Contingency management for treatment attendance: A meta-analysis

Substance use negatively impacts change in reinforcement during the year following substance use treatment

OBJECTIVE

Although research supports an association between increased alternative reinforcement and decreased substance use, the impact of substance use on changes in reinforcement during posttreatment recovery remains untested. This study tested the effect of abstinence duration and substance use frequency on the trajectories of four reinforcement mechanisms, behavioral activation, reward probability, reward barriers, and valued living, from pre- to 12-month posttreatment.

METHOD

Adults in intensive outpatient substance use disorder treatment (N = 206) completed self-report measures of the four reinforcement constructs and substance use over six timepoints from pre- to 12-month posttreatment. Latent curve models were used to test the association between reinforcement trajectories and abstinence duration and substance use frequency, respectively.

RESULTS

Lower substance use frequency was associated with significantly improved behavioral activation, reward probability, and reward barriers across the posttreatment period (ps < .05). Higher substance use frequency was associated with significantly lower valued living at each timepoint (ps < .05). Longer abstinence duration was significantly associated with higher behavioral activation and valued living, and lower reward barriers at 12-months (ps < .05).

CONCLUSIONS

Substance-free reinforcement improves during treatment and is negatively impacted by substance use frequency during posttreatment. Abstinence duration is positively associated with substance-free reinforcement at 12-month posttreatment. These findings support the conceptualization of reinforcement as a malleable treatment target that is negatively impacted by substance use. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Implementing contingency management in family medicine: A qualitative inquiry on provider and patient preferences for a low magnitude reward program compatible with buprenorphine treatment

Background

Contingency management (CM) is an effective yet underutilized behavioral intervention that uses rewards to improve outcomes in medication for opioid use disorder (MOUD) treatment. Prior implementation attempts have focused on specialized addiction clinics, using intensive daily treatment with methadone and high reward values (e.g. >$200 total). However, many people get MOUD from less specialized, more accessible, family medicine clinics. These clinics could also benefit from CM, yet present unique challenges for CM. Family medicine clinics typically use buprenorphine as their primary medication, which requires less intensive dosing schedules and thus provides fewer CM opportunities. They may also have lower institutional willingness to use high-value rewards. As an initial step in user-centered design of a low value reward (<$75 total) CM program for the family medicine context, we conducted qualitative interviews with patients and staff in the buprenorphine treatment program of a family medicine department. We gathered and analyzed qualitative data on CM knowledge, preferred program parameters, and implementation considerations.

Method

Participants (N = 24) were buprenorphine treatment staff (n = 12) and patients (n = 12). Participants completed 30-50-minute semi-structured interviews, analyzed using rapid matrix analysis.

Results

Participants had little experience with CM, but generally viewed CM as acceptable, appropriate, and feasible. Interviewees coalesced around having staff who were not providers with prescription privileges conduct CM, consistent rather than escalating payments, and physical rewards delivered in-person. Potential challenges included medical record integration, demands on staff time, and confirmation of patients' goal completion.

Conclusions

Patient and staff feedback was well-aligned, especially regarding rewards as an opportunity for staff-patient connection and the need for simplicity. Some consensus suggestions (e.g. non-escalating rewards) conflict with extant CM literature. Implications for implementation of CM in this setting are presented. These findings inform user-centered design and iteration of a CM program for this accessible, non-specialized family medicine setting.

Systematic review of cognitive and behavioral strategies used in effective harm reduction interventions for people who use cocaine

OBJECTIVE

The aim of this systematic review is to identify cognitive and behavioral strategies that have been used in effective harm reduction interventions for people who use cocaine.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the search was performed on February 26, 2023 across databases including PsycInfo, PubMed, Scopus, and Web of Science. Studies were included if they (1) report the use of one cognitive or behavioral strategy, (2) have harm reduction as the objective, (3) involve participants who used cocaine as at least one of their substances, (4) be published within the last 10 years, and (5) have a randomized controlled trial design. The Cochrane RoB 2.0 Tool was used to assess risk of bias. The cognitive and behavioral strategies were extracted and organized based on their frequency of use in the studies and their corresponding outcomes.

RESULTS

The final synthesis included k = 10 studies with N = 3,567 participants. Psychoeducation strategies, influence on social norms, personalized feedback, increased self-efficacy and motivational interviewing were the most frequently used promising strategies across studies.

CONCLUSIONS

This review underscores the significance of incorporating cognitive and behavioral strategies within harm reduction interventions, as they represent a promising domain that could enhance the effectiveness of addressing cocaine use.

Mobile telephone contingency management to encourage adherence to supervised medication among individuals most at risk of non-adherence to opioid agonist treatment: a study protocol for a feasibility study (TIES2)

BACKGROUND

Supervision of opioid agonist treatment (OAT) ensures that individuals take their correct daily dose to minimise withdrawal and craving, safeguard against diversion and overdose, and receive optimal benefit from OAT. There is an urgent need to develop effective interventions to increase medication adherence and technological solutions to streamline communication between pharmacies and prescribers. The authors have developed technology to deliver contingency management (CM) remotely by mobile telephone (mCM) and alert prescribers of missed doses. In a previous feasibility study, the authors found mCM was feasible to deliver and acceptable to patients, prescribers, and pharmacists but encountered difficulty recruiting patients starting methadone treatment. Since COVID-19, supervision guidelines have changed to focus on patients at risk of/not adhering to their medication. This study aims to assess the feasibility of conducting a future confirmatory trial to assess the clinical and cost-effectiveness of mCM to encourage adherence with supervised methadone or buprenorphine. It will use broader eligibility criteria, including patients receiving buprenorphine, and target a revised group of serial re-starters.

METHODS

Using a cluster randomised design, three drug services will be randomised 1:1:1 and 20 patients, attending seven pharmacies linked to each service, will be recruited (i.e. a total of N = 60). Each drug service providing supervised medication will be randomly allocated to deliver: (i) telephone-delivered text-message reinforcement with modest financial incentives; (ii) telephone-delivered text-message reminders; or (iii) no telephone text-messages. Prescribers will receive reports of patient attendance. Feasibility will be determined based on four progression criteria: the number of patients enrolled, the percentage of screened patients who are eligible, adherence to the telephone system, based on matches between sign-in at the pharmacy and pharmacy dispensing records and follow-up rates. We will also undertake qualitative assessments of clinicians' perspectives on the revised eligibility criteria undertaken.

DISCUSSION

This study will assess the feasibility of using mCM to target a clinically important group of patients non-adhering to their supervised medication. In the future, and if effective, mCM will encourage medication adherence among patients, enabling them to achieve an optimum dose and full benefit from OAT.

TRIAL REGISTRATION

ISRCTN33965312 (26/06/2023). This manuscript was submitted on February 27th, 2024. While recruitment was due to end on February 29th, we recruited our last patient on February 12th. The last patient/last visit took place on May 2nd, 2024.

