As reported by The Seattle Times, December 28, 2005.

Meth Users Respond to Reward Program

By Charles Ornstein

SAN FRANCISCO — For more than two decades, Robert Bowers stole money, jewelry, identities, even silverware, to feed his methamphetamine addiction. He landed in prison, rehab and Skid Row hotels.

Until earlier this year, when the government paid Bowers to quit.

A little-heralded program run by San Francisco's Public Health Department over the past year has given meth users rewards worth as much as $40 per week to stay off drugs. And, in a break from traditional approaches, participants receive no counseling or lectures, even if they test positive for meth use.

Their end of the bargain is simple: Show up at a clinic three times a week, urinate in a cup and collect their reward — a voucher, not cash — if they test drug-free.

"Here I am getting clean, I feel better and I'm getting something for it," said Bowers, 42, who says he hasn't used meth since early February and has put more than 45 pounds on his formerly ravaged 128-pound frame. "That means something."

Although just a pilot program, the San Francisco venture is the latest in a string of experiments and studies over the years to point in the same intriguing, if controversial, direction: Addicts respond remarkably well to material rewards, even little ones.

"You're using the exact same technique that parents use with their children every day," said Nancy Petry, a researcher at the University of Connecticut School of Medicine who is studying this approach. "It's behavior modification and behavior shaping."

The findings could be especially significant in California, where methamphetamine use continues to surge. It has surpassed alcohol and heroin as the drug of choice among people seeking treatment. The drug increases arousal and reduces inhibitions, sometimes leading to violence, child neglect and serious health problems such as malnutrition and heart failure among chronic users.

In essence, the voucher approach replaces one reward with another — the high of drugs such as meth with the mental boost of grocery money, a gift certificate or a rent subsidy. Given the power of addiction, as shown by many addicts' desperate and self-destructive acts, the trade-off might seem woefully insufficient. But for some reason, researchers say, it works.

Since November 2004, 159 participants have enrolled in the 12-week San Francisco program, which is geared toward gay and bisexual men. So far, about 38 percent of those eligible have completed their stint. Although the success of drug programs is hard to gauge and not systematically tracked, experts said the San Francisco program's numbers are comparable to or better than those of other publicly funded outpatient-treatment options.

What makes the program most noteworthy is that it is simpler than conventional treatment — less time-consuming and substantially less costly, proponents say. Because there are waiting lists for drug rehabilitation in many parts of the country, including San Francisco, such programs also broaden options for treatment.

The benefits go beyond stemming drug addiction, extending to prevention of sexually transmitted diseases, said Dr. Jeffrey Klausner, San Francisco's director of STD control. Extensive research shows that meth is associated with risky sexual behavior.

Some treatment experts are peering over San Francisco's shoulder. Others are borrowing the concept or adding touches of their own.

The Seattle and King County Department of Health, for instance, is preparing a study that rewards gay and bisexual men who remain drug-free. The Addiction Institute of New York recently started giving people vouchers to show up to treatment sessions, regardless of whether they are drug-free.

For nearly 15 years, research has indicated the usefulness of rewards in conjunction with traditional treatment, especially in motivating patients to stick with their programs.

Earlier this year, University of California, Los Angeles researchers published one of the first studies to challenge the idea that vouchers had to be paired with another treatment to work. Over 16 weeks, meth users who received vouchers tested negative for drug use 83 percent of the time, compared with 75 percent for those receiving cognitive behavioral therapy alone.

"Clearly, it wasn't the money," said Steven Shoptaw, one of the UCLA researchers. "It was the fact that somebody recognized them."

Some people in the field of substance abuse are openly skeptical of the results. And even treatment experts and researchers who accept the scientific soundness of the concept are troubled by its ethical implications.

"As soon as you take the reward away — if they haven't had any counseling or other treatment to go along with it — who's to say that it would continue?" said Teri Cannon, executive vice president of Behavioral Health Services.

The operators of the San Francisco program, and others around the country, say addiction is such a costly problem that promising ideas should not be rejected out of hand.

"What we're trying to teach people in the field to do is value science," said Stephen Gumbley, of the Addiction Technology Transfer Center of New England, which works with clinicians to translate research into practice.