In recent years, emergency department visits, hospitalizations, and overdose deaths caused by methamphetamine (alone, or in combination with other drugs) have been on the rise in San Francisco. Recently released data from the San Francisco Department of Public Health (SFDPH) show that 258 San Franciscans lost their lives to fatal meth overdose in 2019–and that the rate of fatal overdoses attributed to meth more than doubled from 2018 to 2019. Based on preliminary data for 2020, SFDPH said that these trends “are expected to continue.”

In response to the surge in methamphetamine-related fatal overdose in San Francisco, a Methamphetamine Task Force–which included Mike Discepola, our vice president of behavioral and substance use health services, Laura Thomas, our director of harm reduction policy, and Wayne Rafus, program coordinator for PROP–released a set of recommendations in 2019 for the city to implement.

A few of the recommendations focused on implementing low-threshold, easy-to-access, harm reduction services and “proven treatment approaches” for stimulant use disorder, including “contingency management to reduce or stop use.” Contingency management is a treatment approach that involves giving tangible rewards to reinforce a behavior (such as abstinence).

Alongside these recommendations, and in accordance with them, San Francisco AIDS Foundation has worked to expand our low-threshold services through a program named PROP for people who use meth and other stimulants at our Harm Reduction Center. The Harm Reduction Center is located in the Tenderloin/SoMa neighborhood on 6th Street and sees approximately 18,000 people who use drugs every year.

“We know from first-hand experience that our contingency management (and other low-threshold engagement options) are effective in supporting health improvement changes among those we serve–and in a manner that works for them,” said Discepola. “The expansion of contingency management to participants at our Harm Reduction Center was an obvious and critical next step for us as we expand access to lifesaving interventions and engagement to a wider participant base. As we expand low-threshold services in response to the recommendations of the Meth Task Force, we hope to partner with the city to ensure the funding for these and other essential services. We stand ready to do our part and are excited by each innovation that we’re able to add to support the lives and health of people who use drugs.”

PROP (Positive Reinforcement Opportunity Project) is a harm reduction program that supports people around goals related to reducing or stopping meth/stimulant use or changing their relationship to these substances. Although there is no requirement for participants to abstain from using stimulants in the program, people who complete urine drug screens and test “non-reactive” (negative), earn paid incentives in the form of gift cards.

“PROP is a contingency management program–an evidence-based program that’s an effective, non-pharmacological treatment for initiating abstinence with people who are currently using stimulants,” said Rafus, the program coordinator. “But it’s flexible, too, since we support people who have goals other than abstinence. Our goal is to understand what our participants want to change about their substance use, and build their self-esteem, confidence, and skills to be able to do so.”

“I’ve seen participants make big changes in their lives with this program,” said Sean La Febre, a health educator. “One participant–who joined the program when it first began–had been living on the street for years. He came to the group consistently and was making changes in his life. But then one day he disappeared, and we couldn’t get hold of him. Maybe a month later, he showed up at the Harm Reduction Center with his dad, who had come in from the East Coast to find him. Our participant looked great–he was wearing nicer clothes, he was smiling, and he wanted to stop by to let us know that he was doing OK and was planning on moving away from San Francisco.”

“I cried a little after he came in,” said Rafus. “We were so worried about him, and then for him to turn up looking so calm and happy. I really attribute that to this program that helps people work on their substance use goals. We told him, ‘San Francisco will always be here. If you come back, you can enjoy the city differently. But your family who came here to find you, they love you. Take this opportunity.’”

PROP is a 12-week program offering drop-in peer support three times a week, access to licensed clinical staff for counseling, and a strengths-based collaborative approach between staff and participants. Participants have the option at every drop-in group to complete a urine drug screen, earning points toward a gift card if the drug screen returns non-reactive. There is no penalty if participants choose not to complete one or more drug screens. If a test returns with a reactive result, the participant can stay in the program and does not lose any of their previous earnings or eligibility for future earnings.

Ultimately, the gift card incentive is meant to create accountability, promote self-confidence, facilitate an atmosphere of communication and trust, and build connections between those giving and receiving incentives, said Rafus.

“We see folks coming in who are in some of the most desperate of situations,” said Rafus. “They are coming in by referral from an addiction care team at a hospital after going to the emergency room. We see people who are dealing with significant trauma and mental illness, who are self-medicating with methamphetamine or opiates.”

“The hardest part is that oftentimes the circumstances of participants’ lives–such as their lack of housing–stay the same even if they’re trying to work on their substance use,” said La Febre. “There aren’t many options to get people off the streets and indoors. So for people who use stimulants to cope with the circumstances of being unhoused, it can be really difficult.”

The COVID-19 pandemic has exacerbated challenges related to substance use treatment. Participants are reporting increased depression and anxiety from the pandemic and shelter-in-place, and increased substance use as a result, said Rafus.

PROP pivoted to virtual group check-ins and one-on-one meetings over the phone with counselors soon after the shelter-in-place order for San Francisco took effect. Limited outdoor in-person check-ins are available one day per week. Although access to the indoor space at the Harm Reduction Center is not currently available, participants can access harm reduction supplies via door service.

“It’s so important for us to keep some of these essential substance use services open and available right now,” said Rafus. We know that overdose rates were high even before the pandemic, and they have certainly increased during quarantine. So for us to still be able to support people who are struggling with their substance use, and offer them a safe way to address their use during this time, is critical.”