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lite.cnn.com - on gopher - inofficial
ARTICLE VIEW:
Small gift cards can be a key tool to stop stimulant addiction, but
stigma stands in the way
By Mira Cheng, CNN
Updated:
6:32 AM EDT, Tue April 16, 2024
Source: CNN
Clyde Davis battled a methamphetamine and heroin addiction for over
nine years. He tried various treatment programs, but none worked for
him before he reached his insurance maximum and was forced to
discharge.
“I was trying to die; just putting myself through torture because I
didn’t feel like I deserved to live and be happy,” Davis said.
Then three years ago, he became one of the first participants in a new
contingency management program at the Rimrock Foundation, Montana’s
oldest nonprofit addiction treatment center.
Contingency management uses positive reinforcement as a behavioral
treatment for stimulant addiction. People are rewarded with small-value
gift cards or vouchers for submitting urine drug tests negative for
stimulants.
Decades of research show that it is the most effective treatment for
stimulant addiction, but it has not been widely implemented due to
policy barriers and stigma.
The program changed the game for Davis. He said that the rewards and
counseling gave him hope and made him more willing to accept help.
“I was able to get myself some clothes, something to eat,” he said.
“It really motivated me to want to keep showing up and keep having
clean [drug tests].”
Davis graduated from the 12-week program successfully and has abstained
from drugs ever since. He now works as a rehabilitation technologist at
the Rimrock Foundation, alongside the people who he says helped save
his life.
“I am living a life that I never thought I would ever dream of
living. It’s beautiful,” he said.
Stimulants are a class of drugs that speed up the body’s systems and
can lead to increased alertness, energy and feelings of euphoria. These
drugs can be very addicting because they flood the brain with dopamine,
hijacking reward pathways, according to a by the Substance Abuse and
Mental Health Services Administration.
Prescription stimulants are used to treat ADHD and narcolepsy. Other
stimulants, like methamphetamine and cocaine, are considered drugs of
abuse, according to the . Misuse of these drugs is associated with
agitation, hostility, panic, aggression, and suicidal or homicidal
tendencies.
Illegal stimulants, like methamphetamine and cocaine, are playing an
increasingly large role in the national overdose crisis. Experts have
called it the of the opioid epidemic. While the of opioid overdose
deaths was driven by prescription opioids, the second wave by heroin,
the third wave by synthetic opioids, this “fourth wave” is
characterized by extremely potent synthetic opioids like fentanyl and
concurrent stimulant use.
Data from the shows that overdose deaths in the United States
involving cocaine increased by more than 5-fold, and overdose deaths
involving methamphetamine increased by more than 14-fold between 2011
and 2021. In 2021, more than 106,000 people died of a drug overdose in
the United States – and over half of those deaths involved a
stimulant.
Michael McDonell, professor of community and behavioral health at the
Washington State University Elson S. Floyd College of Medicine, said
that the increasing potency of stimulants is one factor contributing to
the uptick in stimulant-involved overdose deaths. Another factor is the
increasing concurrent use of stimulants and opioids, he said. Some
people purposefully mix the two to use the “upper” effect of the
stimulant to offset the fatigue caused by opioids, while others
inadvertently end up taking stimulants contaminated with opioids.
“In many cases the supply is so mixed that people don’t even know
what they are using,” McDonell wrote in an email.
Given the danger of deadly overdose from this mixed supply, effective
treatments for both opioid and stimulant addiction are necessary and
urgent, he added.
While there are like methadone and buprenorphine approved by the
US Food and Drug Administration for opioid addiction, no such
treatments exist for stimulant addiction.
“What we’re finding in our program is that a lot of our patients,
while they’re finding success in recovery from opioid use disorder,
the concurrent stimulant use disorder is causing a lot of problems and
really getting in the way of the treatment,” said Katie
Chiasson-Downs, lead clinician for addiction services at West Virginia
University.
How contingency management works
Contingency management is the most effective behavioral treatment for
stimulant addiction, but it remains underutilized, according to the .
“We’re in the midst of a crisis of fatal overdose in the United
States. It’s largely driven by opioids, but it’s also driven by
stimulant use disorder,” said Dominick DePhilippis, deputy national
mental health director for substance use disorders in the Veterans
Health Administration. “There’s a moral imperative to make this
very effective treatment available to patients. It can save lives.”
Contingency management encourages abstinence using positive
reinforcement. The approach has proven highly effective in at
keeping people addicted to stimulants in treatment and reducing their
drug use in both the short-term and the .
Program structures vary, but most are 12 weeks long and require
participants to submit two urine drug tests over the course of a week
– this schedule is based on the two-to-three-day detection window for
stimulants, DePhilippis said. When a participant submits a negative
urine drug test, they receive a reward in the form of a voucher or gift
card ranging in value from $5 to $25. The rewards have restrictions on
them so participants cannot purchase firearms, alcohol, other drugs, or
anything related to gambling, he added.
Often programs will escalate the amount of the reward to encourage
consistent behavior, DePhilippis said. For example, the first two
negative drug tests will be rewarded with $5, the next two with $6.25
and so on. If participants submit a positive urine drug test after a
streak of negative ones, the value of the reward resets back to the
starting amount.
