California’s contingency management (CM) program is slowly getting off the ground, following the Medi-Cal expansion in 2022 that allowed the state to become the first to get CM expenses reimbursed through Medicaid. A 24-week outpatient Recovery Incentives Program will offer participants “low-denomination gift cards” in exchange for producing urine drug screens (UDS) that are negative for methamphetamine, amphetamine or cocaine.
Contingency management is a form of treatment that rewards abstinence, by way of negative UDS, that is often framed as the best treatment pathway for stimulant use disorder—particularly meth. Which doesn’t mean it’s effective so much as it means we have yet to legalize anything better.
Protocols vary, but generally programs last a couple of months and allow participants to earn incrementally larger rewards. They reset back to the starting amount, or sometimes just a lower amount, if a UDS is positive for stimulants. CM is more effective the higher the incentive value, but participants usually can’t earn more than a few hundred dollars due to a handful of artificially imposed restrictions at the state or federal level. The Recovery Incentives Program is unusual in that it allows for up to $599.
People don’t have to produce a meth-positive UDS in order to begin the program, which is promising. Residents of participating counties just need to have Medi-Cal and do an intake screening. Minors under 12 are able to participate, with parental consent.
Researchers in Oregon are looking into whether peer-led programs in which CM participants choose their own treatment outcomes are more effective than traditional CM, which really only ever has one goal—abstinence—whether it’s what the participant would have chosen or not.
Some people who use meth find CM genuinely accessible and encouraging of their recovery goals, and some people will get gift cards they wouldn’t have otherwise, and some people know their way around what look to be pretty standard UDS protocols, and I love that for all of them. What I don’t understand is which kind of meth users the people who design these programs are picturing.
It’s not the people using chaotically, and it’s not the people who are stable.
It’s not the people who use meth in large quantities. Studies show that “problem severity” is a predictor of how many incentives someone is likely to earn, and that people beginning CM from a baseline of higher use unfortunately tend to not do as well.
It’s also not the people who have used meth for a long time; same pattern.
It’s not the people who use meth continuously. Occasionally some programs or studies reference using appointment attendence as an outcome, as opposed to just abstinence. While this is good in the sense that options are good, there’s the small problem of meth withdrawal being extremely unconducive to physically reporting to a clinic, unless the clinic is located in the same place that you sleep. Meth users need meth to go places. Personally, if I’m three days out from my last meth use then the only way I’m making that appointment is if I’ve switched to Adderall or cocaine or crack. In the Recovery Incentives Program, at least, you’re not allowed to do that.
It’s not polysubstance users; not really. Participants in the Recovery Incentives Program are allowed to produce UDS that are positive for non-stimulant drugs, but it’ll trigger some kind of discussion about additional treatment. They’re allowed to participate while on medication for opioid use disorder, but also face their UDS results being recorded on their electronic health record, “to the extent permitted by federal and state confidentiality laws.”
It’s not people in rural areas. Some of these programs have participants coming out to piss in a cup three times a week. The increments by which they increase the reward amounts are something like $1.50 per week.
It’s not the people using chaotically enough for a fixed schedule over a period of months to be unrealistic. The California pilot is more flexible than some others, allowing participants to miss up to six consecutive appointments before disenrolling them
It’s not the people who are financially stable enough to not be motivated to go across town for a $10 gift card. It’s definitely not the people who derive more income from meth than is represented by that kind of pay scale.
CM didn’t invent the concept of financial paternalism toward drug users, but it did make it more annoying.
Mostly I’m confused by what the end game is supposed to be. The thing about CM is that whatever behavioral change might occur while someone’s being incentivized to produce meth-negative UDS, it tends not to stay there after six months or whenever the program concludes.
Evidence shows that CM works better in combination with (noncoercive) community reinforcement, so programs will connect graduates to a few months of other services in an effort to keep them from using meth once no one’s checking their urine anymore.
The way people talk about CM, whether they’re for or against it, sometimes makes me feel slightly insane. It’s all about operant conditioning and how positive reinforcement via gift cards “triggers that reward place in the brain.” The narrative is that CM works the same way “parents coax their children into adopting good behaviors,” and that the function of a $20 gift card is “to get a dopamine release, instead of meth or coke,” rather than to be worth $20.
CM didn’t invent the concept of financial paternalism toward drug users, but it did make it more annoying—getting the broader public on board with the idea that the way to keep meth users healthy is by promising them that if they stay on their best behavior, they will get a treat.
In some programs, participants who produce meth-negative UDS know what tier of incentive they’ll be getting. In others, they pull a raffle ticket out of a jar to find out whether their reward is $1 or a $20 Walmart gift card, or a slip of paper that says “Good job!” In the California pilot, the incentive parameters are determined by individual vendors, but in addition to prohibiting participants (how?) from cashing out the cards to buy marijuana, alcohol or cigarettes, they don’t want you to use them to play the lottery.
Image via South Carolina Secretary of State