As reported by the Los Angeles Times, November 14, 2005.

Quitting Meth Pays Off

Material rewards appear to be quite effective at inducing addicts to stop. But whether they'll stay clean when the gifts end is a matter of debate.

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 last year has given meth users rewards worth up to $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."

Though 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 those 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% of those eligible have completed their stint. Though 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.

Then, earlier this year, UCLA 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% of the time, compared with 75% 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."

The reward programs, known as "contingency management," haven't caught on widely in practice, experts say — at least, not yet.

"Because the treatment approach is a little different from giving medications or counseling, probably that has added an unfamiliar wrinkle to it," said Stephen Higgins, a University of Vermont researcher who pioneered the use of vouchers for drug addicts.

Some 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. Why reward people for dropping habits they never should have taken up to begin with? Why use scarce treatment dollars for rewards if you can't be sure the results will last?

"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 Inc., which provides treatment across Los Angeles County.

"We wouldn't do something like that because we couldn't afford to do something like that," said Marlene Nadel, director of client services for the North Hollywood center Cri-Help. "Even if we had the funds, it would not be the route we would take."

The operators of the San Francisco program, and others around the country, say addiction is such a costly problem in human and economic terms, that promising — and relatively inexpensive — 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. "Some of what gets in the way of translating science into practice is values. And one of the values of this is that we shouldn't be paying people to do what they're supposed to do in the first place."

Some of the resistance is related to the culture of drug treatment, he said.

"Our field can be very negative," he added. "We tend to approach treatment with punishment as opposed to stroking people."

Short-Term Outlook

Drug abuse seems to defy logic.

Consider a 2000 study of pregnant women trying to quit smoking. Women rewarded by vouchers for testing nicotine-free quit at more than three times the rate of those who received advice and referrals.

"The fact that a pregnant woman would discontinue substance use when offered a voucher for doing so, but not to improve the health of her fetus, is perplexing," Higgins said in a paper published last year. "After all, the vouchers are worth a pittance relative to the value of a healthy baby."

But Higgins and others say addicts are people in search of immediate gratification who discount rewards they can't quickly realize (such as a healthy baby six months down the road). Vouchers succeed in part because they replace one immediate reward — the experience of being high — with another, the researchers say.

Another study shows that vouchers work best when linked to a specific achievement. Higgins gave cocaine users counseling and vouchers over 24 weeks of treatment. In one group, addicts received the vouchers only if they tested drug-free. In the other, they received the vouchers regardless of their drug use. The first group did much better than the second.

The explanation may lie in the brain.

Edythe London, a professor of psychiatry and pharmacology at UCLA, has compared the brains of meth addicts and nonaddicts.

"Systems in the cortex, which are important for making decisions, were just not working very well," she said of the meth users. "They had less activity than in normal healthy people."

But meth users had hyperactivity in lower centers of the brain that control emotion and craving, London said. That partially explains why meth addicts consistently make irrational decisions, putting them in a "spiral where things get worse and worse and worse," she said. (Researchers are not sure to what extent meth addicts' brains are inherently different and to what extent meth contributes to the unusual pattern.)

The vouchers themselves don't change the brain. They simply give the person a choice that is less objectionable than "methamphetamine or nothing," London said.

Studies have shown that though rewards can be small, size does matter, at least in a relative sense. One study found that nicotine abstinence increased as rewards were raised from $0 to $12 per day. Over time, patients needed more incentive to stay off drugs.

The San Francisco program allows participants to earn up to $453.75 in vouchers if they attend every scheduled visit and test drug-free over 12 weeks. But Petry, the University of Connecticut researcher, has devised a less costly system, in which addicts with clean urine tests can draw for prizes. They win about half the time, collecting rewards ranging in value from $1 to $100. The rest of the time, their slip says, "Good job."

The chance of winning apparently is a powerful lure.

Connecticut Renaissance, a drug treatment facility in Waterbury, Conn., began using Petry's model in May. To qualify for the drawing, participants must show up for their conventional treatment groups and test drug-free. Although it's still early, those vying for prizes are attending their group counseling sessions far more regularly than those not participating in the drawings, said Eileen Russo, clinical director of residential services.

"There just seems to be this little bit of extra incentive to make sure that they do what they're supposed to be doing," she said. "It's really going very smoothly."

The San Francisco model doesn't just try to integrate rewards into regular substance abuse treatment. The rewards are the treatment.

Program Brings Focus

On a Wednesday morning this past summer, the waiting room at Magnet, a community center in San Francisco's Castro district, was packed as staff members cycled recovering addicts in and out.

Nate Birjukow, then the project coordinator, followed the participants into the bathroom, watched them urinate into a cup and then, wearing gloves, used a dropper to place two drops onto an instant drug-screening device to test for the presence of methamphetamine, cocaine, heroine and marijuana.

Birjukow, who recently left the health department, said he didn't let clients look at their test results because he didn't want any disputes.

"Good job, you tested negative," he told one client before handing him a yellow voucher.

It's a simple routine, and Jerry Frost said it worked for him. His doctor at the county hospital referred him to the voucher program last year, and he became its first enrollee.

"It was obvious — I was getting really sick and I wanted to get [drugs] out of my life," he said.

Frost, a burly 55-year-old artist, said he started using meth and cocaine in the 1980s when his friends were dying of AIDS and his lover left him. He quit for a time but started back up when his lover died.

Frost said he didn't want to enroll in a 12-step program, to stand and say his name and admit his addiction.

With the voucher program, "I didn't really have to tell them anything unless I wanted to tell them," he said. "Since I wanted to quit, they gave me a schedule to go by." With his vouchers, Frost said he bought his roommate a computer desk and a dining room table for "putting up" with him and his addiction.

"I had to do something three times a week. It was a ritual I went through. It kept me focused."

Without meth, Frost said he was able to sleep every night, watch TV, go to the movies, go to the park: "The simple things again."

But Frost's story is not so simple. He was sober for months, then, like so many addicts, relapsed.

"I just didn't feel like I needed to talk to anyone," he said. But "that's not the way it works."

He's back in treatment, the conventional kind, with less tangible rewards.