Jamie Mains showed up for her checkup so high that there was no point in pretending otherwise. At least she wasn’t shooting fentanyl again; medication was suppressing those cravings. Now it was methamphetamine that manacled her, keeping her from eating, sleeping, thinking straight. Still, she could not stop injecting.

“Give me something that’s going to help me with this,” she begged her doctor.

“There is nothing,” the doctor replied.

Overcoming meth addiction has become one of the biggest challenges of the national drug crisis. Fentanyl deaths have been dropping, in part because of medications that can reverse overdoses and curb the urge to use opioids. But no such prescriptions exist for meth, which works differently on the brain.

In recent years, meth, a highly addictive stimulant, has been spreading aggressively across the country, rattling communities and increasingly involved in overdoses. Lacking a medical treatment, a growing number of clinics are trying a startlingly different strategy: To induce patients to stop using meth, they pay them.

The approach has been around for decades, but most clinics were uneasy about adopting it because of its bluntly transactional nature. Patients typically come in twice a week for a urine drug screen. If they test negative, they are immediately handed a small reward: a modest store voucher, a prize or debit card cash. The longer they abstain from use, the greater the rewards, with a typical cumulative value of nearly $600. The programs, which usually last three to six months, operate on the principle of positive reinforcement, with incentives intended to encourage repetition of desired behavior — somewhat like a parent who permits a child to stay up late as a reward for good grades.

Research shows that the approach, known in addiction treatment as “contingency management,” or CM, produces better outcomes for stimulant addiction than counseling or cognitive behavioral therapy. Follow-up studies of patients a year after they successfully completed programs show that about half remained stimulant-free.

Even those who are uncomfortable with the general concept are starting to come around, said Dr. Sally Satel, medical director at a methadone clinic in Washington, D.C., and a senior fellow at the American Enterprise Institute. “Most people recoil at paying people to do the right thing,” she said. “But we’ve got plenty of data that shows this works. So I think we just have to bite the utilitarian bullet.”

Until recently, the Department of Veterans Affairs’ health system was one of the few to adopt CM; the agency has treated over 8,000 veterans with it since 2011. During the pandemic, as meth-related fatalities climbed, the Biden administration gingerly increased federal support, allowing states to apply for Medicaid money to fund rewards. In its final days, the administration boosted substantially the amount that clinics receiving federal grants could award to patients.

Now, CM is in a period of fast-moving growth. Some private employers are authorizing company health insurance to cover it. New apps allow patients in far-flung rural areas to use telehealth CM. Programs are trying out increased amounts and an assortment of gift cards to learn which reward structures individual patients respond to best. A program in Pennsylvania’s Allegheny County rewards patients up to $1000 a year.

Treatment experts estimate there now are more than 600 CM sites nationwide, including 109 in California, which is building a statewide project. In January, San Francisco began a program called “Cash Not Drugs.”

But addiction experts worry that under the Trump administration, CM programs will be difficult to sustain, much less expand to meet the need. Many believe that Robert F. Kennedy Jr., the health secretary, who overcame his heroin addiction with a 12-step program and has praised approaches that threaten to jail people who refuse treatment, would be unlikely to endorse a financial rewards-based strategy.

The Department of Health and Human Services did not respond to questions about CM or meth use, instead issuing a statement saying the agency would not address “potential policy decisions.”

“H.H.S. must return to common-sense public health approaches focused on prevention, treatment, and long-term recovery,” the statement said.

With research indicating that programs with greater rewards and longer duration produce better results, the longstanding criticism of CM could resurface and be amplified: that tax dollars are being used to bribe people not to do drugs.

Dr. Andrew Herring is a director at the Bridge Center, which consults with hospitals nationwide about addiction treatment. He practices at a clinic in Oakland, Calif., that is about to begin a contingency management program, an approach he views as complex.

Many of his patients are financially desperate, he said. “The money edges into a territory that has become so incredibly political because it starts to look like a benefit. And people can become dependent on it — it becomes part of their income.”

Nevertheless, he added, “Money exists in the world to influence the behavior of others. If there’s a behavior you want to see, the most common-sense thing to do is to pay people.”

Why There’s No Medication for Meth

The search for a medication to curb stimulant addiction continues. It’s a formidable mission.

For people addicted to opioids, treatment usually consists of medications that contain low-grade opioids, which satisfy cravings without inducing a high. That effect is far more difficult to achieve in people addicted to meth.

