The dissemination and implementation of contingency management for substance use disorders: A systematic review

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.

Long-Term Effects of Incentives for HIV Viral Suppression: A Randomized Clinical Trial

Achieving viral suppression in people living with HIV improves their quality of life and can help end the HIV/AIDS epidemic. However, few interventions have successfully promoted HIV viral suppression. The purpose of this study was to evaluate the long-term effectiveness of financial incentives for viral suppression in people living with HIV. People living with a detectable HIV viral load (≥ 200 copies/mL) were randomly assigned to Usual Care (n = 50) or Incentive (n = 52) groups. Incentive participants earned up to $10 per day for providing blood samples with an undetectable or reduced viral load. During the 2-year intervention period, the percentage of blood samples with a suppressed viral load was significantly higher among Incentive participants (70%) than Usual Care participants (43%) (OR = 7.1, 95% CI 2.7 to 18.8, p < .001). This effect did not maintain after incentives were discontinued. These findings suggest that frequent delivery of large-magnitude financial incentives for viral suppression can produce large and long-lasting improvements in viral load in people living with HIV. ClinicalTrials.gov Identifier: NCT02363387.

Effectiveness of Contingency Management in Tobacco Smokers with Depressive Symptoms: A Systematic Review

Background: Effective interventions are required to address tobacco smoking in people with depressive symptomatology. In this context, contingency management could be one useful therapeutic strategy. Objectives: This study is a systematic review of tobacco cessation interventions for smokers with depressive symptomatology including a contingency management component, evaluating their efficacy with regards to tobacco abstinence, depressive symptomatology, adherence to treatment and other variables related to tobacco use. For this purpose, a search was carried out in Pubmed, PsycINFO, Cochrane, Web of Science and ClinicalTrials.gov in September 2022. The quality of the studies was assessed using the Cochrane Risk of Bias tool. Results: Of the 208 articles identified, six were included in this review. Results: For the most part, the research included suggests that contingency management is an effective strategy for improving abstinence outcomes, adherence, and other smoking-related variables such as delay discounting and intensity of cigarette demand in smokers with depressive symptomatology. Conclusions: Although contingency management could be a promising intervention in tobacco smokers with depressive symptomatology, further research in this area is still required.

Lessons learned from statewide contingency management rollouts addressing stimulant use in the Northwestern United States

Increases in stimulant drug use (such as methamphetamine) and related deaths creates an imperative for community settings to adopt evidence-based practices to help people who use stimulants. Contingency management (CM) is a behavioral intervention with decades of research demonstrating efficacy for the treatment of stimulant use disorder, but real-world adoption has been slow, due to well-known implementation barriers, including difficulty funding reinforcers, and stigma. This paper describes the training and technical assistance (TTA) efforts and lessons learned for two state-wide stimulant-focused CM implementation projects in the Northwestern United States (Montana and Washington). A total of 154 providers from 35 community-based service sites received didactic training in CM beginning in 2021. Seventeen of these sites, ten of eleven in Montana (90.9%) and seven of 24 in Washington (29.2%), went on to implement contingency management programs adherent to their state's established CM protocol and received ongoing TTA in the form of implementation coaching calls. These findings illustrate that site-specific barriers such as logistical fit precluded implementation in more than 50% of the trained sites; however, strategies for site-specific tailoring within the required protocol aided implementation, resulting in successful CM program launch in a diverse cross-section of service sites across the states. The lessons learned add to the body of literature describing CM implementation barriers and solutions.

Abstinence-contingent wage supplements for adults experiencing homelessness and alcohol use disorder: A randomized clinical trial

This study evaluated the effectiveness of abstinence-contingent wage supplements in promoting alcohol abstinence and employment in adults experiencing homelessness and alcohol use disorder. A randomized clinical trial was conducted from 2019 to 2022. After a 1-month Induction period, 119 participants were randomly assigned to a Usual Care Control group (n = 57) or an Abstinence-Contingent Wage Supplement group (n = 62). Usual Care participants were offered counseling and referrals to employment and treatment programs. Abstinence-Contingent Wage Supplement participants could earn stipends for working with an employment specialist and wage supplements for working in a community job but had to maintain abstinence from alcohol as determined by transdermal alcohol concentration monitoring devices to maximize pay. Abstinence-Contingent Wage Supplement participants reported significantly higher rates of alcohol abstinence than Usual Care participants during the 6-month intervention (82.8% vs. 60.2% of months, OR = 3.4, 95% CI 1.8 to 6.3, p < .001). Abstinence-Contingent Wage Supplement participants were also significantly more likely to obtain employment (51.3% vs. 31.6% of months, OR = 2.6, 95% CI 1.5 to 4.4, p < .001) and live out of poverty (38.2% vs. 16.7% of months, OR = 3.7, 95% CI 2.0 to 7.1, p < .001) than Usual Care participants. These findings suggest that Abstinence-Contingent Wage Supplements can promote alcohol abstinence and employment in adults experiencing homelessness and alcohol use disorder. ClinicalTrials.gov Identifier: NCT03519009.

