How the state is fighting meth with gift cards
Clinics are using innovative methods such as reward incentives to combat substance abuse and addiction
Among the most difficult addictions to witness at San Francisco General Hospital's drug clinic is methamphetamine, which leaves users tearing at their skin and unable to eat, sleep or sign up for help.
The worst part: The clinic workers largely are powerless because unlike with opioid addiction, for which doctors prescribe medicine such as methadone, there is no medicine for stimulant use disorder.
“We live day in and day out watching people suffer in a way that's hard to imagine,” said Dr. Brad Shapiro, medical director of the Opiate Treatment Outpatient Program at Zuckerberg San Francisco General Hospital. “They're just dying in front of us.”
Faced with that immense suffering, California will try a new approach to stimulant addiction: paying people with gift cards to reward them for staying sober.
This model, known as contingency management, rewards people with financial incentives each time their drug tests are negative for stimulants. It's been shown to have success in clinical trials — and the U.S. Department of Veterans Affairs has been using it for more than a decade — but it hasn't taken off in California. Medicaid previously wouldn't cover it, so there was no funding to expand its use. To Shapiro, that's inexcusable. “It's actually, in my opinion, really quite criminal that we've gone decades knowing this is an effective treatment and the powers that be have failed to make a pathway for treatment for people,” he said.
The program is expanding now, thanks to a recent waiver by the federal Centers for Medicare & Medicaid Services. California was the first state in the nation to win approval for a con
tingency management program under Medicaid. The Golden State is launching pilot programs in 24 counties, including San Francisco, Sacramento and Los Angeles. Costs for what collectively is called the Recovery Incentives Program will be reimbursed by CalAIM — the state's recent expansion of Medi-Cal services.
“All of a sudden we have money to provide this incredibly effective intervention,” said Shapiro, whose clinic is launching one of three pilot programs coming to San Francisco.
Though the deadly opioid fentanyl gets most of the attention in the drug epidemic in California and across the country, experts say stimulant use is a major — and growing — concern. In 2021, 65% of drugrelated deaths in California involved cocaine, methamphetamine or other stimulants — up from 22% in 2011, according to the California Department of Health Care Services.
And with California in the midst of a dire homelessness crisis, stimulants are wreaking havoc on the state's unhoused community. Among unhoused residents who use drugs, amphetamines are by far the most common choice, according to a recent study by the UCSF Benioff Homelessness and Housing Initiative. Nearly one-third of people surveyed reported using amphetamines three or more times a week. Some people who live on the street reported using stimulants to stay alert at night, when they fear being attacked if they fall asleep.
To combat stimulant addiction, Zuckerberg San Francisco General Hospital recently launched a sixmonth program as part of the statewide pilot. Clinicians will test participants for stimulants once or twice a week. Each time patients test negative, they'll get a $10 gift card to Walmart or another retailer. The amount of the gift card gradually will increase, for a maximum of $26.50 per test. If they test positive, they get nothing.
Participants can earn a maximum of $599 over the course of the program. That's because payments of $600 or more must be reported to the Internal Revenue Service.
Santa Clara County hopes to launch a similar program within the next few weeks. So far this year, 70% of the 120 drug deaths recorded in the county involved methamphetamine, according to the Office of the Medical Examiner-Coroner.
“We're all excited to try it and see if it does help retain people in treatment for longer periods of time so they are more successful,” said Tammy Ramsey, program manager for the Drug MediCal Organized Delivery System in the county's behavioral health department.
Other programs in counties throughout California — including Alameda, Fresno, Nevada, Sacramento and Los Angeles — will follow the same model.
If the trials are successful, Shapiro hopes the state will allow them to expand and serve everyone on Medi-Cal.
The model already has proven effective for the Department of Veterans Affairs, according to Dominick DePhilippis, the department's deputy national mental health director for substance use disorders. The VA started using contingency management in 2011, and has treated more than 6,300 veterans. Those veterans have attended about half of their appointments — and more than 92% tested negative for the targeted drug, DePhilippis said.
Shapiro believes the model works because it replaces the reward a patient's brain craves (the drug) with a different type of prize.
“It triggers that reward place in the brain that otherwise they would be turning to the drug for,” Shapiro said,
But Tom Wolf, who has battled addiction and homelessness himself and now advocates for drug policy reform, said he worries using Medi-Cal to fund contingency management will create bureaucratic hurdles to treatment. Still, he said, the program is worth a shot.
“I'm willing to try it, basically because we have such a dearth of options for people that are struggling with addictions in California,” he said.
There is also concern, as with any type of treatment, that patients will relapse once the program is over, Shapiro said. To help prevent that, the hospital will provide six additional months of counseling.
Rewarding people for staying sober doesn't work for everyone. Even before it was covered by Medi-Cal, Zuckerberg San Francisco General was experimenting with the model.
One of the people taking part, 54-year-old J.W., ended up in the emergency room with heart failure after two decades of methamphetamine use. After his hospital stay, he enrolled in a 12week program called Heart Plus, which caters to cardiac patients with a history of stimulant use.
Every time J.W. did something positive, such as show up to an appointment, take his medicine or get a negative drug test, he got to draw a Safeway gift card out of a hat.
The cards' value ranged from $5 to the “elusive” $20, and J.W. — who asked to go by his initials — estimates he earned about $180.
“It was definitely something to look forward to,” he said.
But now that the program has ended, he's still using methamphetamine — sometimes as often as three times a day — though he says he's taking smaller doses.
“I still kick myself wondering why I didn't quit altogether,” he said.
“It's actually, in my opinion, really quite criminal that we've gone decades knowing this is an effective treatment and the powers that be have failed to make a pathway for treatment for people.”
— Dr. Brad Shapiro, medical director of the Opiate Treatment Outpatient Program