Addiction specialists' perspectives on digital contingency management and its role within UK drug and alcohol services: A qualitative exploration

INTRODUCTION

Contingency management (CM), based on the principles of operant conditioning, uses positive reinforcement to promote behaviour change in individuals with substance use disorder. Research on CM has grown exponentially, with technology being used to expand the reach and scope of these interventions. The views of policy professionals and treatment providers on the remote delivery of CM are likely to play an important role in the development and application of these interventions.

METHODS

Semi-structured qualitative interviews, analysed using framework analysis, were conducted with 22 UK-based addiction specialists to explore their views on digital CM, including its place within UK drug and alcohol services and future developments. Participants included commissioners, policy professionals and clinicians.

RESULTS

CM was widely acknowledged as an effective, scientifically grounded and appropriate treatment approach for drug treatment and recovery. While addiction specialists see CM as a powerful tool in a comprehensive addiction treatment toolkit, they identify the barriers impeding its implementation, including a lack of awareness among treatment providers, commissioning challenges, resource constraints and ethical concerns. Remote delivery of CM was considered a promising approach for overcoming some of these barriers and enhancing CM delivery and engagement.

DISCUSSION AND CONCLUSIONS

Technology needs to be integrated into clinical practice to expand the reach of treatment. While current evidence supports digital CM, concerns about digital literacy, technological barriers, resource constraints, public acceptability and political hesitancy highlight the need for further research to validate its feasibility and to explore the extent to which it should complement, rather than replace, in-person treatment options.

Barriers to implementing contingency management at a methadone treatment clinic: A qualitative study at a tertiary hospital in Tanzania

INTRODUCTION

Contingency management in addiction behaviors has been widely applied in high income settings. Contingency management entails modification of behavior via the control or manipulation of consequences (contingencies) to the behavior. While a need exists for contingency management in low- and middle- income settings, specifically those of the sub-Saharan Africa region, uptake is low relative to high income settings. This study assessed barriers to implementation of contingency management for methadone treatment clients at the outpatient clinic of a tertiary hospital in Tanzania.

METHODS

This study employed a qualitative design and was conducted at Mbeya Zonal Referral Hospital (MZRH). Guided by the consolidated framework of implementation research (CFIR), data were collected from two sources 1) ten purposively selected key informants (health care workers, methadone treatment clients and hospital leaders) who participated in in-depth interviews, and 2) a mini focus group discussion with five participants (two health care providers, two hospital leaders and one leader of methadone treatment clients). We developed semi-structured guides for in-depth interviews and the mini focus group to explore the key barriers. We analyzed the collected data using thematic analysis.

RESULTS

Reported barriers revolved around the following key themes: lack of awareness and knowledge regarding contingency management, financial constraints to support implementation, trust between clients and health care workers, Health care workers work load, client behaviors and clinic culture. Participants mentioned lack of awareness and knowledge more frequently compared to other themes.

CONCLUSION

In the context of specialized outpatient care in Tanzania, contingency management faces a variety of barriers. Deliberate efforts to establish and sustain contingency management in these settings require strategies that attend to the identified barriers. If the barriers are overcome, contingency management implementation and sustainment may follow and ultimately improve methadone related health outcome for patients.

A randomized pilot trial of two forms of behavioral economics intervention to improve engagement in buprenorphine-naloxone treatment among patients with opioid use disorder

BACKGROUND

Buprenorphine-naloxone treatment engagement for those with opioid use disorder (OUD) is very low. The current randomized effectiveness trial piloted two psychosocial interventions developed to increase buprenorphine-naloxone treatment engagement in 44 individuals with opioid use disorder (OUD) recruited from an OUD treatment clinic.

METHODS

Participants were randomized to receive either variable-value contingency management (CM) or a brief substance free activities session plus mindfulness (BSM) cognitive-behavioral intervention at each of the first 4 return visits to the provider. The primary outcome was buprenorphine metabolite in urine and attendance at 2 or more of 4 possible physician visits.

RESULTS

Relatively high treatment engagement was observed over 16 weeks with no significant differences in effectiveness between the two intervention arms (p = 0.526). There was slightly better treatment engagement in the CM arm (73 % vs. 59 % engaged in CM and BSM arm, respectively), but this was not statistically significant with n = 22 participants in each group. Treatment engagement was significantly better for those who presented at the clinic with prior buprenorphine exposure: 19 (86 %) of the 22 participants with buprenorphine present in urine at baseline were engaged, whereas only 9 (43 %) out of 21 participants without buprenorphine present in urine at baseline were subsequently engaged (p = 0.004).

CONCLUSIONS

Results suggested that patients who are not taking buprenorphine at the start of a psychosocial intervention may require more intensive treatment engagementinterventions than those already taking medication. Satisfaction data were similarly high across the interventions, and qualitative items identified helpful intervention components.

Web-Based Application for Reducing Methamphetamine Use Among Aboriginal and Torres Strait Islander People: Randomized Waitlist Controlled Trial

BACKGROUND

Digital interventions can help to overcome barriers to care, including stigma, geographical distance, and a lack of culturally appropriate treatment options. "We Can Do This" is a web-based app that was designed with input from cultural advisors and end users to support Aboriginal and Torres Strait Islander people seeking to stop or reduce their use of methamphetamine and increase psychosocial well-being.

OBJECTIVE

This study aimed to evaluate the effectiveness of the "We Can Do This" web-based app as a psychosocial treatment for Aboriginal and Torres Strait Islander people who use methamphetamine.

METHODS

The web app was evaluated using a randomized waitlist controlled parallel group trial. Participants were Aboriginal and Torres Strait Islander people aged 16 years or older who self-identified as having used methamphetamine at least weekly for the past 3 months. Participants were randomized on a 1:1 ratio to receive either access to the web-based app for 6 weeks or a waitlist control group. Both groups received access to a website with harm minimization information. The primary outcome was days of methamphetamine use in the past 4 weeks assessed at 1, 2, and 3 months post randomization. Secondary outcomes included severity of methamphetamine dependence (Severity of Dependence Scale [SDS]), psychological distress (Kessler 10 [K10]), help-seeking behavior, and days spent out of role due to methamphetamine use.

RESULTS

Participants (N=210) were randomized to receive either access to the web-based app (n=115) or the waitlist control condition (n=95). Follow-up was 63% at 1 month, 57% at 2 months, and 54% at 3 months. There were no significant group differences in days of methamphetamine use in the past 4 weeks at 1 the month (mean difference 0.2 days, 95% CI -1.5 to -2), 2 months (mean difference 0.6 days, 95% CI -1 to 2.4 days) or 3 months (mean difference 1.4 days, 95% CI -0.3 to 3.3 days) follow-up. There were no significant group differences in K10 scores, SDS scores, days out of role, or help-seeking at any of the 3 follow-up timepoints. There was poor adherence to the web-based app, only 20% of participants in the intervention group returned to the web-based app after their initial log-in. Participants cited personal issues and forgetting about the web-based app as the most common reasons for nonadherence.

