Q&A: Contingency management may be a viable treatment method for stimulant use disorders

Research suggests that contingency management, a behavioral and incentive-based treatment strategy, may be a promising option for patients with stimulant use disorder.

The San Francisco AIDS Foundation (SFAF) has operated a contingency management program for roughly 11 years. The Positive Reinforcement Opportunity Project (PROP) is designed to counsel individuals who are using stimulants like methamphetamine and cocaine. It is a 12-week program that traditionally involves drop-in group meetings, urine analysis testing and one-on-one counseling. Negative urine analysis test results earn participants monetary rewards, with a potential maximum reward of $330 over 36 visits.

According to SFAF data, 63% of participants who finished PROP in 2018 to 2019 stopped using stimulants, and 19% of participants reduced their use despite not completing the program. Moreover, 98% of participants who finished PROP in 2019 to 2020 stopped using stimulants and 100% of participants reduced their use despite not completing the program.

The program has received increased media attention recently for its success and for cosponsoring SB 110, a California bill that would have allowed Medicaid to cover contingency management services in the state. Despite receiving bipartisan support, the bill was recently vetoed by California Governor Gavin Newsom, who said the bill was “premature.” However, in his veto statement, Newsom said that funding has been made available for a Medicare contingency management pilot program in the state.

Healio Primary Care spoke with Rick Andrews, the associate director of contingency management for The Stonewall Project at SFAF, to learn more about contingency management for stimulant use disorders.

Healio Primary Care: Could you briefly describe the PROP program?

Andrews: It’s been around the city since the early 2000s, starting at the Department of Public Health, and then it went through different agencies over the years. It ended up here at The Stonewall Project.

When it came to us, we made a lot of changes to the program to make it, in our eyes, more effective and more inclusive of folks who weren’t quite ready to quit completely and wanted to support people who were cutting down or working toward abstinence. We added a lot of new protocols to increase socialization and peer support, which is something that the program didn't have before. We also added an aftercare group for when the 12 weeks have ended.

We do use contingency management. It’s a behavioral health protocol that’s based on a reward system. It gives people something in return for meeting goals and health outcomes, specifically methamphetamine use.

Clients attend a lightly structured group support three times a week for 12 weeks. People are in different places with their substance use, but everyone wants some kind of change or a different perspective with it. When they’re ready to move on from the group, we take them to the bathroom, where they deliver a quick urine analysis test for methamphetamine and cocaine. We test for these stimulants only.

Each time the test result is non-reactive, a client will get a cash credit that goes into a bank account that we track for them for the 12 weeks. For those who were using or had an unplanned use, they don’t earn the incentive credit for that day. However, they don’t lose any money they previously made, and they still get counseling one-on-one and group support.

Money is a great motivator in some ways, but for those who aren’t ready for abstinence or are working toward it, they get a safe place to discuss what’s going on without any shame or judgement about their use. People are treated with respect and that goes a long way. Also, if they’re not making the incentive, we usually find some other offering to give them, like a movie ticket, a card for a sandwich, a treat or some bus tokens to show our respect and appreciation for their time. Some people don’t even collect the money, or they donate it back to the program. After the urine analysis, the client gets one-on-one time with a counselor.

Healio Primary Care: Can anyone become a client of the program? Do you need a physician referral?

Andrews: No, it is self-referred, although we’ve gotten so much publicity for the program that people have heard about it that way. People bring in their using partners or they’ve had a good experience in the program and bring in people that they care about or someone who they know. I think that’s why it’s grown so much, because we’ve had really great word-of-mouth referrals from clients, and now hospitals, therapists, physicians, health educators and outreach workers. It started very small, and through the years it’s just grown, and our reputation has grown.

One of my favorite referrals I have heard was when someone was referred to us by their dealer, which I thought was like getting an Oscar. That shows buy-in with the drug community; they know it’s a safe place.

