When Michael McDonell was a mental-health clinician at Seattle Children’s hospital, he decided to experiment on himself.
He’d gained 50 pounds in grad school and struggled to lose them since. He’d read about something called “contingency management” — the idea that it’s easier to establish a habit or change a behavior with a reward than a punishment.
The plan: He’d get a dollar for every day he ran. If he got to 365, he could spend it on whatever he wanted, but if he missed even one day, his wife would get to keep it all.
He made it to the end of that year, and 10 years later, he’s only missed one day of running.
As a new wave of methamphetamine crashes over Washington, bigger than it’s been for decades, public health officials have struggled to spread an intervention for meth addiction that’s as effective as medication-assisted treatment has been for people using opioids.
Contingency management, researchers like McDonell say, is that thing: It works, patients like it, and it’s cost-effective. Literature reviews and analyses often agree: A review of 69 reports released from 2009 to 2014 found “high levels of treatment efficacy” in contingency-management treatment. On average, it increased a patient’s odds of reaching abstinence by 117 percent.
How it works
Here’s how the treatment works: You come in a few times a week, complete a urine test, and if it’s negative, you draw for a prize — at a trial McDonell is running in Wallingford, there are “small” prizes like shampoo or a toothbrush, “big” prizes like a coffeemaker, or rare “jumbo” prizes like a DVD player. The longer you’re sober, the more draws you get, but if the test comes back positive, the clinician says “see you next time.”
“It’s like being a kid at a carnival,” said one participant in a 2018 Seattle study McDonell co-authored.
When the Department of Veterans Affairs expanded patients’ access to this treatment in 2011, at the Seattle VA, 87 percent of all urine screens came back negative for meth, cocaine or other targeted substances; and of the 119 patients who have started treatment since 2012, more than half completed all 12 weeks.
“If (contingency management) were a drug, it would have been approved decades ago,” said Dr. Sterling McPherson, one of McDonell’s colleagues at WSU.
It’s cheap — the average cost at the local VA was less than $100 per patient — and since all it needs is someone to take a urine test and give out a prize, you don’t need a licensed provider or clinical staff to do it.
But because it’s not a traditional way of treating addiction, it’s harder to pay for than talk therapy or medication. Medicaid, the nation’s largest source of drug treatment, won’t cover it, and it’s unclear how health care providers would bill for the prizes, according to Dr. Charissa Fotinos, deputy chief medical officer with Washington’s Health Care Authority, which manages the state’s Medicaid program.
The state is exploring whether federal grants could pay for this treatment. But right now, in Washington, the treatment is not widely available for people struggling with any kind of addiction.
The prizes-for-sobriety model is based on an idea that is counterintuitive to how Americans often think about drug use: That people addicted to a drug still can make rational decisions, if they’re given an alternative.
A study in the 1990s offered habitual users a dose of crack cocaine or $5 when the experiment ended in a few weeks. The less crack the person had smoked that day, the more likely they were to say yes to the $5.
“Drug users are rational human beings,” McDonell said.
But contingency management, while not exactly radical, makes some uncomfortable. When the Seattle VA Addiction Treatment Center started providing it in 2012, Hang Ruan, the center’s program manager, was entirely behind it.
Ruan sat down with 500 Post-It notes, and on half he wrote “good job,” “way to go,” and when he ran out of ideas, even “cowabunga!” On the others, he wrote “$1,” “$20,” even “$100” — all redeemable at the VA store. The more weeks a patient was sober, the more times they got to reach into the fishbowl of slips.
But the staff had concerns: Was this essentially paying people not to do drugs? Was the slip-draw method basically gambling?
But once they saw it in action, according to Ruan, staff began referring people into the program. Since then, 72 patients have completed treatment — mostly for cocaine and meth use — and only eight patients have had repeat the program because the first treatment wasn’t successful, according to the VA. Sixty-eight dropped out — an attrition rate similar or better to most studied treatment programs other than methadone (whose attrition rate is low).