CONCLUSIONS

We found poor engagement with this web-based app. The web-based app had no significant effects on methamphetamine use or psychosocial well-being. Poor adherence and low follow-up hindered our ability to accurately evaluate the effectiveness of the web-based app. Future web-based apps for this population need to consider methods to increase participant engagement.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12619000134123p; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376088.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/14084.

Clinical Considerations for Engagement and Retention of Nonabstinent Patients in Care

Despite the overall low rates of treatment participation, patients with substance use disorders (SUD) are regularly dissuaded from initiating treatment until they are willing and able to commit to sustained abstinence from all substances. To improve population outcomes, it is important to reach those who are not engaged in treatment and increase retention of those who do engage in care. To do this, treatment providers must proactively engage individuals in care, including those who are uninterested or ambivalent about treatment, and design services with the intention of increasing patient retention.

Evolution of the substance use landscape: Implications for contingency management

Contingency management (CM), which involves the delivery of incentives upon meeting behavioral goals, has the potential to improve substance use treatment outcomes. The intervention allows for flexibility through numerous modifiable components including changes to incentive magnitude and schedule, target behavior, and intervention structure. Unfortunately, numerous changes in the substance use landscape have occurred in the past 10 to 15 years: Substances are more potent, overdose risk has increased, new substances and methods of use have been introduced, and substance classes are increasingly being intentionally and unintentionally mixed. These developments potentially undermine CM outcomes. We explored recent substance use changes due to legislative, regulatory, social, and economic factors for four substance classes: stimulants, opioids, tobacco, and cannabis. We discuss potential adjustments to the modifiable components of CM for future research in response to these changes. By continually adapting to the shifting substance use landscape, CM can maintain optimal efficacy.

Using lifestyle interventions and the gut microbiota to improve PTSD symptoms

Posttraumatic stress disorder is part of a spectrum of psychological symptoms that are frequently linked with a single defining traumatic experience. Symptoms can vary over the lifespan in intensity based on additional life stressors, individual stability, and connectedness to purpose. Historically, treatment has centered on psychotropic agents and individual and group therapy to increase the individual's window of tolerance, improve emotional dysregulation, and strengthen relationships. Unfortunately, there is a growing segment of individuals with posttraumatic stress disorder who do not respond to these traditional treatments, perhaps because they do not address the multidirectional relationships between chronic cortisol, changes in the brain gut microbiota system, neuroinflammation, and posttraumatic symptoms. We will review the literature and explain how trauma impacts the neuroendocrine and neuroimmunology within the brain, how these processes influence the brain gut microbiota system, and provide a mechanism for the development of posttraumatic stress disorder symptoms. Finally, we will show how the lifestyle psychiatry model provides symptom amelioration.

Voucher-based contingency management to promote treatment engagement in comorbid alcohol use disorder and alcohol-related liver disease: A pilot theory-informed qualitative study with service users

BACKGROUND

Effective interventions for the management of alcohol-related liver disease (ARLD) remain a gap in clinical practice, and patients' engagement with alcohol services is suboptimal. Based upon the principles of operant conditioning, contingency management (CM) is a psychosocial intervention th at involves gradual, increasing incentives upon completion of treatment-related goals such as treatment attendance.

METHODS

A pilot feasibility trial was conducted with 30 adult patients recruited from an inpatient clinical setting. Consecutive sampling was used to recruit patients presenting comorbid alcohol use disorder (AUD) and ARLD. Participants were randomized to integrated liver care (ILC), receiving hepatology and AUD care, or ILC with a voucher-based CM intervention (intervention arm). A longitudinal qualitative approach was adopted to explore anticipated (Stage 1) and experienced acceptability (Stage 2). The Theoretical Framework of Acceptability (TFA) guided semi-structured in-depth interviews and deductive analysis.

RESULTS

Thirty participants were enrolled in the pilot trial, and interviews were conducted with 24 participants at Stage 1 and seven at Stage 2. Over half of the cohort (54.2%, n = 13) presented decompensated liver disease, and an average of 179 units of alcohol were consumed per week. Overall positive views toward voucher-based CM were noted, and explanatory data emerged across five TFA domains (intervention coherence, ethicality, self-efficacy, perceived effectiveness, and affective attitude). The core aspects of the voucher-based CM intervention matched participants' preferences and needs. Participants regarded CM as having a symbolic value and strengthening the therapeutic alliance with healthcare providers.

CONCLUSION

The data support the scope of voucher-based CM intervention to promote engagement with treatment services, and its potential to address the gaps in the care continuum in ARLD. The findings are of practical significance for developing person-centered, tailored interventions for this clinical population. The outcomes of this investigation can inform decision-making among stakeholders and healthcare providers and improve health outcomes for this clinical population.

Discrete Choice Experiment on Financial Incentives for Engaging Young Adults in Vaping Cessation Programs

INTRODUCTION

Contingency management involves rewarding individuals based on objective evidence of behavioral changes. This study explores preferences for financial incentives in vaping cessation programs.

METHODS

A discrete choice experiment (DCE) was conducted among young adult current e-cigarette users aged 19-29. DCE attributes (and levels) included reward amount ($100, $300), reward schedule (consistent value, escalating value), reward procedure (gain-framed, loss-framed), vaping education modules (yes, no), text messaging support (yes, no), and cost ($30, $100). Participants were randomized into one of the four blocks, each containing four choice sets. Each choice set presented two hypothetical vaping cessation programs. Choice data (n × choice sets × alternative programs = 154 × 4 × 2 = 1,232 observations) were analyzed using generalized estimation equation models.

RESULTS

Participants showed a preference for vaping cessation programs offering a higher reward amount (odds ratio [OR] = 11.5; 95% CI,7.0-19.2), gain-framed rewards for sustained abstinence (OR = 1.4; 95% CI,1.0-1.8), text messaging support (OR = 1.9; 95% CI,1.4-2.5), and a lower program cost (OR = 2.6; 95% CI,1.8-3.8). Interaction tests showed significant effects of the rewards procedure among daily e-cigarette users (adjusted OR [AOR] = 2.1; 95% CI,1.3-3.5), but not some-day users; and among those with no quit attempts in the past six months (AOR = 2.7; 95% CI,1.5-4.7), but not those with previous quit attempts. Female participants preferred text messaging support (AOR = 3.6; 95% CI,2.3-5.4), whereas male participants did not show this preference.

CONCLUSION

A multifaceted vaping cessation intervention augmented with financial incentives might improve participation and engagement among young adults. Future studies should investigate how these attributes can enhance program reach and vaping abstinence outcomes in real-world settings.

Contingency Management for Cannabis Use Disorder Treatment

INTRODUCTION

Although recreational cannabis use and abuse are expressive worldwide, the comparison of worldwide used psychotherapies, such as cognitive behavior therapy, with contingency management in the treatment of cannabis use disorder remains inconclusive.

