San Francisco Chronicle - (Sunday)
Controversial drug treatment takes hold in state
Programs use small payments to motivate users to attend counseling and stay sober
For the past 30 years, if Daniel Costa was sober for the holidays, it was because he was in jail.
Now everything is different. Costa, a 61-year-old San Jose native who has struggled with both methamphetamine addiction and housing instability for most of his life, is five months sober for the first time in over three decades, thanks to a new substance-use treatment program called Rewarding Recovery.
As a result of his sobriety, Costa has a new start in life. He moved into his own apartment recently, where he was able to celebrate Christmas with his wife, Monica, for the first time since they were married four years ago. They decorated their new 290square-foot studio with boughs of mistletoe.
“That’s the type of thing that I’m benefiting from now. I’m getting to enjoy the good things in life,” Costa said. “The program took me out of the dark and it brought me to the light.”
The Rewarding Recovery program uses a treatment approach called “contingency management,” where drug users are rewarded with gift cards for attending counseling sessions and staying sober. Despite proof of its efficacy in treating stimulant addiction in research trials, contingency management remains controversial.
Costa’s struggles with substance use began in high school. Emotional abuse at home, he said, drove him to seek attention by causing trouble. On his 18th birthday, his father kicked him out of the house.
“He said, ‘Come on, go to the porch, I got something for ya.’ I thought it was a gift,” Costa said, his blue eyes filling with tears. It turned out to be a bag stuffed
with all his belongings.
Feeling he had nowhere else to turn, Costa entered the Marine Corps, where he served for six years before being honorably discharged. He came away from the experience, though, with posttraumatic stress disorder, which manifests as a nagging feeling of terror and unease that stalks him like a shadow.
He headed back to San Jose, where he got a job as a security guard, but in the months that followed, he began to steal merchandise. Costa was convicted of burglary and sent to jail. It was there that he was introduced to crystal meth.
Over the next 30 years, Costa’s life devolved into a murky whirlwind of drugs, rehab and prison. He served six prison sentences for burglary and failed every substance-use treatment program in Santa Clara County.
“Crystal meth is one of the worst drugs there is because it’s very deceptive. It makes you believe that you are the biggest, baddest, sharpest guy,” he said. “It’s hard to quit something when you think you’re better on it.”
Costa’s struggle isn’t unique. His story is part of a growing local and national problem of people becoming addicted to stimulants like meth and cocaine. While the media and government initiatives have been focused in recent years on the abuse of prescription opioids and the growing prevalence of deadly synthetic opioids like fentanyl on the street, the abuse of stimulants has received less attention, even though stimulant-related overdose deaths have multiplied.
In California, stimulant-related overdose deaths quadrupled from 2011 to 2019, according to an analysis by the California Health Care Foundation, a nonprofit philanthropy organization. And in San Francisco, which in 2023 saw its deadliest year for drug overdoses, meth or cocaine mixed with fentanyl accounted for more 63% of overdose deaths in 2022.
“People are dying. Just putting overdose reduction strategies on the back of opioids alone is never going to reduce those rates,” said Thomas E. Freese, director of the UCLA Integrated Substance Abuse Programs.
In California, amphetamines like meth are the No. 1 drug that people seek treatment for. Despite this, effective treatments for stimulant addiction remain scarce.
Unlike for opioid addiction, there are no FDA-approved medications to treat stimulant addiction. And widely employed behavioral approaches, such as peer-based counseling and support programs, have limited evidence for their use in stimulant addiction treatment, according to the U.N. Office on Drugs and Crime.
The one behavioral intervention that does have decades of research to support its use for stimulant addiction treatment is contingency management.
That is the method that was employed by the Rewarding Recovery program that helped transform Costa’s life. At its core is the principle of positive reinforcement: Participants receive gift cards for attending counseling sessions and submitting negative urine drug tests.
Contingency management takes the basic paradigm of addiction and applies it to treatment, using relatively small yet tangible rewards to counterbalance the dopamine reward unleashed by drug use. This method has been proved highly effective in multiple clinical trials at keeping people addicted to stimulants in treatment and reducing their drug use. According to the California Department of Health Care Services, it is the “only treatment that has demonstrated robust outcomes for individuals living with stimulant use disorder.”
In 2022, California became the first state in the nation to gain approval to use federal funds to pay for contingency management as a Medicaid benefit and to evaluate the effectiveness of the approach at scale.
The statewide pilot, which started in 2023, will run through December 2026 and seek to implement the approach at 166 sites across 24 counties, including San Francisco, Los Angeles and San Diego. As of the end of November, more than 1,000 participants have enrolled, said Freese, who is also the principal investigator for training and implementation of the California pilot program. Addiction experts nationwide are watching to see whether widespread real-world implementation of this approach yields similar results to those found in research.
Costa didn’t know the term “contingency management” when he first enrolled in the Rewarding Recovery program in July. All he knew was that the new substance-use program at his shelter offered Target gift cards for participation, so he signed up.
Rewarding Recovery is not a part of the state pilot, but uses a similar contingency management approach. It’s funded through a partnership between the LifeMoves shelter network and the Stanford Housing Equity Project.
Participants in its pilot receive Target gift cards for consistently attending weekly substance-use counseling sessions. It is a 12week program: During the first four weeks, clients can earn $15 per session. For the next four weeks the reward increases to $20, and then to $25 over the last four weeks. Clients also can earn an extra $10 at every session if they submit a negative urine drug test, making the maximum a participant can earn $360.
Costa said that initially, the program seemed too good to be true. He got a gift card simply for showing up to the sessions, and there was no punishment for turning in a positive urine drug test — in fact, staff offered only encouragement and additional counseling. When he received his first gift card, he said, he looked around for hidden cameras.
