The Rapid Access Addiction Medicine (RAAM) Clinic at UHN's Toronto Western Hospital's is taking a unique approach to treating stimulant use disorder by tapping into the brain's natural reward system with a series of gift cards for those who test negative.
While a variety of medications have been shown to be effective for alcohol and opioid use disorders, options for stimulants such as cocaine and methamphetamine remain limited.
But the voucher incentive program (VIP) is designed to support patients who are interested in reducing or eliminating their use of stimulants through this rewards-based approach.
Participants, recruited from the RAAM Clinic and Emergency Department, begin with a $5 gift card. Each week, they can earn additional cards that increase in value by $5, depending on the results of their weekly urine screening.
The program spans 10 weeks, with participants potentially earning up to $280 if they complete the program. If a participant misses a week or tests positive for stimulants, they can resume collecting rewards the following week at a reduced level.
The program also includes weekly counseling with the clinic's social worker, Ewa Konart, along with an initial medical assessment and the option of pharmacotherapy.
This approach, known as contingency management, leverages the brain's reward system by replacing stimulants with incentives, helping patients develop long-term, goal-oriented behaviour. It provides motivation and structure, essential for patients navigating the complexities of addiction.
"Patients say it's not just about the value of the gift cards, but the anticipation of receiving them that helps manage cravings throughout the week," says Ewa, who discussed the program to mark International Overdose Awareness Day, which falls on Aug. 31 each year.
"That, combined with our counseling sessions where we work on coping skills, provides a support system where they can practice healthy behaviour changes."
While the VIP supports abstinence, it's also flexible — meeting people where they are, whether their focus is on reduction, increasing safety, or making more informed choices.
"A non-judgmental and accepting approach is integral to engaging patients who often face stigma and shame," Ewa says.
VIP has also been offered to select patients experiencing opioid use disorder.
Mason,* a patient in his early 30s with a severe fentanyl addiction that led to brain surgery in 2021, is one such participant. He initially signed up to VIP as part of his outpatient treatment plan following incarceration, but soon embraced it to demonstrate his commitment to sobriety and his goals of securing employment and being with his children.
"I'm 12 months sober, and I'm willing to stay clean," he says. "But I also needed help."
Gift cards are awarded at the end of counselling sessions for negative urine drug screens. Popular options include coffee shops and fast food restaurants, with Tim Horton's being a favourite among participants.
"I'm on an Iced Capp binge," Mason jokes.
Mason appreciated the gift card incentive — the "a cherry on top," is the way he described it — but he emphasizes that the program provided much more than accountability. The emotional support through weekly counseling sessions and a monthly injection of a medication called buprenorphine to manage withdrawal symptoms and reduce cravings, were key to his success.
"Having someone listen to my life story and the personal issues contributing to my addiction was incredibly helpful," he says.
Ewa follows a dialectical abstinence approach to counselling. Abstinence is the aim, but if not possible, she encourages patients to prevent further crises and avoid giving up on the program.
To date, 72 patients have participated in VIP, with 18 successfully completing the 10-week term.
While this number might seem low, Ewa cautions that recurrence rates among patients with substance use disorder are very high, and many participants face significant barriers.
Although, similar initiatives have been run across Canada and the United States, with evidence to demonstrate their efficacy when paired with counselling, the UHN team wasn't aware of another RAAM Clinic operating such a program. (RAAM Clinics are part of public health strategies to combat substance-related issues, with more than 70 publicly-funded clinics across Ontario.)
Mason has graduated from the program. He also just completed a six-week Oasis Addiction Recovery Supports & Employment Services program designed to help individuals with a criminal record find employment.
"My goal was to get a job and be around my family and supports," he says. "That's the main reason why I completed the voucher incentive program."
* The patient's real name is withheld for privacy reasons. Disclosing a diagnosis of a substance use disorder can make it challenging for people to find housing, a job or access social services.
