California could pay drug users to stay sober. New data suggests the strategy leads to long-term recovery.

• A California bill proposes giving drug users financial incentives to stay sober.
• The strategy, called contingency management, aims to address the state's escalating meth crisis.
• Data suggests it leads to long-term recovery, but critics argue it rewards bad behavior.

It's an unorthodox approach, but researchers think it'll work. A California bill is proposing to give drug users financial incentives to stay sober - a strategy known as contingency management. California could become the first US state to implement this service, perhaps opening the door for other states to follow suit.

The bill aims to address California's escalating methamphetamine crisis, which grew worse over the course of the pandemic (though services wouldn't be limited to meth users alone). From March to December of last year, Los Angeles County saw a 79% increase in accidental drug overdose deaths from meth compared to the same time period in 2019.

The Food and Drug Administration hasn't approved any medications to treat meth addictions, like it has for opioid addictions. But regardless of whether prescription treatments become available, researchers still think a rewards system is the most effective way to help meth users achieve and maintain sobriety.

"Drugs in and of themselves are really, really reinforcing, so we need to have reinforcers that can be significant enough that they can upset that balance and have someone change their behavior," Meredith Ginley, a researcher who studies contingency management at East Tennessee State University, told Insider.

Ginley's recent analysis, which pools data from 23 different trials, suggests a rewards system is better at helping illicit drug users maintain sobriety for at least one year than cognitive-behavioral therapy, 12-step programs, or outpatient treatment at hospitals and mental health clinics.

The California bill still faces one major hurdle: It proposes that the state offer contingency management services through its Medicaid healthcare program, Medi-Cal. So the bill could potentially violate a federal law that prevents public-health programs from offering "kickbacks," or bribes. So far, the bill has passed the Senate and is awaiting Gov. Gavin Newsom's signature.

Contingency management programs typically offer $300 or more over 12-16 weeks

If the California bill becomes law, there are still plenty of details to sort out - including what incentives to offer.

Some contingency management programs offer weekly vouchers each time a person's drug test comes back negative. But Ginley said the cheapest, most effective strategy involves a lottery of sorts, where people with negative drug tests are eligible to receive sums of money drawn at random.

"The chance of getting $1 or $20 or $100 is kind of fun," Ginley said.

Drug users are usually eligible for increasing rewards the longer they stay sober. But contingency management programs typically last around 12 to 16 weeks, Ginley added, so the money runs out eventually. She estimated that the average person earns about $360 from a lottery system, and $1,200 from a voucher system, over that time period.

Sums lower than $300 usually aren't enough to incentivize drug users, she said.

The goal is to get drug users to a place where they no longer need the cash, and can start to reap the benefits of a sober lifestyle.

"Because they can pass a drug test, now they can put their name on lists to get interviewed for jobs," Ginley said. "Maybe their mom who says 'You can't come around here if you're high,' says, 'Oh, you've not been high for three weeks, now you can start coming to family dinners.' Their sister says, 'Hey, I'm noticing you're sober now - you can come stay at my house as long as you're not using.'"

The service doesn't work for everyone, she said, but a person's odds of long-term recovery are much higher if they stay sober during the program's 12-week window.

'These people are really, really wanting to change'

Some critics of contingency management argue that it rewards bad behavior. Ginley said she often hears the refrain: "We don't pay diabetics to test their blood sugar. Why should we pay somebody who's choosing to use a drug?"

Other critics argue that drug users need to hit rock bottom before they can get sober, and cash prizes might incentivize people too early in their sobriety journey.

But Ginley said that hasn't been true from her observations.

"These people are really, really wanting to change," she said. "This is absolutely a mental illness."

Already, two contingency management programs have had some success. The Department of Veterans Affairs allows drug users who test negative to draw prizes, including cash vouchers, from a fishbowl. The longer a person stays sober, the more draws they get each week. So far, 92% of the drug tests collected during the program have come back negative, Dominick DePhilippis, a researcher who helped launch the program in 2011, told Kaiser Health News.

The San Francisco AIDS Foundation also gives gift cards, amounting to $300 to $400 over the course 12 weeks, to drug users with negative urine tests. In 2019, 63% of the program's participants stopped using meth entirely, and 19% reduced their use.

Other than these one-off programs, Ginley said, contingency management has been essentially "dead in the water" in the US because of anti-kickback laws. California's bill could change that.

"Our hope has been that if one state is able to be brave enough to do it and show that it works - and the feds don't come after them and the court of public opinion doesn't get too outraged that money is being given to persons with substance use - we will be able to, as clinicians, go to our states' Medicaid systems and say, 'This really works,'" Ginley said.