The urgent need for contingency management among Tribal communities in the United States: Considerations for implementation, policy, and sovereignty

In two randomized controlled trials, culturally adapted contingency management (i.e., incentives provided for substance-negative urine samples) was associated with reduced alcohol and drug use among geographically diverse American Indian and Alaska Native (AI/AN) adults. In response to interest in contingency management from other Tribal and AI/AN communities, our research team in collaboration with AI/AN behavioral health experts, translated the research into practice with new AI/AN community partners. Tenets of community-based participatory research were applied to develop, pilot, and refine contingency management training and implementation tools, and identify implementation challenges. In partnership with the AI/AN communities, four members of the university team developed tools and identified implementation and policy strategies to increase the successful uptake of contingency management in each location. Through our collaborative work, we identified policy barriers including inadequate federal funding of contingency management incentives and a need for further clarity regarding federal anti-kickback regulations. Adoption of contingency management is feasible and can strengthen Tribal communities' capacity to deliver evidence-based substance use disorder treatments to AI/AN people. Unfortunately, non-evidence-based limits to the use of federal funding for contingency management incentives discriminate against AI/AN communities. We recommend specific federal policy reforms, as well as other practical solutions for Tribal communities interested in contingency management.

Recovery incentives program: California's contingency management benefit

OBJECTIVE

The role of methamphetamine and cocaine use in California's drug poisoning (overdose) crisis has dramatically increased in the past five (5) years and has disproportionately affected American Indian, Alaska Native, and Black Californians. No FDA-approved medications currently exist for the treatment of individuals with stimulant use disorder (StimUD). Outside the Veteran's Administration, the Recovery Incentives Program: California's Contingency Management Benefit is the first large scale implementation of contingency management (CM). CM is the behavioral treatment with the most evidence and largest effect sizes for StimUD.

METHODS

The Program uses a CM protocol where participants can receive a maximum of $599 over a six-month period, contingent upon 36 stimulant-negative urine test results. Urine tests are conducted using a set of approved, CLIA-waived, point-of-care urine drug tests (UDTs). To ensure fidelity to the CM protocol and to prevent fraud, waste, and abuse, all aspects of incentive accounting and distribution are managed electronically via a custom-developed software system. Incentive distribution utilizes electronic gift cards. A significant innovation of the project is the conceptualization of the CM Coordinator, a designated and highly trained and supervised individual responsible for all aspects of CM operation in a specific site.

RESULTS AND CONCLUSIONS

The California Department of Health Care Services contracted with UCLA to develop and implement a robust evaluation of the Program; goals include evaluating the effectiveness of real-world implementation and facilitating quality improvement. The project will likely significantly impact the use of CM for StimUD nationally and may well reduce stimulant-related drug poisoning deaths.

Contingency Management for Stimulant Use Disorder: Progress, Challenges, and Recommendations

The United States is currently in the fourth wave of the overdose crisis wherein stimulants together with fentanyl are the major drivers of overdose deaths. To date, there has been limited effort outside the US Veterans Administration Health System health system to disseminate evidence-based treatment for people with stimulant use disorder. Contingency management, a behavioral intervention in which positive reinforcement is provided for a target behavior indicating treatment progress, has decades of empirical support but limited implementation in real-world, non-US Veterans Administration Health System settings. The purpose of the report is to provide an overview of contingency management, the barriers to adoption, and recommendations for overcoming these barriers.

