US CA: QUITTING METH PAYS OFF

QUITTING METH PAYS OFF

Material rewards appear to be quite effective at inducing addicts to
stop. But whether they'll stay clean when the gifts end is a matter of debate.

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

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 last year has given meth users rewards worth up
to $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 is simple: 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 says 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."

Though 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 those seeking treatment. The drug
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 such as meth 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.
So far, about 38% of those eligible have completed their stint.
Though 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.

Some treatment experts are peering over San Francisco's shoulder.
Others are borrowing the concept or adding touches of their own.

The Seattle and King County Department of Health, for instance, is
preparing a study that rewards gay and bisexual men who remain
drug-free. The Addiction Institute of New York recently started
giving people vouchers to show up to treatment sessions, regardless
of whether they are drug-free.

For nearly 15 years, research has indicated the usefulness of rewards
in conjunction with traditional treatment, especially in motivating
patients to stick with their programs.

Then, earlier this year, UCLA 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% of the time, compared with
75% for those receiving cognitive behavioral therapy alone.

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

The reward programs, known as "contingency management," haven'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 in the field of substance abuse are openly skeptical of the
results. 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.

"We wouldn't do something like that because we couldn't afford to do
something like that," said Marlene Nadel, director of client services
for the North Hollywood center Cri-Help. "Even if we had the funds,
it would not be the route we would take."

The operators of the San Francisco program, and others around the
country, say addiction is such a costly problem in human and economic
terms, that promising -- and relatively inexpensive -- ideas should
not be rejected out of hand.

"What we're trying to teach people in the field to do is value
science," said Stephen Gumbley, of the Addiction Technology Transfer
Center of New England, which works with clinicians to translate
research into practice. "Some of what gets in the way of translating
science into practice is values. And one of the values of this is
that we shouldn't be paying people to do what they're supposed to do
in the first place."

Some of the resistance is related to the culture of drug treatment, he said.

"Our field can be very negative," he added. "We tend to approach
treatment with punishment as opposed to stroking people."

Short-Term Outlook

Drug abuse seems to defy logic.

Consider a 2000 study of pregnant women trying to quit smoking. Women
rewarded by vouchers for testing nicotine-free quit at more than
three times the rate of those who received advice and referrals.

"The fact that a pregnant woman would discontinue substance use when
offered a voucher for doing so, but not to improve the health of her
fetus, is perplexing," Higgins said in a paper published last year.
"After all, the vouchers are worth a pittance relative to the value
of a healthy baby."

But Higgins and others say addicts are people in search of immediate
gratification who discount rewards they can't quickly realize (such
as a healthy baby six months down the road). Vouchers succeed in part
because they replace one immediate reward -- the experience of being
high -- with another, the researchers say.

Another study shows that vouchers work best when linked to a specific
achievement. Higgins gave cocaine users counseling and vouchers over
24 weeks of treatment. In one group, addicts received the vouchers
only if they tested drug-free. In the other, they received the
vouchers regardless of their drug use. The first group did much
better than the second.

The explanation may lie in the brain.

Edythe London, a professor of psychiatry and pharmacology at UCLA,
has compared the brains of meth addicts and nonaddicts.

"Systems in the cortex, which are important for making decisions,
were just not working very well," she said of the meth users. "They
had less activity than in normal healthy people."

But meth users had hyperactivity in lower centers of the brain that
control emotion and craving, London said. That partially explains why
meth addicts consistently make irrational decisions, putting them in
a "spiral where things get worse and worse and worse," she said.
(Researchers are not sure to what extent meth addicts' brains are
inherently different and to what extent meth contributes to the
unusual pattern.)

The vouchers themselves don't change the brain. They simply give the
person a choice that is less objectionable than "methamphetamine or
nothing," London said.

Studies have shown that though rewards can be small, size does
matter, at least in a relative sense. One study found that nicotine
abstinence increased as rewards were raised from $0 to $12 per day.
Over time, patients needed more incentive to stay off drugs.

The San Francisco program allows participants to earn up to $453.75
in vouchers if they attend every scheduled visit and test drug-free
over 12 weeks. But Petry, the University of Connecticut researcher,
has devised a less costly system, in which addicts with clean urine
tests can draw for prizes. They win about half the time, collecting
rewards ranging in value from $1 to $100. The rest of the time, their
slip says, "Good job."

The chance of winning apparently is a powerful lure.

Connecticut Renaissance, a drug treatment facility in Waterbury,
Conn., began using Petry's model in May. To qualify for the drawing,
participants must show up for their conventional treatment groups and
test drug-free. Although it's still early, those vying for prizes are
attending their group counseling sessions far more regularly than
those not participating in the drawings, said Eileen Russo, clinical
director of residential services.

"There just seems to be this little bit of extra incentive to make
sure that they do what they're supposed to be doing," she said. "It's
really going very smoothly."

The San Francisco model doesn't just try to integrate rewards into
regular substance abuse treatment. The rewards are the treatment.

Program Brings Focus

On a Wednesday morning this past summer, the waiting room at Magnet,
a community center in San Francisco's Castro district, was packed as
staff members cycled recovering addicts in and out.

Nate Birjukow, then the project coordinator, followed the
participants into the bathroom, watched them urinate into a cup and
then, wearing gloves, used a dropper to place two drops onto an
instant drug-screening device to test for the presence of
methamphetamine, cocaine, heroine and marijuana.

Birjukow, who recently left the health department, said he didn't let
clients look at their test results because he didn't want any disputes.

"Good job, you tested negative," he told one client before handing
him a yellow voucher.

It's a simple routine, and Jerry Frost said it worked for him. His
doctor at the county hospital referred him to the voucher program
last year, and he became its first enrollee.

"It was obvious -- I was getting really sick and I wanted to get
[drugs] out of my life," he said.

Frost, a burly 55-year-old artist, said he started using meth and
cocaine in the 1980s when his friends were dying of AIDS and his
lover left him. He quit for a time but started back up when his lover died.

Frost said he didn't want to enroll in a 12-step program, to stand
and say his name and admit his addiction.

With the voucher program, "I didn't really have to tell them anything
unless I wanted to tell them," he said. "Since I wanted to quit, they
gave me a schedule to go by." With his vouchers, Frost said he bought
his roommate a computer desk and a dining room table for "putting up"
with him and his addiction.

"I had to do something three times a week. It was a ritual I went
through. It kept me focused."

Without meth, Frost said he was able to sleep every night, watch TV,
go to the movies, go to the park: "The simple things again."

But Frost's story is not so simple. He was sober for months, then,
like so many addicts, relapsed.

"I just didn't feel like I needed to talk to anyone," he said. But
"that's not the way it works."

He's back in treatment, the conventional kind, with less tangible rewards.