VANCOUVER, B.C. — David Oliver wins gift cards for staying away from drugs. At St. Paul’s Hospital in Vancouver, British Columbia — which treats more overdoses than any other hospital in Canada — a program rewards users of cocaine and other stimulants with prizes when they don’t use. It’s a new approach to help substance abusers, and it’s also being tried in Veterans Affairs hospitals across the United States.
“I was sober for 19 years from cocaine and 14 from alcohol,” said Mr. Oliver, who is 58. But then, he said, he started using cocaine again in 2013 after feeling overwhelmed by the responsibilities of two jobs, a marriage, and raising two boys.
Mr. Oliver started the eight-week prize programs after being treated at St. Paul’s for an overdose and a bloodstream infection that had spread to his heart. The program staff test his urine for drugs once a week. If it shows no traces of cocaine or crystal meth, he gets to pull chips out of a hat. Each chip has monetary value: 5, 20 or 100 Canadian dollars. The clinics then use the chips to determine the value of the prizes they distribute — gift cards for coffee shops or grocery stores. “Everyone loves the prize. You get a chance to walk out of there with some money,” Mr. Oliver said.
Rewarding drug users directly is an approach also used at the Pender Community Health Center in the Downtown Eastside neighborhood, Vancouver’s ground zero for drug use and problems associated with it, like homelessness and mental illness. At this clinic, a program called Rewarding Change runs twice a year. It costs 800 Canadian dollars (5) every year, for two eight-week cycles that enroll six or seven participants. Usually only four or five finish. In 2018, an overwhelming number of overdoses in Vancouver during a restructuring of clinic services kept the health center’s staff members so busy that they only ran one cycle.
The program could be cost-effective at 20 times the price. A Vancouver-based study in 2017 found that the average daily user of stimulants like crystal meth and cocaine was responsible for crimes that cost victims ,700 a month.
Harkamal Sangha, one of the two counselors who manage the Pender clinic program, says the approach works well for people using stimulants. While most people are unable to get clean completely, he said, many get to a point where they can limit how many drugs they use and how often.
Medicine to treat opioid, heroin, alcohol and tobacco addictions are available. But there is no such medication for those using stimulants. Mr. Sangha said that the clinic found that 80 percent of the people on medications for opioid addiction were also using stimulants; now, however, the program has helped stabilize those struggling with multiple addictions.
The idea for the program is rooted in behavioral economic theory and an understanding that people will change if they are given rewards to do so. Incentives have been used to discourage people from abusing cigarettes, cocaine, marijuana and heroin. Such programs have improved birth weights of babies by getting pregnant women to quit smoking. They also have improved H.I.V. treatment by increasing how often patients take their antiretroviral medications.
Nancy Petry, a professor at the University of Connecticut School of Medicine, dedicated her career studying how to change people’s behaviors using incentives, a field known as contingency management. Dr. Petry, who died last July, led a study in 2005 that showed stimulant users stayed in treatment longer when incentives were used. When I interviewed her in May 2017, she pointed to a study in 2008 that compared different ways to treat addiction. It found that offering incentives for people to change outperformed traditional methods such as counseling.
In 2007, Britain’s National Institute for Health and Clinical Excellence approved incentive programs, and a programs and researchers have started using them in London. But even with the mounting evidence that this approach works, it’s mostly used in research settings and small clinics.
At the Pender clinic, Mr. Sangha said, counselors worried initially that patients be unwilling get their urine tested. But that turned out not to be the case, especially after patients understood that the test results were not meant to shame or punish them, but were a way to start discussions about the challenges of addiction, he said.
When the program began in 2013, the clinic gave out vouchers for every clean urine test. It later switched to a fishbowl model, in which participants draw from a prize bowl with small and large prizes, to help reduce costs and make the program more interactive.
Mr. Oliver said that knowing he has a chance of being rewarded immediately helps him stay clean. “It’s the instant gratification — receiving something with a minimum amount of work,” he said. “It appeals to that stimulant user’s quick brain, the do-get, do-get.” He has received about 0 in vouchers himself; he used them to treat himself to a shaving razor, an electric toothbrush, and a Big Mac at McDonald’s.
Dr. Petry led work for community clinics to take up incentive programs and helped the Department of Veterans Affairs start using them.
Veterans Affairs, which runs the largest health care network in the United States, uses prize incentives in 116 of its hospitals. According to Dominick DePhilippis, a clinical psychologist, the V.A. started using incentives in 2011 after it received guidelines from a joint working group of addiction experts in the V.A. and the Department of Defense.
“Drugs provide immediate reinforcement with all of the negative consequences delayed,” Dr. DePhilippis said. The benefits that come with recovery take time, and the immediate effects of abstinence are unpleasant. But incentive programs, with their quick rewards, tip that balance, he said.
