The Brief

For four years, Shane Hutchison lived in a tent in the middle of the desert outside Lancaster, miles from the nearest grocery store. The 53-year old started each day the same way — with methamphetamine.

“It's almost like you feel you have to have it just to be able to make the seven-mile hike one-way for water,” Hutchison said. “Out there in the desert, it becomes a tool of survival.”

Last summer, an outreach worker asked Hutchison if he wanted to be a part of a new Los Angeles County program in which he could earn gift cards each week he could pass a drug test.

The program, which started last year, is one of the only treatment options available for unhoused Angelenos addicted to stimulants, including methamphetamine. While the approach has been used in drug treatment for decades, it’s now gaining traction in L.A. County. And there’s evidence to show it’s been successful.

People can be prescribed methadone to manage their addiction to heroin, fentanyl and other opioids. But experts say there are no approved medications to help people addicted to meth and other stimulants.

That makes an incentives approach even more crucial, practitioners said.

“ There aren't a whole lot of treatment options that are not just abstinence-based,” said Kim Roberts, chief program officer at shelter provider L.A. Family Housing. “Folks can be looking to change their relationship with stimulants, but maybe not ready to discontinue alcohol use or marijuana use.

“This program is really tailored to the idea that we can start to chip away at a substance use disorder and that it doesn't have to be all or nothing.”

Hutchison said he’d never seriously tried quitting before, but this time he was ready. He’d been recently diagnosed with an aggressive skin and bone cancer.

“I gave up,” he told LAist. “I threw away everything I had out there in the desert. I left there, walked away with my dog and my backpack, and here I am now.”

Hutchison completed the 13-week program in March and earned about $600 in Visa gift cards, according to county health officials. Today, he says he’s sober, living in a two-bedroom apartment in Palmdale and working full-time as a carpenter.

“If it wasn't for the program, I'd probably still be out there on meth,” he said.

About one in three homeless Californians regularly use methamphetamine, according to a UC San Francisco report released in March. Meth is a leading cause of overdose death among L.A. County’s unhoused population, according to the L.A. County Public Health Department.

California started experimenting with incentives programs in 2023, becoming the first state to get federal approval to spend Medicaid dollars on programs that essentially pay people to break their addiction to stimulants.

The concept, known to some as “contingency management,” is not yet common among L.A. County’s homeless service providers. There are more than 75,000 unhoused people in the county, but so far programs have been offered at six local homeless shelters and drop-in centers.

And it’s not without skeptics. Over the years, some clinicians and members of the public have likened the approach to bribery and expressed ethical concerns about paying people for something they should be doing anyway.

A contingency management patient checks in with county health workers before a urine analysis test.

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Thomas Lynch

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L.A. County Department of Health Services

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‘Not about a transaction’

L.A. County’s program began last spring as a collaboration between the Department of Health Services’ Housing for Health division and several homeless services providers.

It’s funded by a county grant aimed at reducing overdose deaths among the unhoused. For the fiscal year that began this month, more than $400,000 in county funds are dedicated to that grant.

The county provides money for gift cards and sends behavioral health teams trained in contingency management. Those teams work mostly out of vans equipped as mobile clinics, rotating through various locations including recent stops in North Hollywood and the San Gabriel Valley.

In May, the county launched new programs in Santa Fe Springs and Harbor City. Later this month, they’ll launch one near MacArthur Park, county officials said.

L.A. County Supervisor Lindsey Horvath supported bringing the program to a transitional shelter in Canoga Park called the Willows, where 25 residents are expected to complete their 13-week cycle later this month.

“This program is not about a transaction,” Horvath told LAist. “It's about how you develop trust and an ongoing relationship with people. So not only do they know that you are invested in their wellbeing, but they become invested in their wellbeing themselves.”

Participants in the county’s program get weekly Visa gift cards ranging from $10 to $50 for passing drug tests and also for meeting other goals like going to medical appointments, obtaining identification cards or signing up for public benefits.

The programs do not remove participants for failing drug tests.

“It's very much come as you are,” said Savann Duong, a clinical work supervisor with the county program. “There's no judgment. If you test positive, that's OK. Let's talk about it. You know, what happened this week?”

Methamphetamine can be detected in urine analysis tests up to three days after use. If participants test positive, they won’t get their weekly gift card, but they’ll still have the chance to be tested again the following week.

That’s crucial, according to Kim Roberts of L.A. Family Housing, which operates the Willows.

“We've created the space for people to come back and say, ‘Hey, this week wasn't it for me. I'm gonna try again next week,’” said Roberts. “And their housing is not dependent on it.”

To end the homelessness crisis, Horvath said the county must provide unhoused Angelenos with more than just shelter. Additional support, like drug treatment, is crucial.

