SEATTLE — Michael Crowley knew he wanted to quit drinking. He’s tried before, but without someone checking on his progress, holding him accountable, it hasn’t stuck.
So when a case manager came by his apartment in a building run by Plymouth Housing, offering gift cards to anyone who could make and keep goals to reduce their substance use, he signed up. The cards were small — $15 or $20 to Safeway — but they represented a marker of Crowley’s progress. If he met a goal, he’d get a card; if he didn’t, he wouldn’t.
“It put me in a position where I’m held accountable to somebody else in my life,” he said.
Crowley was among the first cohort of a new program being offered in Plymouth Housing buildings that ties small financial rewards to reducing, or eliminating, substance use. It’s called “contingency management,” an inscrutably dry name for trying the carrot instead of the stick to help people fight their addictions.
Seattle City Hall’s interest comes as King County sees a record number of overdose deaths, the majority of which involve both fentanyl and methamphetamine. More than 1,330 people died of overdoses in 2023. So far in 2024, nearly 500 people have died from drugs and alcohol, and while some experts say a peak is likely coming, it might not be this year.
Seattle’s program is in its infancy. Washington is one of two states in the country allowed by public insurance to try these programs and Seattle is now among a handful of places in Washington running a pilot program.
Contingency management has been tried elsewhere — with success — but its deployment in Plymouth Housing is the first time it’s left the clinical setting for a residential one.
Proponents of contingency management don’t sell it as a fix to the broader addiction crisis. Participants opt-in, often at a time in their lives when they feel motivated to make a change. The definition of “success” in the program is nuanced, and not always shared with the outside world’s. Participants aren’t required to give up substances entirely.
The program has attracted backlash partly for those reasons. Opponents scorn the incentive as a form of bribery.
But Michelle Peavy, who’s helping to analyze the program for Washington State University, said the focus on the dollar amount of the gift cards misses the larger purpose. She said what makes it work is relying on principles that influence behavior, in this case positive reinforcement.
“We’re taking what we know about behavior and putting it into practice,” she said.
Restrictions lift on old idea
The basic concept of contingency management — incentives to help treat addiction — has been around since the 1960s. Its focus is generally on people using methamphetamines. There are no proven medical treatments for addiction to methamphetamines, leaving clinicians and case workers eager to try something new.
Studies suggest that, when paired with medication for opioid use, contingency management is one of few effective approaches for people using stimulants. An analysis in the Journal of American Medical Association concluded an expansion of its “services are sorely needed.”
The Department of Veterans Affairs began offering it in select locations in 2011 where more than 6,000 people have participated. Researchers found it to be effective.
But despite its promise, contingency management’s expansion has been limited, largely due to restrictions by Medicaid and Medicare.
Now those restrictions are lifting, albeit slowly. Washington last year became just the second state in the country to receive a waiver for the program, said Rachelle Alongi, policy communications director for the Washington State Health Care Authority, joining California as a place Medicaid and Medicare can cover its use.
In 2022, Seattle’s auditor concluded more needed to be done to combat methamphetamine addiction and recommended the city try contingency management.
Mayor Bruce Harrell announced the test run in 2023, as part of an executive order on addiction in Seattle. It’s funded with an $800,000 grant from the health care authority. So far, 21 people have enrolled.
Although it’s geared toward substance use without clear medical treatment, it can also serve as an opening for those dealing with concurrent opioid addictions to begin a medical regimen. Staff will often offer Sublocade — an injectable form of buprenorphine — to help those struggling with a fentanyl addiction.
In Crowley’s case, however, it was for an alcohol addiction that had him polishing off liters of vodka in a day.
Incentives and acceptance
Crowley, 54, struggled with addiction since he was 12. He was “born into it,” he said, as his father struggled as well.
Things got worse at the outset of the pandemic. Quarantined at home, Crowley found himself drinking all day — waking up at 6 a.m., drinking, taking a nap, then drinking some more. It wore him down.
“I just got tired of having to drink to not feel like I’m going to die,” he said.
