Patients at VA recovery sessions draw from a plastic fishbowl that holds 500 slips of paper. Half of those slips contain positive messages: “Good job.” “Way to go.” Another 209 slips are worth $1, while 40 are worth $20 and one “jumbo” prize of $100 lurks in every bowl. As patients continue to stay clean, the number of slips they get to draw increases, to a maximum of eight. If they skip meetings or test positive, they go back to drawing a single slip. The money is paid in the form of vouchers that can be used through the VA’s canteen system to buy food and other items, but not alcohol or tobacco.
In other programs that employ the approach, including the one Tyrone Clifford Jr. found in San Francisco in 2011, patients receive gift cards worth $300 to $400 over 12 weeks in exchange for regularly attending meetings and producing clean tests. Most of the incentive programs are designed to end after three months, on the theory that patients have used the time to regularly attend counseling and therapy sessions and kick-start their recoveries.
That is what happened to Clifford, who fell into meth use after learning he was HIV-positive at age 21. He and his partner (now husband) soon moved from Georgia to San Francisco, where his use spiraled out of control until he was advised to visit PROP, administered through the San Francisco AIDS Foundation.
“The money wasn’t the main thing for me — but it is for some of the guys who come in here,” Clifford said. “They may need that small amount to keep a cellphone bill paid. They may need that for a doctor. I hear people say, ‘Why should we pay a drug user to stop using drugs?’ My answer is that it works. You keep coming in, week after week, and pretty soon you’re back on your feet.”
Some critics have moral qualms about paying a patient for good behavior, and therapists are sometimes wary of the approach. But effective approaches are needed. In San Francisco, the meth overdose death rate has increased more than 500% since 2008, and half of all psychiatric emergency room admissions at San Francisco General Hospital are now meth-related.
“As a gay man in San Francisco, my community has been deeply affected by meth use,” Wiener said. Meth use spiked 20% nationally among those tested in the early months of the pandemic.
Those who’ve seen the approach used successfully in treating meth addiction are befuddled by its unavailability, especially now that states offer everything from marijuana to Yankees tickets to persuade people to get vaccinated against COVID-19.
Still, Rawson said he doubts California’s bill can override the HHS restrictions as currently written. Wiener, on the other hand, doesn’t believe the use of therapy was ever in violation of anti-kickback statutes.
Clifford simply knows it works.
“I see it now from the other side,” said Clifford, who is 10 years sober and now counsels those trying to kick meth addiction through the San Francisco AIDS Foundation. “Guys keep coming back. You can see it building every week.”
Update: A response from the HHS Office of the Inspector General has been added to this story.
This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.