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.

Effectiveness of contingency management using transdermal alcohol monitoring to reduce heavy drinking among driving while intoxicated (DWI) arrestees: A randomized controlled trial

BACKGROUND

Driving while intoxicated (DWI) is a serious public health problem. However, treatment for DWI arrestees is not readily available. This study examines the effectiveness of a contingency management (CM) procedure using transdermal alcohol concentration (TAC) monitoring to reduce drinking among DWI arrestees.

METHOD

The study participants were 216 DWI arrestees under pretrial and included both Mandated participants undergoing court-ordered TAC monitoring and Non-Mandated participants wearing a study-provided TAC monitor. Participants were randomly assigned to either a CM (Mandated = 35; Non-Mandated = 74) or a Control condition (Mandated = 37; Non-Mandated = 70) and completed the 8-week intervention. CM participants received $50/week for not exceeding a TAC of 0.02 g/dL during the previous week. Payments to Controls were yoked to the CM group.

RESULTS

Among Non-Mandated participants, the probability of meeting the contingency was higher and remained stable (about 65%) over time in the CM group, whereas the probability was lower and declined in the Control group, widening the gaps in the probability between the study conditions (16.7%-24.1% greater in the CM group from visit 4 to 8, all p < 0.05). Among Mandated participants, the probability was not significantly different between conditions (p = 0.06-0.95). Furthermore, among Non-Mandated participants, the percentage of heavy drinking days remained low (9.16%-11.37%) in the CM group, whereas it was greater and increased over time (17.43%-26.59%) in the Control group. In Mandated participants, no significant differences in percent heavy drinking days were observed between conditions (p = 0.07-0.10).

CONCLUSION

We found that contingency effects on alcohol use are more pronounced among frequent and heavy alcohol users, i.e., Non-Mandated DWI arrestees. However, for individuals whose drinking was already suppressed by existing contingencies (i.e., court-mandated TAC monitoring), our CM procedure did not produce additional reductions in drinking.

Perspectives on contingency management for alcohol use and alcohol-associated conditions among people in care with HIV

BACKGROUND

Contingency management (CM) is an evidence-based approach for reducing alcohol use; however, its implementation into routine HIV primary care-based settings has been limited. We evaluated perspectives on implementing CM to address unhealthy alcohol use and associated conditions for people with HIV in primary care settings.

METHODS

From May 2021 to August 2021, we conducted two focus groups with staff involved in delivering the intervention (n = 5 Social Workers and n = 4 Research Coordinators) and individual interviews (n = 13) with a subset of participants involved in the multi-site Financial Incentives, Randomization, and Stepped Treatment (FIRST) trial. Qualitative data collection and analyses were informed by the Promoting Action on Research Implementation in Health Service (PARIHS) implementation science framework, including evidence (perception of CM), context (HIV primary care clinic and CM procedures), and facilitation (feasibility outside the research setting).

RESULTS

Several major themes were identified. Regarding the evidence, participants lacked prior experience with CM, but the intervention was well received and, by some, perceived to lead to lasting behavior change. Regarding the clinical context for the reward schedule, the use of biochemical testing, specifically fingerstick phosphatidylethanol testing, and the reward process were perceived to be engaging and gratifying for both staff and patients. Participants indicated that the intervention was enhanced by its co-location within the HIV clinic. Regarding facilitation, participants suggested addressing the intervention's feasibility for non-research use, simplifying the reward structure, and rewarding non-abstinence in alcohol use.

CONCLUSIONS

Among patients and staff involved in a clinical trial, CM was viewed as a helpful, positive, and feasible approach to addressing unhealthy alcohol use and related conditions. To enhance implementation, future efforts may consider simplified approaches to the reward structure and expanding rewards to non-abstinent reductions in alcohol consumption.

An unexplored equity factor: differential beliefs and attitudes toward contingency management by providers' ethnicity

BACKGROUND

Although considered one of the most effective interventions for substance use disorders (SUD), the widespread implementation of contingency management (CM) has remained limited. In more recent years there has been surge in the implementation of CM to address increasing rates of substance use. Prior studies at the provider-level have explored beliefs about CM among SUD treatment providers and have tailored implementation strategies based on identified barriers and training needs, to promote implementation of CM. However, there have been no implementation strategies that have actively sought to identify or address potential differences in the beliefs about CM that could be influenced by the cultural background (e.g., ethnicity) of treatment providers. To address this knowledge gap, we examined beliefs about CM among a sample of inpatient and outpatient SUD treatment providers.

METHODS

A cross-sectional survey of SUD treatment providers was completed by 143 respondents. The survey asked respondents about their attitudes toward CM using the Contingency Management Beliefs Questionnaire (CMBQ). Linear mixed models examined the effect of ethnicity (non-Hispanic White and Hispanic) on CMBQ subscale (general barriers, training-related barriers, CM positive-statements) scores.