Providing behavioral workforce development technical assistance during COVID-19: adjustments and needs

COVID-19 social distancing policies have triggered a historic shift in the delivery of behavioral health prevention and treatment services. Among the first responders to this monumental workforce development challenge were the Substance Abuse and Mental Health Services Administration-funded Technology Transfer Centers (TTCs), which are charged with building the behavioral health workforce's capacity to provide evidence-based prevention, treatment, and recovery services. TTCs documented unprecedented attendance at their events in the early months of the pandemic. This study applied content analysis to identify the most common COVID-related technical assistance (TA) topics and examine attendance by topic from March to July 2020. Across 393 events, TA topics explicitly related to COVID-19 encompassed eight emergent themes: (a) delivering services via telehealth, (b) providing support and services to behavioral health consumers, (c) promoting workforce self-care, (d) understanding new laws/policies, (e) delivering evidence-based practices, (f) advancing racial equity, (g) offering networking spaces, and (h) altering organizational management and communication infrastructure. The most heavily attended events focused on the TA themes "Advancing Racial Equity" (average = 352) and "Telehealth Service Delivery" (average = 271). There was a documented shift from more intensive TA to briefer, more targeted TA provision. The TTCs rapidly virtualized training and TA offerings to address workforce needs and serve as a model for providing remote workforce development support during the COVID-19 pandemic and future national crises.

Implementation of the hub and spoke model for opioid use disorders in California: Rationale, design and anticipated impact

As part of the State Targeted Response to the opioid epidemic, California has adopted the Hub and Spoke model to expand access to medications for opioid use disorder, particularly buprenorphine, throughout the state. By aligning opioid treatment programs as hubs with primary care, office-based practitioners, and other health care settings as spokes, a broader treatment model can reach more people with opioid use disorder, improve access to medications for opioid use disorders, and decrease overdose deaths. Expanding access requires expanding knowledge and intensive implementation support of new practices. This paper describes the rationale, specific activities and anticipated impact of the implementation plan in California's Hub and Spoke system. Training and technical assistance are designed to: increase the number and capacity of waivered prescribers; enhance skills of prescribers and multidisciplinary teams; and create systems change. Activities include buprenorphine waiver trainings and provider support, a practice facilitator program, Project ECHO sessions, webinars, clinical skills trainings, and regional learning collaboratives. This overview highlights the steps California is taking to build treatment capacity to address the opioid epidemic.

Using ECHO Clinics to Promote Capacity Building in Clinical Supervision

INTRODUCTION

Project Extension for Community Healthcare Outcomes (ECHO™) is a hub-and-spoke knowledge-sharing network, led by expert teams who use multipoint videoconferencing to conduct virtual clinics with community providers in order to improve the quality of care. For this project, members of the Addiction Technology Transfer Center network applied this model in order to enhance workforce capacity to deliver clinical supervision for the treatment of substance use disorders.

METHODS

Clinical supervisors (n=66) employed in substance use disorder treatment programs were recruited to participate in this pilot study. The virtual ECHO clinic consisted of 12 total sessions, each lasting 1 hour and comprising a 15-minute mini-lecture on a clinical supervision topic and a 45-minute case presentation and review. All data were collected and analyzed between September 2016 and June 2017.

RESULTS

Forty-eight staff attended at least one ECHO session (mean=6.38) and results are presented for 20 staff who completed the follow-up survey. Participants were highly satisfied with the overall intervention, organization of the clinic and the facilitation of Hub experts, relevance of the technical assistance to their work, and with the impact of the intervention on their effectiveness as a supervisor. Results also indicate that there were significant self-reported improvements in clinical supervision self-efficacy following participation in the ECHO clinic.

CONCLUSIONS

Results from this pilot study suggest that ECHO virtual clinics are feasible to implement for the purpose of workforce development, are well liked by participants, and can enhance clinical supervision self-efficacy among participants. Further research should explore the impact of self-efficacy on the effective implementation of clinical supervision practices.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

Real-World Strategies to Engage and Retain Racial-Ethnic Minority Young Men Who Have Sex with Men in HIV Prevention Services

