Taking too long? Close loading screen.
Connect with us

Business

This Addiction Treatment Works. Why Is It So Underused?

Published

on

PHILADELPHIA — Steven Kelty had been addicted to crack cocaine for 32 years when he tried a different kind of treatment last year, one so basic in concept that he was skeptical.

He would come to a clinic twice a week to provide a urine sample, and if it was free of drugs, he would get to draw a slip of paper out of a fishbowl. Half contained encouraging messages — typically, “Good job!” — but the other half were vouchers for prizes worth between $1 and $100.

“I’ve been to a lot of rehabs, and there were no incentives except for the idea of being clean after you finished,” said Mr. Kelty, 61, of Winfield, Pa. “Some of us need something to motivate us — even if it’s a small thing — to live a better life.”

The treatment is called contingency management, because the rewards are contingent on staying abstinent. A number of clinical trials have found it highly effective in getting people addicted to stimulants like cocaine and methamphetamine to stay in treatment and to stop using the drugs. But outside the research arena and the Department of Veterans Affairs, where Mr. Kelty is a patient, it is nearly impossible to find programs that offer such treatment — even as overdose deaths involving meth, in particular, have soared. There were more than 16,500 such deaths last year, according to preliminary data, more than twice as many as in 2016.

Early data suggests that overdoses have increased even more during the coronavirus pandemic, which has forced most treatment programs to move online.

Researchers say that one of the biggest obstacles to contingency management is a moral objection to the idea of rewarding someone for staying off drugs. That is one reason publicly funded programs like Medicaid, which provides health coverage for the poor, do not cover the treatment.

Some treatment providers are also wary of giving prizes that they say patients could sell or trade for drugs. Greg Delaney, a pastor and the outreach coordinator at Woodhaven, a residential treatment center in Ohio, said, “Until you’re at the point where you can say, ‘I can make a good decision with this $50,’ it’s counterproductive.”

ImageSam Lookatch of the Philadelphia V.A. Medical Center with $1 voucher rewards for Mr. Goldschmidt, to recognize his time being drug free.
Credit…Hannah Yoon for The New York Times

Two medications used to treat opioid addiction, methadone and buprenorphine, have often been viewed with similar suspicion because they are opioids themselves, even though there is abundant research showing they substantially reduce the risk of death and help people stay in treatment. But the federal government has started aggressively promoting such treatment for opioid addiction, and has heavily invested in expanding access to it.

As of yet, there are no medicines proven to suppress the intense cravings that come with addiction to meth and cocaine. Instead, there are a raft of behavioral interventions, some of which have very little evidence of effectiveness.

“The most common treatment is to do whatever the hell you feel like,” said Michael McDonell, an associate professor at Washington State University who has conducted a number of studies on contingency management. “We had two statewide meetings about meth recently, and at one, a colleague said, ‘Why aren’t we just doing contingency management? Why would we spend all this money on interventions that won’t work?’”

The fact that no public or private insurer will pay for contingency management, except in a few pilot programs, is a major challenge to expanding it; the biggest obstacle is that offering motivational rewards to patients has been interpreted as violating the federal anti-kickback statute. A group of treatment experts recently asked the Department of Health and Human Services to waive the statute for two years as it pertains to contingency management, but the agency refused, saying programs that provide rewards need to be evaluated on a case-by-case basis.

Congress recently told states that they could start spending federal “opioid response” grants on treatment for stimulant addiction, but the agency that distributes the grants allows only $75 per patient, per year to be spent on contingency management — far less than what research has found effective.

“The biggest question is how do we get the payers on board with this,” said Eric Gastfriend, the chief executive of DynamiCare Health, a technology company in Boston that has worked with BrightView and other treatment programs to provide contingency management through a phone app that patients can use to share saliva test results with providers in real time, via video. For rewards, patients can earn up to $600 over the course of a year through DynamiCare, on a debit card that blocks cash withdrawals and purchases at liquor stores and bars based on merchant category codes.

Credit…Hannah Yoon for The New York Times

“I was hesitant to try it — like, hey, is this legal?” said Dr. Shawn Ryan, the chief medical officer and president of BrightView Health, an addiction treatment provider with locations throughout Ohio, which started using contingency management last year. But the results have been striking, he said, adding, “I’m talking about significant improvements in attendance to therapy sessions, significant reductions in drug and alcohol use.”

