substance use is so seductive. It provides powerful, immediate reinforcement," DePhilippis says. "Whereas recovery, its immediate consequences, are often unpleasant: withdrawal symptoms, a clear-eyed view of the devastated landscape that is one's life."
Contingency management embraces this challenge head on, he adds, by offering immediate rewards and reinforcement for abstinence. The small payments or prizes aim to rewire the brain's reward system, so the person seeks the money or gift card to get a dopamine release, instead of meth or coke.
"You're like, 'Oh! Oh! I can feel good without the daily use of that substance. Let me try and go one more week,'" says Lemon. "And then all of a sudden, you're at 90 days and you've actually made a change."
Despite its effectiveness, the treatment is controversial. Critics have scoffed at the idea of paying drug users not to use drugs, calling it unethical or a bribe. Most insurers don't cover it. Neither do state Medicaid programs. The feds generally forbid them from offering financial incentives to patients, as a protection against fraud and waste, and state officials have interpreted that rule as prohibiting reimbursement for contingency management.
California will try to scale up an effective treatment for stimulant addiction
But as the drug epidemic continues to worsen throughout California and the nation, with overdoses from stimulants like meth tripling in recent years, state officials are questioning those policies and pushing for changes. Critics are softening their stance. A bill now on the governor's desk – SB 110 – would allow the state's Medicaid program to pay for contingency management services, with the goal of encouraging more drug treatment centers to offer it.
"We need to embrace this proven, effective approach to meth addiction, make it clearly legal and start reimbursing for it, so we can address this health epidemic," says state Sen. Scott Wiener (D-San Francisco), who sponsored the bill.
Wiener says he was surprised to see the bill pass the California legislature with near unanimous, bipartisan support.
"The Republicans love it," he says. "I didn't think they would, but they actually like it because there's an abstinence component to it: we pay you money and you abstain from using."
The state's Department of Health Care Services, which runs California's Medicaid program, is also on board. Department leaders have already asked federal regulators for explicit permission to offer contingency management through a statewide pilot project, and the feds appear poised to grant it.
Until quite recently, the federal government has been reluctant to relax rules that bar public health programs from offering contingency management. In 2020, during the Trump administration, treatment experts asked the U.S. Department of Health and Human Services to waive the rules for two years, but the agency refused.
"It's clear the [Trump] administration had minimal interest in looking at evidence or science, on a wide variety of topics," says Laura Thomas, director of harm reduction policy at the San Francisco AIDS Foundation, which helped sponsor the bill.
The Biden administration, on the other hand, specifically stated in its 2021 drug control policy that one of its main priorities is to "identify and address policy barriers related to contingency management."
As stimulant overdoses soar, California looks to a proven behavioral intervention
The need is urgent, explains Dr. Kelly Pfeifer, deputy director of behavioral health at the California Department of Health Care Services. In 2020, more Californians died from meth and cocaine overdoses than from fentanyl overdoses, and stimulant abuse is wreaking havoc on California's jails and courts, foster care, and hospitals.
"Which are obviously not only devastating to the person and the family, but very expensive for our health care system," Pfiefer says.
There's also an increasing sense of hopelessness among stimulant users, she adds, because of the lack of effective, available treatments. For opioid addiction, there are now three FDA-approved medication therapies: methadone, buprenorphine and naltrexone. For meth and coke, there are no such medications.
Making contingency management more widely available would make more people willing to seek treatment, Pfiefer says.
"Because people will see success stories," she says. "They'll see friends and family getting treatment and getting help and getting better."
One drawback of contingency management is that the benefits may dwindle once the active treatment ends. For that reason, some doctors believe the incentive treatment should be delivered continuously, in the same way that medication therapies for opioid use disorder are sometimes prescribed indefinitely. But new research indicates the benefits may last longer than previously thought. In a review of 23 previously published trials, researchers at the University of Connecticut found that people who participated in contingency management were 22% more likely to be abstinent 6 months after treatment ended than people who received other treatments.
For Billy Lemon, contingency management was just what he needed to jumpstart his recovery, and to stay the course in residential rehab. When he cashed out all his incentive payments, he used the $330 to buy himself a new cell phone.
"Because up until then, Breaking Bad-style is burner phones," he says, referring to the prepaid disposable phones drug sellers use, then discard, to avoid detection by the police. "My number was never the same."
Now, nine years later, he's still sober - he runs the Castro Country Club, a recovery space in San Francisco - and the number he got with his new phone is still his number.
"It's a nice reminder of what making good decisions for yourself can turn into," he says.
This story comes from NPR's health reporting partnership with KQED and Kaiser Health News.
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