The Brief

Among the most difficult addictions to witness at San Francisco General Hospital’s drug clinic is methamphetamine, which leaves users tearing at their skin and unable to eat, sleep or sign up for help.

The worst part: The clinic workers largely are powerless because unlike with opioid addiction, for which doctors prescribe medications such as methadone, there is no medicine for stimulant use disorder.

“We live day in and day out watching people suffer in a way that’s hard to imagine,” said Dr. Brad Shapiro, medical director of the Opiate Treatment Outpatient Program at Zuckerberg San Francisco General Hospital. “They’re just dying in front of us.”

Faced with that immense suffering, California will try a new approach to stimulant addiction: Paying people with gift cards to reward them for staying sober.

This model, known as “contingency management,” rewards people with financial incentives each time their drug tests are negative for stimulants. It’s been shown to have success in clinical trials — and the U.S. Department of Veterans Affairs has been using it for more than a decade — but it hasn’t taken off in California. Medicaid previously wouldn’t cover it, so there was no funding to expand its use.

To Shapiro, that’s inexcusable.

“It’s actually, in my opinion, really quite criminal that we’ve gone decades knowing this is an effective treatment and the powers that be have failed to make a pathway for treatment for people,” he said.

The program is expanding now, thanks to a recent waiver by the federal Centers for Medicare & Medicaid Services that allows the agency to cover its costs. California was the first state in the nation to win approval for a contingency management program under Medicaid. The Golden State is launching pilot programs in 24 counties, including San Francisco, Sacramento and Los Angeles. Costs for what collectively is called the Recovery Incentives Program will be reimbursed by CalAIM – the state’s recent expansion of Medi-Cal services.

“All of a sudden we have money to provide this incredibly effective intervention,” said Shapiro, whose clinic is launching one of three pilot programs coming to San Francisco. “So it makes a huge difference.”

Fighting meth with gift cards

Shapiro’s clinic focuses primarily on opioid addiction, but more than half of their patients also have a stimulant use disorder, he said.

While the deadly opioid fentanyl gets most of the attention in the drug epidemic in California and across the country, experts say stimulant use is a major — and growing — concern. In 2021, 65% of drug-related deaths in California involved cocaine, methamphetamine or other stimulants — up from 22% in 2011, according to the California Department of Health Care Services.  Nationally, there were 15,489 overdose deaths involving stimulants other than cocaine (largely methamphetamine) in 2019, up 180% from 2015, according to a study by the National Institute on Drug Abuse.

And with California in the midst of a dire homelessness crisis, stimulants are wreaking havoc on the state’s unhoused community. Among unhoused residents who use drugs, amphetamines are by far the most common choice, according to a recent study by the UCSF Benioff Homelessness and Housing Initiative. Nearly one-third of people surveyed reported using amphetamines three or more times a week, compared to just 11% who used opioids with the same frequency. Some people who live on the street reported using stimulants to stay alert at night, when they fear being attacked if they fall asleep.

To combat stimulant addiction among its patients, Zuckerberg San Francisco General Hospital recently launched a six-month contingency management program as part of the statewide pilot. The hospital opened enrollment on July 17, and staff hope ultimately to serve about 50 people. Clinicians will test participants for stimulants once or twice a week. Each time patients test negative, they’ll get a $10 gift card to Walmart or another retailer. The amount of the gift card gradually will increase, for a maximum of $26.50 per test. If they test positive, they get nothing.

Participants can earn a maximum of $599 over the course of the program. That’s because payments of $600 or more must be reported to the Internal Revenue Service.

The Opiate Treatment Outpatient Program at Zuckerberg San Francisco General Hospital on July 20, 2023.

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Mark Leong

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CalMatters

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Santa Clara County hopes to launch a similar program within the next few weeks. So far this year, 70% of the 120 drug deaths recorded in the county involved methamphetamine, according to the Office of the Medical Examiner-Coroner.

“We’re all excited to try it and see if it does help retain people in treatment for longer periods of time so they are more successful,” said Tammy Ramsey, program manager for the Drug Medi-Cal Organized Delivery System in the county’s behavioral health department.

Contingency management works

Other programs in counties throughout California — including Alameda, Fresno, Nevada, Sacramento and Los Angeles — will follow the same model.

If the trials are successful, Shapiro hopes the state will allow them to expand and serve everyone on Medi-Cal.

The model already has proven effective for the Department of Veterans Affairs, according to Dominick DePhilippis, the department’s deputy national mental health director for substance use disorders. The VA started using contingency management in 2011, and as of the beginning of July, the program has treated more than 6,300 veterans. Those veterans have attended about half of their appointments and produced nearly 82,000 urine samples – of which more than 92% were negative for the targeted drug, DePhilippis said.

