Experiment tests paying meth users to stay off drug

San Francisco tries approach

long-term results are open to question


SAN FRANCISCO -- For more than two decades, Robert Bowers stole money, jewelry, silverware and identities to feed his methamphetamine addiction. He landed in prison, rehab and Skid Row.

Until earlier this year, when the government paid Bowers to quit.

A little-heralded program run by San Francisco's Public Health Department over the past year has given meth users rewards worth as much as $40 per week to stay off drugs. And, in a break from traditional approaches, participants receive no counseling or lectures, even if they test positive for meth use.

Their end of the bargain: Show up at a clinic three times a week, urinate in a cup and collect their reward - a voucher, not cash - if they test drug-free.

"Here I am getting clean, I feel better and I'm getting something for it," said Bowers, 42, who said he hasn't used meth since early February and has put more than 45 pounds on his formerly ravaged 128-pound frame. "That means something."

Although just a pilot program, the San Francisco venture is the latest in a string of experiments and studies over the years to point in the same intriguing, if controversial, direction: Addicts respond remarkably well to material rewards, even little ones.

"You're using the exact same technique that parents use with their children every day," said Nancy Petry, a researcher at the University of Connecticut School of Medicine who is studying this approach. "It's behavior modification and behavior shaping."

The findings could be especially significant in California, where methamphetamine use continues to surge. It has surpassed alcohol and heroin as the drug of choice among people seeking treatment. Meth increases arousal and reduces inhibitions, sometimes leading to violence, child neglect and serious health problems such as malnutrition and heart failure among chronic users.

In essence, the voucher approach replaces one reward with another - the high of drugs with the mental boost of grocery money, a gift certificate or a rent subsidy. Given the power of addiction, as shown by many addicts' desperate and self-destructive acts, the trade-off might seem woefully insufficient. But for some reason, researchers say, it works.

Since November 2004, 159 participants have enrolled in the 12-week San Francisco program, which is geared toward gay and bisexual men. About 38 percent of those eligible have completed their stint. Although the success of drug programs is hard to gauge and not systematically tracked, experts said the San Francisco program's numbers are comparable to or better than those of other publicly funded outpatient treatment options.

What makes the program most noteworthy is that it is simpler than conventional treatment - less time-consuming and substantially less costly, proponents say. Because there are waiting lists for drug rehabilitation in many parts of the country, including San Francisco, such programs also broaden options for treatment.

The benefits go beyond stemming drug addiction, extending to prevention of sexually transmitted diseases, said Dr. Jeffrey Klausner, San Francisco's director of STD control. Extensive research shows that meth is associated with risky sexual behavior.

This year, University of California, Los Angeles researchers published one of the first studies to challenge the idea that vouchers had to be paired with another treatment to work. Over 16 weeks, meth users who received vouchers tested negative for drug use 83 percent of the time, compared with 75 percent for those receiving cognitive behavioral therapy alone.

"Clearly, it wasn't the money," said Steven Shoptaw, a UCLA researcher. "It was the fact that somebody recognized them."

The reward program, or "contingency management," hasn't caught on widely in practice, experts say - at least, not yet.

"Because the treatment approach is a little different from giving medications or counseling, probably that has added an unfamiliar wrinkle to it," said Stephen Higgins, a University of Vermont researcher who pioneered the use of vouchers for drug addicts.

Some people in the field of substance abuse are openly skeptical, and even treatment experts and researchers who accept the scientific soundness of the concept are troubled by its ethical implications. Why reward people for dropping habits they never should have taken up to begin with? Why use scarce treatment dollars for rewards if you can't be sure the results will last?

"As soon as you take the reward away - if they haven't had any counseling or other treatment to go along with it - who's to say that it would continue?" said Teri Cannon, executive vice president of Behavioral Health Services Inc., which provides treatment across Los Angeles County.

Marlene Nadel, director of client services for the North Hollywood center Cri-Help, said, "Even if we had the funds, it would not be the route we would take."

Charles Ornstein writes for the Los Angeles Times.

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