Seventy clinics started the program in 2011. Now more than half the V.A.’s 170 health centers offer prizes for clean urine tests. More than 3,000 patients have gone through the program and of the nearly 40,000 urine samples collected, more than 90 percent have tested negative, said Dr. DePhilippis.
The V.A. programs run for 12 weeks at a time. Twice a week, participants have their urine tested and get the opportunity to draw a chip from a fishbowl. Other treatments like counseling or medications for addiction continue. The patient gets extra draws for having negative urine samples in consecutive weeks.
Average earnings for veterans during the program are 0 to 0. Dr. DePhilippis said that the prizes come from the V.A. canteen; many veterans buy food, while others save up for more substantial items like Marine Corps leather jackets.
In our interview, Dr. Petry said that despite the decades of science to back up this approach, most hospitals in the United States didn’t use rewards to help drug users change. Dr. DePhilippis told me that even in the V.A., some people have difficulty with the idea of paying drug users. But there are other reasons the idea hasn’t taken off.
Dr. Petry said one is that insurers don’t directly benefit from the cost-savings of treating addiction. She also pointed out that most insurers don’t have a system to pay drug users directly. The V.A. sees patients at all stages of treatment, so it recoups the costs of the incentive programs by avoiding the expensive hospitalizations that follow untreated addiction.
Each program designs its own prizes. Some clinics give increasing amounts of cash rewards or more draws the longer participants stay clean. Other programs have rewarded participants with paying jobs. Dr. Petry said programs that provide more valuable rewards and run long enough for changes in a patient’s behavior to get established generally get better results.
Dr. Petry, who coached doctors and psychologists in New England, acknowledged that incentive programs don’t always succeed. Some small clinics run watered-down versions, with smaller prizes or shorter durations, that don’t work as well, she said. Another problem is that some clinics delay in testing urine; testing it immediately when a patient walks in helps keep get the most accurate reading, which keeps them in the program longer, she said.
At Pender, Mr. Sangha says some participants struggle to maintain their gains when the group ends. Mr. Oliver, who completed the program at St. Paul’s, said that he wished it had lasted longer.
The program made him accountable by forcing him to disclose his drug use, while the chance to draw a chip was a big incentive. “It really was quite pathetically as simple as that,” he said.
