The Best Way to Fight Meth Addiction? Gift Cards

Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode! 

Dan Gorenstein: Last year, nearly six out of every 10 fatal overdoses in the U.S. involved cocaine or methamphetamine — stimulants. That’s 60,000 people, about double the number of deaths involving these drugs just 5 years ago. Unlike for opioids, there are no FDA-approved medications for stimulant addiction. Instead, the treatment with the most evidence is pretty low-tech.

Rick Rawson: Giving people gift cards for not using cocaine and methamphetamine.

DG: Yes, giving someone a small reward every time they go a few days without using meth or coke – called contingency management — is the most effective treatment we’ve got. But for the last 30 years, it’s been mostly confined to small studies. Today, contingency management’s struggle to break through, and all eyes turn to California as the Golden State tests how well this approach works at scale. From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

****

DG: We began to learn that gift cards were our best line of defense against meth and cocaine in the 1980s. University of Vermont Professor Steve Higgins was studying addiction as celebrities started dying from cocaine.

Steve Higgins: I remember John Belushi being one.

News clip: His investigation concluded that Belushi died of an overdose due to intravenous injections of heroin and cocaine.

DG Steve remembers Len Bias too: a star college basketball player, dead just days after getting drafted #2 by the Boston Celtics.

News clip: He died of heart failure because he used cocaine.

SH: It was sad. He was a tremendous player. And celebrating what should have been a great career in the NBA. And instead he was dead that night.

DG: At the time, many viewed cocaine as a fun, social drug.Use skyrocketed — more than a million people ended up addicted. Pretty quickly, Steve says it became clear cocaine was hardly a party for everyday Americans.

SH: They are getting fired from their jobs. Their marriages are breaking up. They’re getting arrested, prostituting themselves to get money for more cocaine. And we had no treatment.

DG: The nation’s growing cocaine crisis had caught policymakers and researchers flat-footed. Congress responded with a sledgehammer: increasing federal prison sentences for drug possession. That policy did little to discourage use and put a disproportionate number of Black Americans behind bars. Researchers like Steve started hunting hard — initially for a medication. But Steve knew cocaine and other stimulants like meth produce dopamine, the brain chemical that helps us feel joy, carry out functions of daily life — eating, sleeping, going to work.

SH: Are we going to be able to develop a medication that’s effective enough to reduce cocaine use and selective enough to leave the other things that dopamine does intact?

DG: Steve saw chemistry as a dead end. Instead, he put his faith in psychology.

SH: You want something, you incentivize it. It’s a basic facet of behavioral science. 

DG: Decades of research had shown positive reinforcement could be a great motivator. You could get animals to pull a lever by rewarding them with food, get kids to behave in class by letting them watch TV afterward. And you could get patients with opioid addiction to attend counseling sessions more often if you rewarded their good attendance with a bit more control over how and where they got their medication. Researchers attached a clunky name to this reward strategy: contingency management.

SH: This basic approach of reinforcing desirable behavior is effective, so we weren’t making up that basic scientific relationship. We were just bold enough to think it had a place in treating cocaine. 

DG: Steve and his colleagues set up a small trial in Vermont in 1989. If a patient tested negative for cocaine in the urine tests they took a few times a week, they got a gift card, and the payout got bigger with each test. If you tested negative every time over 12 weeks, you could make more than $1,000.

SH: But if you had a lapse – you use cocaine – then you’d have to go back to the beginning. 

DG: Steve and his colleagues compared their treatment to a counseling program. Half of Steve’s gift card group tested negative for at least eight weeks in a row. No one could claim that in the counseling program. Steve checked with other researchers trying to develop medications for cocaine addiction. Steve’s approach was the only one having this kind of success.

SH: That’s when we realized, wow, we’ve got something pretty good here. We can get them to remain in treatment. And about half of them are cocaine abstinent. 

DG: Around the time Steve was seeing contingency management help people in Vermont, Rick Rawson was seeing talk therapy do painfully little for his patients in Los Angeles.

Rick Rawson: I felt helpless. This was something we should be able to help these patients with, but we needed to find a way to do better.

DG: Rick, an addiction researcher at UCLA, ran a cocaine treatment center in the city. He remembers being stunned and a little suspicious of Steve’s work.

RR: Nobody was getting results like this. They were very positive, like almost unbelievably positive.

DG: For many people in the field, Steve’s methods seemed so not clinical.

