SUNDAY, APRIL 3 , 2022. THE WASHINGTON POST EZ RE K A25
the opinions essay
Incentives for health-related behav-
iors will always make some people balk,
as shown by criticism of covid-19 cam-
paigns promising to award doughnuts,
cruises, even millions of dollars to those
who got vaccinated. When drugs enter
the picture, the stigma often increases.
But even people with staggeringly differ-
ent views are getting behind contingen-
cy management.
In California, state legislators who
couldn’t agree on whether Donald Trump
had won the 2020 election did agree last
summer — without a single “no” vote — to
expand access to CM programs statewide.
State Sen. Scott Wiener (D), who intro-
duced the California bill, told me that
although he “assumed it would be hyper-
controversial... it turned out, even
though there are people who have that
initial reaction, once people look at it
more closely, they tend to be persuaded.”
What convinces the skeptics? For
some, it’s the taxpayer benefits: CM is
incredibly cost-effective. (No surprise
there — a single emergency-room visit for
meth-induced psychosis can easily cost
more than three months of cash rewards.)
For others, it’s understanding that CM
won’t just fund someone’s drug habit.
Participants earn rewards only whenthey offer objective evidence of absti-
nence; someone who isn’t ready to stop
using simply will not earn money.
So if moral objections to CM aren’t as
common as one might expect, why isn’t it
already more widespread? The major
obstacles, as we shall see, aren’t moral
ones at all. They’re mundane and bureau-
cratic — and easily fixed.N
o matter what anyone thinks we
should do to address the addiction
crisis — legalize or criminalize all
drugs, attempt to restrict supply, induce
the government to provide a safe supply
— there will always be people in this
country struggling to change their rela-
tionship to mind-altering substances.
And those people deserve all the help
they can get.
People like Anileah Buswell.
In March 2020, Buswell was living with
her boyfriend in a condemned Florida
trailer park — without phone service,
electricity or running water, both of them
high on meth and other drugs. She was
20 and at the peak of her addiction after
years of using. For weeks, she’d been
wrapped in her high, oblivious to the
outside world.
Hunger finally drove the two outside.When they emerged, they found a ghost
town.
They tried to enter a McDonald’s to
charge their phones, but the doors were
locked. A nearby homeless shelter was
closed. Eventually, they made their way to
a pizza shop where Buswell’s mother
sometimes worked, and there they
watched the news and discovered with
horror that people across the country
were dying from a mysterious new virus.
This was how it often went with her
addiction: The whole world could be
falling apart, and she wouldn’t even
know.
Buswell and her boyfriend spent a
night with her grandmother, who
bought them bus tickets to New Hamp-
shire, where the two had previously
lived. In that first year back, she experi-
enced several cycles of sobriety and
relapse — until just before her 21st
birthday, in April 2021, when she learned
she was pregnant.
The pregnancy motivated Buswell to
stop using. She entered a residential
treatment program for women and chil-
dren, where she gave birth. And several
months later, she moved into her own
apartment with her baby daughter.
It is in such transitional moments —fraught with instability and uncertainty
— that many people find it difficult to stay
sober. Navigating the stresses of life with-
out enough support, or encountering fa-
miliar triggers, can lead to relapse.
It is worth mentioning that some
people who use drugs, even so-called
hard drugs, do so without throwing their
lives off balance. But for others, drug use
can quickly spiral into chaos. Although
cutting back might unlock natural re-
wards in a person’s life — the chance to
repair loving relationships, find mean-
ingful employment, create a home — for
someone trying to quit a substance,
those benefits might seem incredibly
remote. Meanwhile, the biological and
psychological rewards for using a drug,
and the punishments for abstaining, are
immediate.
Buswell, caring for her infant, had
been “white-knuckling it,” she told me —
worried about her sobriety and her well-
b eing. Then she was offered a space in the
contingency management program.
Initially, she had her doubts. “It’s going
to be stupid,” she thought. “What am I
going to want with some piece of paper
that says ‘Good job’?”
But then she made her first prize draw
— and received her first positive affirma-
tion. As she described the experience, she
teared up. “People don’t realize how hard
it is,” she said. “There’s a lot of struggles
that people don’t see. It just feels good to
have somebody recognizing that.”C
ontingency management is not
new. In fact, researchers have been
experimenting with it for decades,
and the road to its development is lined
with many of the familiar components of
scientific discovery — peer-reviewed
studies, randomized experiments — as
well as a few unusual ones. For instance:
porpoises.
Maxine L. Stitzer, a professor emerita at
Johns Hopkins University School of Medi-
cine, was a graduate student in psychop-
harmacology at the University of Michi-
gan in the 1960s when a paper about
“creative porpoises” — show animals —
crossed her desk. Stitzer’s main interest
was understanding the effects of psycho-
active drugs on behavior. When she read
about the porpoises, she became in-
trigued.