RESULTS

Fifty-nine percent of respondents to the CMBQ self-identified as non-Hispanic White and 41% as Hispanic. Findings revealed that treatment providers who identified as Hispanic had significantly higher scores on the general barriers (p < .001) and training-related barriers (p = .020) subscales compared to the non-Hispanic White treatment providers. Post-hoc analyses identified differences in the endorsement of specific individual scale items on the general barriers (e.g., CM interventions create extra work for me) and training-related (e.g., I want more training before implementing CM) subscales.

CONCLUSIONS

Dissemination and implementation strategies for CM need to consider equity-related factors at the provider-level that may be associated with the adoption and uptake of CM.

Feasibility, Engagement, and Usability of a Remote, Smartphone-Based Contingency Management Program as a Treatment Add-On for Patients Who Use Methamphetamine: Single-Arm Pilot Study

BACKGROUND

In the United States, methamphetamine-related overdoses have tripled from 2015 to 2020 and continue to rise. However, efficacious treatments such as contingency management (CM) are often unavailable in health systems.

OBJECTIVE

We conducted a single-arm pilot study to evaluate the feasibility, engagement, and usability of a fully remotely delivered mobile health CM program offered to adult outpatients who used methamphetamine and were receiving health care within a large university health system.

METHODS

Participants were referred by primary care or behavioral health clinicians between September 2021 and July 2022. Eligibility criteria screening was conducted by telephone and included self-reported methamphetamine use on ≥5 out of the past 30 days and a goal of reducing or abstaining from methamphetamine use. Eligible participants who agreed to take part then completed an initial welcome phase that included 2 videoconference calls to register for and learn about the CM program and 2 "practice" saliva-based substance tests prompted by a smartphone app. Participants who completed these welcome phase activities could then receive the remotely delivered CM intervention for 12 consecutive weeks. The intervention included approximately 24 randomly scheduled smartphone alerts requesting a video recording of themselves taking a saliva-based substance test to verify recent methamphetamine abstinence, 12 weekly calls with a CM guide, 35 self-paced cognitive behavioral therapy modules, and multiple surveys. Financial incentives were disbursed via reloadable debit cards. An intervention usability questionnaire was completed at the midpoint.

RESULTS

Overall, 37 patients completed telephone screenings, with 28 (76%) meeting the eligibility criteria and consenting to participate. Most participants who completed a baseline questionnaire (21/24, 88%) self-reported symptoms consistent with severe methamphetamine use disorder, and most had other co-occurring non-methamphetamine substance use disorders (22/28, 79%) and co-occurring mental health disorders (25/28, 89%) according to existing electronic health records. Overall, 54% (15/28) of participants successfully completed the welcome phase and were able to receive the CM intervention. Among these participants, engagement with substance testing, calls with CM guides, and cognitive behavioral therapy modules varied. Rates of verified methamphetamine abstinence in substance testing were generally low but varied considerably across participants. Participants reported positive opinions about the intervention's ease of use and satisfaction with the intervention.

CONCLUSIONS

Fully remote CM can be feasibly delivered within health care settings lacking existing CM programs. Although remote delivery may help reduce barriers to treatment access, many patients who use methamphetamine may struggle to engage with initial onboarding. High rates of co-occurring psychiatric conditions in the patient population may also contribute to uptake and engagement challenges. Future efforts could leverage greater human-to-human connection, more streamlined onboarding procedures, larger incentives, longer durations, and the incentivization of non-abstinence-based recovery goals to increase uptake and engagement with fully remote mobile health-based CM.

An Unexplored Equity Factor During Pre-Implementation of Contingency Management: Differential Beliefs and Attitudes by Providers' Ethnicity

Background Although considered one of the most effective interventions for substance use disorders (SUD), the widespread uptake of contingency management (CM) has remained limited. Prior studies at the provider-level have explored beliefs about CM among SUD treatment providers and have tailored implementation strategies based on identified barriers and training needs. However, there have been no implementation strategies that have actively sought to identify or address potential differences in the beliefs about CM that could be influenced by the cultural background (e.g., ethnicity) of treatment providers. To address this knowledge gap, we examined beliefs about CM among a sample of inpatient and outpatient SUD treatment providers. Methods A cross-sectional survey of SUD treatment providers was completed by 143 respondents. The survey asked respondents about their attitudes toward CM using the Contingency Management Beliefs Questionnaire (CMBQ). Linear mixed models were used to examine the effect of ethnicity on CMBQ subscale (general barriers, training-related barriers, CM positive-statements) scores. Results Fifty-nine percent of respondents self-identified as non-Hispanic White and 41% as Hispanic. Findings revealed that SUD providers who identified as Hispanic had significantly higher scores on the general barriers (p < .001) and training-related barriers (p = .020) subscales compared to the non-Hispanic White SUD providers. Post-hoc analyses identified differences in the endorsement of specific individual scale items on the general barriers and training-related subscales. Conclusions Dissemination and implementation strategies for CM among treatment providers need to consider equity-related factors at the provider-level that may be associated with the adoption and uptake CM.

