Fentanyl and other opioids dominate discussions about the overdose crisis on the West Coast. But stimulants, like methamphetamine and cocaine, are often involved in fatal drug overdoses, too, especially when they are mixed with opioids like fentanyl, intentionally or not.
That’s why San Francisco city leaders are looking to increase access to treatment for stimulant use with the help of the millions of dollars the city is receiving through settlements with opioid manufacturers and pharmacies.
Wayne Rafus is a manager at a program at the San Francisco AIDS Foundation (SFAF) that helps people change their meth or cocaine use, called PROP 4 All. He said that about 40% of the time, fentanyl is showing up in voluntary drug tests — even though the participants haven’t intended to use that drug. This unintended use of opioids is contributing to the crisis of fatal overdoses. “Fentanyl is showing up in stimulant use, particularly meth and cocaine, which is very sad because sometimes folks are not intentionally wanting to use an opioid,” he said.
San Francisco is slated to receive about $352 million over the next 15 years through settlements with a number of companies, including Walgreens, CVS, Teva, Allergan and others for their role in the opioid epidemic. The funding is earmarked to address problems that have come out of the opioid crisis, from increased overdoses to dangerous street-level activity.
As part of that, Mayor London Breed is proposing to use $56.2 million of the settlement in the 2023–24 fiscal year budget and $46.5 million in the 2024–25 budget. Of that, $2 million (PDF) would be allocated each year for contingency management programs to address stimulant use. These programs use an incentive and positive-reinforcement-based approach to curbing addictions, primarily for stimulants like meth or cocaine.
San Francisco is simultaneously using settlement funding to increase access to opioid treatments, such as buprenorphine, suboxone and methadone medications, as well as abstinence-based programs and residential facilities.
But unlike opioids, there are no federally approved medications to treat stimulant use.
Instead, contingency management has been employed by Veterans Affairs for many years as one option that’s shown success; the agency was the first to complete a large-scale implementation of the approach. A 2018 study found that, on average, VA patients attended more than half of their counseling sessions, and 91% of participants tested negative for the targeted substance.
A study in 2021 meanwhile found that contingency management showed “long-term benefit in reducing objective indices of drug use, above and beyond other active, evidence-based treatments.”
Rick Andrews, director of contingency management at SFAF, said that some participants are also enrolled in Alcoholics Anonymous, Crystal Meth Anonymous, other 12-step recovery programs or additional counseling while they are at PROP. Graduates often transfer to longer-term treatment after they complete the program.
“We have folks in CMA, AA and other programs working in conjunction with us as well,” said Andrews. “And folks who are not ready for abstinence, what’s great for them is that they can come here, feel like they are trying to do something, and be around people. They get something to eat, counseling and community, even if they aren’t ready now.”
Addiction experts say that tackling meth and cocaine addiction is crucial as the city works to address its overdose crisis, because those substances also appear in a large portion of fatal accidental overdoses, according to data from the San Francisco Office of the Chief Medical Examiner.
“Meth is a big, big problem that gets overshadowed by opioids, but a significant percentage of people who are using drugs in our streets are using meth, either alone or in combination with other drugs,” said Sen. Scott Wiener (D-San Francisco), who has advocated for expanding approaches to treat meth addiction. “Contingency management is an incredibly important and impactful approach or treatment for meth addiction.”
At PROP 4 All and PROP, a similar program at SFAF that focuses on the gay male community, participants attend weekly group sessions in a calmingly dim conference room off Market Street. They discuss their use patterns, challenges and goals for how they want to adjust their use.
They also are given the option to take a drug test, and if it comes back negative, they can earn a cash incentive in the form of gift cards. After the 12-week program, participants often transition to longer-term counseling and care, depending on their specific goals and needs.
Participants can earn up to $330 in gift cards, if they test negative throughout the entire 12-week program. The cash may start as a draw, but leaders and participants said that what keeps people coming is having a new community, finding stability and getting connected to other services, like housing or longer-term treatment programs.
Tyrone Clifford was a participant at PROP before becoming a manager of contingency management at the program. On his 21st birthday, just before moving to San Francisco, he found out he was HIV-positive and was told he had maybe two years to live. Clifford then began partying and using more drugs in an effort to cope with the diagnosis.
But after he far outlived the prognosis, his doctor encouraged him to reevaluate his relationship to meth. Clifford had been thinking about changing his drug use, so the encouragement spurred him to give contingency management a try.
The weekly visits and community he built helped Clifford keep his promises to himself, he said, and gave him a chance to stabilize from the everyday chaos that heavy meth use can bring. The substance can keep users up for days, straining sleep and eating schedules, and lead to other physical and emotional harm in the long run.
“Being in the group, it helped me to stay balanced, you know, helping to appreciate the lives of others and to understand that we’re all doing the same thing. But we all have different reasons for why we do it. We’re all looking to do it to help us get through different things,” said Clifford.
In coordination with UCSF and nonprofits, the San Francisco Department of Public Health provides contingency management at the Citywide Clinic’s Stimulant Treatment Outpatient Program, the Office-Based Buprenorphine Induction Clinic and Project HOUDINI LINK (Hospital Opioid Use Disorder treatment INItiation and LINKage to care).
To date, the expansion of San Francisco’s contingency management programs has come from Prop. C, which passed in 2018 to provide funds to address homelessness. But the Department of Public Health’s overdose prevention plan suggests that these programs won’t be sufficiently utilized without sustained longer-term funding.
Now, San Francisco is looking to add at least one additional contingency management program and increase the number of overall participants by 25% in the next four years, according to the overdose prevention plan.
Those efforts are paralleled by a statewide initiative. In 2021, California became the first state to cover contingency management through Medi-Cal, potentially opening doors for people who may have struggled to afford residential treatment or other treatment options.
The state also allocated $58.5 million to pilot contingency management programs in nearly two dozen other California counties. Each patient receives a maximum of $599 over six months, after which they are referred for follow-up recovery programs and services.
Still, it can be hard to find or even know about contingency management program options. Many people at PROP, for example, arrive through word of mouth, court-ordered treatment or referrals from doctors, like Clifford did. But advocates say it’s an under-utilized approach that more people could benefit from.
That’s particularly concerning for experts looking at the overlap between homelessness and substance-use disorder.
Meth is almost three times more commonly used than nonprescribed opioids among people experiencing homelessness in California, a recent UCSF study found. Of a representative sample of unhoused adults in the state, 31% reported regular use of methamphetamines, 11% used nonprescribed opioids such as fentanyl, and 3% reported cocaine, the study found.
“Methamphetamine kept them awake and alert, but it obviously comes at a big cost,” said Dr. Margot Kushel, lead author of the study, which also found that about 20% of participants wanted and were ready to enter drug treatment but could not access it.
Wiener stressed that the efforts to expand contingency management need to accelerate to meet the current and urgent need. PROP, as just one example, has 12 people on its waitlist right now.
In 2021, he authored a bill that aimed to expand contingency management, SB 110, but Gov. Gavin Newsom vetoed it to instead launch the current statewide pilot program.
“The state has been really slow in rolling out these pilot programs,” Wiener said, “but we need to do whatever we can to help people suffering from meth addiction.”
This story has been updated.
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