Rewarding recovery: how California will pay addicts to give up drugs

The writer is an FT contributing columnist

It’s a mystery why some people get addicted to drugs or alcohol while others don’t, but it’s more of a mystery how anyone ever gets clean and sober. Now California plans to try a novel approach to this age-old problem: it will pay addicts to stay off drugs.

It’s an approach with decades of science behind it but little real-world track record, largely because public and private health insurers have refused to pay for it. But now that attitude is changing — largely because over the past year, one pandemic has led to another: nearly 100,000 people died of a drug overdose in the first 12 months of the Covid-19 pandemic in the US, up nearly a third from the 12 months beforehand.

And it’s not just state public health authorities that are getting creative about addiction. In a world where there’s an app for everything, there are now smartphone applications that pay addicts to ditch drugs.

Affect Therapeutics is a digital treatment app for methamphetamine, crack and cocaine addiction that uses micropayments — as well as more traditional forms of telehealth therapy — to encourage recovery. Users may earn $3 for showing up on Zoom for a counselling call, or 15 cents for studying tips for better sleep — and they can watch their rewards add up in the app.

Ironically, the goal seems to be to make it just as addictive to abstain as to use: Kristin Muhlner, Affect’s chief executive, told the FT that the app relies on game design to “create a compulsion loop” that “draws people back daily or hourly”.

The US Department of Veterans Affairs, which provides healthcare to military veterans, has been rewarding veterans for recovering — a technique known as “contingency management” — for ten years. The only large-scale, long-term user of the treatment in the US, the VA says that of 5,700 veterans treated, 92 per cent of their 73,000 urine samples were negative for drugs.

Now California has asked the federal Medicare and Medicaid authorities for permission to start a $58.5m pilot project next year to reward patients who stay off stimulants such as meth and cocaine. The state’s Department of healthcare Services says medications exist to treat opioid or alcohol disorders, but not stimulants. “Multiple studies have shown that contingency management consistently leads to abstinence for the majority of people, and decreased drug use for people not yet abstinent. No other treatments for substance use disorder have achieved these consistent results,” the department said.

Tyrone Clifford, 53, stopped using through a “contingency management” programme in San Francisco. He earned $330 for negative drug tests over the 12-week programme. “When I walked in the door that first time, I thought, I can do this, I’ve gone 12 weeks before when my dealer was away, and then I’ll have $330 to get high with,” he told the FT. But that’s not what happened: he got sober and used the money towards a laptop to study as a substance abuse counsellor.

Julia, 31, and Martin, 45, are participants in a Washington state study on contingency management for alcohol use disorder. “All my friends are dead of alcohol or cocaine abuse,” says Julia, who used up to $3,000 in rewards to furnish her flat. Martin, who says he was “drunk half the time and hearing voices”, takes his rewards in Starbucks and other retail gift cards, and is down to one beer a day. “Just thinking of the reward overwhelms the craving.” 

AJ Daulerio, host of the recovery podcast Really Good Shares, is sceptical addicts will avoid using for the sake of gift cards. But Richard Rawson, retired co-director of UCLA’s Integrated Substance Abuse Program, estimates that about half of those treated with contingency management sustain the benefits after a year. “The theory is that you use external rewards to stop using and then the naturally occurring rewards of life” kick in to replace the external motivation, he says.

Dr Alta DeRoo, medical director of three California recovery programmes for the Hazelden Betty Ford Foundation, America’s largest non-profit addiction treatment provider, says rewards can be a “catalyst” on the way to discovering “Hey, my life is better without drugs or alcohol.” California thinks it’s worth a try: maybe the rest of us can learn from it.