Controversial but effective treatment for meth addiction gains traction in California

Bernard Groves spent five years trying to quit meth.

He lost his job. He lost his car. He almost lost his apartment. Worse still, he says, his addiction harmed his family.

“I went (to lunch) with my aunt and I saw such sadness in her eyes,” Groves said.

The 35-year-old enrolled in several rehabilitation programs in San Diego and San Francisco in hopes of “becoming the Bernard I was to the people I love.”

But each time, Groves felt that the progress he had made in therapy translated into people talking to him, telling him what to do. Eventually, he would always return to meth.

“My best friend said to me: “I don’t understand, Bernard. You focused on something, you always managed to achieve it. Why can’t you get over this meth? ” Groves said. “I don’t know why. And it’s horrible.

Unlike opioid addiction, there are no FDA-approved medications for the more than 3 million Americans addicted to stimulants like methamphetamine and cocaine. Instead, the most effective treatment is low-tech — and more controversial: Offer people retail gift cards typically worth less than $30 in exchange for negative drug tests. Research shows it works, and after more than three decades of resistance, policymakers are finally giving this strategy a chance.

“It’s not a treatment”

Offering small rewards to people who do not use drugs – so-called contingency management – ​​dates back to the 1980s. Patients are subjected to drug tests regularly over several months. They receive a gift card for each negative result and payments increase with each test.

The treatment is based on a well-established concept that positive reinforcement is an effective motivator. Animals pull the levers when rewarded with food. Pupils’ behavior improves by letting them watch television after class. Compared to traditional advice, researchers found that people are twice as likely to stop using meth or cocaine if they receive gift cards.

Studies suggest that the immediate excitement of receiving a gift card after a negative test replaces the dopamine rush people feel when using drugs. Scientists hypothesize that this activity effectively rewires our brains.

But this approach has failed to take hold despite the evidence.

Rick Rawson, professor emeritus of psychology at UCLA and an early proponent of contingency management, says many addiction treatment providers have historically dismissed treatment as a form of corruption.

“You would hear things like: It’s not treatment, it’s just paying people not to use drugs,” Rawson said. “It wasn’t medicine. It wasn’t talk therapy. It was that transactional kind of thing.

Fears of fraud have also hampered the growth of contingency management. Rawson persuaded California health officials to fund a pilot program in 2005. But work stopped abruptly after federal health officials warned participating clinics that the project violated rules intended to prevent doctors from lure patients into their practices and then bill Medicaid for care they never received. provided.

“I had pretty much given up,” Rawson said after Medicaid stopped the pilot. “I thought it just wouldn’t happen.”

Contingency management gets a second chance

Outside of the Department of Veterans Affairs, which has offered emergency management since 2011, the treatment has been dormant for nearly a decade. But attitudes began to change after fentanyl, a synthetic opioid, fueled a surge in overdose deaths in the United States, Rawson said.

“People have started to realize that a lot of these people are buying cocaine or meth and dying from fentanyl overdoses because fentanyl is mixed into the drug supply,” Rawson said.

Over the past four years, some states have relied on federal grants or court rulings against opioid manufacturers to fund their emergency management programs. In California — where meth overdose deaths have soared — health officials have asked the federal government to allow the state to become the first in the nation to fund contingency management with Medicaid dollars.

The Biden administration greenlighted the plan as well as a broader set of nontraditional health care services that California is testing, called CalAIM. Under the state’s emergency management program, launched last year, gift cards after each stimulant-free urine test start at $10 and go up to $26.50. A patient who tests negative every time for six months can earn up to $599, which can be paid individually or as a lump sum.

It’s unclear if this will be enough to convince people to stop. Most studies show that contingency management works best when patients can earn more than $1,000. California chose a lower amount to avoid triggering tax problems for patients or jeopardizing their eligibility for other public benefits like food assistance.

The value of gift cards worked for Bernard Groves. He hasn’t used meth since the first week of July, one of his longest stretches since he started trying to kick the habit.

He used the gift cards to buy exercise weights at Walmart and food for his pet bird London at Petco. He also used the money to buy donuts or for a movie night with his mother, sister and grandmother.

“Being able to care for my family and do things for them is special,” Groves said. “It brought some joy back into my life.”

He is surprised at how much fun the program gives him.

“Like, how can you say you’re excited about peeing in a cup?” But I was, every week.

Groves hopes this approach will finally help him quit his meth use. Recent studies have shown that people are more likely to stay off stimulants for up to a year after these programs, compared to counseling and 12-step programs.

California approach leaves out some patients

Nearly 4,000 people participated in California’s new program as of September 2024. UCLA researchers say at least 75% of urine samples submitted by patients in the program tested negative for stimulants, and clinics say many of their patients have found housing and moved on. return to work and reconnect with their families.

But California has about 210,000 people on Medicaid who are addicted to meth or cocaine. Medicaid in California generally only covers addiction treatment at specialty addiction clinics, so most people who receive their treatment from primary care doctors, community health clinics, or hospitals cannot access to emergency management.

Ayesha Appa is an addiction specialist who runs an HIV clinic at San Francisco General Hospital, where most of her patients are homeless, use meth and are on Medicaid. She offered emergency management through a private grant until funds run out in June, and she is not eligible to offer it through CalAIM.

“It’s both incredibly frustrating and heartbreaking as a provider,” Appa said, to know that there is a powerful treatment that she can’t offer. “I feel like I have a diabetic patient and instead of being able to offer them insulin, all I can do is talk to them about diet and exercise, even though I know that ‘There is a better option.’

She often thinks of one patient, a 45-year-old woman, who “desperately wanted to stop using” meth, but had difficulty quitting. Appa urged her to go to a CalAIM clinic to get emergency management treatment, but the woman didn’t trust other doctors. Ultimately, the woman overdosed and died.

“What if we had been able to offer her emergency management in the clinic where she was already arriving?” Appa said. “When I think of her, it’s an equal mix of guilt and regret, because I really felt like we could have done more.

“People are better”

California Medicaid Director Tyler Sadwith believes in the power of this treatment, but has taken a cautious approach as the state attempts to expand this work due to the stigma that emergency management still carries among some health care providers and legislators.

Sadwith said he appreciates that more people can benefit now, but starting small gives supporters their best chance to convince state and federal leaders to extend and expand the program beyond its date current end of 2026.

“We need to prove that it works and that it works well,” Sadwith said. “We feel the importance and the weight of getting this right” as the first state in the nation to cover this type of treatment under Medicaid.

To ensure programs deliver treatment effectively and minimize the risk of fraud, California requires clinics to undergo additional training and inspections, and requires clinicians to enter their results into a central database. Clinics also must dedicate three staff members to the program, a labor requirement that has forced some providers to delay starting treatment or not participate at all.

So far, state officials have set aside $5.6 million to help clinics implement their programs, and Sadwith is eager to reach more patients.

“We want to take this opportunity to prove to the public, to the field, to our federal partners and to other states that this works,” Sadwith said. “People are getting better and Medicaid has a role to play in handling contingencies.”

At least three other states — Montana, Washington and Delaware — now operate their own programs through Medicaid, and four more are seeking federal approval.

This story comes from the health policy news organization Tradeoffs. Ryan Levi is a reporter/producer for the show, where a version of this story appeared for the first time. Listen to the story here:

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