The backlash over Seattle's plan to reward drug users for staying clean

D

arryl Lee shifts in his seat and stares down at his lap as he unearths some distant memories of childhood. This isn’t nostalgia. His dad was a “chronic alcoholic” and “abusive.” To escape, his mom moved the family to Seattle from Dallas. Eventually, Lee fell in with the wrong crowd, he said.

“I got addicted to drugs and started going to jail and started being a criminal, and it just snowballed after that,” he said.

Lee has spent most of his life either homeless or incarcerated. These days he’s got a place to live in the First Hill neighborhood, at Plymouth Housing, which offers supportive housing for people who were chronically homeless. But the drugs have taken a toll, and he’s still using.

Lee said he once overdosed on meth and fentanyl. Paramedics were able to save his life using Narcan. But he worries about what could happen next time.

Overdose deaths soared 72% in the city last year, mostly due to meth and fentanyl. Seattle city leaders including Mayor Bruce Harrell say more needs to be done.

That’s why they’re backing a new drug treatment program called “contingency management.”

It involves rewarding people with gift cards or prizes for not using drugs. The idea has been around for decades but is controversial and hasn’t been widely used, partly because there is resistance to the idea of rewarding people struggling with addiction.

But researchers say the method is effective and may help people like Lee get into recovery. Studies have shown that rewards programs can work for many different types of addiction.

Over 80% of studies found contingency management worked to reduce the use of stimulants like meth, for example, according to one recent meta-analysis.

“If contingency management was a medication, it would have been FDA approved 30 years ago,” said Professor Michael McDonell of Washington State University, who studies contingency management and is helping lead a new statewide pilot program.

Seattle’s pilot is a part of that. It will launch later this year at Plymouth Housing, where Lee lives. An $800,000 grant from the Washington State Health Care Authority will fund the Seattle arm of the program.

Other sites that will take part in the pilot include hospitals and clinics in Klickitat County and Grays Harbor County.

But Seattle’s program is the only one happening in a residential setting. The hope is that it can help people like Lee where they live, without requiring participants to make it to appointments offsite.

McDonell said Washington is one of only three states, including Montana and California, that are starting to use contingency management. One reason why it's been slow to gain acceptance is the stigma against drug addiction.

“The idea of paying someone to not use drugs feels unpalatable,” explained Denise Walker, an expert in addictive behaviors at the University of Washington. Whereas most experts these days consider substance use a “learned behavior,” in the past the public and even health care providers tended to view addiction more as a “moral failure” or “personality disorder,” she said.

One study found many health care workers were hesitant to implement contingency management partly for that reason.

Even some former drug users who work in the field of recovery balk at the idea of contingency management. “I didn't get paid to stop using drugs. Why should this person get paid to stop using drugs?” the thinking goes, according to McDonnell.

It's also become a political issue in the Seattle area. Over the last year, as the idea has started to gain traction, local conservative pundits poured the concept of contingency management into the blender of hyper-partisanship.

A conservative advocacy group Change Washington called it "Seattle’s absurd giveaway proposal for drug addicts." A Republican talk show host called it "bribing" addicts, and “Seattle's latest inevitable failure.” More recently a Fox News segment featured a local conservative think tank fellow who “slammed” the plan as “gamifying” addiction.

But according to researchers, these sorts of politicized criticisms are refuted by the evidence. Contingency management can be effective, they say. And Seattle leaders from across the political spectrum believe help is urgently needed to address the city's drug crisis.

Seattle City Councilmember Sara Nelson, who is in recovery herself, said contingency management is a way to help people dealing with addiction, and that also has the potential to improve Seattle for all residents.

“Addiction lies at the intersection of both our public safety and our homelessness crisis," Nelson said. "This is ground zero for really making meaningful sustainable progress on a lot of fronts, including improving downtown.”

Contingency management can be particularly helpful for meth users. There are no proven medicines available for meth, as opposed to opiate abuse, for which medications like Suboxone can help. When it comes to meth use, contingency management is the only option that’s shown promise, McDonell said.

Plymouth Housing resident Darryl Lee said that while he’s tried almost every drug, the draw of meth has been different. He compared it to taking a powerful dose of caffeine. “A lot of cups of coffee, times coffee,” he said.

When he was homeless, meth helped him stay alert, he said.

University of Washington professor Caleb Banta-Green told KUOW that some unsheltered people use meth to help them function under extremely harsh living conditions. He said that helps explain why the drug can be so hard for people to quit.

Surveys show 80% of opioid users say they want to stop or reduce their drug use, while only half of meth users say they want to cut down or quit, Banta-Green noted.

Lee said he recognizes the dangers of meth. He’s already overdosed once and knows meth can lead to other problems like heart failure, stroke, and sudden death. Meth use can also lead to a condition called meth-induced psychosis, with symptoms that include hallucinations or violent behavior.

For people wanting to get off meth, researchers say, contingency management is a really important treatment option. But they also warn that contingency management is no panacea. It won't work for everyone. For some, it might just be a first step toward recovery.

The new state pilot programs will be a modest first step. Each, including the one in Seattle, is expected to enroll about 20 people to start. They’ll be open to those struggling with any form of addiction.

For his part, Lee said he’s ready to try the new reward program at Plymouth. He compared his lifelong experience with drugs to a “roadblock.” He said it feels like he’s been stuck on a corner, unable to cross the street. He hopes contingency management can help him stop using, and eventually repair connections to loved ones.

“I hope to just have a better relationship with my family, and to leave a legacy of something positive behind,” he said.

Plymouth plans to launch its new pilot treatment program this fall.

This story previously spelled Darryl Lee's name as "Daryl." It has been updated with the correct spelling of his name.