METHODS

We screened all articles published on MEDLINE (via PubMed) published until October 2023 and conducted a systematic review with meta-analysis.

RESULTS

Sixteen studies were included, and contingency management intervention likely promotes abstinence outcomes and more negative urinalyses for adults or adolescents with cannabis use disorder.

DISCUSSION

This review provides moderate- to high-quality evidence that contingency management can be used to treat cannabis use disorder. However, further trials need to be developed to analyze the quantity of substance use, personal achievements, and operational improvements after treatment.

Should contingency management protocols and dissemination practices be modified to accommodate rising stimulant use and harm reduction frameworks?

BACKGROUND

Stimulant-related overdoses have increased dramatically, with almost 50% of overdoses in the United States now involving stimulants. Additionally, harm-reduction approaches are increasingly seen as key to reducing the negative impact of substance use. Contingency management (CM), the provision of financial incentives for abstinence, is the most effective treatment for stimulant use disorder, but historically has not been widely implemented. Many recent, large-scale implementation efforts have relied upon foundational CM protocols that may not sufficiently account for recent increases in the prevalence and lethality of stimulant use nor the growing preference for harm reduction versus abstinence-only frameworks.

ARGUMENT

We argue the need to (1) consider whether and how CM protocols might be modified to address rising stimulant use and harm reduction frameworks and (2) make CM widely accessible so that it can reduce population-level stimulant use while ensuring that it is delivered with fidelity to its basic principles. Proposed changes include changing CM reinforcement schedules to emphasize treatment engagement and reductions in use in addition to abstinence, changing guidelines on the duration of and re-engagement in CM, investing in research on virtual CM, incentivizing providers and health systems to deliver CM, making it easier to purchase and use point-of-care drug screens, using direct-to-consumer marketing to increase demand for CM and adapting CM to the community in which it is being implemented.

CONCLUSIONS

Our proposed modifications to contingency management (CM) protocols and accessibility may more effectively address rising stimulant use and align CM more closely with harm-reduction frameworks. Given the urgent need to reduce overdose deaths, developing and testing modified CM protocols may need to rely upon methods other than randomized controlled trials. Efforts to disseminate CM widely to reduce population-level stimulant use must be balanced with the need to maintain fidelity to CM's basic principles.

Contingency management for substance use disorders in the U.S. Veterans Health Administration: 2018-2022

INTRODUCTION

Contingency management (CM) is one of the most effective interventions for substance use disorders (SUDs), including stimulant use disorder. In the United States, the Veterans Health Administration (VHA) led the largest-scale rollout of CM in the US to date, but little is known about characteristics of patients treated and CM clinical practices.

METHODS

In this retrospective cohort study, we used VHA electronic health records data to descriptively examine CM treatment course (e.g., number of visits, time between visits, duration of treatment episode) and characteristics of patients receiving CM for SUDs from 2018 to 2022.

RESULTS

From January 2018 to September 2022, 2844 patients received CM at 90 VA Health Systems (including 98 VA Medical Center, 7 community-based outpatient clinics, and 15 other sites). The median number of CM visits was 8 (mean = 10.17, SD = 8.12) visits over the course of 1.5 months (median = 45 days, mean = 57.46 days, SD = 62.65). The target substance was stimulants in 86.42 % of visits. Average age of patients was 52.29 years (SD = 12.10), with 55.06 % of patients experiencing homelessness or housing instability, and 97.50 % of patients diagnosed with more than one SUD. Compared to the year prior to the COVID-19 pandemic (03/2019-02/2020; mean = 957.33, SD = 157.71 visits/month), CM visits declined by 83.20 % in the year following the pandemic (03/2020-02/2021; mean = 160.83, SD = 164.14), and have yet to return to pre-pandemic levels.

CONCLUSIONS

The CM rollout has been markedly successful in the VHA, with adoption across multiple VHA sites within a complex patient population, indicating the potential for effective, more widespread CM implementation. At the same time, there was a considerable reduction in CM care during the COVID-19 pandemic and CM has not yet returned to pre-pandemic levels. Moreover, only a small minority of VA patients with stimulant use disorder have received CM. Given increasing rates of overdose, including stimulant-involved overdose, it is important to increase CM provision in VHA and non-VHA settings.

The reflections of health service providers on implementing contingency management for methamphetamine use disorder in Australia

INTRODUCTION

Contingency management (CM) is the most effective treatment for reducing methamphetamine use. We sought to understand why CM has not been taken up to manage methamphetamine use disorder in Australia.

METHODS

Six focus groups (4-8 participants per group) were conducted with health workers from agencies in Australia that provided drug-related health care to people who use methamphetamine. These agencies had no previous experience delivering CM for substance use. The potential acceptability and feasibility of implementing CM in their services were discussed.

RESULTS

Participants felt that it would be beneficial to have an evidence-based treatment for methamphetamine use disorder. This sentiment was offset by concerns that CM conflicted with a client-centred harm-reduction approach and that it dictated the goal of treatment as abstinence. It was also perceived as potentially coercive and seen to reify the power imbalance in the therapeutic relationship and therefore potentially reinforce stigma. There was also concern about the public's perception and the political acceptability of CM, who would fund CM, and the inequity of providing incentives only to clients with a methamphetamine use disorder. Some concerns could be ameliorated if the goals and structure of CM could be tailored to a client's needs.

DISCUSSION AND CONCLUSIONS

Many healthcare workers were keen to offer CM as an effective treatment option for people with methamphetamine use disorder, but CM would need to be sufficiently flexible to allow it to be tailored to client needs and implemented in a way that did not adversely impact the therapeutic relationship.

A qualitative exploration of the experiences of transdermal alcohol sensor devices amongst people in receipt of treatment for alcohol use disorder

Introduction

Transdermal alcohol sensors (TAS) have the potential to be used as a clinical tool in alcohol treatment, but there is limited research with individuals with alcohol dependence using TAS. Our study is a qualitative evaluation of the views of people attending alcohol treatment and their experiences of wearing the BACtrack Skyn, within alcohol services in South London.

Methods

Participants with alcohol dependence wore a BACtrack Skyn TAS for one week and met with the researcher every two days, for a total of four meetings (for example: Monday, Wednesday, Friday, and Monday). In the final meeting, a post-wear survey (on their physical, social and comfort experience of the TAS) and semi-structured interview were completed. The Technology Acceptance Model (TAM) informed the topic guide and data analysis.

Results

Adults (N = 16) receiving alcohol treatment were recruited. Three core topics guided analysis: perceived usefulness, perceived ease of use and attitudes towards use. Participants found the TAS easy to wear and felt positive about its appearance and comfort. The only challenges reported were side effects, mostly skin irritation. The main two perceived uses were 1) TAS working as a drinking deterrent and 2) reducing daily breathalyser visits during detox.

