It’s an issue that has come up before and led to some vigorous debate, for and against, including here. An earlier post:

Do Incentives Work?

Two reasons for reopening the discussion. One, the fastest growing drug of abuse in many areas is methamphetamine, a stimulant. Incentive programs for drug abuse patients first appeared in the treatment of stimulant disorders, and much of the  evidence in support of the practice is based there.

Second, some governments, including in California, have been paying drug users for negative drug tests, as much as $599 a year. They’re convinced it’s working. Here’s something from The New York Times on recent trends.

From the standpoint of some voters, paying people to stay off drugs makes a lot of sense. “Why do we care why some street user didn’t use meth?” confided a legislative aide. “None of my business. I don’t even know the guy. And the public is just interested in getting drug use off the street. If this is a step forward, I’m all for it.”

Makes sense, from that perspective. They want a negative drug test. If they have to pay for it, so what?

Then there’s a harm reduction argument. “Maybe we are simply paying for compliance, but at least it helps keep people in treatment,” argued one psychologist. “That has to better than nothing.We can still work with them, encourage healthy behaviors, maybe minimize the risk of OD, even if they are still relapsing.”

Which also makes sense, from that viewpoint.

When we interview recovery -oriented clinicians, we may get another story. They may complain that:

  • Some patients use gift cards to buy contraband, including alcohol and pot products, and sometimes re-sell them on the street;
  • Motivation based in payment is transactional rather than internal, and therefore doesn’t represent real progress in recovery, or in behavior change, either.

“We’re purchasing a clean test result, not a clean and sober person,” one clinician maintained. She has a point. To many clients I’ve met, those are two different things entirely.

The second is a commitment. The first is just a deal — and deals expire.

Other clinicians have been skeptical about the reported outcomes. “We tried gift cards for six months and didn’t get anything like the results we were told to expect,” runs a common complaint. I could see that. Results in general practice often fall short of those achieved in the more structured, supported environment of a funded research project.

So is there a middle ground? A possible compromise?

“I work with probation clients,” a veteran counselor offered, “so if my bosses want to pay people for passing drug tests, that’s up to them. But I don’t want any part of it. How can you have a therapeutic relationship if you’re essentially hiring somebody to relate to you?”

“It feels like I’m bribing someone to do something I want them to do, instead of what they would choose,” he continued.”That’s not the way therapy works, or recovery, either. If you think it is, you’re just kidding yourself.”