Rewarding people for changing a behavior or adopting a new habit is a familiar concept, used by everyone from parents who are trying to get their children to do chores to companies that are trying to get their employees to stop smoking. Research has found it also helps people who are addicted to opioids, but for them, there are other treatments that are equally or more effective. For addiction to stimulants like meth and cocaine, however, contingency management has the best outcomes — especially when combined with therapy that helps people find healthier ways to meet their social and emotional needs than using drugs.

A 2018 meta-analysis of 50 clinical studies of interventions for cocaine and amphetamine addiction, for example, found contingency management combined with an intervention called the community reinforcement approach was the most effective.

Federal officials say that they want to expand access to contingency management for stimulant addiction, but that finding an effective medication for it would be better.

“If we were paying for it, that would help,” Dr. Nora Volkow, the director of the National Institute on Drug Abuse, said of contingency management for meth addiction. “But we badly need medications to help strengthen the response to behavioral interventions. This is a highly, highly addictive drug.”

One patient at BrightView Health, Jodi Waxler-Malloy, 47, of Toledo, tried contingency management treatment after participating in more than a dozen treatment programs for cocaine, heroin and meth addiction since starting to use drugs in her early 20s.

BrightView restarted her on buprenorphine for her heroin addiction and set her up with the DynamiCare app and debit card as an incentive to stay off meth. DynamiCare would add between $1 and $25 to her debit card whenever she went to BrightView for a doctor appointment or therapy, though she never knew the amount ahead of time.

Credit…Maddie McGarvey for The New York Times

“Nothing’s for free, so at first I said, ‘Yeah, yeah,’” Ms. Waxler-Malloy said. “But the next day, I looked at the app on my phone and they’d given me $25 for detoxing. Wow, really? I went back the next day and I got $5 more.”

Ms. Waxler-Malloy said the monetary rewards helped her get through the first month of sobriety in particular, a period when her housing was precarious, her cravings were intense and she needed to save whatever money she earned waitressing for rent at a sober living house that she was waiting to move into.

“It was enough to buy cigarettes or grab something to eat,” she said. “Maybe I was going to the appointments and meetings for the wrong reason at that time, but it helped me in the long run — helped me meet people, have a support group.”

Contingency management has been used the most by the Department of Veterans Affairs, where 110 clinics and hospitals have employed it since 2011 to try to help more than 5,100 veterans stay off drugs.

Dominick DePhilippis, a licensed clinical psychologist who oversees the program at the department, said he had seen new interest in the approach outside the department as meth addiction has surged again over the past few years. He published a paper in 2018 that found that, on average, patients in the department’s contingency management program attended more than half of their scheduled sessions, and that the average percent of urine samples that tested negative for the target drug was 91.1.

“It’s not a panacea — not all patients respond to contingency management,” Dr. DePhilippis said. “But I think of it as a scaffolding. We can’t provide this reinforcement indefinitely, but for a sufficient amount of time that the patient will begin to experience the naturally occurring benefits of recovery.”

For rewards, the department’s treatment programs give vouchers for $1, $20 or $100 donated by the Veterans Canteen Service, which runs cafeterias, coffee shops and retail stores in many of the department’s medical centers. Patients receive an average $200 in coupons over 12 weeks, which they can spend only in those outlets. For now, these programs are suspended at most of the department’s centers because of the pandemic; at those that have resumed, Dr. DePhilippis said, a clinician can make prize draws from the fishbowl on the patients’ behalf.

Credit…Hannah Yoon for The New York Times

“In the drawings, I did pretty good,” said Eric Alick, 63, of Philadelphia, who completed a contingency management program for cocaine addition at the Corporal Michael J. Crescenz V.A. Medical Center in Pennsylvania. “I might get three ‘good jobs’ in a row, but then, bingo.”

Among the things he bought with his rewards were a new drill set for his job as a handyman, perfume for his wife and coffee and meals for homeless veterans whom he had met in the hospital cafeteria.

One problem with contingency management, evidence suggests, is that people have less success staying abstinent after the treatment ends. For that reason, Richard Rawson, a researcher at the University of Vermont who has studied meth addiction for decades, believes it should be used indefinitely, just as medications for opioid addiction often are.

