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. He’s run seven marathons and one ultramarathon, and today as a WSU addiction-treatment researcher, he spends most of his time studying and advocating for contingency management as a way to fight addiction.
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%.
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 might sound infantilizing, but decades’ worth of research has shown that it works.
“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.
“With meth, nothing seems to work — except this,” McDonell said. “It’s just a sin that we’re not doing it.”
“Rational human beings”
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.
That study led many researchers, like McDonell, to see drug addiction as a product of someone’s environment and the options available to them, rather than a mindless attraction to the substance itself.
“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. Patients would dance and sing when they won big prizes. One patient, undergoing treatment in an effort to be a better father, used his vouchers to buy an iPod for his daughter.
Since then, 72 patients have completed treatment — mostly for cocaine and meth use — and only eight patients have had to go back through 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).
Now, the biggest struggle the VA faces is that staff are usually completing it in addition to other duties, and they don’t have enough room or enough staff at the Addiction Treatment Center to expand further.
Proven but still not used
Today, McDonell still studies contingency management, refining and individualizing it. His current study for alcohol use, operating out of Community Psychiatric Clinic’s office in Seattle’s Wallingford neighborhood, looks at how people respond when you start simply by giving them prizes just for drinking less, and then moving on to abstinence, among other things.
The more intangible part of this treatment is the power of being held accountable by someone who cares. A 2018 Seattle study McDonell co-authored found that in addition to the prizes, people liked having something to work for and someone to cheer them on.
“The prizes I don’t care. It’s accountability,” said one participant. “You’ve been really patient with me,” another said to staff. “I’m gonna miss working with you.”
In these studies, between 40 and 60% of participants are homeless people, who often say they’re treated poorly at treatment centers or health-care facilities. They’re also eight times more likely than housed participants to drop out of the treatment, McDonell said.
Some programs have used the accountability aspect to simply encourage people to show up for treatment.
Evergreen Treatment Services, which provides methadone and buprenorphine to treat opioid addiction in King County, started offering rewards in 2012 at its Sodo clinic to get new patients — who often drop out in the first month — to make their first appointments. They get $5 gift cards to Subway or Fred Meyer for taking their medication every day and meeting with their counselors.
“At first when we started doing it I thought, ‘they’re not going to want to do that for just $5 or $20,’ but people feel challenged to do something,” said Sue Bailey, engagement specialist at the clinic.
Evergreen saw a 15% bump in attendance for counseling visits during its three-month trial period.
Years after he started studying contingency management, McDonell is still one of its cheerleaders. But as he continues to study it, his enthusiasm for the treatment is tempered by the fact that its use is limited.
“It’s frustrating to do studies like this over and over again and see how much it works — but not see it in practice,” McDonell said.