Expanding access to treatment for stimulant use disorder in a frontier state: A qualitative study of contingency management and TRUST program implementation in Montana

BACKGROUND

The client population eligible for treatment services supported by State Opioid Response (SOR) grant funding, administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), was expanded to include individuals with a stimulant use disorder (stimUD) in 2020. Due to a significant need to improve services for individuals with stimUD in Montana, the Behavioral Health and Developmental Disabilities Division (BHDD) of the Montana Department of Public Health and Human Services used the grant opportunity to work with experts in the field of stimUD to pilot contingency management (CM) and the Treatment for Individuals who Use Stimulants (TRUST) treatment model. The CM protocol included twice weekly visits for twelve weeks, using an escalating schedule of gift card incentives contingent upon stimulant-negative urine samples. TRUST is a multi-component treatment program, incorporating exercise, group therapy, and individual therapy with content guided by cognitive behavioral therapy (CBT) and clinical research associate (CRA) materials. In addition to SOR dollars, BHDD used additional funding for CM reinforcers provided by state tax dollars to meet research-supported target incentive totals.

METHODS

In this pilot project, TRUST/CM was implemented by four state-approved treatment providers and three Federally Qualified Health Centers (FQHCs), all of which had little prior experience with CM as a component of their treatment programs for stimUD. This article examines the processes of training staff, the experiences among staff with initial implementation of the treatment model, and the client characteristics of initial pilot treatment cohorts. Data for this study include primary qualitative data collected from providers, as well as client characteristics collected on the SAMHSA Government Performance and Results Act (GPRA) data collection form.

RESULTS

Seven sites were trained in TRUST/CM, and these sites enrolled a total of 70 patients in the program. Qualitative data collected through interviews with site staff revealed the following themes: the value of intensive technical assistance being integrated in the program, concerns about staff retention and loss of expertise, adjustments of target client populations, and the importance of creative strategies for the provision of evidence-informed incentive totals.

CONCLUSIONS

TRUST/CM was implemented throughout Montana, including rural and urban communities. Qualitative and quantitative data support that providers viewed the CM component as beneficial for treatment retention and improved outcomes for people with stimUD. These implementation study results provide insight into challenges and solutions for providers who are considering the implementation of CM within either a state-approved substance use treatment clinic or FQHC.

Implications of epidemic-pandemic convergence for routine care adoption of contingency management: A case study

The significant increase in opioid-related drug overdoses during the coronavirus disease (COVID-19) pandemic has put an unprecedented burden on hospital emergency departments, who saw as high as an approximate 150% increase in emergency department (ED) admission rates in the initial months of the pandemic. Although overdose is a clear sign of problem drug use, only a small proportion of nonfatal overdose patients enroll in treatment within 30 days of their overdose. To bridge the gap between opioid overdoses and treatment entry, a smartphone-smart debit card contingency management program was developed to promote entry into medication-assisted treatment by out-of-treatment opioid users who have recently received care in a hospital emergency department. The case study described in this article highlights a successful implementation of this intervention despite numerous disruptions related to COVID-19 that would have made engagement difficult without the remote access to contingency management provided by this technology. Patient status over time is presented in conjunction with contingency management earnings. Technology-based contingency management may provide improved scalability, rigorous outcomes metrics, and lower costs than prior onsite, manual contingency management (CM) approaches. The COVID-19 pandemic, in combination with the opioid epidemic has created a context in which historical obstacles to the adoption of contingency management may be overcome. This case study demonstrates the potential utility of smartphone-based contingency management when in-person care is difficult to access or disrupted. The requirement for further research demonstrating the efficacy of these approaches is discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Evidence-based Treatment for Substance Use Disorders in Community Mental Health Centers: the ACCESS Program

A significant gap remains in the availability and accessibility of evidence-based treatments (EBTs) in community substance use disorder (SUD) treatment. This study describes a 2-year statewide training initiative that sought to address this gap by training community-based therapists in motivational enhancement/cognitive behavioral therapy (MET/CBT). Therapists (N = 93) participated in a 2-day MET/CBT workshop followed by bi-weekly clinical consultation, fidelity monitoring, guided readings, and online resources. Therapists completed pre-training and follow-up assessments measuring knowledge, attitudes, confidence, and implementation barriers. Most therapists attended 10 or more consultation calls. Submission of session recordings for feedback was the least utilized training element. Therapists reported increased confidence in their ability to implement MET/CBT for SUD and demonstrated improvement in MI and CBT knowledge. Therapists reported several implementation barriers, including lack of time and opportunity to treat patients with MET/CBT. Recommendations for future training initiatives and addressing the barriers identified in this study are discussed.

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.

