California lawmakers are urging US federal agencies to approve a therapy that pays meth users to abstain


In his numerous attempts to overcome a methamphetamine addiction that spanned two decades of his life, Tyrone Clifford Jr. remembers the closest he got to him. “I had my greatest success,” he said, “when my dealer was in prison.”

Then Clifford entered a San Francisco rehab clinic called PROP, the Positive Reinforcement Opportunity Project. There he came across an approach so simple that he sounds slightly amused when he explains it. The secret? The program paid him to show up and stay clean.

“It wasn’t a lot of money – very little, and I didn’t really need it,” said Clifford, 52. “But I needed the support. I needed the connection. For the first time in a long, long time, I did something positive and it changed my attitude. “

The concept of sobriety reward – known as emergency management – is at the heart of many addiction therapy success stories. research It goes back decades that it is a highly effective tool for treating substance abuse disorders, especially stimulants.

The Veterans Affairs Department has busy for a long time the therapy and makes it available to more than 5,600 veterans. About 92% of the 72,000 urine samples collected during treatment tested negative for the targeted drug, said Dominick DePhilippis, a clinical psychologist and researcher who helped launch the VA program in 2011.

But outside of the VA? “It uses almost zero,” said Richard Rawson, a UCLA professor emeritus who researched the therapy for almost 30 years. Providers fear that they will violate by paying patients Anti-Kickback Regulations and thereby jeopardize their federal funding through Medicaid.

But California seems poised to question the regulations. On June 1st the State Senate Adopted unanimously SB 110, introduced by Sen. Scott Wiener (D-San Francisco), declared Emergency Management (CM) a law firm and approved its funding by adding it to the list of those offered by Medi-Cal, the government version of Medi-Cal Drug treatment services will be added to Medicaid. The price of the bill depends on how many patients are using the therapy, but it would only cost about $ 179,000 a year to include the approach in treating 1,000 people trying to quit stimulant use, according to a Financial analysis.

California’s newest budget, which was passed by the state legislature on Monday but is subject to ongoing changes, could ultimately include money for a CM pilot program for next year. Wiener’s standalone bill would provide permanent funding – if that means Medi-Cal can get federal approval for the practice.

The federal anti-kickback law prohibits giving a patient an incentive to choose a particular program or type of treatment. The Office of the Inspector General of the Department of Health and Human Services has so far agreed with the Centers for Medicare & Medicaid Services that a violation would occur for any monetary incentive greater than $ 75 per year, which, according to Emergency Management Expert not enough to get results.

More than a dozen organizations have written to HHS requesting a waiver of the anti-kickback statute related to therapy. A group led by Dr. Westley Clark, the former director of the Federal Center for the Treatment of Substance Abuse, is asking Congress to instruct HHS to allow treatment in Medicaid programs. (HHS did not respond to a request from KHN as to whether a waiver would be considered.)

The VA can ignore the OIG’s interpretation of the rule as the department’s budget covers all of its costs. “VA is the ideal setting for in many ways [the therapy’s] Implementation, ”said DePhilippis. “We are not subject to the funding concerns I have raised by my colleagues in programs outside of the VA.”

As the name suggests, in a CM program, patients are rewarded for changing their behavior based on a contingency – specifically, by not missing out on recovery meetings or by failing a drug test. While the approach can be used to treat any type of substance addiction, it is particularly useful for stimulants such as meth and cocaine, for which there are no established drugs to control addiction, such as. B. methadone versus opioids.

Patients at VA recovery sessions draw from a plastic fishbowl that holds 500 pieces of paper. Half of these pieces of paper contain positive messages: “Good work”. “Way to go.” Another 209 panties are worth $ 1, 40 are worth $ 20, and a “jumbo” price of $ 100 lurks in each bowl. As patients continue to stay clean, the number of pieces of paper they can pull out increases to a maximum of eight. If they skip meetings or test positive, pull out a single piece of paper again. The money is paid out in the form of vouchers, which can be used via the VA canteen system to buy food and other items, but not alcohol or tobacco.

In other programs that use this approach, including the one discovered by Tyrone Clifford in San Francisco in 2011, patients receive gift cards valued at $ 300-400 over a 12-week period in return for attending and conducting meetings regularly cleaner tests. Most incentive programs are intended to end after three months, as patients have used the time to regularly attend counseling and therapy sessions and to stimulate their recovery.

This also happened to Clifford, who got caught up in meth use after learning he was HIV positive at the age of 21. He and his partner (now husband) soon moved from Georgia to San Francisco, where his use was spiraling out of control until he was advised to visit PROP, administered by the San Francisco AIDS Foundation.

“For me, money wasn’t the most important thing – but it was for some of the guys who come in here,” said Clifford. “Maybe they need that small amount to keep a cell phone bill paid. Maybe they need this for a doctor. I hear people say, ‘Why should we pay a drug user to stop using drugs?’ My answer is that it works. You come in week after week and soon you’ll be back on your feet. “

Some critics have moral concerns about paying a patient for good behavior, and therapists are sometimes suspicious of this approach. But effective approaches are needed. In San Francisco, the death rate from meth overdoses has increased more than 500% since 2008, and half of all psychiatric emergency rooms at Zuckerberg San Francisco General Hospital are now linked to meth.

“As a gay man in San Francisco, my community is severely affected by meth use,” said Wiener. Meth use up 20% nationwide among those tested in the first few months of the pandemic.

Those who have seen the approach successfully used in treating meth addiction are confused about its unavailability, especially now that it is called offer everything of marijuana to Yankees tickets to convince people to get vaccinated against Covid-19.

Still, Rawson said he doubts California law can override HHS restrictions. Wiener, on the other hand, does not believe that the use of therapy has ever violated anti-kickback laws.

Tyrone Clifford just knows it works.

“I see it the other way now,” said Clifford, who has been sober for 10 years and now advises those trying to overcome meth addiction through the San Francisco AIDS Foundation. “Boys keep coming back. You can see how it is built every week. “

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