Racial/ethnic minority young men who have sex with men (YMSM)-particularly African Americans and Hispanics/Latinos-are at particularly high risk for HIV infection. Devising strategies to improve engagement and retention in HIV prevention services among minority YMSM is critical if the United States is going to achieve the National HIV/AIDS Strategy goal of reducing HIV health-related disparities. This article presents findings from a national summit on racial/ethnic YMSM services convened by the Substance Abuse and Mental Health Services Administration-funded Center of Excellence on Racial and Ethnic Minority Young Men Who Have Sex with Men and Other Lesbian, Gay, Bisexual, and Transgender Populations (YMSM + LGBT CoE) in September 2015. The summit included (1) subgroup discussions focused on issues related to treatment access, outreach/engagement/retention, continuing care/recovery support, and health literacy for minority YMSM; and (2) a ranking process, where the NIATx Nominal Group Technique was used to identify the strategies and approaches that summit participants believed to be most promising for engaging and retaining minority YMSM in HIV prevention services. Analyses of results from summit activities highlight four key cross-cutting strategies-utilizing peers, providing holistic care, making services fun, and utilizing technology-as critical for engaging minority YMSM in HIV prevention care. Examples of programs that utilize these strategies and implications of these findings for policy and practice are discussed.

Making Collaboration Work: Key Components of Practice/Research Partnerships

Drawing on our experiences as researchers and community-based providers, this paper outlines several key components of successful practice/research collaboration: forming equal partnerships, bilateral communication, ensuring nonhierarchical collaborations, and appropriate dissemination of outcomes. Many concrete benefits can result from collaborative research projects, including additional services, program development, and training for service agency staff. Building partnerships takes time and a good amount of planning and negotiation prior to writing proposals. However, these collaborations can result in more effective efforts to solve common problems and reach common goals.

Editors' introduction: Identifying and assessing promising practices for criminal justice clients--California Substance Abuse Research Consortium (SARC) meetings, 2010

Although some practices clearly have stronger supporting evidence than others, a single authoritative list of evidence-based practices (EBPs) that can be applied in the treatment of criminal justice clients does not exist. Nationally, use of EBPs is low, and such practices are generally only implemented under certain circumstances. To clarify these issues, experts from around the nation were invited to California for two research-to-policy meetings focused on EBP identification and implementation. Their presentations and the resulting series of articles in this special theme issue describe the current state of EBP research for criminal justice clients. To advance the field beyond the compilation of EBP lists, which can only represent a partial solution at best, next steps should include a greater focus on quality of implementation, intensity of quality assurance and monitoring, and training for underlying skills and principles.

Partnerships and pathways of dissemination: the National Institute on Drug Abuse-Substance Abuse and Mental Health Services Administration Blending Initiative in the Clinical Trials Network

Since 2001, the National Drug Abuse Treatment Clinical Trials Network (CTN) has worked to put the results of its trials into the hands of community treatment programs, in large part through its participation in the National Institute on Drug Abuse-Substance Abuse and Mental Health Services Administration Blending Initiative and its close involvement with the Center for Substance Abuse Treatment's Addiction Technology Transfer Centers. This article describes (a) the CTN's integral role in the Blending Initiative, (b) key partnerships and dissemination pathways through which the results of CTN trials are developed into blending products and then transferred to community treatment programs, and (c) three blending initiatives involving buprenorphine, motivational incentives, and motivational interviewing. The Blending Initiative has resulted in high utilization of its products, preparation of more than 200 regional trainers, widespread training of service providers in most U.S. States, Puerto Rico, and the U.S. Virgin Islands and movement toward the development of Web-based implementation supports and technical assistance. Implications for future directions of the Blending Initiative and opportunities for research are discussed.

Improving client engagement and retention in treatment: the Los Angeles County experience

This article discusses a two-phase demonstration project focused on the implementation of the Network for the Improvement of Addiction Treatment model of process improvement among substance abuse treatment providers in Los Angeles County, California. A total of 30 Change Teams from 12 county-contracted treatment agencies planned and executed one or more rapid-cycle change projects to reduce wait time to treatment, reduce no-shows to scheduled appointments, increase admissions, or improve continuation in treatment. The findings and lessons learned illustrate the importance of a concrete and straightforward methodology and consistent peer-to-peer interaction provided in a learning collaborative environment. In addition, both ongoing technical assistance and coaching are essential for successful implementation of this innovative, low-cost, evidence-based process improvement strategy.