Association of Methamphetamine and Opioid Use With Nonfatal Overdose in Rural Communities

Importance

Overdoses continue to increase in the US, but the contribution of methamphetamine use is understudied in rural communities.

Objective

To estimate the prevalence of methamphetamine use and its correlates among people who use drugs (PWUD) in rural US communities and to determine whether methamphetamine use is associated with increased nonfatal overdoses.

Design, Setting, and Participants

From January 2018 through March 2020, the National Rural Opioid Initiative conducted cross-sectional surveys of PWUD in rural communities in 10 states (Illinois, Kentucky, New Hampshire, Massachusetts, North Carolina, Ohio, Oregon, Vermont, West Virginia, and Wisconsin). Participants included rural PWUD who reported any past-30-day injection drug use or noninjection opioid use to get high. A modified chain-referral sampling strategy identified seeds who referred others using drugs. Data analysis was performed from May 2021 to January 2022.

Exposures

Use of methamphetamine alone, opioids alone, or both.

Main Outcomes and Measures

Unweighted and weighted prevalence of methamphetamine use, any past-180-day nonfatal overdose, and number of lifetime nonfatal overdoses.

Results

Among the 3048 participants, 1737 (57%) were male, 2576 (85%) were White, and 225 (7.4%) were American Indian; the mean (SD) age was 36 (10) years. Most participants (1878 of 2970 participants with any opioid or methamphetamine use [63%]) reported co-use of methamphetamine and opioids, followed by opioids alone (702 participants [24%]), and methamphetamine alone (390 participants [13%]). The estimated unweighted prevalence of methamphetamine use was 80% (95% CI, 64%-90%), and the estimated weighted prevalence was 79% (95% CI, 57%-91%). Nonfatal overdose was greatest in people using both methamphetamine and opioids (395 of 2854 participants with nonmissing overdose data [22%]) vs opioids alone (99 participants [14%]) or methamphetamine alone (23 participants [6%]). Co-use of methamphetamine and opioids was associated with greater nonfatal overdose compared with opioid use alone (adjusted odds ratio, 1.45; 95% CI, 1.08-1.94; P = .01) and methamphetamine use alone (adjusted odds ratio, 3.26; 95% CI, 2.06-5.14; P < .001). Those with co-use had a mean (SD) of 2.4 (4.2) (median [IQR], 1 [0-3]) lifetime overdoses compared with 1.7 (3.5) (median [IQR], 0 [0-2]) among those using opioids alone (adjusted rate ratio, 1.20; 95% CI, 1.01-1.43; P = .04), and 1.1 (2.9) (median [IQR], 0 [0-1]) among those using methamphetamine alone (adjusted rate ratio, 1.81; 95% CI, 1.45-2.27; P < .001). Participants with co-use most often reported having tried and failed to access substance use treatment: 827 participants (44%) for both, 117 participants (30%) for methamphetamine alone, and 252 participants (36%) for opioids alone (χ22 = 33.8; P < .001). Only 66 participants (17%) using methamphetamine alone had naloxone.

Conclusions and Relevance

These findings suggest that harm reduction and substance use disorder treatment interventions must address both methamphetamine and opioids to decrease overdose in rural communities.

Contingency management for alcohol use disorder reduces cannabis use among American Indian and Alaska Native adults

OBJECTIVE

Determine whether a culturally tailored contingency management (CM) intervention targeting alcohol abstinence resulted in secondary effects on cannabis use among American Indian and Alaska Native (AI/AN) adults.

METHODS

The research team conducted this secondary data analysis to examine cannabis abstinence using data from a randomized control trial of CM for alcohol use among three AI/AN-serving organizations. One hundred and fifty-eight adults met the randomization criteria (i.e., submission of 50% or more urine samples and one alcohol-positive urine test during a 4-week, pre-randomization, observation period). For 12 weeks after randomization, participants received incentives for submitting a urine test negative for ethyl glucuronide (EtG < 150 ng/mL, CM group) or incentives for submitting a urine sample regardless of abstinence (Non-contingent [NC] Control group). Generalized linear mixed effects models assessed group differences in cannabis abstinence during the intervention, verified by urine tetrahydrocannabinol negative tests (11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid <50 ng/mL).

RESULTS

At baseline, 42.2% (n = 35) of participants in the NC group and 40.0% (n = 30) of those in the CM group had a cannabis positive urine test. An overall intervention by time interaction was detected for a cannabis negative urine test (χ2 = 13.40, p = 0.001). Compared to the NC group, the CM group had 3.92 (95% CI:1.23-12.46) times higher odds of having a cannabis negative urine test during the intervention period and 5.13 (95% CI:1.57-16.76) times higher odds of having a negative cannabis test at the end of intervention period.

CONCLUSION

CM addressing alcohol misuse may be an effective strategy for decreasing cannabis use among AI/AN adults.

TRIAL REGISTRATION

ClinicalTrials.gov number, Identifier: NCT02174315.

