Cash incentives to stop using meth
Proposed state legislation would boost drug treatment option
As overdose deaths soar throughout California, proposed state legislation would legalize a program that encourages people to curb their methamphetamine use with incentives like gift cards and cash.
The approach, called contingency management, is a controversial but effective practice. Researchers have found it helps people control their substance use, particularly for methamphetamine. It’s yet another approach that San Francisco officials hope they can use to address the deadly drug epidemic that killed approximately two people a day in the city last year.
“There’s an increasing urgency around ensuring we have all of the tools available to address overdoses and substance use disorder,” said Laura Thomas, director of Harm Reduction Policy at the San Francisco AIDS Foundation, which is supporting state legislation sponsored by Sen. Scott Wiener, DSan Francisco, to legalize the practice and allow MediCal — the state’s insurance for lowincome people — to pay for it.
“We know there are more people out there who want and deserve these services,” Thomas added.
Methamphetamine use has spiked dramatically in San Francisco over the past few years, and the pandemic has exacerbated the problem. According to the San Francisco Department of Public Health, meth overdose deaths have increased by 500% since 2008. Meanwhile, according to city statistics, 50% of psychiatric emergency room admissions at San Francisco General Hospital are related to meth.
Contingency management is often used for meth addiction because no medication exists to help wean users
off the stimulant. Those who use opioids like heroin and fentanyl can use FDAapproved medications, such as buprenorphine or methadone, to manage their addictions.
The way contingency management works is simple: Someone struggling with substance use voluntarily pees in a cup at least once a week. If no drugs are detected in their system, they get a small reward like a few dollars added into an account or a gift card. They don’t get a reward if drugs are detected. But they are often encouraged to try again.
Critics of the practice are against the idea of essentially paying people not to use drugs, and say the state should focus on increasing other options like drug treatment and supportive housing. But those who support it say it is a cheaper and lowerbarrier option for people who may not have had success with traditional rehab programs.
Even though researchers — like those at the National Institute of Health — say contingency management is an effective way to help people stay sober, it’s underutilized in California because MediCal does not reimburse those who offer it. That’s because the treatment exists in a legal gray area in California, where there’s no law that
explicitly authorizes or bans it. The incentives can also be considered kickbacks under federal law.
However, organizations like the SF AIDS Foundation are able to offer contingency management programs because of local funding. The Department of Veterans Affairs also offers contingency management across its health care system around the country.
Wiener’s bill, the Recovery Incentives Act, which was introduced last week, would legalize the practice in California and authorize MediCal to cover it.
“If we’re serious about tackling meth addiction, we need to use every available tool,” Wiener
said. “People are dying; it’s destroying people’s lives. It’s impacting our health care system. And in particular, it’s having big impacts in the LGBTQ community.”
Contingency management worked for Billy Lemon, who enrolled in the SF AIDS Foundation contingency management program when he was in rehab for his meth addiction a few years ago.
Every time he tested negative, he said he got a small little rush that he wanted to keep experiencing. By the end of the 12week program, he said he tested negative every time and saved about $ 300. He said the program likely worked for him because he was able to couple it with the support he got from his rehab
program.
“You’re building up these really small wins that can seem really inconsequential,” Lemon said. “But for someone who has thrown their life aside and trying to make a change, it was really helpful.”
Contingency management is most effective when paired with other services — like rehab, medication management, therapy and housing. But San Francisco’s networks of drug treatment services are understaffed and overwhelmed, particularly as the pandemic has disrupted services like dropin centers and inperson support groups.
If the law passes, Lauren Kahn, a spokeswoman for HealthRight 360 — the city’s largest provider of drug treatment services — said the nonprofit would “absolutely offer the service.”
While fentanyl — a deadly opioid that can be 50 to 100 times more potent than morphine — was the main driver behind the record overdose deaths in 2020, the skyrocketing use of meth has also wreaked havoc on San Francisco’s streets.
According to a 2019 report by the city’s Meth Task force, meth is contributing to “violent encounters, property damage, thefts and hazardous waste.” It can also lead to psychosis in some users, which has in turn exacerbated the city’s mental health crisis.
Isaac Jackson said he tried contingency management a couple of years ago, and it helped him stay sober from meth for about a month. But, he said, it was hard to eventually stay away from the drug because he also struggles with depression.
While Jackson still uses meth regularly, he said he’s able to keep his use under control because he stays busy with projects — like running the Urban Survivors Union, which advocates for drug users. He also has stable housing.
“I think it could be an effective program if it is part of a range of things offered to people,” he said. “People have different pathways.”
If the legislation passes, it could help expand San Francisco’s drug treatment offerings. The city has been slow to add new addiction treatment programs and expand existing ones.
For example, a meth sobering center that was supposed to open last year was put on hold amid the pandemic. City leaders have also long called for a safe consumption site, but that effort is stalled until the state passes legislation — which Wiener has also proposed — authorizing it.
Meanwhile, the city is seeing a record number of fatal overdoses.
Thomas Wolf, a recovering drug user, has mixed feelings about contingency management. He worries that if it isn’t coupled with comprehensive rehab, therapy and other services, people will use the money earned in the program to buy more drugs.
But, he said, given the gravity of the crisis, officials should try everything.
“I’m of the belief that we need to try anything and everything at this point, including safe consumption sites,” he said. “At this point, we need the kitchen sink.”