How Long Does Craving Predict Use of Methamphetamine? Assessment of Use One to Seven Weeks after the Assessment of Craving

Aims

This study lays the foundation for a clinical prediction model based on methamphetamine craving intensity and its ability to predict the presence or absence of within-treatment methamphetamine use.

Design

We used a random effects logistic approach for estimating repeated-measures, generalized linear mixed models (GLMM) using craving as the sole predictor of methamphetamine. A multivariate GLMM included craving, length of treatment, treatment assignment, and methamphetamine use the previous week as covariates to control for potential confounds. We performed receiver operating characteristic (ROC) analyses to evaluate predictive accuracy. We investigated further whether methamphetamine craving predicted subsequent use more accurately at intervals more proximal to versus those more distal to assessment, examining one-week periods ending one to seven weeks after assessment of craving.

Setting

The study was part of the Center for Substance Abuse Treatment (CSAT) Methamphetamine Treatment Project (MTP).

Subjects

Analyses were based on data from 691 methamphetamine dependent outpatients enrolled in the MTP.

Measurements

Craving was assessed by self-report on a 0–100 scale. Self-reported methamphetamine use was toxicologically verified. Craving and drug use were assessed weekly for 8 weeks.

Findings

In the univariate analysis craving predicted methamphetamine use in the week immediately following the craving report (p < 0.0001), with subject-specific use increasing 0.38% for each one-point increase in craving on a 0–100 scale. In the multivariate analysis the probability of use decreased by 2.45% for each week in treatment increased by 33.11% for previous methamphetamine use, and the probability of methamphetamine use still increased with craving, rising 0.28% for each one-point increase in craving score (all p < 0.0001). Predictive accuracy was strongest at the one-week time-lag and declined in magnitude the more distal the assessment period.

Conclusions

Craving is a predictor of within-treatment methamphetamine use. Intensity of craving is appropriate for use as a surrogate marker in methamphetamine dependence.

Behavioral treatment approaches for methamphetamine dependence and HIV-related sexual risk behaviors among urban gay and bisexual men

BACKGROUND

Methamphetamine-dependent gay and bisexual men (GBM) are at high risk for HIV transmission, largely due to drug-associated sexual risk behaviors. This project evaluated the efficacy of four behavioral drug abuse treatments for reducing methamphetamine use and sexual risk behaviors among this population.

METHODS

In this randomized controlled trial, 162 methamphetamine-dependent (SCID-verified) GBM in Los Angeles County were randomly assigned to one of four treatment conditions for 16 weeks: standard cognitive behavioral therapy (CBT, n=40), contingency management (CM, n=42), combined cognitive behavioral therapy and contingency management (CBT+CM, n=40), and a culturally tailored cognitive behavioral therapy (GCBT, n=40). Stimulant use was assessed thrice-weekly during treatment using urine drug screens (48 measures). Sexual risk behaviors were monitored monthly (four measures). Follow-up assessments were conducted at 6 (80.0%) and 12 months (79.9%).

RESULTS

Statistically significant differences in retention (F(3,158)=3.78, p<.02), in longest period of consecutive urine samples negative for methamphetamine metabolites (F(3,158)=11.80, p<.001), and in the Treatment Effectiveness Score were observed by condition during treatment (F(3,158)=7.35, p<.001) with post hoc analyses showing the CM and CBT+CM conditions to perform better than standard CBT. GEE modeling results showed GCBT significantly reduced unprotected receptive anal intercourse (URAI) during the first 4 weeks of treatment (X2=6.75, p<.01). During treatment between-group differences disappeared at follow-up with overall reductions in outcomes sustained to 1-year.