Trends in comorbid opioid and stimulant use disorders among Veterans receiving care from the Veterans Health Administration, 2005-2019

BACKGROUND

Identifying solutions to the continued rise in overdose deaths is a public health priority. However, there is evidence of change in recent substance type associated with morbidity and mortality. To better understand the continued rise in overdose deaths, in particular those attributed to opioid and stimulant use disorders, increased knowledge of patterns of use is needed.

METHODS

Retrospective cohort study of Veterans diagnosed with an opioid or stimulant use disorder between 2005 and 2019. The outcome of interest was diagnosis of substance use disorders, specifically examining combinations of opioid and stimulant use disorders among this population.

RESULTS

A total of 1932,188 Veterans were diagnosed with at least one substance use disorder (SUD) during the study period, 2005 through 2019. While the annual prevalence of opioid use disorder (OUD) diagnoses increased more than 155%, OUD diagnoses absent of any other SUD diagnosis increased by an average of 6.9% (95% CI, 6.4, 7.5) per year between 2005 and 2019. Between 2011 and 2019, diagnoses of co-morbid methamphetamine use disorder (MUD) and OUD increased at a higher rate than other SUD combinations.

CONCLUSIONS

The prevalence of comorbid SUD, in particular co-occurring opioid and methamphetamine use disorder, increased at a higher rate than other combinations between 2005 and 2019. These findings underscore the urgent need to offer patients a combination of evidence-based treatments for each co-morbid SUD, such MOUD and contingency management for persons with comorbid opioid and methamphetamine use disorders.

New Directions for Motivational Incentive Interventions for Smoking Cessation

Background

Motivational incentive interventions are highly effective for smoking cessation. Yet, these interventions are not widely available to people who want to quit smoking, in part, due to barriers such as administrative burden, concern about the use of extrinsic reinforcement (i.e., incentives) to improve cessation outcomes, suboptimal intervention engagement, individual burden, and up-front costs.

Purpose

Technological advancements can mitigate some of these barriers. For example, mobile abstinence monitoring and digital, automated incentive delivery have the potential to lower the clinic burden associated with monitoring abstinence and administering incentives while also reducing the frequency of clinic visits. However, to fully realize the potential of digital technologies to deliver motivational incentives it is critical to develop strategies to mitigate longstanding concerns that reliance on extrinsic monetary reinforcement may hamper internal motivation for cessation, improve individual engagement with the intervention, and address scalability limitations due to the up-front cost of monetary incentives. Herein, we describe the state of digitally-delivered motivational incentives. We then build on existing principles for creating just-in-time adaptive interventions to highlight new directions in leveraging digital technology to improve the effectiveness and scalability of motivational incentive interventions.

Conclusions

Technological advancement in abstinence monitoring coupled with digital delivery of reinforcers has made the use of motivational incentives for smoking cessation increasingly feasible. We propose future directions for a new era of motivational incentive interventions that leverage technology to integrate monetary and non-monetary incentives in a way that addresses the changing needs of individuals as they unfold in real-time.

Dissemination of Contingency Management for the Treatment of Opioid Use Disorder

Contingency management is an intervention for substance use disorders based on operant principles. The evidence base in support of contingency management is massive. It is effective in treating substance use disorder in general and opioid use disorder in particular. Dissemination has remained slow despite the urgency created by the opioid epidemic. Key barriers include a lack of expertise, time, and money. Implementing contingency management with smartphones eliminates the need for special training. It also solves logistical issues and requires little time on the part of clinicians. Thus, remaining barriers relate to cost. Federal anti-kickback regulations complicate solutions to the cost barrier. Other important regulatory challenges related to cost include the lack of billing codes and the difficulty of obtaining FDA approval for digital therapeutics. Even after the cost barrier is overcome, provider adoption is not guaranteed. Incentivizing providers for collaborative care may increase adoption and generate referrals. Recently proposed legislation and governmental policy statements provide optimism regarding the near-term large-scale adoption of contingency management in the treatment of opioid use disorder.

Impact of the bonus approach on recertification strategies for LEED-EB v3 office projects in major US metropolitan areas: A case study

Leadership in Energy and Environmental Design for Existing Buildings (LEED-EB) version 3 (v3) encourages the recertification of existing buildings by offering them four bonus points (“bonus approach”). This study investigates the influence of a bonus approach on recertification strategies. We analyzed 112 LEED-EB v3 certification-to-recertification office space projects in Washington, DC; Chicago; and New York City. The percentage of average score (PAS) was used to evaluate the difference in certification strategies between (1) gold certification and recertification (with bonus); (2) silver certification and gold recertification (with bonus); (3) gold certification and recertification (without bonus); and (4) silver and gold certification, and gold recertification (combined data from Cases 1–3). In Case 1, recertification showed worse results in the materials and resources (MR), and indoor environmental quality (EQ) categories. In Case 2, recertification showed better results in the water efficiency, and energy and atmosphere categories. In Case 3, certification and recertification showed the same results. We found that recertification of LEED-EB v3 projects with a four-point bonus system resulted in lower results in the MR and EQ categories. This highlights the need to include additional controls in the LEED-EB v3 and v4.1 bonus systems, possibly including a moderate penalty for diminishing achievements in certain categories.