It’s a little overwhelming because we only have two PROP contingency management programs right now. The one that I am in charge of is specifically for LGBTQI and gender-fluid individuals. About 2 years ago, we started a branch called PROP For All that is for anyone, no matter your sexual orientation.

Healio Primary Care: If someone were to unfortunately relapse after going through the program, are they allowed to repeat PROP?

Andrews: It used to be one-time only for years. However, we’ve discovered that people sometimes need a second chance or maybe their first experience with PROP didn’t come at quite the right time. We see a lot of people from different demographics: people who are without shelter, doing sex work or who have tech jobs and come during their lunch hour, etc. We have a wide range of clients. We try to limit it to once a year, but there are circumstantial needs. If people are in crisis, we of course do what we can to get them in if it’s more than once a year.

Healio Primary Care: What has the program been like during the pandemic?

Andrews: We have been virtual since the shutdown in March 2020. Currently, we’re looking at ways to go back in person because things are shifting here in San Francisco. We had to do a quick scramble when the pandemic first hit. It took us a week to figure out some kind of version that might work. Obviously, we couldn’t do the urine analysis virtually. The structure is the same: three times a week for 12 weeks on Zoom. We’ve had to reimagine the intervention time as a more structured support group. People are getting their incentive added to their bank each time they attend the group. If they don’t attend the group, they don’t make money that day. We have found there are some advantages to the virtual protocol, surprisingly. We have a wider net; we’ve been able to support a broader range of people who don’t live in San Francisco, who have been attending the groups because it is virtual and they do not have harm reduction resources in their communities.

Soon, we are going to start an alumni group to further support people who have gone through the program already and are struggling.

Healio Primary Care: If someone were to miss a group session or urine test, what would happen?

Andrews: We don’t kick people out. We don’t believe in scolding people or preventing them from engaging with us. We encourage people to come in when they’re high if it helps them, and they’re still participating that way. They get something from coming in for community support, referrals, food or counseling. If they’ve made only a little bit of money, we would probably line up another cycle for them to repeat it if it was something that they felt like they wanted to do.

Healio Primary Care: How is the program doing compared to when it first started?

Andrews: It’s grown so much. There are medications for different drugs like opioids and alcohol, but nothing for meth, and obviously it’s all over the country. Overdose is also a really big concern and I think a lot of people are convinced that contingency management is having a huge moment right now. It started here so small. It was a small grant. My perception was it wasn’t going to last. I think what made it work was softening the approach because it was very abstinence-driven when it was at a few different agencies. Here, we have a broader range of outlooks on recovery. Not everyone is ready or can be abstinent. And we know that people are on a journey with this drug.

Healio Primary Care: Were you surprised by the bipartisan support for SB 110?

Andrews: Yes and no. A lot of people who don’t understand how the program works think that we're paying people to use drugs or paying for them not to use drugs. I guess I’m a little surprised but then on the other hand, given the severity of the addiction across the country and in San Francisco, and there not being a medication-assisted therapy for stimulants, people are looking at contingency management with new eyes right now.

It’s very disappointing that SB 110 did not pass. There is overwhelming evidence to support that contingency management programs work, and this is something that was known by the administration when it was vetoed. The pilot now will take several years to complete; no one in California should have to wait that long for a proven and effective evidence-based program for stimulant use.

The SFAF and Stonewall Project will continue to fight stigma and misinformation in our advocacy for legislation that supports the health and lives of people who use drugs.

References:

Governor Newsom issues legislative update 10.8.21. https://www.gov.ca.gov/2021/10/08/governor-newsom-issues-legislative-update-10-8-21/. Published Oct. 8, 2021. Accessed Oct. 28, 2021.

To combat meth, California will try a bold treatment: pay drug users to stop using. https://www.npr.org/sections/health-shots/2021/09/30/1040412804/to-combat-meth-california-will-try-a-bold-treatment-pay-drug-users-to-stop-using. Published Sept. 30, 2021. Accessed Oct. 25, 2021.