Earlier this year, the Biden administration gave the green light to a harm-reduction program that incentivized substance users to quit drug use by paying them to stay clean.
Payment plan harm-reduction programs work by offering substance users financial rewards for staying away from drug use. In general, they offer substance users a financial reward for negative drug tests, providing instant gratification for abstention.
Payment plans may be particularly useful for stimulant addictions, such as methamphetamine, which currently cannot be effectively treated with medication. The need is urgent – stimulant overdose rates have been rising in the US since 2012, and cocaine was involved in one in five overdose deaths in 2019. On the other hand, people with opioid addictions may be prescribed medications like buprenorphine and methadone to reduce cravings for opioids and decrease the risk of overdose.
Scientists suggest that payment plans are so effective because of their interactions with the brain’s reward system. The reward system is a natural part of how the brain works, helping to reinforce life-preserving behaviors like eating and having sex. When we engage in beneficial activities, our brain releases a small amount of the chemical dopamine (and other neurotransmitters), signaling that we should repeat the activity.When someone takes a stimulant drug, it floods the brain with dopamine, forming strong neuronal connections that encourage substance use. Over time, these connections become an addiction, producing strong urges to use the drug that are difficult to resist.
When someone receives a financial reward, their brain also releases dopamine. This can interfere with the reward pathways related to substance use, helping substance users to stay away from the drug. It also offers substance users instant gratification that contrasts with the long-term benefits of quitting drugs (such as better health and social outcomes). Substance users typically find it more difficult to relate to long-term outcomes, instead focusing on immediate reward or harm.
While payment plan programs have huge potential, so far their use has been limited. Companies have feared that anti-kickback statutes (which prohibit the exchange of anything of value to reward the referral of business reimbursable by federal healthcare programs) would penalize the implementation of programs that offer money to clients.
However, in March 2022, the Department of Health and Human Services posted an advisory opinion stating that the company DynamiCare Health would not face any criminal or civil penalties for its harm-reduction payment plan. The opinion states that “although the arrangement would generate prohibited remuneration under the federal anti-kickback statute if the requisite intent were present, the Office of Inspector General will not impose administrative sanctions on requestors in connection with the arrangement.”
The DynamiCare plan offers so-called “contingency management” through a mobile phone application. It invites clients to conduct self-administered saliva drug tests in front of their phone camera, overseen by an employee of the company. The video is then sent to the company to ensure the test was correctly administered.
The DynamiCare plan offers a range of rewards of varying sizes. It gives small incentives for accomplishments like attending meetings, and larger ones for applying for jobs or participating in vocational programs. Financial rewards are transferred onto a debit card which is coded to prevent spending on alcohol, gambling, and similar activities – and also prevents the user from converting the rewards to cash.
As well as DynamiCare, Medicaid is set to fund a $58.5 million test program in California for people living with stimulant use disorder, beginning in late 2022. According to the California Department of Health Care Services, contingency management is the only treatment that has shown robust outcomes for people living with stimulant use disorder, including reduced drug use and longer treatment durations. While contingency management has been tested from other funding sources, California is the first state to receive federal approval for contingency management through the Medicaid program.
Under California’s payment plan, participants will consent to urine tests twice a week for 24 weeks, receiving a reward for every negative (clean) test. The payments will start at $10, increase to $26.50 at the halfway point, and then decline again. In the final week, participants will receive $21 per test. The total amount received is capped at $599 (the highest amount that may be received without paying tax).
As with the DynamiCare Plan, participants will not receive cash but will access the rewards on a gift card that is restricted to prevent spending on alcohol or drugs.
Despite concerns surrounding the “gifting” of taxpayer money to users of illegal drugs, directors of the institution argue that the data is unequivocal. As the only reliable and effective type of harm reduction program for stimulant drug reduction is currently available, there is nothing else that can move people towards recovery.
While it may use taxpayers’ money in the short-term, addiction treatment programs save money in the long run. The estimated cost of drug abuse in the United States (including alcohol, tobacco, and illegal drugs) is more than $740 billion annually. Drug abuse has cost the health service, increases criminal activity, and lowers the productivity of the nation. On the other hand, supporting substance users to recover from stimulant abuse decreases the likelihood that they will need medical treatment for overdose, increases their capacity to work, and keeps them away from criminal activity.
While the use of contingency management is in its early stages, health officials hope that successful trials will lead to their proliferation across the country. Doing so could help substance users across the country recover from stimulant drug use and save thousands of lives each year.