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We examined the impact of four bonus points on LEED-EB v3 recertification.

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112 LEED-EB v3 offices in Washington, DC; Chicago; and New York City were analyzed.

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Gold certification-to-recertification led to decreased MR and EQ credits.

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We offer a moderate penalty as a form of control over the re-certified categories.

Contingency Management for Patients Receiving Medication for Opioid Use Disorder: A Systematic Review and Meta-analysis

Importance

Medication treatment for opioid use disorder (MOUD) is efficacious, but comorbid stimulant use and other behavioral health problems often undermine efficacy.

Objective

To examine the association of contingency management, a behavioral intervention wherein patients receive material incentives contingent on objectively verified behavior change, with end-of-treatment outcomes for these comorbid behavioral problems.

Data Sources

A systematic search of PubMed, Cochrane CENTRAL, Web of Science, and reference sections of articles from inception through May 5, 2020. The following search terms were used: vouchers OR contingency management OR financial incentives.

Study Selection

Prospective experimental studies of monetary-based contingency management among participants receiving MOUD.

Data Extraction and Synthesis

Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline, 3 independent investigators extracted data from included studies for a random-effects meta-analysis.

Main Outcomes and Measures

Primary outcome was the association of contingency management at end-of-treatment assessments with 6 clinical problems: stimulant use, polysubstance use, illicit opioid use, cigarette smoking, therapy attendance, and medication adherence. Random-effects meta-analysis models were used to compute weighted mean effect size estimates (Cohen d) and corresponding 95% CIs separately for each clinical problem and collapsing across the 3 categories assessing abstinence and the 2 assessing treatment adherence outcomes.

Results

The search identified 1443 reports of which 74 reports involving 10 444 unique adult participants met inclusion criteria for narrative review and 60 for inclusion in meta-analyses. Contingency management was associated with end-of-treatment outcomes for all 6 problems examined separately, with mean effect sizes for 4 of 6 in the medium-large range (stimulants, Cohen d = 0.70 [95% CI, 0.49-0.92]; cigarette use, Cohen d = 0.78 [95% CI, 0.43-1.14]; illicit opioid use, Cohen d = 0.58 [95% CI, 0.30-0.86]; medication adherence, Cohen d = 0.75 [95% CI, 0.30-1.21]), and 2 in the small-medium range (polysubstance use, Cohen d = 0.46 [95% CI, 0.30-0.62]; therapy attendance, d = 0.43 [95% CI, 0.22-0.65]). Collapsing across abstinence and adherence categories, contingency management was associated with medium effect sizes for abstinence (Cohen d = 0.58; 95% CI, 0.47-0.69) and treatment adherence (Cohen d = 0.62; 95% CI, 0.40-0.84) compared with controls.

Conclusions and Relevance

These results provide evidence supporting the use of contingency management in addressing key clinical problems among patients receiving MOUD, including the ongoing epidemic of comorbid psychomotor stimulant misuse. Policies facilitating integration of contingency management into community MOUD services are sorely needed.

Barriers and Facilitators That Influence Providers' Ability to Educate, Monitor, and Treat Substance Use in First-Episode Psychosis Programs Using the Theoretical Domains Framework

In this qualitative study, we explore providers' experiences with addressing substance use among individuals with first-episode psychosis (FEP) enrolled in coordinated specialty care (CSC) programs. Three focus groups were conducted with 24 providers from CSC programs for FEP in Washington. Questions were focused on barriers and facilitators to addressing substance use using the Theoretical Domains Framework (TDF) as a guide. Thematic analysis was used to code all transcripts. Identified TDF domains were then mapped onto the COM-B (Capability, Opportunity, Motivation, Behavior) intervention functions and behavior change techniques. Seven theoretical domains were identified as the most relevant to addressing substance use: "Knowledge," "Skills," "Environmental Context and Resources," "Social Influences," "Social and Professional Role and Identity," "Beliefs about Capabilities," and "Reinforcement." The use of the TDF provides a framework to explore barriers and facilitators for targeting substance use and suggestions for behavior change techniques when considering implementation of evidence-based strategies to enhance CSC models.

One-Year Efficacy and Incremental Cost-effectiveness of Contingency Management for Cigarette Smokers With Depression

INTRODUCTION

Contingency management (CM) is efficacious for smoking cessation. To date, the number of cost-effectiveness evaluations of behavioral and pharmacological smoking cessation treatments far outnumbers the ones on CM. This study estimated 1-year efficacy and incremental cost-effectiveness of adding CM in relation to abstinence outcomes for a cognitive-behavioral therapy (CBT)+behavioral activation (BA) treatment.

