Among the most challenging addictions to witness in San Francisco General Hospital’s drug clinic is methamphetamine addiction. Users of this drug experience severe physical and mental effects, including tearing at their skin and the inability to eat, sleep, or seek help. Unfortunately, unlike opioid addiction, there is currently no specific medication for treating stimulant use disorder, leaving clinic workers feeling powerless. Dr. Brad Shapiro, the medical director of the Opiate Treatment Outpatient Program at Zuckerberg San Francisco General Hospital, expressed the distressing reality of watching individuals suffer and deteriorate before their eyes.
To address this immense suffering, California is adopting a new approach to stimulant addiction: providing financial incentives in the form of gift cards to individuals who stay sober. This approach, known as “contingency management,” rewards individuals with gift cards each time their drug tests come back negative for stimulants. Although this model has shown success in clinical trials and has been utilized by the U.S. Department of Veterans Affairs for over a decade, it has not been widely implemented in California due to lack of funding. However, with Medicaid now covering the program’s costs following a recent waiver by the federal Centers for Medicare & Medicaid Services, the program is expanding in California.
California has become the first state in the nation to receive approval for a contingency management program under Medicaid. The state is launching pilot programs in 24 counties, including San Francisco, Sacramento, and Los Angeles. The costs of these programs, collectively known as the Recovery Incentives Program, will be reimbursed by CalAIM, the state’s expanded Medi-Cal services. Dr. Shapiro’s clinic is among those launching a pilot program in San Francisco.
The program involves regular testing for stimulant use, with individuals receiving a $10 gift card to a retailer like Walmart for each negative test result. The value of the gift cards gradually increases, reaching a maximum of $26.50 per test. If an individual tests positive, they receive no reward. Participants can earn up to $599 throughout the program. Santa Clara County also plans to implement a similar program in the near future due to the prevalence of methamphetamine-related deaths.
Contingency management has already proven effective in the Department of Veterans Affairs. Over 6,300 veterans have received treatment through this model, attending about half of their appointments and producing nearly 82,000 urine samples, of which over 92% were negative for the targeted drug. Multiple studies have also reported significant increases in participants’ abstinence rates when using contingency management for stimulant addiction.
Dr. Shapiro believes this model’s effectiveness lies in providing an alternative reward for patients, satisfying the brain’s reward center without resorting to drugs. However, some concerns have been raised regarding potential bureaucratic barriers to treatment as individuals wait for eligibility confirmation from Medi-Cal. Despite these concerns, advocates like Tom Wolf, who have personal experience with addiction and homelessness, believe the program is worth a try due to the lack of effective alternatives.
Although contingency management may not work for everyone, Dr. Shapiro hopes that at least a quarter of participants will significantly reduce or cease stimulant use. Additionally, to prevent relapse, the hospital will provide six months of additional counseling after the program concludes. While it may not be a perfect solution, implementing a program that rewards sobriety can provide motivation and support for individuals struggling with stimulant addiction.