Feds approve experiment to pay drug and alcohol users to stay sober

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But until last week, when the Office of the Inspector General of the Department of Health and Human Services posted an advisory legal opinion, its use was severely limited by concerns that such a program would violate a federal law prohibiting bribery of patients. At the request of a company that used the method and conducted research into the effectiveness of payments to drug users, alcoholics and smokers, the government for the first time allayed those fears.

In the nine-page notice, Robert K. DeConti, HHS assistant inspector general for legal affairs, said Boston-based DynamiCare Health would not face criminal or civil penalties for its payment plan.

“Although the arrangement would generate prohibited compensation under federal anti-bribery law if the requisite intent were present, the OIG [Office of Inspector General] will not impose administrative penalties on the plaintiff in connection with the arrangement,” DeConti wrote.

The decision allows the company to pay customers up to $599, a steep increase from the $75 limit the government had previously observed, which many experts considered too low to be effective. DynamiCare chose $599 because that is the maximum a customer can receive without having to pay taxes on the money.

The opinion and an HHS spokeswoman stressed that the decision only applies to DynamiCare. Others wishing to offer similar incentives should receive their own advice from the OIG. But DynamiCare co-founder David Gastfriend and others who have tried to persuade HHS to allow higher-paying contingency programs said they expect many others to act quickly. to provide therapy.

“It’s a breakthrough,” Gastfriend said.

The Biden administration made removing barriers to contingency management a priority when it announced it was embracing harm reduction in April. The administration was embroiled in minor controversy last month after Conservatives launched an online furor falsely claiming the government would spend $30 million on crack smoking pipes.

Contingency management is considered particularly useful for treating people addicted to stimulants such as methamphetamine and cocaine, as there are no proven medications for this disorder. Opioid abuse is best treated with drugs such as buprenorphine and methadone, although too few people receive them.

Under an HHS waiver, California is set to launch a $58.5 million contingency management trial for people with stimulant use disorders in July, using funds from Medicaid. So far, 27 counties are enrolled in two phases, a participation rate that is expected to bring in thousands of clients, said Kelly Pfeifer, assistant director of behavioral health at the California Department of Health Care Services.

Under the plan, participants would agree to take in-person urine tests twice a week for 24 weeks and receive increasing rewards for each clean test. Payouts would start at $10 and increase to $26.50 in the 12th week, before tapering off for the second half of the program and climbing to $21 per test in the final week.

Evidence of drug use in the test would reset the program, but clients could only receive $599, Pfeifer said.

The money would be placed on a gift card, with protections built into the program to prevent spending on alcohol, cigarettes, vaping gear, marijuana and gambling, she said. But Pfeifer acknowledged that “no program we put in place will be 100% abuse-proof.”

When asked why taxpayers’ money should go to people who use illegal drugs, Pfeifer said: “The data is solid, unequivocal. There is nothing else that works to bring people to healing.

Keith Humphreys, professor of psychiatry and drug policy researcher at Stanford University, said contingency management works because of the focus on immediate rewards. People with substance use disorders have even less ability to delay gratification than those who are not under the influence of drugs, he said.

“You’re interested in what’s going to happen now, not what’s going to happen in a week or a year,” Humphreys said. “You can’t think that far ahead of a bigger, later reward.”

A constant concern is how customers will fare once the incentives run out. Coaching and other forms of therapy may be needed.

DynamiCare, a digital health company, moved contingency management to a phone app. In its trials over the past few years, clients had to wear saliva-based drug test kits at all times and be selected for testing at random times.

The tests are done in front of the phone camera, watched by company staff, according to Gastfriend, an addiction specialist at several treatment locations, including Massachusetts General Hospital, before founding the company with his son in 2016. The video is uploaded to the company to verify that the test was performed correctly.

Starting with tiny rewards for accomplishments like going to a meeting, the incentives escalate to find a job or enroll in a professional program, he said. Like the California program, the debit card that receives the funds is coded to block spending at liquor stores, casinos, bars, and other venues, and to prevent the user from converting the credits to cash.

Gastfriend partnered with the National Council for Mental Wellbeing to develop DynamiCare’s strategy and legal approach to obtaining the Inspector General’s Advisory Opinion. The decision clarifies that the company uses the same emergency management plan for opioids, nicotine and alcohol.

“We try to remove every obstacle, every excuse, every inhibition in order to motivate people to move forward with the effort to stay clean,” Gastfriend said. “Because it takes a tremendous amount of effort to overcome addiction.”

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