Updated October 09, 2024 at 18:37 PM ET
Bernard Groves has spent five years trying to quit methamphetamine.
He lost his job. He lost his car. He nearly lost his apartment. Worse than that, he says, his addiction has hurt his family.
“I went [to lunch] with my auntie and I saw such sadness in her eyes,” Groves said.
The 35-year-old checked himself into several rehab programs in San Diego and San Francisco hoping "to be that Bernard I used to be for the people that I love."
But each time, Groves felt the progress he made in therapy morphed into people talking at him, telling him what to do. Eventually, he would always return to meth.
“My best friend was like, ‘I don't get it, Bernard. You put your mind to something, you've always been able to achieve it. Why can't you get over this meth?’ ” Groves said. “I don't know why. And it feels awful.”
Unlike opioid addiction, there are no FDA-approved medications for the more than 3 million Americans addicted to stimulants like meth and cocaine. Instead, the most effective treatment is low-tech — and more controversial: Give people retail gift cards usually worth less than $30 in exchange for negative drug tests. Research shows that it works, and after more than three decades of resistance, policymakers are finally giving that strategy a chance.
‘This isn’t treatment’
Offering people small rewards for not using drugs — known as contingency management — dates back to the 1980s. Patients are tested for drugs regularly over several months. They receive a gift card for every negative result, and payouts grow with each test.
The treatment is based on a well-established concept that positive reinforcement is an effective motivator. Animals pull levers when rewarded with food. Students’ behavior improves by letting them watch TV after class. Compared to traditional counseling, researchers have found people are twice as likely to stop using meth or cocaine if they receive gift cards.
Studies suggest the immediate excitement of getting a gift card after a negative test replaces the dopamine rush people get from using drugs. Scientists hypothesize this activity effectively rewires our brains.
But the approach has failed to catch on in spite of the evidence.
Rick Rawson, a professor emeritus of psychology at UCLA and early proponent of contingency management, says many addiction care providers historically dismissed the treatment as a form of bribery.
“You would hear things like, this isn't treatment, this is just paying people not to use drugs,” Rawson said. “It wasn't a medicine. It wasn't talk therapy. It was this sort of transactional thing.”
Concerns of fraud have also stymied contingency management's growth. Rawson persuaded California health officials to fund a pilot program in 2005. But the work stopped abruptly after federal health officials warned participating clinics that the project ran afoul of rules designed to prevent doctors from luring patients into their offices and then charging Medicaid for care they never provided.
“I'd pretty much given up,” Rawson said after Medicaid shut down the pilot. “I figured this just isn't going to happen.”
Contingency management gets second chance
Outside of the Department of Veterans Affairs, which has offered contingency management since 2011, the treatment lay dormant for nearly a decade. But attitudes began to shift after the synthetic opioid fentanyl fueled a rise in overdose deaths in the U.S., Rawson said.
“People started to recognize that a lot of these people are buying cocaine or methamphetamine and dying of fentanyl overdoses because fentanyl is mixed into the drug supply,” said Rawson.
In the last four years, some states have relied on federal grants or court rulings against opioid manufacturers to fund their contingency management programs. In California — where overdose deaths involving meth have skyrocketed — health officials asked the federal government to allow the state to become the first in the nation to pay for contingency management with Medicaid dollars.
The Biden administration greenlit the plan along with a broader package of non-traditional health care services California is testing called CalAIM. Under the state’s contingency management program, which launched last year, gift cards after each stimulant-free urine test start at $10 and climb up to $26.50. A patient who tests negative every time over six months can earn up to $599, which can be paid out individually or in a lump sum.
It's unclear if that is enough money to persuade people to quit. Most studies show contingency management works best when patients can make upward of $1,000. California picked a lower amount to avoid triggering tax problems for patients or compromising their eligibility for other public benefits like food assistance.
The value of the gift cards have worked for Bernard Groves. He's been off meth since the first week of July, one of his longest stretches since he started trying to shake the habit.
He's used the gift cards to buy exercise weights at Walmart and food for his pet bird London at Petco. He's also used the money to pick up donuts or a movie night with his mom, sister and grandma.
“Being able to treat my family and do things for them is special,” Groves said. “It brought some joy back in my life.”
He’s surprised at how much pleasure he’s gotten from the program.
“Like, how could you say you're excited to pee in a cup? But I was, every week.”
Groves hopes this approach will help him finally kick his meth use. Recent studies have found people are more likely to stay off stimulants for up to a year after these programs, compared to counseling and 12-step programs.
California’s approach leaves some patients out
Nearly 4,000 people have participated in California’s new program as of September 2024. Researchers at UCLA say at least 75% of urine samples submitted by patients in the program have been negative for stimulants, and clinics say many of their patients have gotten into housing, gone back to work and reconnected with their families.
But California has an estimated 210,000 people on Medicaid who are addicted to meth or cocaine. Medicaid in California generally only covers addiction treatment through specialty addiction clinics, so most people who get their treatment from primary care doctors, community health clinics or hospitals are unable to access contingency management. (Those other providers could technically offer it, but it would require them jumping through several administrative hoops first.)
Ayesha Appa is an addiction specialist who runs an HIV clinic at San Francisco General Hospital, where most of her patients are homeless, using meth and on Medicaid. She offered contingency management through a private grant until funding ran out in June, and and her hospital is currently ineligible to offer it through CalAIM.
“It feels both incredibly frustrating and just heartbreaking as a provider,” Appa said, to know a powerful treatment exists that she can’t offer. “It feels like I have a patient living with diabetes, and instead of being able to offer them insulin, all I can do is talk with them about diet and exercise, even though I know there’s a better option out there.”
She thinks often of one patient, a 45-year-old woman, who “desperately wanted to stop using” meth, but who struggled to quit. Appa urged her to visit a CalAIM clinic to get contingency management treatment, but the woman didn’t trust other doctors. Ultimately, the woman overdosed and died.
“What if we could have offered her contingency management in the clinic that she was coming into already?” Appa said. “When I think about her, it's an equal mix of guilt and regret because it truly felt like we could have done more.”
'People get better'
California Medicaid Director Tyler Sadwith believes in the power of this treatment, but has taken a careful approach as the state attempts to scale this work because of the stigma contingency management still has among some health providers and lawmakers.
Sadwith said he appreciates that more people could benefit right now, but starting small gives proponents their best chance of convincing state and federal leaders to extend and expand the program beyond its current end date of 2026.
“We need to prove that this works and that this 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 sort of treatment under Medicaid.
To make sure programs deliver the treatment effectively and minimize the chance of fraud, California requires clinics go through extra training and inspections, and makes clinicians enter their results into a central database. Clinics also have to dedicate three staffers to the program, a workforce requirement that has forced some providers to delay starting the treatment or not participate at all.
So far, state officials have set aside $5.6 million to help clinics stand up their programs, and Sadwith is eager to reach more patients.
“We want to use this opportunity to prove to the public, to the field, to our federal partners, and to other states that this works,” Sadwith said. “People get better, and there is a role for contingency management in Medicaid.”
At least three other states — Montana, Washington and Delaware — are now running their own programs through Medicaid, and four others are seeking federal approval.
This story comes from the health policy news organization Tradeoffs. Tradeoffs' coverage of CalAIM is supported in part by the California Health Care Foundation.
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