“Unfortunately, addiction is a chronic brain disease and treatments need to be designed to accommodate this reality,” he said.

For Ms. Waxler-Malloy, losing the debit card when her four months of contingency management ended in early January was hard, although her therapy sessions and 12-step meetings helped. Then, in May, she lost her waitressing job because of the pandemic and she relapsed, using meth and heroin “full force,” she said, for three weeks before stopping with help from Brightview.

Still, the eight months she went without using drugs was her longest stretch of abstinence in more than two decades. She believes she may not have relapsed if contingency management, with its promise of rewards, had still been part of her treatment regimen.

“That kept me real accountable,” she said recently. “Even just to stop at McDonald’s when you have that little bit of extra money, to get a hamburger and a fries when you’re hungry. That was really big to me.”

Source

Continue Reading
Advertisement
Click to comment

Leave a Reply

Your email address will not be published. Required fields are marked *

Business

The Trump campaign celebrated a growth record that Democrats downplayed.

Published

on

The White House celebrated economic growth numbers for the third quarter released on Thursday, even as Joseph R. Biden Jr.’s presidential campaign sought to throw cold water on the report — the last major data release leading up to the Nov. 3 election — and warned that the economic recovery was losing steam.

The economy grew at a record pace last quarter, but the upswing was a partial bounce-back after an enormous decline and left the economy smaller than it was before the pandemic. The White House took no notice of those glum caveats.

“This record economic growth is absolute validation of President Trump’s policies, which create jobs and opportunities for Americans in every corner of the country,” Mr. Trump’s re-election campaign said in a statement, highlighting a rebound of 33.1 percent at an annualized rate. Mr. Trump heralded the data on Twitter, posting that he was “so glad” that the number had come out before Election Day.

The annualized rate that the White House emphasized extrapolates growth numbers as if the current pace held up for a year, and risks overstating big swings. Because the economy’s growth has been so volatile amid the pandemic, economists have urged focusing on quarterly numbers.

Those showed a 7.4 percent gain in the third quarter. That rebound, by far the biggest since reliable statistics began after World War II, still leaves the economy short of its pre-pandemic levels. The pace of recovery has also slowed, and now coronavirus cases are rising again across much of the United States, raising the prospect of further pullback.

“The recovery is stalling out, thanks to Trump’s refusal to have a serious plan to deal with Covid or to pass a new economic relief plan for workers, small businesses and communities,” Mr. Biden’s campaign said in a release ahead of Thursday’s report. The rebound was widely expected, and the campaign characterized it as “a partial return from a catastrophic hit.”

Economists have warned that the recovery could face serious roadblocks ahead. Temporary measures meant to shore up households and businesses — including unemployment insurance supplements and forgivable loans — have run dry. Swaths of the service sector remain shut down as the virus continues to spread, and job losses that were temporary are increasingly turning permanent.

“With coronavirus infections hitting a record high in recent days and any additional fiscal stimulus unlikely to arrive until, at the earliest, the start of next year, further progress will be much slower,” Paul Ashworth, chief United States economist at Capital Economics, wrote in a note following the report.

Source

Continue Reading

Business

Black and Hispanic workers, especially women, lag in the U.S. economic recovery.

Published

on

The surge in economic output in the third quarter set a record, but the recovery isn’t reaching everyone.

Economists have long warned that aggregate statistics like gross domestic product can obscure important differences beneath the surface. In the aftermath of the last recession, for example, G.D.P. returned to its previous level in early 2011, even as poverty rates remained high and the unemployment rate for Black Americans was above 15 percent.

Aggregate statistics could be even more misleading during the current crisis. The job losses in the initial months of the pandemic disproportionately struck low-wage service workers, many of them Black and Hispanic women. Service-sector jobs have been slow to return, while school closings are keeping many parents, especially mothers, from returning to work. Nearly half a million Hispanic women have left the labor force over the last three months.

“If we’re thinking that the economy is recovering completely and uniformly, that is simply not the case,” said Michelle Holder, an economist at John Jay College in New York. “This rebound is unevenly distributed along racial and gender lines.”