Show animals are often taught to
perform specific tricks: wagging their
tails to music, leaping over ropes in
unison. But this paper described how
porpoises that were offered positive re-
inforcements (i.e., food) for new behav-
iors began inventing moves unlike any
their trainers had ever seen.
Stitzer was no stranger to animal-
b ehavior studies. Her lab had published
several reports showing that animals will
repeatedly dose themselves with drugs
when given the opportunity. But the por-
poise study showed there could be other
powerful motivators — modest rewards,
strategically applied. She wondered:
What if these reinforcers were to com-
pete? Could strategic positive reinforce-
ment be strong enough to counter the
pull of drugs?
When Stitzer moved to Johns Hopkins,
in the 1970s, she had a chance to investi-
gate these questions. Patients in a clinic
at Baltimore City Hospital, now known as
Johns Hopkins Bayview Medical Center,
were managing their heroin addictions
with daily doses of methadone — which,
taken as prescribed, reduces cravings and
staves off the agonizing withdrawal that
drives so many people to keep using.
Some had quit heroin but were still using
other drugs, such as cocaine and benzodi-
azepines (benzos), commonly abused an-
tianxiety medications.
Stitzer and her colleagues recruited
SEE THE OPINIONS ESSAY ON A26W
hen I first crossed paths
with Anileah Buswell, she
was living with her infant
daughter in Nashua, N.H.,
and trying to stay off meth.
And for the first time in many years, she
was succeeding.
Buswell, 21, was enrolled in a program
with a radically simple premise: Get paid
to abstain from drugs. The approach,
known as “contingency management,” or
CM, has racked up a slew of successes. It
has been shown to dramatically reduce
people’s smoking during pregnancy and
to help decrease binge drinking. It is also
highly promising for combating meth-
amphetamine addictions.
The treatment, however, is vastly un-
derused. Buswell is among the relatively
small number of Americans involved in a
CM program, at a time when metham-
phetamines are increasingly contribut-
ing to the country’s devastating overdose
crisis.
Between April 2020 and April 2021
alone, the nation recorded more than
100,000 overdose deaths. Most of those
deaths involved opioids, but in recent
years the country has also seen a spike in
addiction and deaths involving psycho-
stimulants — largely meth. According to
provisional data from the Centers for
Disease Control and Prevention, over-
dose deaths involving stimulants besides
cocaine increased more than fivefold be-
tween 2015 and 2021, from 5,777 per year
to more than 30,000.
Meth’s growing role is concerning.
While the Food and Drug Administration
has approved medications, including
methadone, that can ease people’s opioid
cravings, there are no such FDA-
a pproved medications for methamphet-
amine. That is why contingency manage-
ment could prove to be so crucial: It has
consistently been shown to increase ab-
stinence among stimulant users more
effectively than other, more ubiquitous
methods, such as 12-step programs or
cognitive behavioral therapy.
It’s no wonder, then, that several states
— including California, Montana and
Washington — are either engaged in or
spinning up CM pilot programs. And for
those who can pay out of pocket, a grow-
ing number of telehealth companies are
offering fully remote contingency man-
agement.
“The science is well established,” said
H. Westley Clark, an adviser to Califor-
nia’s pilot program and a former director
of the federal Center for Substance Abuse
Treatment. “When you compare it to
other treatments, CM ranks at the head of
the pack.”
The way it works is straightforward.
When people pass a drug test, they earn
rewards, usually a draw from a bowl
containing prizes — written phrases of
affirmation (“Good job!”), gift certificates
in amounts from a few dollars to $50.
Testing occurs twice a week or more, and
rewards often escalate to encourage peo-
ple to stick it out long term; you might get
one draw from the prize bowl for your
first drug-free sample, three draws the
next week and five the following week.
Some programs remove the element of
chance or offer straight cash instead of
gift cards. Sometimes, a different behav-
ior is rewarded, such as showing up for
counseling. But the rewards are always
immediate, to help the positive reinforce-
ment land.
To some, this all might sound a bit
fishy. Paying people to stay off drugs? One
can imagine the arguments: Isn’t anyone
struggling with addiction just going to
spend the money they earn on drugs
again? Why should states devote taxpayer
dollars to this?
by Emefa Addo AgawuShe was paid
t o stay o≠ drugs.
Here’s why
this approach c ould
help many others.
PHOTO BY TONY LUONG FOR THE WASHINGTON POST“The science is well established. When you compare it to other treatments,
[contingency management] ranks at the head of the pack.”
H. Westley Clark, former director of the federal Center for Substance Abuse Treatment