Conclusion

Findings support the use of TAS amongst alcohol service users. Wearing the TAS for one week was acceptable and feasible for objective alcohol concentration measurement. Participants reported high perceived ease of use and usefulness of the Skyn in the context of alcohol treatment. These results are encouraging for the use of TAS in clinical settings.

Contingency Management for Drug Use Disorders: Meta-Analysis and Application of Tolin's Criteria

Several professional organizations and federal agencies recommend contingency management (CM) as an empirically supported treatment for drug use disorder. However, the release of the "Tolin criteria" warrants an updated recommendation. Using this methodology, five meta-analyses (84 studies, 11,000 participants) were reviewed. Two meta-analyses were rated moderate quality, and three were rated low or critically low quality. Comparator conditions included active treatment, placebo, treatment as usual, and no treatment. The primary outcome was abstinence. Considering only the moderate quality meta-analyses, the effect of CM versus control on posttreatment abstinence was d = 0.54 [0.43, 0.64] and follow-up abstinence was d=0.08 [0.00, 0.16]. A "strong" recommendation was provided for CM as an empirically supported treatment for drug use disorder.

The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder

The American Society of Addiction Medicine/American Academy of Addiction Psychiatry (ASAM/AAAP) Clinical Practice Guideline on the Management of Stimulant Use Disorder provides guidance on evidence-based strategies for the treatment of stimulant use disorders (StUDs), stimulant intoxication, and stimulant withdrawal, as well as secondary and tertiary prevention of harms associated with stimulant use. The Clinical Guideline Committee (CGC) comprised experts from ASAM and AAAP representing a range of clinical settings and patient populations. The guideline was developed following modified GRADE methodology. The process included a systematic literature review as well as several targeted supplemental searches. The CGC utilized Evidence to Decision tables to review available evidence and rate the strength of each recommendation. The clinical practice guideline was revised based on external stakeholder review. Key takeaways included: Contingency management represents the current standard of care for treatment of StUDs; Pharmacotherapies may be utilized off-label to treat StUDs; Acute stimulant intoxication can result in life-threatening complications that should be addressed in an appropriate level of care; Secondary and tertiary prevention strategies should be used to reduce harms related to risky stimulant use.

Gamification of Behavior Change: Mathematical Principle and Proof-of-Concept Study

BACKGROUND

Many people want to build good habits to become healthier, live longer, or become happier but struggle to change their behavior. Gamification can make behavior change easier by awarding points for the desired behavior and deducting points for its omission.

OBJECTIVE

In this study, we introduced a principled mathematical method for determining how many points should be awarded or deducted for the enactment or omission of the desired behavior, depending on when and how often the person has succeeded versus failed to enact it in the past. We called this approach optimized gamification of behavior change.

METHODS

As a proof of concept, we designed a chatbot that applies our optimized gamification method to help people build healthy water-drinking habits. We evaluated the effectiveness of this gamified intervention in a 40-day field experiment with 1 experimental group (n=43) that used the chatbot with optimized gamification and 2 active control groups for which the chatbot's optimized gamification feature was disabled. For the first control group (n=48), all other features were available, including verbal feedback. The second control group (n=51) received no feedback or reminders. We measured the strength of all participants' water-drinking habits before, during, and after the intervention using the Self-Report Habit Index and by asking participants on how many days of the previous week they enacted the desired habit. In addition, all participants provided daily reports on whether they enacted their water-drinking intention that day.

RESULTS

A Poisson regression analysis revealed that, during the intervention, users who received feedback based on optimized gamification enacted the desired behavior more often (mean 14.71, SD 6.57 times) than the active (mean 11.64, SD 6.38 times; P<.001; incidence rate ratio=0.80, 95% CI 0.71-0.91) or passive (mean 11.64, SD 5.43 times; P=.001; incidence rate ratio=0.78, 95% CI 0.69-0.89) control groups. The Self-Report Habit Index score significantly increased in all conditions (P<.001 in all cases) but did not differ between the experimental and control conditions (P>.11 in all cases). After the intervention, the experimental group performed the desired behavior as often as the 2 control groups (P≥.17 in all cases).

CONCLUSIONS

Our findings suggest that optimized gamification can be used to make digital behavior change interventions more effective.

TRIAL REGISTRATION

Open Science Framework (OSF) H7JN8; https://osf.io/h7jn8.

Feasibility of a telehealth-based contingency management intervention for alcohol use disorders using the phosphatidylethanol (PEth) 16:0/18:1 alcohol biomarker: a pilot randomized trial

Background: Phosphatidylethanol (PEth) is a blood-based biomarker for alcohol consumption that can be self-collected and has high sensitivity, specificity, and a longer detection window compared to other alcohol biomarkers.Objectives: We evaluated the feasibility and acceptability of a telehealth-based contingency management (CM) intervention for alcohol use disorder (AUD) using the blood-based biomarker PEth to assess alcohol consumption.Methods: Sixteen adults (7 female, 9 male) with AUD were randomized to Control or CM conditions. Control participants received reinforcers regardless of their PEth levels. CM participants received reinforcers for week-to-week decreases in PEth (Phase 1) or maintenance of PEth consistent with abstinence (<20 ng/mL, Phase 2). Blood samples were self-collected using the TASSO-M20 device. Acceptability was assessed by retention in weeks. Satisfaction was assessed with the Client Satisfaction Questionnaire (CSQ-8) and qualitative interviews. The primary efficacy outcome was PEth-defined abstinence. Secondary outcomes included the proportion of visits with PEth-defined heavy alcohol consumption, negative urine ethyl glucuronide results, and self-reported alcohol use.Results: Retention averaged 18.6 ± 8.8 weeks for CM participants. CM participants reported high levels of satisfaction (CSQ-8, Mean = 30.3 ± 1.5). Interview themes included intervention positives, such as staff support, quality of life improvement, and accountability. 72% of PEth samples from CM participants were consistent with abstinence versus 34% for Control participants (OR = 5.0, p = 0.007). PEth-defined heavy alcohol consumption was detected in 28% of CM samples and 52% of Control samples (OR = 0.36, p = 0.159). CM participants averaged 1.9 ± 1.7 drinks/day versus 4.2 ± 6.3 for Control participants (p = 0.304).Conclusion: Results support the acceptability and satisfaction of a telehealth PEth-based CM intervention, though a larger study is needed to assess its efficacy [NCT04038021].

Adapting the ADVANCE group program for digitally-supported delivery to reduce intimate partner violence by men in substance use treatment: a feasibility study

Introduction

COVID-19 restrictions created barriers to "business as usual" in healthcare but also opened the door to innovation driven by necessity. This manuscript (1) describes how ADVANCE, an in-person group perpetrator program to reduce intimate partner violence (IPV) against female (ex)partners by men in substance use treatment, was adapted for digitally-supported delivery (ADVANCE-D), and (2) explores the feasibility and acceptability of delivering ADVANCE-D to men receiving substance use treatment.