METHODS

The study sample comprised 120 smokers with depression (% females: 70.8%; mean age: 51.67 [SD = 9.59]) enrolled in an 8-week randomized controlled clinical trial. Clinical effectiveness variables were point-prevalence abstinence, continuous abstinence, longest duration of abstinence (LDA), and Beck-Depression Inventory-II (BDI-II) scores at 1-year follow-up. Cost-effectiveness analyses were based on resource utilization, unit costs per patient, and incremental cost per additional LDA week at 1 year.

RESULTS

There was a significant effect of time by treatment group interaction, which indicated superior effects of CBT+BA+CM across time. Point-prevalence abstinence (53.3% [32/60]) was superior in participants receiving CBT+BA+CM compared with those in CBT+BA (23.3% [14/60]), but both groups were equally likely to present sustained reductions in depression. The average cost per patient was €208.85 (US$236.57) for CBT+BA and €410.64 (US$465.14) for CBT+BA+CM, p < .001. The incremental cost of using CM to enhance 1-year abstinence by one extra LDA week was €18 (US$20.39) (95% confidence interval: 17.75-18.25).

CONCLUSIONS

Behavioral treatments addressing both smoking and depression are efficacious for sustaining high quit rates at 1 year. Adding CM to CBT+BA for smoking cessation is highly cost-effective, with an estimated net benefit of €4704 (US$5344.80).

IMPLICATIONS

Informing on the cost-effectiveness of CM might expedite the translation of research findings into clinical practice. Findings suggested that CM is feasible and highly cost-effective, confirming that its implementation is worthwhile. At a CM cost per patient of €410.64 (US$465.14), the net benefit equals €4704 (US$5344.80), although even starting from a minimum investment of €20 (US$22.72) was cost-effective.

CLINICALTRIALS-GOV IDENTIFIER

NCT03163056.

Juvenile probation officers' perceptions on youth substance use varies from task-shifting to family-based contingency management

The majority of justice-involved youth have problems with substance use, but juvenile justice agencies face numerous barriers to providing evidence-based treatments for these youth. Task-shifting is one strategy for increasing access to such treatments. That is, training juvenile probation officers (JPOs) to deliver substance use treatments, such as contingency management (CM) could improve youths' motivation and behavioral outcomes. However, probation traditionally emphasizes sanctions over incentives, so JPOs must alter their perspectives to accept protocols such as CM for substance use. Using mixed focus group and survey methods at baseline and one year later, this randomized study examined heretofore unstudied JPO perceptions during a task-shifting experiment in which JPOs were asked to start delivering CM for youth substance use, compared to a control group of JPOs who did not change their practices. At baseline, JPOs expressed a perception of hopelessness about their work with substance-using youth and their parents, but they generally held positive views toward use of tangible incentives. One year after randomization to participate in CM training and delivery, JPO perceptions changed positively about working with youth and their parents, substance use programs and resources, and whether they believed tangible incentive programs were worthwhile. Over the same time, there was a perceptual stasis in hopelessness for JPOs randomized to deliver probation services as usual, and there was degradation in their previously positive perception toward tangible incentives. The study advances thinking regarding tools that JPOs can use for working with youth and families and the role that task-shifting can play in both increasing access to evidence-based treatments and improving attitudinal outcomes of JPOs.

Initial testing of a computer-based simulation training module to support clinicians' acquisition of CBT skills for substance use disorder treatment

Cognitive behavioral therapy (CBT) is one of the most common and effective treatments for substance use disorders (SUD); however, effective delivery of CBT depends on a wide variety of nuanced skills that require practice to master. We created a computer-based simulation training system to support the development of necessary skills for student trainees to be able to apply CBT effectively for clients with SUDs. CBT: Introducing Cognitive Behavioral Therapy is an interactive, role-play simulation that provides opportunities for clinician trainees to hone their skills through repeated practice and real-time feedback before application in a clinical setting. This is the first study that tests whether such a simulation improves trainee skills for the treatment of clients with SUDs. Graduate students (N = 65; social work, clinical psychology) completed standardized patient (SP) interviews, were randomized to the simulation training program or manual comparison condition (Project MATCH manual), and completed SP interviews three months post-baseline. Using general linear models, results indicated a significant time x group effect, with students assigned to the simulation training program showing greater improvement in "extensiveness" and "skillfulness" ratings across three skill categories: general agenda setting (p = .03), explaining CBT concepts (p = .007), and understanding of CBT concepts (p = .001). However, manual comparison participants showed greater improvement than simulation trainees in "assessing primary drug use" (p_range = .013-.024). No changes in extensiveness or skillfulness of motivational interviewing (MI) style were observed. This pilot test of CBT: Introducing Cognitive Behavioral Therapy offers support for use of this novel technology as a potential approach to scale up CBT training for students, and perhaps clinicians, counseling people with SUDs.