Consistency is critical to recovery, DePhilippis said. When someone’s
brain is chronically exposed to stimulants, their reward centers become
dysfunctional to the point where they can no longer derive pleasure
from everyday activities such as being with loved ones or eating a good
meal. However, has shown that the brain can heal if it is given
time away from the drugs.
“Contingency management is like a scaffold we place on the brain to
allow the brain to heal so that in the long run, when we withdraw the
incentives, the naturally occurring incentives that come from recovery
can maintain the behavior,” DePhilippis said.
DePhilippis has been running the for stimulant addiction since
2011 – the largest implementation of the approach to date. He said
the program has treated over 6,800 participants and the outcomes are
comparable to what is found in research. Of the over 88,000 urine drug
tests submitted, more than 92% have tested negative for the target
drug, he said.
“You can take this treatment from bench to bedside. It translates
effectively in a complex healthcare organization,” DePhilippis said.
Contingency management has been shown to reduce complications of
substance use and promote better health outcomes, including better
heart health and a reduction in high-risk sexual behaviors in people
who use drugs, according to an . It is also associated with positive
social outcomes, such as improvements in employment and in family and
social relationships.
‘I don’t want to feel sick like that anymore’
Matt Cottrell was in his last year of high school in West Virginia when
he started abusing prescription opioid pills. Things spiraled from
there – for the next 22 years, he struggled with an opioid and
methamphetamine addiction.
“It’s a bigger struggle than anybody would ever imagine,” he
said. “It’s one thing I would never wish on any human being, not
even my worst enemy.”
Cottrell, who is now 41 years old, entered a comprehensive opioid
addiction treatment program at West Virginia University run by
Chiasson-Downs in the spring of 2022 that utilized the contingency
management approach. He successfully graduated from the program, and
this spring marks his second year abstinent from drugs.
The contingency management program “makes you feel good, it actually
gives you hope,” he said. “It makes you feel like there’s
somebody out there wanting to see you succeed instead of fail.”
He said that the program gave him a sense of self-efficacy and helped
him realize that he could do something good with his life if he tried.
He used the rewards he got for negative urine drug tests to buy gas so
he could drive to and from the treatment center and to buy snacks at
work.
Gradually, the naturally occurring rewards of recovery became clear to
him and motivated him to stay sober even after the program was over.
“It’s a better life being able to go to work and function,” he
said. “I don’t want to feel sick like that anymore.”
Nowadays, Cottrell spends his time working at a lumber yard and fixing
up cars – he’s currently working on restoring a Ford Bronco. He
said these activities give him a newfound sense of purpose.
Barriers to implementation
While contingency management was life-changing for both Cottrell and
Davis, the treatment is not a perfect solution for everyone struggling
with a stimulant addiction, Chiasson-Downs said.
“I see it as a tool in the bigger toolbox,” she said. “There’s
the therapy component, the peer support component, the contingency
management component. We want patients’ recovery to be well-rounded
so we as a treatment system need to be well-rounded.”
Dr. Nora Volkow, director of the National Institute on Drug Abuse,
echoed this sentiment and said that combining contingency management
with other approaches, such as community reinforcement programs, can
improve outcomes in the long run.
Contingency management has been criticized for being a short-term
solution that does not lead to long-term recovery, Volkow said. While
there are that show that it is does effectively lower drug use for up
to one year, more research is needed to evaluate and improve the
long-term efficacy of the approach. She also said that more research is
needed to develop medication-assisted therapies for stimulant
addiction.
As there are currently no medications approved to treat stimulant
addiction, contingency management remains the most effect intervention,
but it faces some challenges to implementation due to stigma and policy
barriers, McDonell said.
The approach has received some pushback due to moral concerns about
paying people for refraining from harmful, and in some cases, illegal
activity, DePhilippis said. Although these criticisms are in good
faith, he said, they are misguided.
“In contingency management, we are reinforcing a behavior that is in
the patient’s best interest,” he said.
McDonell said that the stigma tends to fade once people learn more
about the approach and witness its benefits.
Implementation of contingency management also faces policy and funding
challenges, McDonell said. Under current government fraud and abuse
laws, a contingency management reward could be considered an illegal
“kickback:” an incentive for a user to enter a program that the
operator is compensated for on the basis of enrollment. While these
laws are important for preventing fraud, they should be revised to
exempt contingency management which is an evidence-based health
intervention, he added.
Another barrier is the $75 annual limit per client that HHS imposes on
grant recipients, McDonell said. This limit is well below the
scientifically established value of incentives required for effective
contingency management (closer to $599 or more over 12 weeks), he said.
DePhilippis added that the $75 limit is problematic because it may
miscast contingency management as an ineffective treatment, when in
fact it is the implementation that is wrong.
“It’s like giving an effective medication, but at an ineffective
clinical dose,” he said.
Dr. Yngvild Olsen, director of the federal Center for Substance Abuse
Treatment, said at the 2024 Rx and Illicit Drug Summit that SAMHSA is
aware that the grant limit is “subtherapeutic” and the matter of
increasing it is “under review.”
In the meantime, certain states like California, Washington, Montana
and Delaware have gained approval to use federal funds to pay for
contingency management as a Medicaid benefit and to evaluate its
effectiveness at scale. California launched a in 2023 that aims to
implement the approach at 166 sites across 24 counties.
“Contingency management may have its challenges in implementation,
but its effectiveness is unquestionable,” DePhilippis said. “The
need for it is unquestionable.”
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