By the time contingency management became an option to him, Crowley had already decided he wanted to cut down on his drinking. He’d made that choice before, but it had never worked for him.
“I was counting days sober, and I had an end game, which was to celebrate sobriety by not being sober,” he said.
So when case managers asked if he wanted to try this new program, where he could earn up to $499 in gift cards to Safeway in exchange for reducing his alcohol use, he said yes.
For Plymouth staff, the pilot is a new entry into providing an on-site service for residents who’ve previously been homeless. In some ways, it’s the inverse of jail — external pressure, but in the form of incentive rather than punishment.
“There are many out there that think people either need to be clean and sober or they’re not good people,” said Gabrielle Nomura Gainor, communications director for Plymouth Housing. “So we’re always just trying to combat that perception.”
Aaliyah Bains, behavioral health program manager for Plymouth Housing, said connecting residents with treatment options has always been a struggle. What resources exist are overtaxed and located somewhere else. As the demand outstrips supply, wait times to get into treatment stretch.
“Before now, we outsourced,” she said.
Contingency management, though, gives Plymouth Housing a more direct role in its residents’ treatment.
WSU researcher Peavy said that’s the innovation of the program in Seattle.
“Wouldn’t it be great if you could put it where people are?” she said.
Contingency management is broadly viewed as related to the “harm reduction” approach to substance use — the idea that not everyone will get or is ready to be completely clean and sober, but people who use drugs and alcohol can make their use safer, and that hopefully leads to treatment.
That’s not how staff with Plymouth currently see it, because the ultimate goal is to get participants to reduce or eliminate substance use. But that doesn’t mean success is defined for each individual.
“We’re not asking people to meet the goals we have for them,” Bains said. “We’re not asking them to be 100% sober, we’re asking them to meet the goals they set for themselves.”
The goal Crowley set for himself was to no longer drink to excess. Simply, he wanted to look at himself in the mirror again.
Receiving his gift cards meant agreeing to a urine analysis several times a week. He didn’t pass them all. But when he failed, he never felt shame and, therefore, stuck with the program.
“It’s not an all or nothing type situation,” he said. “If you screw up or if you have a hot [urine analysis] the demeanor of the people that are working with us doesn’t change because of it. They’re very interested in what it takes to fix this problem.”
Crowley graduated from the program this year and his drinking is down to maybe a beer or two. He still smokes marijuana as well, but feels like a person again. Time will tell if it sticks, but he feels confident it will.
Results still to come
An analysis of the program in Seattle and its long-term effectiveness is likely to take until at least the fall.
“We are very interested in learning more about the effectiveness of administering the program in a residential setting and are hopeful about expansion to other supportive housing and treatment providers as contingency management is now covered by Medicaid in Washington,” Callie Craighead, spokesperson for Harrell, said.
Meanwhile, patience is waning for many who say giving out gift cards — or clean syringes, or opioid overdose-reversal medication — encourages people to remain addicted.
“This is another case of the city missing the forest for the trees,” the advocacy group Change Washington wrote of the program.
Some might support the concept but don’t want those resources near them, such as a supervised drug consumption site that was funded by a previous Seattle City Council but failed to materialize.
Still, as a new drug possession law is enforced, Harrell and other officials have been under pressure to take bolder action on the meteoric rise in overdose deaths. That has included a methadone clinic on wheels that meets homeless people where they are, as well as King County opening a new behavioral health center.
Initial anecdotal evidence from the Plymouth program shows promise.
For Ronald Hicks, the program got him into the rhythm of receiving shots to ease his fentanyl addiction, while the gift card portion is to help him with his methamphetamine use. He doesn’t pass all his urine tests and, therefore, doesn’t always receive a gift card. But he’s had success, insofar as he said he’s using less than he was.
Hicks’ story is a common one among participants — a man, worn down by years of addiction and homelessness, taking steps both forward and backward, focused on even incremental improvements as symbolized by a plastic card to Safeway.
“I’m not using like I was,” he said. “I’m tired of being tired.”
