The Workforce Paid to Treat You Judges You Hardest

On August 12, a journalist named Kastalia Medrano published an essay in Filter with a headline most editors would have talked her out of: “Big Shoutout to Meth.” She was not being cute. She used methamphetamine daily for three or four years, and she wrote about it plainly.

“I used meth for three or four years, every day, and while it made a lot of things in my life harder I’m not sure how else I could have managed the things it made easier,” she wrote.

That sentence is the whole argument, and almost nobody in a clinical setting is prepared to sit with it. Not because it’s wrong. Because it doesn’t sort neatly into the two categories the treatment system has on offer: tragic victim, or person who won’t get it together.

Stigma is not something the treatment system fights. It is something the treatment system carries.

Five days after Medrano’s essay ran, researchers at the University of Georgia published findings that put numbers under it. They surveyed 1,600 people across 13 Southern states and found that mental health workers and first responders — the people whose entire job is to be in the room when someone is at their worst — agreed more strongly than the general public with statements blaming people for their own opioid addiction. The people trained to help judge harder than the people who weren’t trained at all.

The call is coming from inside the building

The study, led by Virginia Brown, an evaluation specialist at University of Georgia Cooperative Extension, ran in Community Mental Health Journal and was covered by UGA and Georgia Public Broadcasting on August 17. Participants were asked how much they agreed with statements like “People with opioid use problems are to blame for their situation,” “I tend to negatively judge people with opioid use problems,” and — this is the one that should stop you cold — “People with opioid use problems who take drug therapies like methadone are replacing one addiction with another.”

That last item is not an opinion. It is a factual error about how medication works, and it was endorsed more readily by clinicians and first responders than by the general public. Methadone and buprenorphine are the two medications with the strongest evidence base in all of addiction medicine for keeping people alive. If the person doing your intake believes those medications are a lateral move from your addiction into a new one, that belief does not stay in their head. It shows up in what they offer you, what they document, and how fast they suggest you taper off something that was working.

GPB’s coverage named the mechanism directly: workers holding stigmatizing views may avoid prescribing or supporting the medications that would help. The stigma converts into a clinical decision, and the clinical decision converts into a body count.

Brown’s read is more generous than mine, and worth quoting because it complicates the easy villain story. “We know that people get into these professions to help people, but for whatever reason, they’re experiencing stigma towards people struggling with opioid addiction,” she said. And: “We have evidence from this study that people want to help each other get better, but they don’t necessarily have the tools to do it.”

She’s right that intent isn’t the problem. Almost nobody enters this field to punish people. But intent is also not a defense, because the patient does not experience your intent. They experience your face when you read their urine screen. Brown’s own framing of the stakes is the sharpest line in the coverage: “Stigma is a mental barrier to seeking help. If you’re afraid that someone will judge you because you are experiencing an opioid use disorder, you are less likely to seek treatment.”

Brown’s own framing of the stakes is the sharpest line in the coverage: “Stigma is a mental barrier to seeking help.

Her team’s recommendation is targeted anti-stigma training for the workforce, with an emphasis on non-judgmental listening. That’s the right ask. It’s also a striking admission: the field has spent two decades building public-facing anti-stigma campaigns aimed at employers, landlords, and families, and comparatively little energy auditing its own staff. We aimed the campaign outward. The survey says we should have aimed it at the break room.

The drug never changed. The sentence did.

None of this is new. In 1986, mid-panic over crack cocaine, Congress passed the Anti-Drug Abuse Act and wrote a 100-to-1 ratio into federal law: five grams of crack carried the same five-year mandatory minimum as five hundred grams of powder. Crack is cocaine and baking soda. What differed was the picture in the public’s head — crack belonged to poor Black neighborhoods, powder to white people with money — and the sentences followed the picture, not the chemistry. The Fair Sentencing Act of 2010 took twenty-four years to cut the ratio to 18-to-1, which is Congress looking at a disparity built on nothing and choosing to keep 18 percent of it.

That is the machinery Brown’s study caught in 2026, wearing a lanyard instead of a robe. Whose drug use reads as a medical emergency and whose reads as a character defect has never tracked what a substance does to a body. It tracks who is using it.

Medrano makes exactly this point about the gap between opioids and stimulants right now. “It’s not quite okay to openly demonize the victims of a mass death situation,” she writes. “But if you want to openly demonize meth users, that’s okay.” Fentanyl deaths produced a grieving-parent politics, a naloxone-in-every-school politics, a this could be your kid politics. Meth never got that, because meth’s public image is a mugshot progression, and because the people it most visibly serves — unhoused people, sex workers, people with no route to a psychiatrist — were already outside the circle of who counts as a victim.

Her account of what the drug actually does for people is not an endorsement and shouldn’t be read as one. It’s a description of function. “It’s there for the people who need to stay awake when it’s not safe to sleep,” she writes. “It’s there for the people who can’t access antidepressants. It’s there to facilitate sex work.” And most disarmingly: “I never would have met my husband if meth hadn’t kept him alive for the decade or so when the rest of the world was trying to kill him.”

You can find that sentence hard to take and still have to answer it. If a stimulant is doing the work that housing, psychiatry, and a safe place to sleep were supposed to do, then “just stop” is not a treatment plan. It’s an eviction notice with a clipboard.