“From a dollars-and-cents perspective, it's just waste if you aren't actually treating people and meeting them where they are,” Horvath said.

Not everyone completes the treatment. In the first few cycles of the county program, about three in 10 participants completed the full 13 weeks, officials said.

The incentive program uses rewards for clean drug tests to combat substance abuse and addiction.

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Mark Leong

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CalMatters

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History and evidence

Rewards programs are a new approach for L.A.’s homeless service providers, but dozens of studies have shown that positive reinforcement through small incentives is the most effective treatment available for stimulant use disorder.

Participants who received contingency management were 22% more likely to be drug-free six months after treatment than participants who received other types of treatment, like cognitive behavioral therapy, according to a recent research review.

“The one thing that we have to really significantly address stimulant use, based on 30 years of research, is contingency management,” said Thomas Freese, director of UCLA’s Integrated Substance Abuse programs.

The U.S. Department of Veterans Affairs has offered gift cards to reward people for clean drug tests since 2011. Since that time, those programs have served more than 8,000 veterans struggling with stimulant addiction, according to the VA.

The American Society of Addiction Medicine and American Academy of Addiction Psychiatry recommended this kind of treatment as the standard of care for stimulant use disorder in 2023, pointing to evidence showing it’s been more effective than anything else at helping people overcome stimulant addiction.

That same year, California became the first state to earn federal approval to use Medicaid dollars to pilot contingency management programs for Medi-Cal patients struggling with stimulant use. Earlier this year, more than 6,000 patients were enrolled in about 100 programs in the statewide pilot. About 35% of those who started the program finished, according to the UCLA researchers.

That pilot is expected to continue until at least the end of 2026.

The budget reconciliation bill signed into law by President Donald Trump this month cuts Medicaid spending in California, in part by imposing new work requirements on Medicaid recipients beginning in 2027.

Gov. Gavin Newsom said he expects the paperwork and administrative hurdles involved will result in up to 3 million California enrollees losing coverage.

The new law includes an exemption to the work requirements for people who are in treatment for substance use disorder. This should save the state’s contingency management pilot, but experts say they are waiting to see how the new rules play out in practice.

L.A. County’s program operates separately from California's Medicaid pilot. Despite some recent cuts to county homelessness funding, this particular county-led effort is funded for at least one more year, county officials said.

The fourth cycle of L.A. County’s traveling contingency management program will conclude this month at the Willows, a transitional housing site in Canoga Park.

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PracticeLA

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Battling addiction and stigma

Public programs that support people experiencing addiction often face pushback from voters and elected leaders, service providers told LAist.

Harm reduction is a public health approach that recognizes addiction is a health condition and that some people aren’t going to quit using drugs. Harm reduction interventions typically focus on minimizing the negative health effects of drug use.

In L.A. County, that includes distributing items like clean syringes, drug testing kits and doses of naloxone to treat opioid overdoses.

Many struggle to understand that approach, said L.A. Family Housing’s Roberts.

“If you talk about wearing a seatbelt when you're driving and frame that as harm reduction, people are totally fine with it,” said Roberts. “If you talk about drinking one less glass of wine as a housed person, people are totally fine with it. When you start to introduce paying people to stop meth use, all of a sudden there's a real visceral reaction that folks have, that in some way we are enabling.”

The county’s contingency management program relies on harm reduction principles, but it’s also explicitly aimed at motivating people to stop using stimulants.

Holden Bender-Bernstein, a mental health specialist at The Willows transitional shelter in Canoga Park, sees the approach as a middle ground.

"While this is a harm reduction program in some ways — in that no one's punished for coming back with a test that's positive for a stimulant, it also really relies on abstinence,” he said. “I think this is actually a good bridge for folks to understand that there's a difference between the idea of needle exchange and something like this, where they are depending on negative urine tests.”

Shane Hutchison, 53, says he used methamphetamine for nearly 20 years before getting clean last year.

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Aaron Schrank

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LAist

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Many participants stop attending treatment if they fail a drug test, even though the program encourages them to return, program managers told LAist.

“A lot of our folks, because they have that long history of feeling shame and guilt when it comes to substance use, they don't come back,” said Savann Duong. “ And that part is really hard.”

Hutchison said he saved up the gift cards he earned in his treatment program. After graduating, he bought a toaster, slow cooker and other new appliances for his apartment.

But, he said, the real reward was weekly contact with treatment providers invested in his wellbeing. His mother died four years ago, while he was incarcerated on meth-related charges.

“I don't have a family, but I had a reason to go every Thursday,” he said. “They gave me hope to be somebody. I think the reason, more than the incentive, is just having somebody there who cares.”