RR: It wasn’t a medicine. It wasn’t a talk therapy. It was this sort of transactional thing. And come on, that’s not real treatment.

DG: Rick, himself, was open-minded about it. He knew his approach usually just helped a small slice of people stop their use for short stretches. Rick wanted more than that, so he secured federal funding to test this gift card thing for himself. When the results came in, Rick was blown away.

RR: We found that about 60% of them discontinued their cocaine completely. 

DG: Some participants had told Rick they’d signed up for his program just to get the money, figured they’d start using again once the 16-week study was over. But after they’d been sober for a few months, cocaine had lost its appeal. Rick was ecstatic.

RR: This was not some kind of parlor game or magic trick where they could do this for a while and then they would immediately go back to using cocaine. This was a potential game changer.

DG: By the early 2000s, studies consistently showed this treatment was nearly twice as effective as counseling at getting people to stop using cocaine and meth. Still, paying people to stop using drugs just seemed wrong to lots of folks. Rick, though, was a true believer, and he was on a mission to get contingency management to as many people as he could. He even developed a kind of mantra. 

RR: The time has come. I mean, we have this thing that works.

DG: Rick ultimately convinced California health officials to fund pilot programs at about a dozen clinics. Results looked promising. Patients were doing well, lawmakers in Sacramento were watching, talking expansion. And then suddenly, it was all over. 

RR: I got an email one day from a group in Santa Clara County saying, we just had a Medicaid audit for our treatment program.

DG: This was 2006, about 15 months in.

RR: And the auditor said, we can’t do contingency management, that, in fact, giving people gift cards for participating in treatment is giving them kickbacks. And we’re getting a cease and desist order, and we’re told if we don’t stop, it could jeopardize our Medicaid license. And so we’re stopping. 

DG: Rick was confused. He’d never heard of Medicaid anti-kickback rules. He knew Medicaid was the state and federal insurance program for low-income and disabled Americans. But his work was separate, paid for by a state grant.

RR: Medicaid said it doesn’t matter. It’s using money from anywhere to get people to participate in treatment or to reward people for participating in any kind of treatment is considered a kickback.

DG: The rules, Rick learned, were designed to prevent fraud, to stop doctors from paying patients just to walk through the door so the doctors could then charge Medicaid pretending to provide care they never provided. Over the next few weeks, all of Rick’s clinics — under pressure from Medicaid — shut down the work.

RR: So that pretty much stopped everything.

DG: Rick understood Medicaid’s concerns, knew they were just doing their job. But Rick’s job was to help people pull their lives back from the grips of meth and cocaine. And contingency management was, really, the only tool that had given people some legitimate hope. Rick’s appeal to federal officials went nowhere.

RR: I’d pretty much given up. I figured this just isn’t going to happen.

DG: Rick was right. Outside a few thousand veterans who got the treatment, contingency management went dormant for a decade. Then, fentanyl hit the scene

RR: Starting in about 2016, 2017…

News clip: Overdose deaths involving stimulants are also on the rise…

RR: …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.

News clip: More people are dying from meth overdoses than heroin across Colorado…

RR: So the addiction that’s driving the drug use is their cocaine and methamphetamine use.

DG: Between 2011 and 2019, overdose deaths involving meth in California quadrupled. This time, state health officials were knocking on Rick’s door. California was seeking permission from federal officials to use Medicaid dollars for a bunch of outside-the-box treatments, an initiative they dubbed “CalAIM.” And they wanted to include contingency management. When the feds signed off at the end of 2021, Rick knew hundreds of thousands of people addicted to cocaine and meth were finally that much closer to the treatment that had the highest rate of success. 

RR: I was thrilled. I was absolutely thrilled. And when that happened, it was like, okay, let’s get to work.

DG: After the break, a front-row seat to California’s new contingency management program, and why the state’s deliberate approach comes with a price.

MIDROLL

DG: Welcome back.

Andrew Dertien: How was art therapy? 

Bernard Groves: It was great. Yeah, art therapy was so much fun.

DG: Counselor Andrew Dertien and his patient, Bernard Groves, sit in a cramped exam room in San Francisco. Bernard is 35, dressed in jeans, a black t-shirt and black baseball cap. He beams as he shows Andrew the book of art he’s working on.

BG: I did this one right here for my mom. It says love. I’m going to frame them all and give them out as Christmas gifts to family members. They’re a big part of what helps me stay sober.