As Dr. Kristen B. Silvia, who oversees a hospital-based CM program in Portland through MaineHealth, explains to patients:

Meth causes the brain to release exorbitant amounts of dopamine, the feel-good neurotransmitter. On a ho-hum day, she tells them, an individual’s dopamine levels could rise to, say, 50.

“If you have the best meal ever, the best sex ever, the best day of your life, you can get your levels up to 100.” When someone uses crack, another stimulant, within seconds their levels rise to 300, she continues, “or three times the best day of your life.”

But on meth, dopamine levels skyrocket to 1,000 and can remain there for hours: “No medication can safely compete with that.”

Given the ferocity of meth addiction, it almost defies credulity that small rewards can quell drug hunger. But treatment experts say that as negative screening results accrue and abstinence builds, the immediacy of a reward and the ability to purchase something satisfying can bathe the brain in cascades of frequent, modest dopamine jolts.

Appetite returns. So does sleep. And patients become more amenable to counseling.

That is what Ms. Mains experienced. Six months after her doctor told her no medication existed for meth, she heard, in early 2024, about a pilot CM program at Spurwink, a clinic in Portland, Maine.

Ms. Mains, 43, was desperate to get sober to be allowed to visit her young grandson. She hadn’t believed that would ever happen. “But for me,” she said, “money was a good enough reason to try.”

She moved into a shelter to white-knuckle through withdrawal. Her first negative urine screening earned her $10 on a debit card plus encouraging nods and warm smiles from the clinic staff. The second negative test that week got her $12.50 more.

She used the money to buy months-late Christmas gifts for her grandson. She could not remember when exhilaration had sprung from pride and joy, rather than from drugs.

Positive reinforcement treatment has been a game changer for staff as well as patients, said Richard A. Rawson, a research psychologist at the University of Vermont and U.C.L.A. who consults with states implementing CM. “Urine testing was always about catching people using drugs and employing sanctions, like kicking them out of housing or treatment,” he said. “But now when they test positive, we say, ‘In two days, you can earn a gift card if you can get from here to there without using. So what can you do to be successful?’”

Often patients who know that they will test positive will show up for appointments anyway, seeking connection and nonjudgmental support, Dr. Rawson said.

With each negative drug screen, Ms. Mains’s rewards inched up, peaking at about $65. Her life began to improve. She moved to a sober house, started volunteering at a thrift shop and began going to church three times a week. She regularly attended recovery meetings, learning to face the painful trauma that drugs had long cloaked: at 9, she had started binge-drinking; at 12, her mother had given her a taste of heroin.

For all its promise, CM is vulnerable to scamming by patients. In the privacy of a bathroom stall, they can substitute their urine sample for one they know is meth-free. And some patients trade their rewards for drugs or alcohol.

Such loopholes are tightening. Tech companies like Contingency Management Innovations, which implements programs in California and Maine, can block debit card purchases related to gambling, tobacco, alcohol or firearms.

Workarounds for the urine screens are also gaining traction. Some programs have switched to mouth swabs, which a therapist can observe. On the app made by DynamiCare, patients record themselves on phone cameras, swiping and then dipping the saliva-soaked swab into a container with test strips. Staff members review the recording and can release rewards through the app.

Uncertainties about the financial incentives still give clinics — and their lawyers — pause. Programs usually cap awards at $599, because federal tax law requires 1099 forms for earnings of $600 or more. But lawyers for Allegheny County’s human services department have argued that its $1,000 cumulative incentive fits a general tax exclusion for low-income individuals.

The funding of CM programs remains an issue. In 2021, Medicaid, which did not cover contingency management, permitted states to apply for pilot programs, an arduous process. Only a handful, including California, Montana and Washington, have so far passed muster.

As meth use grew and the success of CM became better known, some 40 states lobbied federal authorities to allow greater awards for enrolled patients. In January, the Biden administration raised the cumulative cap on federal grants for CM awards to $750 per patient from $75, provided that awards are issued as gift cards or services, not cash.

Uncertain about whether these policies will continue under the Trump administration, some public health officials have been seeking grants from local and state opioid litigation settlement funds. According to the National Academy of State Health Policy, more places, including Michigan, Rhode Island, Vermont, Virginia and Arizona’s Maricopa County, have started CM programs with settlement money.

Today, 16 months after Ms. Mains took her first negative urine test in the CM program, she has stopped using alcohol and illegal drugs. Temptation is omnipresent. But even during a car ride to the funeral of a beloved aunt, as her stepmother smoked crack in the back seat, she said, she managed to resist.

“I was getting paid not to use and that was nice and that was the beginning,” she said. “But now I feel like being sober is payment enough, not waking up sick is payment enough, being trusted is payment enough.”