It’s not just the VA. Of 22 studies testing contingency management’s impact on stimulant addiction, 82% reported “significant increases” in participants’ abstinence, according to a 2021 meta-analysis published in JAMA Psychiatry.

Dr. Brad Shapiro is director of the Opiate Treatment Outpatient Program at Zuckerberg San Francisco General Hospital.

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Mark Leong

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CalMatters

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Shapiro believes the model works because it replaces the reward a patient’s brain craves (the drug) with a different type of prize.

“It’s a little bit like winning something,” Shapiro said. “It triggers that reward place in the brain that otherwise they would be turning to the drug for.”

But Tom Wolf, who has battled addiction and homelessness himself and now advocates for drug policy reform, said he worries using Medi-Cal to fund contingency management will create bureaucratic hurdles to treatment as patients wait for the state to decide if they are eligible. Still, he said, the program is worth a shot.

“At this point I’m willing to try it, basically because we have such a dearth of options for people that are struggling with addictions in California,” he said.

Because of how difficult it is to treat his patients that use stimulants — many of them use methamphetamine every day — Shapiro would be happy if even a quarter of participants significantly reduced or stopped using. There is also concern, as with any type of treatment, that patients will relapse once the program is over, he said. To help prevent that, the hospital will provide six additional months of counseling after the contingency management program ends.

It’s not a perfect solution

Rewarding people for staying sober doesn’t work for everyone. Even before it was covered by Medi-Cal, Zuckerberg San Francisco General Hospital was experimenting with the model in small programs.

One of the participants in those programs, 54-year-old J.W., ended up in the emergency room with heart failure after two decades of methamphetamine use. After his hospital stay, he enrolled in a 12-week program called Heart Plus, which caters to cardiac patients with a history of stimulant use. Every time J.W. did something positive, such as show up to an appointment, take his medication or get a negative drug test, he got to draw a Safeway gift card out of a hat. The cards’ value ranged from $5 to the “elusive” $20, and J.W. — who asked to go by his initials out of fear of being stigmatized for his drug use — estimates he earned about $180 throughout the entire program. He wasn’t working at the time, so the cards helped him get treats such as deli sandwiches and fancy bottles of kombucha.

“It was definitely something to look forward to,” he said. “And it was something fun to spend.”

But it wasn’t enough to get J.W. off drugs. Now that the program has ended, he’s still using methamphetamine — sometimes as often as three times a day — though he says he’s taking smaller doses. And he said he feels much healthier than when he showed up in the emergency room last year, out of breath after the slightest amount of exertion.

J.W. isn’t sure why he didn’t quit using during the program. But methamphetamine has become an entrenched routine in his daily life. He uses upon waking up, in a ritual he compares to having a morning cup of coffee.

“I still kick myself wondering why I didn’t quit altogether,” he said. “There’s no better opportunity.”

In the wake of the Eaton Fire, Altadena and Pasadena’s music community have really shown up to support fire survivors, especially fellow musicians who lost instruments and record collections.

That effort continues this weekend with a special donation concert at a Pasadena record store, with the aim of getting vinyl records back in the hands of survivors who lost their collections.

“You know, our name is Healing Force of the Universe, and I think that gives me a pretty clear direction… especially after the fires,” said Austin Manuel, founder of Pasadena record store, where Sunday’s show will be held.

The record donation effort is the brainchild of musician Brandon Jay, who founded the nonprofit Altadena Musicians after losing his home and almost all of his family’s instruments in the Eaton Fire. Through Altadena Musicians’s donation and registry platform, Jay said he and his partners have helped some 1,200 fire survivors get their music instruments back.

Brandon Jay.

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Robert Garrova

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LAist

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Now, that effort has fanned out to restoring vinyl record collections.

“All of that stuff evaporated for thousands of people,” Jay said. “Look at your own record collection and be like, ‘Wow, what if that whole thing disappeared?’”

You might know Jay from several bands over the years, including Lutefisk, a 1990s alt-rock band based in Los Angeles. He and his wife, Gwendolyn Sanford, composed music for TV shows, including Orange is the New Black and Weeds.

Jay plans to play some holiday tunes at Sunday's record donation show (which LAist is the media sponsor), along with fellow musician Daniel Brummel of Sanglorians. Brummel, who was also a founding member of Pasadena’s indie-rock sensation Ozma, said he was grateful to Jay for his fire recovery work and to Manuel for making Healing Force available for shows like this.

Brummel, who came close to losing his own home in the Eaton Fire, recalled a show he played at Healing Force back in March.

Ryen Slegr (left) and Daniel Brummel perform with their band, Ozma, on the 2014 Weezer Cruise.

