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Soraya Azari, MD, uses contingency management techniques to help people overcome meth addiction. Photo: Constanza Hevia H.

On November 30, 2021, JC was admitted to Zuckerberg San Francisco General Hospital for symptoms of heart failure. Her legs were swollen, which can be a sign that her heart isn’t pumping properly, and she was having trouble breathing. He ended up spending seven days in the hospital with no one to talk to but the hospital staff. That’s when he decided it was time to change his life.

“Spending a week in a hospital room by yourself will do that to you. I had a lot of time for self-examination and introspection,” said JC, whose full name is being withheld to preserve privacy. your privacy

His conclusion: It was time to kick his meth habit. A drug user for about two decades, JC, who is 52, had been using stimulants with increasing regularity over the past five years, to the point where he was taking a hit several times a day. He used it in the morning to motivate himself, before going to work at his job as a stage technician, in the evening to relax, or late at night to party.

Despite his heavy drug use, JC said he never felt it was a problem until he ended up in the hospital. He had several friends who also used methamphetamine and had died of heart failure, and “It really shook me,” he said. “I decided I wasn’t going to die like my friends had.”

Heart Plus Program

At the urging of his cardiologist, JC joined San Francisco General’s Heart Plus, a 12-week outpatient program that combines cardiovascular follow-up care with drug rehab support. Stimulant drugs, such as cocaine and amphetamines, are known to cause and exacerbate cardiovascular problems, so the goal of the program is to improve patients’ health by addressing both issues together.

“Stimulant use disorders complicate at least 15% of heart failure hospitalizations,” said Soraya Azari, MD, a UCSF clinical associate professor who co-founded Heart Plus. “At San Francisco General, we found that methamphetamine use was an independent predictor of readmission for heart failure. There is separate medical evidence that if you stop using methamphetamine, your heart failure can improve in terms of how squeeze your heart and if you have to keep going back to the hospital.”

Patients enrolled in Heart Plus saw a cardiologist and an addiction specialist during twice-weekly appointments where doctors monitored their heart health and counseled them about their drug use. Perhaps the most innovative aspect of the program is that patients received rewards, either a $5 or $10 gift card or a positive affirmation, each time they showed up and each time they had a negative urine drug screen .

Contingency management

The strategy of offering rewards for treatment compliance, known as contingency management, is rooted in a fundamental theory in psychology known as operant conditioning. The idea is to reinforce the behaviors you want to keep rewarding people every time they do it. The other side of operant conditioning, which has been used with minimal success in traditional drug treatment strategies, is to punish people when they do something you want them to stop.

Contingency management “is about how to sculpt or change one’s behavior, and it’s based on … the principles of positive reinforcement,” Azari said. “It generally has a very strong effect in perpetuating that behavior and seems to work better than things like punishment.”

Contingency management can be used to reinforce any type of behavior, but has been shown to be particularly successful in helping people with substance use disorders. For opioid use disorder, there are three FDA-approved medications that help people stop or reduce their use. However, for people struggling with cocaine or methamphetamine use, there are no specific drug treatments available.

While all illicit drugs activate the brain’s reward circuits and make people want to use the drug again and again, stimulants hijack the system more completely than any other type of drug. Over time, normally pleasurable experiences such as food, music, or sex become less rewarding by comparison. The goal of contingency management is to counteract the reinforcing properties of stimulant drugs by rewarding people for not using them. “You’re rewarding abstinence,” Azari said. “You’re creating this new memory or learning that not using drugs can be positive and reinforcing.”

Substance use disorders are chronic diseases, just like hypertension, just like high cholesterol.

—Soraya Azari, MD, co-founder of Heart Plus

The strategy works. According to a meta-analysis published in JAMA Psychiatry, 80% of studies that tested contingency management for stimulant use showed that the method was effective in helping people reduce their drug use. Another study by the Department of Veterans Affairs found that people who regularly attended contingency management sessions tested negative for drugs more than 90 percent of the time.