Methods

Firstly, the person-based approach and mHealth development framework were used to iteratively adapt ADVANCE for digitally-supported delivery including conceptualization, formative research, and pre-testing. Then, a non-randomized feasibility study was conducted to assess male participants' eligibility, recruitment, and attendance rates and uptake of support offered to their (ex)partners. Exploratory analyses on reductions in IPV perpetration (assessed using the Abusive Behavior Inventory; ABI) and victimization (using the revised ABI; ABI-R) at the end of the program were performed. Longitudinal qualitative interviews with participants, their (ex)partners, and staff provided an understanding of the program's implementation, acceptability, and outcomes.

Results

The adapted ADVANCE-D program includes one goal-setting session, seven online groups, 12 self-directed website sessions, and 12 coaching calls. ADVANCE-D includes enhanced risk management and support for (ex)partners. Forty-five participants who had perpetrated IPV in the past 12 months were recruited, forty of whom were offered ADVANCE-D, attending 11.4 (SD 9.1) sessions on average. Twenty-one (ex)partners were recruited, 13 of whom accepted specialist support. Reductions in some IPV perpetration and victimization outcome measures were reported by the 25 participants and 11 (ex)partners interviewed pre and post-program, respectively. Twenty-two participants, 11 (ex)partners, 12 facilitators, and 7 integrated support service workers were interviewed at least once about their experiences of participation. Overall, the program content was well-received. Some participants and facilitators believed digital sessions offered increased accessibility.

Conclusion

The digitally-supported delivery of ADVANCE-D was feasible and acceptable. Remote delivery has applicability post-pandemic, providing greater flexibility and access. Given the small sample size and study design, we do not know if reductions in IPV were due to ADVANCE-D, time, participant factors, or chance. More research is needed before conclusions can be made about the efficacy of ADVANCE-D.

Adjunctive Medication Management and Contingency Management to enhance adherence to acamprosate for alcohol dependence: the ADAM trial RCT

Background

Acamprosate is an effective and cost-effective medication for alcohol relapse prevention but poor adherence can limit its full benefit. Effective interventions to support adherence to acamprosate are therefore needed.

Objectives

To determine the effectiveness of Medication Management, with and without Contingency Management, compared to Standard Support alone in enhancing adherence to acamprosate and the impact of adherence to acamprosate on abstinence and reduced alcohol consumption.

Design

Multicentre, three-arm, parallel-group, randomised controlled clinical trial.

Setting

Specialist alcohol treatment services in five regions of England (South East London, Central and North West London, Wessex, Yorkshire and Humber and West Midlands).

Participants

Adults (aged 18 years or more), an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis of alcohol dependence, abstinent from alcohol at baseline assessment, in receipt of a prescription for acamprosate.

Interventions

(1) Standard Support, (2) Standard Support with adjunctive Medication Management provided by pharmacists via a clinical contact centre (12 sessions over 6 months), (3) Standard Support with adjunctive Medication Management plus Contingency Management that consisted of vouchers (up to £120) to reinforce participation in Medication Management. Consenting participants were randomised in a 2 : 1 : 1 ratio to one of the three groups using a stratified random permuted block method using a remote system. Participants and researchers were not blind to treatment allocation.

Main outcome measures

Primary outcome: self-reported percentage of medication taken in the previous 28 days at 6 months post randomisation. Economic outcome: EuroQol-5 Dimensions, a five-level version, used to calculate quality-adjusted life-years, with costs estimated using the Adult Service Use Schedule.

Results

Of the 1459 potential participants approached, 1019 (70%) were assessed and 739 (73 consented to participate in the study, 372 (50%) were allocated to Standard Support, 182 (25%) to Standard Support with Medication Management and 185 (25%) to Standard Support and Medication Management with Contingency Management. Data were available for 518 (70%) of participants at 6-month follow-up, 255 (68.5%) allocated to Standard Support, 122 (67.0%) to Standard Support and Medication Management and 141 (76.2%) to Standard Support and Medication Management with Contingency Management. The mean difference of per cent adherence to acamprosate was higher for those who received Standard Support and Medication Management with Contingency Management (10.6%, 95% confidence interval 19.6% to 1.6%) compared to Standard Support alone, at the primary end point (6-month follow-up). There was no significant difference in per cent days adherent when comparing Standard Support and Medication Management with Standard Support alone 3.1% (95% confidence interval 12.8% to -6.5%) or comparing Standard Support and Medication Management with Standard Support and Medication Management with Contingency Management 7.9% (95% confidence interval 18.7% to -2.8%). The primary economic analysis at 6 months found that Standard Support and Medication Management with Contingency Management was cost-effective compared to Standard Support alone, achieving small gains in quality-adjusted life-years at a lower cost per participant. Cost-effectiveness was not observed for adjunctive Medication Management compared to Standard Support alone. There were no serious adverse events related to the trial interventions reported.

Limitations

The trial's primary outcome measure changed substantially due to data collection difficulties and therefore relied on a measure of self-reported adherence. A lower than anticipated follow-up rate at 12 months may have lowered the statistical power to detect differences in the secondary analyses, although the primary analysis was not impacted.

Conclusions

Medication Management enhanced with Contingency Management is beneficial to patients for supporting them to take acamprosate.

Future work

Given our findings in relation to Contingency Management enhancing Medication Management adherence, future trials should be developed to explore its effectiveness and cost-effectiveness with other alcohol interventions where there is evidence of poor adherence.

Trial registration

This trial is registered as ISRCTN17083622 https://doi.org/10.1186/ISRCTN17083622.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 22. See the NIHR Journals Library website for further project information.

Perspectives and sentiments on contingency management from people who use methamphetamine

INTRODUCTION

Contingency management (CM) is currently the most efficacious treatment for methamphetamine use, yet it is rarely available in routine care. We examined the viewpoints of people who use methamphetamine on CM as a potential treatment for methamphetamine use disorder.

METHODS

Semi-structured qualitative interviews with 30 Australians aged 18 years or older who had used methamphetamine at least weekly in the past 6 months.

RESULTS

Participants reported overall positive attitudes towards CM as a potential treatment option for methamphetamine use disorder. However, there was need for greater flexibility in meeting participant treatment goals (e.g., reduced use or complete abstinence), with particular concern about the viability of initiating abstinence, both in terms of the sufficiency of the initial financial incentive and managing withdrawal symptoms. There was strong interest in the use of digital technologies to provide remote CM, particularly around the convenience and flexibility this offered. Despite this, participants remained keen to access adjunctive treatment and support services but stressed that engagement with these additional services should not be mandatory. Marketing of CM will need to address preconceptions about drug-testing used in abstinence-based CM being punitive (especially urine testing) and its connotations with criminal justice interventions.

DISCUSSION AND CONCLUSION

Positive attitudes towards CM bode well for potential uptake should CM be made available in routine clinical practice. However, there is a need to adapt CM to ensure it is feasible and attractive to people who are seeking treatment for methamphetamine use disorder.