DG: Bernard has spent the last five years trying to quit meth. For the last 16 weeks, he’s come here to HealthRIGHT 360, a primary care and addiction clinic in the city’s Mission neighborhood.

AD: So we’ll start off like we always do with our test.

DG: Andrew hands Bernard a small clear plastic cup for Bernard to pee in. Under California’s contingency management pilot, Medicaid patients like Bernard take regular drug tests for six months and earn gift cards for each one that, like today, is meth- and cocaine-free.

AD: Stimulant negative.
BG: Negative. Yay! Awesome.
AD: That’s what’s up.

DG: Andrew turns to his computer to enter Bernard’s negative test into the system.

AD: So you are on week 16. This incentive is worth 15 bucks.

DG: Gift cards start at $10 for the first negative test and go up to $26.50. Patients can choose: take each gift card individually, or “bank them” and save up. Since Bernard started, he’s bought weights from Walmart and, at Petco, food for his pet bird, London.

AD: You’re at $80.50.
BG: Ayyyy. Love that.
AD: Great job. What are we saving for this time-around?
BG: I think this time around, I’m saving for Nikes. I think I want to get myself some kicks.
AD: Okay.
BG: Maybe buy my sister a little Nike something. She’d like that.

DG: If Bernard tested negative every week for the entire program, he would earn $599. Most studies show contingency management works best when patients can make about $1,000. California went with the lower amount to avoid triggering tax problems for patients or messing with their eligibility for other benefits like food assistance. It’s unclear if offering $599 will be as effective in the long-run, but so far, it’s worked for Bernard.

BG: I’ve really been doing well recently, and I’ve just been feeling so happy.

DG: He’s been off meth for the last 73 days, one of his longest stretches since he started trying to quit. This feels different to Bernard. Over the last five years, he checked himself into rehab several different times. It always seemed to be the same deal: group therapy, individual therapy. But eventually, he’d chafe, like everybody was just telling him what to do. And he’d go back to using.

BG: My best friend was like, I don’t get it, Bernard. He’s like, you put your mind to something, you’ve always been able to achieve it. He’s like, I don’t understand. He’s like, why can’t you get over this meth? It’s just it’s one of the goals that has been so hard for me to achieve. I don’t know why. And it feels awful.

DG: Bernard says he hates who he is on meth.

BG: I was sort of just isolated and all by myself, hiding away, scared of the world.

DG: He’d stay in his bedroom for days, shut everything out. One of the things that gets him about his use is that he sees what it does to the people he loves most.

BG: I went out with my auntie. She was here at the beginning of the year.

DG: Bernard was high when they met for lunch.

BG: I just saw such sadness in her eyes. And it was it really, it was really sad for me. I’d always seen, like, irritation on people’s faces or people didn’t have patience with me when I was using. So to see somebody sad was a totally different experience.

DG: The small rewards that come from contingency management feel good to Bernard. He can do stuff he really enjoys, like buy Krispy Kreme donuts for his mom, sister and grandma on movie nights.

BG: It brought some joy back in my life. I was excited. Like, how could you say you’re excited to pee in a cup. But I was. Every week I am. I can’t wait for my appointment with Andrew.

DG: What’s happening for Bernard there is that the excitement of getting a gift card replaces the excitement of using meth. Researchers hypothesize it’s effectively rewiring his brain. And recent studies have found people are more likely to stay off meth for up to a year after these programs, compared to counseling. But Bernard is honest with himself. Even if he makes it through contingency management, what happens in November when the gift cards stop?

BG: I’ve been trying for five years now. So I’m hoping that this chapter is the last chapter, and I’m sober from here on out. That would be amazing.

DG: Bernard is one of 4,000 people to go through CalAIM’s contingency management program since it launched 18 months ago. Many of those people, like Bernard, are having success, according to interviews with clinics. People have gotten off the streets, gone back to work and reconnected with their families. Researchers at UCLA say at least 75% of urine samples have been negative for stimulants.

Here’s the rub. Those 4,000 patients are a tiny fraction — just 2% — of the some 210,000 Californians on Medicaid who are addicted to meth and cocaine. Lots of providers who want to offer their patients this treatment are on the outside right now looking in.

Ayesha Appa: The CalAIM pilot is a phenomenal step forward. But did it allow my patients to access contingency management? No.