The G.D.P. report released Thursday doesn’t break down the data by race, sex or income. But other sources make the disparities clear. A pair of studies by researchers at the Urban Institute released this week found that Black and Hispanic adults were more likely to have lost jobs or income since March, and were twice as likely as white adults to experience food insecurity in September.

The financial impact of the pandemic hit many of the families that were least able to afford it, even as white-collar workers were largely spared, said Michael Karpman, an Urban Institute researcher and one of the studies’ authors.

“A lot of people who were already in a precarious position before the pandemic are now in worse shape, whereas people who were better off have generally been faring better financially,” he said.

Federal relief programs, such as expanded unemployment benefits, helped offset the damage for many families in the first months of the pandemic. But those programs have mostly ended, and talks to revive them have stalled in Washington. With virus cases surging in much of the country, Mr. Karpman warned, the economic toll could increase.

“There could be a lot more hardship coming up this winter if there’s not more relief from Congress, with the impact falling disproportionately on Black and Hispanic workers and their families,” he said.

Source

Continue Reading

Business

Ant Challenged Beijing and Prospered. Now It Toes the Line.

Published

on

As Jack Ma of Alibaba helped turn China into the world’s biggest e-commerce market over the past two decades, he was also vowing to pull off a more audacious transformation.

“If the banks don’t change, we’ll change the banks,” he said in 2008, decrying how hard it was for small businesses in China to borrow from government-run lenders.

“The financial industry needs disrupters,” he told People’s Daily, the official Communist Party newspaper, a few years later. His goal, he said, was to make banks and other state-owned enterprises “feel unwell.”

The scope of Mr. Ma’s success is becoming clearer. The vehicle for his financial-technology ambitions, an Alibaba spinoff called Ant Group, is preparing for the largest initial public offering on record. Ant is set to raise $34 billion by selling its shares to the public in Hong Kong and Shanghai, according to stock exchange documents released on Monday. After the listing, Ant would be worth around $310 billion, much more than many global banks.

The company is going public not as a scrappy upstart, but as a leviathan deeply dependent on the good will of the government Mr. Ma once relished prodding.

More than 730 million people use Ant’s Alipay app every month to pay for lunch, invest their savings and shop on credit. Yet Alipay’s size and importance have made it an inevitable target for China’s regulators, which have already brought its business to heel in certain areas.

These days, Ant talks mostly about creating partnerships with big banks, not disrupting or supplanting them. Several government-owned funds and institutions are Ant shareholders and stand to profit handsomely from the public offering.

The question now is how much higher Ant can fly without provoking the Chinese authorities into clipping its wings further.

Excitable investors see Ant as a buzzy internet innovator. The risk is that it becomes more like a heavily regulated “financial digital utility,” said Fraser Howie, the co-author of “Red Capitalism: The Fragile Financial Foundation of China’s Extraordinary Rise.”

“Utility stocks, as far as I remember, were not the ones to be seen as the most exciting,” Mr. Howie said.

Ant declined to comment, citing the quiet period demanded by regulators before its share sale.

The company has played give-and-take with Beijing for years. As smartphone payments became ubiquitous in China, Ant found itself managing huge piles of money in Alipay users’ virtual wallets. The central bank made it park those funds in special accounts where they would earn minimal interest.

After people piled into an easy-to-use investment fund inside Alipay, the government forced the fund to shed risk and lower returns. Regulators curbed a plan to use Alipay data as the basis for a credit-scoring system akin to Americans’ FICO scores.

China’s Supreme Court this summer capped interest rates for consumer loans, though it was unclear how the ceiling would apply to Ant. The central bank is preparing a new virtual currency that could compete against Alipay and another digital wallet, the messaging app WeChat, as an everyday payment tool.

Ant has learned ways of keeping the authorities on its side. Mr. Ma once boasted at the World Economic Forum in Davos, Switzerland, about never taking money from the Chinese government. Today, funds associated with China’s social security system, its sovereign wealth fund, a state-owned life insurance company and the national postal carrier hold stakes in Ant. The I.P.O. is likely to increase the value of their holdings considerably.

“That’s how the state gets its payoff,” Mr. Howie said. With Ant, he said, “the line between state-owned enterprise and private enterprise is highly, highly blurred.”