Precision medicine in alcohol use disorder: Mapping etiologic and maintenance mechanisms to mechanisms of behavior change to improve patient outcomes

Precision medicine has been advanced as a potential solution to the problem of alcohol use disorder heterogeneity and modest alcohol use disorder treatment efficacy. The success of precision medicine lies in our ability to first identify the etiologic and maintenance mechanisms at play for a given person and then choose the treatment that is most likely to address such mechanisms. There exist several frameworks that describe empirically supported substance use disorder (SUD) etiologic and maintenance mechanisms (e.g., the Etiologic, Theory-based, Ontogenetic, Hierarchical [ETOH] Framework). There also exists a large literature on mechanisms of behavior change in alcohol use disorder treatment. However, the mechanism of behavior change literature on alcohol use disorder treatments has focused broadly on mechanisms of change rather than more specifically on core alcohol use disorder etiologic and maintenance mechanisms. Thus, the two types of mechanisms have never been integrated or systematically evaluated for their overlap. As such, the aim of the present brief review is to demonstrate how commonly used alcohol use disorder treatments may overlap with and directly target certain alcohol use disorder etiologic and maintenance mechanisms (specifically those described by the ETOH framework). We delineate empirically plausible overlapping mechanisms and theoretically plausible overlapping mechanisms that warrant more research. Last, based on the identification of empirically and theoretically plausible overlapping mechanisms, we elaborate on how ongoing work related to alcohol use disorder precision medicine may test specific hypotheses regarding which treatments work best for whom. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Methamphetamine dependence in Australia-why is 'ice' (crystal meth) so addictive?

Australia has one of the highest rates in the world of the use of the crystalline form of methamphetamine, a highly addictive stimulant that is often associated with a chronic, relapsing dependency. Methamphetamine use is associated with both acquisitive and violent offending, which cause substantial personal and societal costs. Whilst the short-term euphoria and stimulation provide a positive reinforcement to methamphetamine use, the aversive states of withdrawing from methamphetamine and the associated craving, which may last up to five weeks into abstinence, underlie the negative reinforcement to continued methamphetamine use. Although many methamphetamine-dependent users experience high levels of psychological distress, it is likely that less than half engage with treatment or support services, and current intervention and treatment programmes have high discontinuation rates. Stigma and discrimination, even from paramedics and health clinicians, are prominent barriers to methamphetamine-dependent users accessing treatment in Australia.

Patient Preferences for Mobile Health Applications to Support Recovery

INTRODUCTION

Smartphone apps to support individuals in recovery from substance use disorders (SUDs) are increasingly available. Although many people with SUDs express interest in recovery support apps, few try them or use them long-term. Strategies like gamification and contingency management are increasingly being considered to sustain engagement. This study sought to describe features of a recovery support app called the Addiction version of the Comprehensive Health Enhancement Support System (A-CHESS) that are most used by individuals in SUD recovery and what makes individuals more likely to use these apps.

METHODS

A total of 202 people with A-CHESS accounts completed an online survey assessing their experiences using A-CHESS between April and June 2021. We described app features reported to be most beneficial for managing anxiety, loneliness, and isolation during COVID-19; reasons for not using A-CHESS; and suggested app features for future recovery support apps.

RESULTS

Respondents had a mean age of 41 years, 85% were White, and 61% were female. Respondents reported that app features related to messaging (ie, open discussion boards and private messaging) and informational or motivational resources were the most useful for managing isolation, anxiety, and loneliness. Reasons for not using A-CHESS were not knowing how to use the app and the app not being part of a personalized treatment plan. The most common suggested components for future apps were rewards for meeting goals and a support meeting locator.

CONCLUSIONS

Ensuring that health apps are intuitive and include features that appeal to patients and educating patients about features apps already include that help them meet goals may enhance engagement with recovery apps.

A contextualized reinforcer pathology approach to addiction

Behavioural economic accounts of addiction conceptualize harmful drug use as an operant reinforcer pathology, emphasizing that a drug is consumed because of overvaluation of smaller immediate rewards relative to larger delayed rewards (delay discounting) and high drug reinforcing value (drug demand). These motivational processes are within-individual determinants of behaviour. A third element of learning theory posits that harmful drug use depends on the relative constraints on access to other available activities and commodities in the choice context (alternative reinforcers), reflecting the substantial influence of environmental factors. In this Perspective, we integrate alternative reinforcers into the contemporary behavioural economic account of harmful drug use - the contextualized reinforcer pathology model - and review empirical literature across the translational spectrum in support of this model. Furthermore, we consider how increases in drug-related mortality and health disparities in addiction can be understood and potentially ameliorated via a contextualized reinforcer pathology model in which lack of alternative reinforcement is a major risk factor for addiction.

Client Views of Contingency Management in Gambling Treatment: A Thematic Analysis

Low levels of treatment access and poor retention among those with gambling problems suggests a need to improve treatment. Contingency management (CM) is a behavioural intervention involving the identification of target behaviours and the provision of incentives when targets are met. There exists a substantial evidence base for CM increasing abstinence and attendance in substance misuse treatment, but this has not been widely extended to gambling treatment setting. This study sought to explore the views of clients about CM for the treatment of problematic and disordered gambling. We conducted semi-structured interviews with 25 gambling treatment clients who were, or had previously been, engaged in treatment in Great Britain. Participants were provided with an explanation of CM, two hypothetical scenarios, and two structured questionnaires to facilitate discussion. Thematic analysis was used to interpret findings. Some participants felt that clients could manipulate CM while in treatment to obtain money to gamble, and that mechanisms of CM could trigger recovering clients into relapse. Participants also identified potential benefits of CM to achieve treatment goals, by enhancing motivation and engagement while in treatment, and helping bring people into treatment earlier. Gambling treatment clients broadly supported the use of incentives for treatment. CM is seen as a facilitator of extended engagement in treatment, and an encouragement for clients to make progress in the treatment process.

Rewarding recovery: the time is now for contingency management for opioid use disorder

Contingency management (i.e. rewarding people, often with money, for achieving their recovery goals) is backed by decades of empirical support yet remains highly underutilized. Rewards are rarely used in real-world clinical practice due to a number of concerns, including most notably, the apparent lack of innovation, as well as moral, philosophical, ethical, and economic concerns, and even federal rules meant to prevent illegal inducements in health care. Still, other opponents argue that some patients will try to "game" the system by simply doing whatever it takes to earn monetary rewards. This paper provides a succinct, up-to-date overview of the current evidence base for contingency management for opioid use disorder. Common barriers and solutions to implementation, as well as implications for future research and clinical practice are discussed. Although important, greater uptake of contingency management interventions is about more than legislation and regulations; it's about recognizing stigma, shaping attitudes, and increasing awareness. Provider involvement in advocacy efforts at all levels and collaboration involving academic-industry partnerships is necessary to advance the burgeoning digital health care space and improve outcomes for people with opioid use disorder. Key MessagesContingency management is highly effective but highly underutilized.Low uptake is largely attributed to a lack of innovation and moral, ethical, and economic concerns, among other barriers.Technology-enabled solutions and academic-industry partnerships are critical to advance opioid use disorder care.