DG: Ayesha Appa is an HIV and addiction doctor at San Francisco General Hospital. Most of her patients are homeless, using meth and on Medicaid. But there are no gift cards for them.

AA: It feels incredibly both frustrating and just heartbreaking as a provider. 

DG: To offer contingency management through Medicaid in California … providers must be part of a special addiction treatment program run by the state. Any provider can apply, but it’s mostly addiction clinics like HealthRIGHT 360 where Bernard goes that participate. Few primary care docs, community health clinics and hospitals — including the one where Ayesha works — have joined, even though they care for lots of people addicted to meth and coke. Ayesha offered contingency management at her clinic until a private grant ran out back in June. The consequences of not offering that care are real, Ayesha says, as she remembers one 45-year old patient.

AA: She really desperately wanted to stop using. That was the focus of every conversation we had.

DG: Ayesha describes the woman as close with her family and someone who loves bedazzling handbags. She’d managed her HIV well, Ayesha says, but her meth use kept tripping her up. 

AA: She began using more and more methamphetamine, stopped taking her HIV medications. Hospitalized a couple of times.

DG: Because her hospital isn’t in Medicaid’s addiction treatment program, contingency management wasn’t an option. Ayesha tried to convince her to visit one of the CalAIM clinics, but the woman didn’t trust other doctors, only Ayesha. Ultimately, she overdosed and died.

AA: 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. What if we could have offered her contingency management in the clinic that she was coming into already? When I think about her, it’s an equal mix of guilt and regret because it truly felt like we could have done more.

DG: Ayesha’s patients being left out of CalAIM or that $599 annual limit on gift cards, these are two examples of the compromises California health care officials made when they moved this approach from small, carefully crafted research trials into the real world of the U.S. health care system. California Medicaid Director Tyler Sadwith wants to be intentional and careful as he brings a controversial treatment like this to scale.

Tyler Sadwith: We’re approaching this with the long game in mind.

DG: Tyler believes in contingency management, and he’s got until the end of 2026 to convince his bosses – state and federal leaders – that Medicaid should keep paying for it. Remember, this is a pilot program. Tyler says making the service available to a larger pool of people would’ve required major changes to California’s whole Medicaid program. Starting small, he said, gave the state the best chance at success.

TS: We needed to prove and demonstrate that this works and that this works well.

DG: Tyler and his colleagues knew the history. Policymakers and many clinicians had spent decades blocking contingency management — scoffing at the idea that small payments could be an effective treatment, also afraid it could lead to fraud. The growing death count tied to meth and cocaine has opened the minds of a lot of skeptics. But, still, Tyler and his team feel a lot of responsibility. California is the first state in the nation to use Medicaid money for this. A misstep, like problems with fraud, could doom the idea.

TS: We didn’t take that responsibility lightly. And I think we continue to feel the importance and the weight of getting this right.

DG: They want to avoid gift cards that go missing or the treatment being a flop. So they require clinics to do extra training, buy special equipment, and then submit to an inspection, all before they can give out a single gift card. Tyler understands these guardrails have slowed the program’s roll out and narrowed its impact, especially the requirement for clinics to have three staffers go through ongoing training.

TS: We know that some providers would love to jump in, but they’re delayed by a few months or some actually pulled back because they can’t hire new staff to help set this up, or they’re losing staff.

DG: The state set aside $5.6 million to help clinics stand up their programs. Tyler is excited to reach more patients, eventually. He hopes going slow now will allow the state to do just that. 

TS: 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. People get better, and there is a role for contingency management in Medicaid. 

DG: At least 3 other states are convinced and have followed California’s lead — Montana, Washington and Delaware — with four more seeking federal approval.

DG: Rick Rawson is excited that contingency management is finally getting a chance. The stories of people like Bernard and the early results from CalAIM are why he pushed the idea so hard for so many years.

But he knows there are still some unanswered questions. Namely, how long do people need to stay on the program to achieve lasting sobriety? Is $599 a year enough to get people to quit? 

RR: We know that $100 is inadequate. We’ve seen in the studies $1,000, $1,200, that does make a difference. We’re trying to figure out the sweet spot for what we need to use.

DG: Researchers have spent 30 years fighting to get people in power to accept the facts:  Rewarding someone with money can help get them off drugs. That idea finally seems to have gained some traction. Now, Rick hopes programs like CalAIM can make the treatment even better, spread it to more people, and save more lives.

I’m Dan Gorenstein, this is Tradeoffs.