Medrano also lands the point that should embarrass harm reduction specifically: the movement built its playbook around fentanyl and then handed meth users the same pamphlet. “The movement hasn’t known what it’s supposed to offer meth users because it approaches the problem through a fentanyl lens, thinking in terms of meth’s physical effects and risks and harms,” she writes. Test strips and naloxone are magnificent and they do not address a person who has been awake for four days because sleeping outside is how you get hurt. And the cost of the silence around stimulants is not abstract. “Once you say someone used meth, nobody questions why they died,” she writes. “They were unarmed and police shot them 10 times? Well, they were on meth.”

The treatment that works is embarrassing, so we don’t offer it

Here is the part that makes the stigma finding operational rather than philosophical. There is no FDA-approved medication for methamphetamine or cocaine addiction. None. Alcohol has naltrexone and acamprosate. Opioids have methadone and buprenorphine. Stimulants have nothing on the pharmacy shelf, and roughly 800,000 Medicaid enrollees between 12 and 64 carry a diagnosed stimulant use disorder.

Stimulants have nothing on the pharmacy shelf, and roughly 800,000 Medicaid enrollees between 12 and 64 carry a diagnosed stimulant use disorder.

What does work is almost stupidly simple. You come in, you give a urine sample, and if it’s negative for stimulants you walk out with a gift card. Next week it’s negative again, the gift card is worth a little more. Miss a week or test positive, the amount resets to the base and you start climbing again. Gift cards typically start around $10 or $12. Programs run 12 to 64 weeks. That’s it. That’s the intervention. Its clinical name is contingency management, and per the meta-analytic evidence summarized by APA’s Monitor on Psychology this spring, it outperforms cognitive behavioral therapy and the other behavioral standards for stimulant use disorder, works alongside counseling and on its own, and pencils out economically — programs with total rewards above $500 had roughly a 78 percent chance of returning more than they cost.

So why has the best available treatment for a disorder with no medication spent thirty years mostly unavailable? Partly regulatory: federal anti-kickback rules made paying patients legally fraught, and until recently SAMHSA capped incentives at $75 per patient per year, an amount low enough to guarantee the thing wouldn’t work. That cap rose to $750 in January 2025, and APA CEO Arthur C. Evans Jr. put it bluntly: “Make no mistake, this change will save lives and protect families.” CMS has now approved Section 1115 waivers letting five state Medicaid programs — California, Washington, Montana, Delaware, and Hawaii — pay for it, with Michigan and Rhode Island pending. About 22 percent of Medicaid enrollees with stimulant use disorder live in a state where it’s covered.

But the deeper barrier is the one Brown’s survey measures. Contingency management offends people. It looks like paying addicts to behave. Staff say it out loud in meetings — we’re rewarding them for doing what they should do anyway — which is a moral position dressed as a clinical one, and it is the exact belief that costs lives while everyone waits for a molecule that isn’t coming. Nobody says a diabetic hasn’t earned their insulin.

If you run a program or carry a caseload, there is a concrete version of this you can do inside a week. Put one question on your next team meeting agenda: does anything we offer function as contingency management, and if not, what’s stopping us — the waiver, the budget, or the discomfort? Then pull your intake forms and read them out loud. “Clean,” “dirty,” “denies use,” “non-compliant,” “failed treatment.” Those words were written by people who thought they were being neutral, and the survey says they weren’t.

Who gets paid to describe their own life

There’s a reason Medrano’s essay is the best thing published on meth this month and also one of the last things Filter will ever publish. The magazine shut down on August 11 after eight years, unable, editor-in-chief Will Godfrey wrote, “to survive an increasingly difficult funding landscape, like too many other harm reduction and independent media organizations.”

Read what he says the magazine actually did. Its coverage was “often authored, importantly but far too unusually, by people who actually use the drugs in question.” Its mass incarceration reporting “has been spearheaded by a group of dedicated incarcerated journalists.” Note the phrase far too unusually. He is describing a market in which the people with the most direct knowledge of drug use are the least likely to be paid to write about it — and one of the only outlets that reversed that arrangement just ran out of money.

That’s the same stigma with a different budget line. In the clinic it decides which medication you’re offered. In publishing it decides whose account of their own life is treated as evidence and whose is treated as a symptom. A person who used meth every day for four years knows more about what meth does than the entire panel convening to discuss it, and the structure that would pay her for that knowledge is the one that just closed.

In publishing it decides whose account of their own life is treated as evidence and whose is treated as a symptom.

If you’re reading this from inside your own use, or from the fragile early part of not-using, you already knew all of this before the survey confirmed it. You knew which intake worker’s face changed. You knew which words in your chart would follow you. You have almost certainly been the smartest person in a room where you were treated as the problem in it. What’s new is only that it’s now documented, in a peer-reviewed journal, by researchers who went looking and found it in the last place a press release would want it.

The things that are still real: contingency management exists and it works, and if you’re in California, Washington, Montana, Delaware, or Hawaii, Medicaid may already pay for it — ask by name. Methadone and buprenorphine are still the most effective medications in this field regardless of what the person across the desk believes about them. Syringe programs and naloxone are still free in most places and still don’t require you to explain yourself. Peer-run groups still exist where nobody uses the word clean.

Medrano’s essay will stay online at a magazine that no longer has a staff. Brown’s study will get cited in grant applications for anti-stigma training that may or may not get funded. Somewhere this week, a program director is going to hear the words “contingency management” and say they don’t feel right about paying people, and a person who has been awake for three days is going to walk out of that building with a pamphlet about fentanyl test strips. The drug did not decide any of that. We did.