“When you look at studies comparing contingency management with other behavioral health interventions for substance use disorders, contingency management consistently shows that it is effective in helping people reduce their use of stimulants” , said Anton Nigusse-Bland, MD, clinical associate professor at UCSF. “They are used less frequently and are able to maintain these gains for long periods of time after the contingency management intervention stops.”

CalAIM to pay for contingency management treatment

Contingency management is so effective in helping people with substance use disorder that California will become the first state Medicaid program to pay for the treatment. The pilot program, which will launch in early 2023, is part of the California Advancing and Innovating Medi-Cal (CalAIM) initiative, a multi-year plan to overhaul the state’s Medicaid program. Working with the Centers for Medicare and Medicaid Services (CMS), the California Department of Health Care Services (DHCS) received authorization for what they call the Recovery Incentive Program. DHCS estimates the program will cost $58.5 million, which includes federal funding.

“Under CalAIM, DHCS won approval from CMS for the first time to cover contingency management as a Medicaid program benefit,” said Tyler Sadwith, DHCS Assistant Director of Behavioral Health. “It’s really meaningful.”

The contingency management program will initially be piloted through 24 county behavioral health agencies that already participate in the state’s Medi-Cal Organized Drug Delivery System (PDF), which launched on 2015 to expand and improve substance use disorder treatment through Medi-Cal. These 24 counties represent a large portion of both rural and urban geographic areas and include 88% of the Medi-Cal population.

The State Recovery Incentive Program will be structured slightly differently than Heart Plus, but the fundamentals are the same. To be eligible, people must have a substance use disorder and not be receiving inpatient treatment for it. The first 12 weeks of this Medi-Cal program will consist of twice-weekly meetings with the Contingency Management Coordinator at a substance use disorder clinic. At each meeting, the participant will submit a urine sample, and for each negative drug test they will receive a gift card. Gift cards will start at $10 and increase throughout the 12 weeks for consistently negative tests. A second 12-week period will focus on stabilization: participants only sell once a week, but earn higher amounts for negative urine tests. In total, people can earn up to $599 for successfully completing the 24-week program.

If someone has a positive urine drug test, they will not be removed from the program. “It’s important to recognize that recovery is a long process and that people may or may not have lapses in use along the way,” said Nigusse-Bland, who also serves as a clinical consultant for DHCS. “We want to really support the commitment and keep showing up, and so in the event that someone tests positive for drugs, the message is very clear: ‘Today wasn’t your day, but please come back. [week].’”

Participants in the Recovery Incentive Program may also receive other treatment services, such as individual or group counseling, medication to help manage their other drug use, and connections to community resources. “It’s basically a comprehensive addiction treatment program,” Sadwith said. These recovery support services will continue for up to six months following the completion of the 24-week contingency management program.

Challenges and possibilities

Criticism of contingency management often centers around paying people with substance use disorders to stop using drugs and questions about whether people will use them again when the payments end. But rewards should not be thought of as money, per se, but like any other treatment for a chronic disease. And as with any chronic disorder, the disease can wax and wane.

“Substance use disorders are chronic diseases, just like hypertension, just like high cholesterol,” Azari said. “So we shouldn’t expect you to do 12 weeks of contingency management and then be cured for the rest of your life… This is no different than other chronic diseases where if the treatment is removed, the disease could recur.”

In this way, JC, who has not used methamphetamine since participating in the Heart Plus program in January 2022, is somewhat unusual. Many people who receive treatment for substance use disorders, including those who participate in contingency management programs, experience setbacks along the way. But her case also shows what is possible when people are highly motivated to stop using methamphetamine and get the support they need and deserve.

While the payments were a nice perk, JC said the most valuable part of Heart Plus was the support he received from Azari and the other doctors. “Talking about life without drugs or how to move on … just discussing these issues with them really helped make it happen,” she said. “You can’t go somewhere if you don’t know it exists.”

Dana G. Smith

Dana G. Smith, PhD, is a freelance health and science writer based in North Carolina. He has written for many publications, including Scientific American, Popular Science, Medium, The Atlantic, and The Guardian. Before pursuing a career in journalism, he obtained a PhD in experimental psychology from the University of Cambridge.

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Source: Finally, an effective treatment for meth addiction