China, in less than two generations, went from having a state-planned financial system to being at the global vanguard of internet finance, with trillions of dollars in transactions being made on mobile devices each year. Alipay had a lot to do with it.

Alibaba created the service in the early 2000s to hold payments for online purchases in escrow. Its broader usefulness quickly became clear in a country that mostly missed out on the credit card era. Features were added and users piled in. It became impossible for regulators and banks not to see the app as a threat.

ImageAnt Group’s headquarters in Hangzhou, China.
Credit…Alex Plavevski/EPA, via Shutterstock

A big test came when Ant began making an offer to Alipay users: Park your money in a section of the app called Yu’ebao, which means “leftover treasure,” and we will pay you more than the low rates fixed by the government at banks.

People could invest as much or as little as they wanted, making them feel like they were putting their pocket change to use. Yu’ebao was a hit, becoming one of the world’s largest money market funds.

The banks were terrified. One commentator for a state broadcaster called the fund a “vampire” and a “parasite.”

Still, “all the main regulators remained unanimous in saying that this was a positive thing for the Chinese financial system,” said Martin Chorzempa, a research fellow at the Peterson Institute for International Economics in Washington.

“If you can’t actually reform the banks,” Mr. Chorzempa said, “you can inject more competition.”

But then came worries about shadowy, unregulated corners of finance and the dangers they posed to the wider economy. Today, Chinese regulators are tightening supervision of financial holding companies, Ant included. Beijing has kept close watch on the financial instruments that small lenders create out of their consumer loans and sell to investors. Such securities help Ant fund some of its lending. But they also amplify the blowup if too many of those loans aren’t repaid.

“Those kinds of derivative products are something the government is really concerned about,” said Tian X. Hou, founder of the research firm TH Data Capital. Given Ant’s size, she said, “the government should be concerned.”

The broader worry for China is about growing levels of household debt. Beijing wants to cultivate a consumer economy, but excessive borrowing could eventually weigh on people’s spending power. The names of two of Alipay’s popular credit functions, Huabei and Jiebei, are jaunty invitations to spend and borrow.

Huang Ling, 22, started using Huabei when she was in high school. At the time, she didn’t qualify for a credit card. With Huabei’s help, she bought a drone, a scooter, a laptop and more.

The credit line made her feel rich. It also made her realize that if she actually wanted to be rich, she had to get busy.

“Living beyond my means forced me to work harder,” Ms. Huang said.

First, she opened a clothing shop in her hometown, Nanchang, in southeastern China. Then she started an advertising company in the inland metropolis of Chongqing. When the business needed cash, she borrowed from Jiebei.

Online shopping became a way to soothe daily anxieties, and Ms. Huang sometimes racked up thousands of dollars in Huabei bills, which only made her even more anxious. When the pandemic slammed her business, she started falling behind on her payments. That cast her into a deep depression.

Finally, early this month, with her parents’ help, she paid off her debts and closed her Huabei and Jiebei accounts. She felt “elated,” she said.

China’s recent troubles with freewheeling online loan platforms have put the government under pressure to protect ordinary borrowers.

Ant is helped by the fact that its business lines up with many of the Chinese leadership’s priorities: encouraging entrepreneurship and financial inclusion, and expanding the middle class. This year, the company helped the eastern city of Hangzhou, where it is based, set up an early version of the government’s app-based system for dictating coronavirus quarantines.

Such coziness is bound to raise hackles overseas. In Washington, Chinese tech companies that are seen as close to the government are radioactive.

In January 2017, Eric Jing, then Ant’s chief executive, said the company aimed to be serving two billion users worldwide within a decade. Shortly after, Ant announced that it was acquiring the money transfer company MoneyGram to increase its U.S. footprint. By the following January, the deal was dead, thwarted by data security concerns.

More recently, top officials in the Trump administration have discussed whether to place Ant Group on the so-called entity list, which prohibits foreign companies from purchasing American products. Officials from the State Department have suggested that an interagency committee, which also includes officials from the departments of defense, commerce and energy, review Ant for the potential entity listing, according to three people familiar with the matter.

Ant does not talk much anymore about expanding in the United States.

Ana Swanson contributed reporting.

Source

Continue Reading

Trending