How Rewards Aid Addiction Recovery

Harold Lewis has been battling drug addiction for years, but it wasn’t until recently that he began to think that recovery could be fun.

The 59-year-old former chef won small prizes — candy, gum, gift cards, sunglasses and headphones — for attending meetings and staying in treatment for opioid addiction during a 12-week program in Bridgeport, Connecticut.

“Recovery should be fun because you’re getting your life back,” Lewis said.

For a growing number of Americans, addiction treatment involves not only hard work, but also earning rewards — sometimes totaling $500 — for negative drug tests or showing up to counseling or group meetings.

There is a brain science behind the method, which is known as contingency management. And barriers to wider adoption of rewards programs, such as government concerns about fraud, are starting to break down.

“We’re in a desperate situation where we have to pull out all the stops, and this is something that works,” said Dr. James Berry, who directs addiction medicine at West Virginia University.

Overdose deaths in the US have risen to an all-time high during the pandemic. While opioids are primarily responsible, deaths involving stimulants such as methamphetamines are also on the rise. Often, people die with multiple drugs in their system.

Medication can help people stop abusing opioids, but addiction to stimulants has no effective medicine. Rewards programs – especially when the value of the dollar increases with a steady return – are widely recognized as the most effective treatment for people addicted to stimulants.

Since 2011, the US Department of Veterans Affairs has used the method with 5,700 veterans. Rewards are coupons that vets redeem at their local canteen. Over the years, 92 percent of urine tests done on these veterans have come back negative for drugs, said Dominick DePhilippis of the VA’s substance use disorder program.

When done right, reward programs can be a bridge from the difficult days of early recovery to a better life, said Carla Rash, an associate professor of medicine at UConn Health, who studies the method. It helps people make better decisions in the moment, tipping the scales when it’s hard to resist the immediate rewards of drug use.

Rewards can “provide a little recognition for people’s efforts,” Rash said.

For Casey Thompson, 41, of Colville, Washington, the first month after quitting the method was the worst. Without stimulants, he felt burnt out and exhausted.

“Even standing up, you could sleep,” Thompson said.

Help earn gift cards to pass drug tests, she said. During his 12-week program, he received about $500 in Walmart gift cards that he spent on food, shirts, socks and shampoo. He is a trained welder and is looking for work after a recent layoff.

“I’m a completely different person than I was,” Thompson said. “I was already planning on being clean, so it was just extra.”

More than 150 studies over 30 years have shown that rewards work better than counseling alone for addictions such as cocaine, alcohol, tobacco and, when used with drugs, opioids.

The method is based on brain science. Psychologists have known for years that people who prefer small, immediate rewards to larger, delayed ones are vulnerable to addiction. They may vow to quit smoking every morning and start using again by the afternoon.

And neuroscientists have learned from imaging studies how addiction hijacks the brain’s reward center, hijacking dopamine pathways and robbing people of the ability to enjoy simple pleasures.

“Using the same dopamine reward system is the basis for addictions to promote healthy behavior change,” said University of Vermont psychologist Stephen Higgins, who pioneered the method in 1991. His recent research shows that it helps pregnant women to stop smoking and improves the health of their newborns.

“Biologically, substance use lights up the same part of the brain that lights up when a person wins the lottery, falls in love, or experiences something really positive and exciting,” said psychologist Sara Becker of Northwestern University.

The same path is lit if one wins a reward.

“That’s part of what’s strong about these programs,” Becker said.

Support has never been stronger. The Biden administration supports the method in the National Drug Control Strategy. This fall, California will launch a pilot program designed to reward $10 gift cards that pass drug tests for stimulants. Oregon will use tax revenue from the state’s legal marijuana industry to pay for similar incentives. Montana started a program in March using a federal grant.

The US Department of Health and Human Services is working to revise its guidelines on how much government grant money can be spent on prizes, rewards and cash cards. Researchers say the current cap of $75 per patient is arbitrary and ineffective and should be raised to $599.

The method “is a widely studied and proven intervention that has been successful in treating people with a variety of substance use disorders,” said Dr. Yngvild K. Olsen, who directs the US government’s Center for Substance Abuse Treatment.

Rewards programs can be low-tech — slips from a fishbowl — or high-tech — using “smart” debit cards programmed so they can’t be spent at liquor stores or turned into cash at an ATM.

Maureen Walsh is a 54-year-old flower shop owner in Philadelphia who is avoiding opioids with the help of a smartphone app called DynamiCare. When he passes a saliva test, he earns cash on a smart card. She uses the money to treat herself to a new pair of shoes or make a donation to a favorite cause.

“The payoff for me was that I knew I was clean and the test showed it,” Walsh said.

For Lewis, the Connecticut man recovering from opioids, a weekly prize drawing became a way to bring home gifts for his mother.

“Awards make me feel good,” he said. “But the awards make my mother feel great. I’m talking about Tony the Tiger AWESOME!”

On a recent summer day, Lewis had won a chance to draw 10 tickets — 10 chances to win prizes, including a tablet computer. The grand prize eluded him, but he won six small prizes and $20 in grocery gift cards.

“Recovery isn’t all fists and gritted teeth, you know what I mean?” Lewis said later. “It can be fun, where you can exhale and breathe in and get excited – because you don’t know what you’re going to win today.”


AP video reporter Emma H. ​​Tobin contributed to this report.


The Associated Press Health and Science Section is supported by the Howard Hughes Medical Institute Science Education Division. AP is solely responsible for all content.

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