SF could expand program that pays drug users to stay clean

‘It’s clear that we need creative solutions for our addiction crisis’

By Sydney Johnson

Examiner staff writer

A San Francisco program that pays drug users to stay clean is looking poised for expansion under a new bill that’s headed for Gov. Gavin Newsom’s desk for his signature.

“We need to move to widespread adoption and we need the conditions to allow for that,” said ​​Hillary Kunins, director of Behavioral Health Services and Mental Health San Francisco.

The Recovery Incentives Act, authored by State Sen. Scott Wiener (D-San Francisco), would legalize the substance use disorder treatment known as “contingency management” and authorize Medi-Cal to cover it. Currently, Medicaid and Medi-Cal do not cover this type of treatment, largely due to existing rules that prevent health care providers from incentivizing patients to choose one form of treatment over another in the form of kickbacks.

But advocates say the current regulatory language is hindering a treatment option that has shown success, particularly with methamphetamine users, in San Francisco and beyond.

“San Francisco has been a pioneer in this,” said Kunins. “With this new policy, this really can and should become standard of care as part of the routine menu of treatment that’s available.”

The model is relatively simple: A person is rewarded with cash or another prize for the desired behavior, such as showing a negative drug test. But successful execution must be timely and precise, according to Kunins. Perhaps most challenging, it needs funding.

A wide body of research supports contingency management for a variety of behavioral health issues, including meth addiction, which does not have a medication-based treatment option, unlike opioids. Veterans Affairs programs were among the largest and earliest adopters of the treatment and continue to offer it today.

But options in San Francisco are scarce. Across all contingency management programs for which the health department provides funding, just 125 people are involved annually, according to a spokesperson for the department.

If signed by Newsom, the bill could provide a much-needed expansion of the treatments and solutions that San Francisco has made available in response to its escalating drug overdose crisis.

Meth overdose deaths in San Francisco have increased by 500% since 2008, according to the health department. And about 404 people have died of a drug overdose in San Francisco from January to July 2021, according to the San Francisco Medical Examiner’s office.

“We’re seeing meth overdose deaths skyrocket, and it’s clear that we need creative solutions for our addiction crisis,” said Wiener. “We know that contingency management works; it’s one of the only effective and evidence-based treatments for stimulant addiction.”

According to the San Francisco AIDS Foundation, 63% of participants stopped using meth entirely and another 19% reduced their use within one year of the organization’s contingency management program, called the Positive Reinforcement Opportunity Project, or PROP.

People enrolled in PROP agree to visit the clinic three times a week for 12 weeks for a drug test. A small monetary incentive is given for each negative result, with a maximum of $330, usually in gift cards.

Such a small cash incentive surely can’t cover rent in the pricey Bay Area. But it has been able to help get drug users through the door to begin receiving care.

Programs like PROP have been life-changing for San Franciscans like Tyrone Clifford, who now works as a counselor at the San Francisco AIDS Foundation’s Stonewall Project. Having seen his grandmother go through a horrible experience with court-ordered drug rehabilitation, Clifford wanted to avoid the same treatment he had witnessed.

Instead, at PROP, he found something any stipend couldn’t buy: hope for his future well-being.

“It’s not a lot of money in San Francisco. But it provided me with a sense of community,” said Clifford. “For someone who is isolating in their apartment or SRO, this could be the first time you come into contact with anyone who isn’t your dealer or someone down your hall.”

San Francisco health officials have responded to the crisis with a suite of new emergency services, including the formation of a new Street Overdose Response Team that serves to identify and connect individuals who survived an overdose with treatment in order to prevent a fatal overdose.

Mayor London Breed is also allocating $13.2 million in The City’s budget to run the program and expand other overdose prevention programs, including programs that incentivize people to continue addiction treatments.

Programs like Houdini Link, out of San Francisco General Hospital, rely primarily on outside grants. And while initiatives like Proposition C have generated more funds for homelessness services that go toward substance disorder treatment, logistical and legal roadblocks continue to stand in the way.

Kunins, of the Department of Public Health, sees Wiener’s legislation as a necessary step to growing The City’s behavioral health care capacities.

“S.F. has learned from these programs that people want to participate and are finding them helpful,” said Kunins. “Systems need to evolve to set up the mechanics of how this works.”


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