“At first, that’s like giving a criminal a get out of jail free card,” he said.
Costa calls this period “phase one” of his experience with contingency management. He would go to the sessions, doze off, then grab his gift card and walk out without saying a word.
Clayton Soward, the substance-use counselor who led Costa’s group sessions, said that just getting the pilot program’s participants to phase one is a step in the right direction. Before adopting the contingency management approach, he had just four or five people showing up sporadically for group sessions. After the rewards program began, attendance grew to double digits. He said he had to limit enrollment to manage his workload.
“It’s additional accountability for them because they want the card. Not to mention they come back to see me when I pay them, so I get extra time to talk with them,” Soward said. “Any chance I have to interact with them, I think, is beneficial.”
“Phase two,” as Costa calls it, began a few weeks into the program. He started to stay awake during the sessions, began listening, and learned things about setting boundaries and avoiding triggers. He also started to feel motivated to turn in negative urine tests to increase his gift card earnings.
“I hadn’t arrived,” he said, “but I saw there was now a light at the end of the tunnel. Before it was just filled with darkness.”
Costa’s experience highlights what distinguishes contingency management from other forms of treatment: It uses rewards instead of punishments. Participants can engage with the program and the counselors without fear of being kicked out for continuing to use drugs.
“There was no motivation to hide (drug use). And that’s what causes relapse. Hiding,” Costa said. “Most programs use the fear tactic.”
As he came out of hiding, Costa entered what he calls “phase three,” essentially the final stage of contingency management. He attended all the weekly sessions and began to actively share with others what he had learned. He submitted a negative urine drug test each week and signed up for additional appointments with Soward.
“I share. I expose myself. Why?” he asked. “Because I want to keep this going. I love the light too much, you know, and I want to get rid of the darkness completely.”
“What’s darkness? Darkness is hiding. Darkness is not being able to look you in the eye and answer a question. Darkness is doing dope in the closet or outside behind the building at (the shelter). Darkness is not wanting to talk to people, God forbid, because then they might find out.”
Now a graduate of the Rewarding Recovery program, Costa has been sober for five months.
Given the success of Costa, and that of others like him in clinical trials over the past few decades, why has this contingency management not been widely implemented?
The method’s slow adoption is due to a variety of issues, including regulatory challenges, moral objections to the approach, and financial concerns.
Under government regulations, it’s been considered illegal to use federal funds for such programs because they could be viewed as providing a “kickback”: incentivizing drug users to enter programs for which operators are compensated on the basis of enrollment.
Anti-kickback statutes have prevented the implementation of such programs outside of the Department of Veterans Affairs, which has been using contingency management to treat stimulant addiction since 2011 with great success — in the first five years of the program, more than 91% of urine samples submitted across 94 sites were negative.
However, regulations are changing and more states, such as Washington, Montana, Delaware and West Virginia, are gaining approval to use federal funds to pilot reward-based therapy as a Medicaid benefit.
Still, contingency management remains controversial. Many people find it morally objectionable, the idea of rewarding drug users for refraining from harmful and, in most cases, illegal activity.
Soward, the substance-use counselor who worked with Costa, initially felt conflicted about the approach. His resistance came in part from personal experience. During his early 20s, Soward struggled with alcohol and stimulant-use disorders. Contingency management was not an option when he was in recovery; he had to motivate himself to stop using.
Soward said he came around to the idea after seeing how the program had immediate impact on clients he’d been unsuccessful in helping for many years.
“I see people change their lives completely,” Soward said. “They’re able to function. Why would I dislike that?”
The economic feasibility of the approach is another point of contention.
Calculations based on 2021 Los Angeles County Public Health data estimate that almost 40% of people who use meth end up in the hospital for meth-related reasons each year. Meanwhile, the data shows, the estimated annual average hospital cost per person using meth, not just those who end up in the hospital, is roughly $25,000. That figure does not take into account other social and financial costs of meth use, such as increased crime, prosecution, incarceration and negative outcomes for family members and loved ones.
Those figures appear to make contingency management programs, such as the state pilot, where rewards max out at $599, an excellent investment if they can help just 2.5% of participants refrain from stimulant use for a year.
There are secondary gains to every dollar invested in contingency management, said Steven D’Antoni, director of clinical services at Behavioral Health Services, a network of substance-use treatment programs in Los Angeles County.
“When somebody can save up a gift card to go to Foot Locker and get a pair of running shoes, then that’s value added,” D’Antoni said. “They feel comfortable with going and exercising, which furthers their recovery.”
While contingency management is not a perfect solution, D’Antoni believes it offers substance-use programs an effective tool for combating a worsening problem that is killing people daily.
“It helps us see sobriety,” Costa said. “The rewards become incidental, whereas before they were the motivating factor.”
Costa’s new apartment is in Markham Plaza, an unassuming complex located in an industrial area of San Jose. It is bounded by a six-lane road and old railroad tracks; the building’s cheerful pastel walls bring color to an otherwise gray landscape. For Costa, the building is both a haunting reminder of the past and a symbol of a new beginning.
The block where Markham Plaza stands is known locally as the Four Corners, a place Costa used to frequent to buy drugs from a friend, and where that same friend died of an overdose. Costa had avoided the area for years.
Now, though, he’s back, free from the grip of the drug that killed his friend and ruined his life for more than 30 years. The light from his new apartment’s window shines down on the dark street corners where he used to hide.
“I share. I expose myself. Why? Because I want to keep this going. I love the light too much, you know, and I want to get rid of the darkness completely.”
Daniel Costa