Addressing stimulant use disorder through state opioid response grants from the substance abuse and mental health services administration: Missouri's initial approach

Background: The alarming growth of stimulant-involved deaths underscores the urgent need for states to expand existing opioid-specific approaches to intentionally reach and serve people who use stimulants. Recent permission from federal agencies has allowed states to spend grant funding that was previously restricted to opioid-related activities on approaches addressing stimulant use.Objectives: This manuscript describes the rationale, methods, and initial results supporting the implementation of Missouri's recent stimulant-focused efforts - including previously-prohibited activities such as Contingency Management and fentanyl test strip distribution.Methods: Missouri's State Opioid Response team facilitated the design and implementation of Contingency Management pilot programming abiding by federal spending limits of no more than $75 of incentives per client, mass distribution of fentanyl test strips, and publicly accessible harm reduction trainings and materials specific to stimulant use. Data sources used for initial evaluations included state-level treatment claims, fentanyl test strip distribution counts by type and region of organizations receiving them, and qualitative feedback from stakeholders.Results: Six substance use treatment agencies developed Contingency Management programs, serving 29 individuals in the first nine months. Over 20,000 fentanyl test strips were distributed using a prioritization system designed to reach those most likely to benefit from their use.Conclusions: Recent federally funded efforts to better address stimulant use in Missouri have increased access to evidence-based treatment and harm reduction resources. Lessons learned from early implementation, especially those regarding time allowed for program development and how best to ensure equitable resource distribution, will inform future stimulant-focused program efforts.

Can we enhance the clinical efficacy of cognitive and psychological approaches to treat substance use disorders through understanding their neurobiological mechanisms?

Despite decades of research in the field of addiction, relapse rates for substance use disorders remain high. Consequently, there has been growing focus on providing evidence-based treatments for substance use disorders, resulting in the increased development and use of cognitive and psychological interventions. Such treatment approaches, including contingency management, community-reinforcement approach, and cognitive bias modification, have shown promising clinical efficacy in reducing substance use and promoting abstinence during treatment. However, these interventions are still somewhat limited in achieving sustained periods of abstinence post-treatment. The neurobiological mechanisms underpinning these treatment approaches remain largely unknown and under-studied, in part, due to a lack of translational animal models. The adoption of a reverse translational approach may assist in development of more representative models that can facilitate elucidation of the mechanisms behind these clinically relevant interventions. This review examines our current understanding of addiction neurobiology from clinical, preclinical research and existing animal models, and considers how the efficacy of such behavioral-oriented interventions alone, or in combination with pharmacotherapy, may be enhanced to improve treatment outcomes.

A randomized controlled trial of social media interventions for risky drinking among adolescents and emerging adults

PURPOSE

Alcohol use among adolescents and emerging adults is an important public health issue requiring prevention approaches. Herein, we describe outcomes from a randomized controlled trial testing the efficacy of group-based social media interventions targeting risky drinking among youth.

PROCEDURES

Using social media advertisements to screen potential participants, we recruited 955 youth (ages 16-24) reporting recent risky drinking. After completing a baseline assessment, participants were randomized to 8-week secret Facebook group conditions: Social Media Intervention + Incentives for engagement, Social Media Intervention only, and attention-placebo control. Electronic coaches trained in motivational interviewing facilitated interaction in intervention groups. Primary outcomes include past 3-month alcohol use and consequences over 3-, 6-, and 12-month follow-ups. Secondary outcomes include other drug use, consequences, and impaired driving. We also measured intervention engagement and acceptability.

RESULTS

The interventions were well-received, with significantly greater acceptability ratings and engagement in the SMI+I condition relative to other groups. In adjusted analyses, there were no significant differences between interventions and control on alcohol-related outcomes, with all groups showing reductions. Regarding secondary outcomes (70.4% used other drugs), compared to control, the incentivized group reduced other drug use, consequences, and cannabis-impaired driving; the non-incentivized group did not significantly differ from the control condition.

CONCLUSIONS

Among this predominantly poly-substance using sample, findings were mixed, with significant effects of the incentivized social media intervention on drug (but not alcohol) outcomes. Future studies are needed to further refine social media-delivered interventions to reduce alcohol and other drug use.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02809586; University of Michigan HUM#00102242.

Contingency management and cognitive behavior therapy for smoking cessation among veterans with posttraumatic stress disorder: Design and methodology of a randomized clinical trial

BACKGROUND

Smoking is a prevalent concern among Veterans, especially those with posttraumatic stress disorder (PTSD). Despite the availability of interventions for smoking cessation, these treatments have not been as effective among Veteran populations, particularly Veterans with PTSD. The present study seeks to describe the methods of a randomized clinical trial examining the efficacy of CPT-SMART, a multidimensional treatment combining cognitive processing therapy (CPT) for PTSD, smoking cessation counseling, pharmacotherapy, and contingency management (CM) compared to a yoked comparison group.

METHODS

One hundred twenty Veterans with PTSD who smoke cigarettes will be enrolled. All participants will receive CPT in addition to counseling and pharmacotherapy for smoking cessation. Participants will be randomized to the CPT-SMART condition, which includes monetary reinforcement that is contingent on bioverification of smoking abstinence (i.e., contingency management), or a yoked comparison with monetary reinforcement matched to the participant to whom they are yoked. The primary outcome is bioverified smoking abstinence at the 6-month follow-up appointment.

CONCLUSION

If shown efficacious, a combined PTSD and smoking treatment plus incentive-based approach for smoking could be implemented into specialty PTSD programs. The positive public health impact of reducing smoking among Veterans with PTSD could be enormous as it would prevent significant smoking-related morbidity and mortality.

Mechanisms of Behavior Change in Substance Use Disorder With and Without Formal Treatment

This article provides a narrative review of studies that examined mechanisms of behavior change in substance use disorder. Several mechanisms have some support, including self-efficacy, craving, protective behavioral strategies, and increasing substance-free rewards, whereas others have minimal support (e.g., motivation, identity). The review provides recommendations for expanding the research agenda for studying mechanisms of change, including designs to manipulate putative change mechanisms, measurement approaches that expand the temporal units of analysis during change efforts, more studies of change outside of treatment, and analytic approaches that move beyond mediation tests. The dominant causal inference approach that focuses on treatment and individuals as change agents could be expanded to include a molar behavioral approach that focuses on patterns of behavior in temporally extended environmental contexts. Molar behavioral approaches may advance understanding of how recovery from substance use disorder is influenced by broader contextual features, community-level variables, and social determinants of health. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.