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Even Keel Imagery

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“The trauma of the fires was still really fresh,” Brummel said. After playing a cover of Rufus Wainwright’s “Going to a Town,” that night — which includes the lyrics “I’m going to a town that has already been burnt down” — Brummel said his neighbors in the audience told him the rendition hit them hard. “It felt really powerful. And without that space, it just wouldn’t have occurred.”

Details

Healing Force of the Universe Record Donation Show
Featuring: Quasar (aka Brandon Jay), Sanglorians (Daniel Brummel) and The Acrylic.
Sunday, Dec. 14; 2 to 5 p.m.
1200 E. Walnut St., Pasadena
Tickets are $15 or you can donate 5 or more records at the door. More info here.

Topline:

The case: In September, the city settled a lawsuit brought forward by two brothers in their 70s who said they suffered serious injuries after an LAPD officer crashed into their car. Days before the $18 million settlement was reached, lawyers for the brothers said Feldstein Soto called an expert witness testifying for the plaintiffs and “attempted to ingratiate herself with him and asked him to make a contribution to her political campaign,” according to a sworn declaration to the court by the plaintiffs’ attorney, Robert Glassman.

The response: Feldstein Soto did not respond to an interview request. Her spokesperson said the settlement “had nothing to do” with the expert witness. Her campaign manager told LAist the city attorney had been making a routine fundraising call and did not know the person had a role in the case, nor that there were pending requests for her office to pay him fees.

What Jurado says: In a statement to LAist, Jurado said she wants to “make sure that the city’s legal leadership is guided by integrity and accountability, especially when their choices affect public trust, civic rights and the city’s limited resources."

What’s next: The motion needs to go through a few committees before reaching the full City Council. If it passes, the motion calls for the city attorney to “report to council in closed session within 45 days regarding the ethics breach violation and give updates to the City Council."

Every year in Santa Ana, Luis Cantabrana turns the front of his home into an elaborate altar in honor of La Virgen de Guadalupe that draws hundreds of visitors.

Along the front of the house, the multi-colored altar is filled with lights, flowers and a stained-glass tapestry behind a sculpture of the Lady of Guadalupe. Cantabrana’s roof also is lit up with the green, white and red lights that spell out “Virgen de Guadalupe” and a cross.

Visitors are welcomed with music and the smell of roses as they celebrate the saint, but this year’s gathering comes after a dark year for immigrant communities.

Luis Cantabrana stands in front of the stunning altar he built in front of his home in honor of La Virgen de Guadalupe. Every year, his display draws hundreds of visitors.

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Destiny Torres

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LAist

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Why do they celebrate? 

In 1513, the Virgin Mary appeared before St. Juan Diego between Dec. 9 and Dec. 12, asking him to build a church in her honor. Her image — a brown-skinned woman wearing a green veil with her hands together in prayer and an angel at her feet — miraculously appeared on his cloak.

To celebrate in Santa Ana, worshippers gathered late-night Wednesday and in the very early hours Dec. 12 to pray the rosary, sing hymns and celebrate the saint.

Cantabrana has hosted worshippers at his home for 27 years — 17 in Santa Ana.

The altar started out small, he said, and over the years, he added a fabric background, more lights and flowers (lots and lots of flowers).

“It started with me making a promise to la Virgen de Guadalupe that while I had life and a home to build an altar, that I would do it,” Cantabrana said. “Everything you see in photos and videos is pretty, but when you come and see it live, it's more than pretty. It's beautiful.”

The Santa Ana home's elaborate altar in honor of La Virgen de Guadalupe draws hundreds of visitors each year.

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Destiny Torres

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LAist

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Gathering in a time of turmoil 

Many also look to the Lady of Guadalupe for protection, especially at a time when federal enforcement has rattled immigrant communities.

“People don’t want to go to work, they don’t want to take their kids to school, but the love we have for our Virgen de Guadalupe,” Cantabrana said. “We see that la Virgen de Guadalupe has a lot of power, and so we know immigration [enforcement] won’t come here.”

Margarita Lopez of Garden Grove has been visiting the altar for three years with her husband. She’s been celebrating the Virgencita since she was a young girl. Honoring the saint is as important now as ever, she said.

“We ask, and she performs miracles,” Lopez said.

Claudia Tapia, a lifelong Santa Ana resident, said the Virgin Mary represents strength.

“Right now, with everything going on, a lot of our families [have] turned and prayed to the Virgen for strength during these times,” Tapia said. “She's a very strong symbol of Mexican culture, of unity, of faith and of resilience.”

See it for yourself

The shrine will stay up into the new year on the corner of Broadway and Camile Street.