In 2002, San Francisco voters approved a measure named “Care Not Cash” with a clear objective: stop providing cash directly to homeless individuals, as it might be spent on drugs and alcohol. At the same time, a different approach was being tested; researchers were paying participants who used drugs significant amounts to participate in studies. It was believed this funding might lead to relapse, yet findings contradicted that belief. People predominantly used the money for necessities like rent, food, and bills.

Advancements in treatment can only be achieved if individuals have the time and resources to participate in necessary research. Early studies focused on the buprenorphine and naloxone combination, now known as Suboxone, involving people actively using heroin. These studies directly influenced treatment development.

Currently, the federal government, through the HHS Office of Inspector General, is examining the issue. The Office has requested comments by August 24 on whether to protect payments to clinical trial participants, a practice previously in a legal gray area due to existing statutes penalizing inducements to Medicare and Medicaid patients.

Concerns exist that reimbursing federal beneficiaries could appear as inducing usage of reimbursable services, even when normal care costs would apply. Additionally, ethical worries suggest that payments might influence vulnerable individuals’ decisions. However, studies show that paying individuals with substance use disorders does not increase drug use nor does it undermine consent. Participants generally refute the idea that monetary incentives unduly influence their choices; they have other means to obtain drugs.

Evidence indicates that higher payments may increase participants’ attention to risk information, signifying that they perceive higher payments as linked to increased stakes. A 2021 study further demonstrated that while cash incentives improved enrollment in one trial, in others it had no effect on risk perception, nor did it skew the sample demographic.

Ensuring justice and scientific credibility means involving those most affected by substance use in trials. Previous research, including those leading to Suboxone’s development, included active substance users rather than excluding them as compromised. Insufficient or no compensation shifts research costs to participants, which is counterproductive.

The inspector general should adopt rules reimbursing participants for genuine out-of-pocket expenses, an approach supported in 2018 by the FDA, which clarified that travel and lodging reimbursements do not pose undue-influence issues. Giving fair compensation for participants’ time should be determined by institutional review boards rather than hard caps, as the study’s demands dictate appropriate compensation levels.

Clinical trials rely on participation, which is legitimate work requiring commitment and sometimes physical risk. In contrast to the “Care Not Cash” principle, research shows that some individuals, even those actively using drugs, can responsibly manage payment. The results, as with Suboxone, provide life-saving treatments. It’s crucial that compensation in clinical trials reflects this recognition of work, aligning policies with evidence over old fears.

Matthew Baggott, PhD, is a neuroscientist and CEO of Tactogen Inc. John Mendelson, MD, is a board-certified internist experienced in addiction treatment, currently serving as Chief Medical Officer and Founder of Ria Health.