In his multiple attempts to overcome a methamphetamine addiction that ground through two decades of his life, Tyrone Clifford Jr. remembers well the closest he came. “The most success I had,” he said, “is when my dealer was in jail.”
Then, Clifford walked into a rehab clinic in San Francisco called PROP, the Positive Reinforcement Opportunity Project. There, he encountered an approach so simple he sounds slightly bemused explaining it. The secret? The program paid him to show up and stay clean.
“It wasn’t much money — very little, in fact, and I didn’t really need it,” said Clifford, 52. “But I did need the support. I did need the connection. I was doing something positive for the first time in a long, long time, and it changed my outlook.”
The concept of a reward for sobriety — known as contingency management — lies at the heart of many an addiction therapy success story. Research showing it’s a highly effective tool for managing substance use disorder, especially for stimulants, goes back decades.
The Department of Veterans Affairs has long employed the therapy, providing it to more than 5,600 veterans. Some 92% of the 72,000 urine samples collected during treatment tested negative for the targeted drug, said Dominick DePhilippis, a clinical psychologist and researcher who helped launch the VA’s program in 2011.
But outside of the VA? “It is used almost zero,” said Richard Rawson, a professor emeritus at UCLA who has researched the therapy for nearly 30 years. Providers worry that by paying patients they’ll violate anti-kickback regulations and thus jeopardize their federal funding through Medicaid.
But California appears poised to challenge the regulations. On June 1, the state Senate unanimously passed Senate Bill 110, introduced by state Sen. Scott Wiener, D-San Francisco, which declares contingency management (CM) a legal practice and authorizes its funding by adding it to the list of drug treatment services offered through Medi-Cal, the state’s version of Medicaid. The price tag for the bill depends on how many patients use the therapy, but it would cost only about $179,000 a year to include the approach in treatment for 1,000 people trying to kick stimulant use, according to a financial analysis.
California’s latest budget, passed by the state Legislature in late June but subject to continuing modifications, may ultimately include money for a CM pilot program for next year. Wiener’s standalone bill would provide permanent funding — if, that is, Medi-Cal can get federal signoff on the practice.
The federal anti-kickback statute prohibits offering an inducement to a patient to choose a specific program or type of treatment. The Department of Health and Human Services’ Office of the Inspector General has to this point agreed with the Centers for Medicare & Medicaid Services that a violation would occur at any monetary incentive beyond $75 a year, which contingency management experts say isn’t enough to get results.
More than a dozen organizations have written to the Department of Health and Human Services to ask for a waiver of the anti-kickback statute as it pertains to the therapy. A group led by Dr. Westley Clark, former director of the federal Center for Substance Abuse Treatment, is asking Congress to instruct HHS to allow the treatment in Medicaid programs.