Sahil Gupta serves as an emergency medicine doctor at St. Paul’s Hospital in Vancouver, Royal Alexandra Hospital in Edmonton, and St. Michael’s Hospital in Toronto. He is also a freelance journalist. He does not hold any position with the teams and programs described in this article.
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2017六盒彩27期打生肖【这】【下】【何】【思】【福】【单】【来】【到】【了】【白】【塔】【湖】【党】【高】【官】【章】【志】【平】【办】【公】【室】。 【章】【志】【平】【正】【在】【埋】【头】【批】【阅】【文】【件】，【何】【思】【福】【轻】【轻】【敲】【了】【一】【下】【门】【说】：“【章】【书】【记】，【你】【们】【需】【要】【的】【相】【关】【资】【料】【和】【都】【带】【来】【了】。” “【哦】，【这】【么】【快】。”【章】【志】【平】【合】【上】【文】【件】【盒】，【起】【身】【招】【呼】【何】【思】【福】【进】【来】。 【章】【志】【平】【走】【进】【办】【公】【室】，【把】【文】【件】【袋】【里】【的】【文】【件】【取】【出】【后】【放】【到】【章】【书】【记】【办】【公】【桌】【上】，【然】【后】【跟】【章】【志】【平】【说】
【苏】【甜】【骨】【子】【里】【仅】【存】【的】【骄】【傲】【怎】【么】【会】【允】【许】【她】【做】【出】【乞】【求】【别】【人】【怜】【悯】【的】【可】【怜】【事】？ 【所】【以】【想】【都】【不】【要】【想】。 【苏】【甜】【没】【说】【话】，【她】【等】【着】【权】【珒】【说】【他】【没】【说】【完】【的】【后】【半】【句】【话】。 “【你】【后】【悔】【过】【吗】？”【权】【珒】【一】【字】【一】【句】【的】【开】【口】【道】。 【没】【有】【听】【到】【意】【料】【的】【后】【半】【句】【话】，【苏】【甜】【微】【微】【一】【愣】，“【后】【悔】【什】【么】？” “【离】【开】【我】，【后】【悔】【吗】？”【权】【珒】【道】，【却】【又】【像】【是】【不】【想】【要】【她】【的】
【最】【开】【始】【的】【时】【候】，【白】【珠】【以】【为】【脑】【海】【里】【那】【道】【自】【动】【播】【报】【技】【能】、【经】【验】【获】【取】【的】【女】【声】【是】【穿】【越】【者】【的】【福】【利】，【就】【跟】【前】【世】【那】【些】【穿】【越】【小】【说】【里】，【穿】【越】【者】【都】【会】【必】【备】【一】【个】【的】【系】【统】【大】【佬】【一】【样】。 【但】【是】【后】【来】【的】【种】【种】【迹】【象】，【以】【及】【白】【珠】【的】【试】【探】【性】【实】【验】【都】【表】【明】【了】【一】【个】【事】【实】：【神】【秘】【女】【声】【所】【给】【予】【的】【面】【板】【属】【性】【图】【以】【及】【各】【种】【技】【能】，【存】【在】【于】【每】【一】【个】【生】【物】【的】【身】【上】。 【但】【是】【就】【目】【前】
【言】【年】【轩】【听】【伊】【拉】【要】【走】【了】，【立】【马】【瞪】【大】【了】【眼】【睛】【站】【在】【他】【的】【身】【边】。 “【你】【考】【到】【的】【学】【校】【不】【是】【这】【边】【的】【吗】？【我】【听】【说】【你】【去】【报】【到】【了】【呀】，【怎】【么】【又】【改】【去】【其】【他】【的】【地】【方】【了】？” “【因】【为】【我】【想】【要】【去】【那】【个】【学】【校】，【所】【以】【我】【跟】【学】【校】【申】【请】【了】【交】【流】【声】【去】【交】【流】【两】【年】，【所】【以】【我】【现】【在】【要】【走】【了】。” “【这】【样】【啊】，【那】【好】【吧】，【那】【祝】【你】【好】【运】。” 【伊】【拉】【跟】【伊】【白】【笑】【着】【点】【点】【头】，【杨】2017六盒彩27期打生肖“【圣】【主】【在】【上】，【那】【是】【什】【么】【玩】【意】【儿】?” 【警】【方】【确】【认】【此】【事】【正】【在】【和】【一】【个】【野】【兽】【人】【战】【斗】【着】，【而】【当】【他】【抬】【起】【头】【的】【时】【候】，【却】【看】【到】【一】【个】【高】【达】【从】【空】【中】【直】【接】【坠】【落】【下】【来】，【砸】【在】【了】【战】【场】【的】【中】【央】，【随】【着】【高】【达】【的】【出】【现】，【在】【现】【场】【的】【所】【有】【地】【下】【世】【界】【的】【怪】【物】【都】【欢】【呼】【了】【起】【来】，【不】【仅】【仅】【如】【此】，【在】【他】【们】【的】【头】【顶】【还】【有】【一】【个】【飞】【空】【艇】【盘】【旋】【在】【黑】【暗】【之】【门】【的】【上】【空】，【黑】【漆】【漆】【的】【炮】【孔】【对】【准】
【这】【孩】【子】【让】【人】【一】【看】【就】【不】【由】【的】【心】【生】【喜】【爱】。 【三】【仙】【姑】【站】【立】【在】【一】【旁】，【也】【是】【露】【出】【喜】【悦】【之】【色】，【满】【是】【欢】【喜】【的】【看】【着】【那】【个】【新】【出】【生】【的】【孩】【子】。 【红】【孩】【儿】【和】【铁】【扇】【公】【主】【这】【几】【天】【也】【在】【苍】【梧】【做】【客】，【红】【孩】【儿】【在】【一】【旁】【叫】【着】：“【娘】【亲】，【玉】【谡】【娘】【娘】【快】【让】【我】【抱】【抱】【弟】【弟】。【嘻】【嘻】，【我】【也】【有】【弟】【弟】【了】。” 【神】【色】【间】【显】【得】【异】【常】【的】【兴】【奋】【开】【心】。 【两】【只】【眼】【睛】【都】【在】【不】【由】【自】【主】【的】【放】
“【乐】【书】【瑶】，【对】【不】【起】，【昨】【晚】【的】【事】，【我】【向】【你】【道】【歉】。【并】【不】【是】【因】【为】【凉】【之】【哥】【哥】【让】【我】【来】【我】【才】【来】【的】，【是】【我】【自】【己】【发】【自】【内】【心】【想】【跟】【你】【说】【对】【不】【起】【的】。”【林】【妙】【别】【扭】【地】【说】【出】【这】【番】【话】，【随】【后】【生】【怕】【乐】【书】【瑶】【笑】【她】【似】【地】【挪】【开】【眼】，【不】【跟】【她】【有】【任】【何】【的】【对】【视】。 【乐】【书】【瑶】【失】【笑】，【一】【个】【孩】【子】【心】【性】【的】【人】【而】【已】，【自】【己】【又】【能】【同】【她】【计】【较】【什】【么】。 “【我】【收】【下】【你】【的】【道】【歉】。”【反】【正】，【以】