CONCLUSIONS

Among high-risk methamphetamine-dependent GBM, drug abuse treatments produced significant reductions in methamphetamine use and sexual risk behaviors. Drug abuse treatments merit consideration as a primary HIV prevention strategy for this population.

Bringing buprenorphine-naloxone detoxification to community treatment providers: the NIDA Clinical Trials Network field experience

In October 2002, the U.S. Food and Drug Administration approved buprenorphine-naloxone (Suboxone) sublingual tablets as an opioid dependence treatment available for use outside traditionally licensed opioid treatment programs. The NIDA Center for Clinical Trials Network (CTN) sponsored two clinical trials assessing buprenorphine-naloxone for short-term opioid detoxification. These trials provided an unprecedented field test of its use in twelve diverse community-based treatment programs. Opioid-dependent men and women were randomized to a thirteen-day buprenorphine-naloxone taper regimen for short-term opioid detoxification. The 234 buprenorphine-naloxone patients averaged 37 years old and used mostly intravenous heroin. Direct and rapid induction onto buprenorphine-naloxone was safe and well tolerated. Most patients (83%) received 8 mg buprenorphine-2 mg naloxone on the first day and 90% successfully completed induction and reached a target dose of 16 mg buprenorphine-4 mg naloxone in three days. Medication compliance and treatment engagement was high. An average of 81% of available doses was ingested, and 68% of patients completed the detoxification. Most (80.3%) patients received some ancillary medications with an average of 2.3 withdrawal symptoms treated. The safety profile of buprenorphine-naloxone was excellent. Of eighteen serious adverse events reported, only one was possibly related to buprenorphine-naloxone. All providers successfully integrated buprenorphine-naloxone into their existing treatment milieus. Overall, data from the CTN field experience suggest that buprenorphine-naloxone is practical and safe for use in diverse community treatment settings, including those with minimal experience providing opioid-based pharmacotherapy and/or medical detoxification for opioid dependence.

The effects and consequences of selected club drugs

Ecstasy (MDMA), gamma-hydroxybutyrate (GHB), ketamine, and methamphetamine are 4 examples of club drugs that are increasing in popularity. Although the pharmacological classifications of these drugs vary, MDMA has structural similarities to both amphetamine and the hallucinogen mescaline. Ketamine and GHB are anesthetic agents and methamphetamine is a long-acting psychostimulant. Medical visits for club drug-related toxicity have sharply increased across the country. This article provides a brief review of the literature on club drugs.

Patient characteristics, HIV serostatus, and risk behaviors among gay and bisexual males seeking treatment for methamphetamine abuse and dependence in Los Angeles

Methamphetamine, a drug used at alarming rates among gay/bisexual males in the West, is often combined with sexual activities, thereby increasing HIV-related risks in an already high-risk group. Findings from 68 gay/bisexual men seeking treatment for methamphetamine dependence in Hollywood, California were analyzed to predict HIV serostatus based on demographic, drug use, or sexual behavior variables. Results showed that more HIV-infected participants than non-infected men reported medical problems (97.6% versus 46.2%; X2 = 24.7, df = 1, p < .0001), histories of genital gonorrhea (59.5% versus 26.9%; X2 = 6.9, df = 1, p < .01), use of injection methods (45.2% versus 19.2%; X2 = 4.8, df = 1, p < .03), and more sexual partners with unprotected receptive anal intercourse in the 30 days prior to intake (5.9 versus 0.7; separate t = 3.5, df = 43.7, p < .001). More non-infected participants (19.2%) reported suicidal thoughts than HIV-infected men (0%; X2 = 4.8, df = 1, p < .03). Discriminant function analysis correctly classified 74.6% of cases into serostatus groupings based on presence of suicidal thoughts, history of gonorrhea, number of sexual partners with unprotected receptive anal intercourse and prior methamphetamine treatment. Findings provide information that may prove helpful in tailoring culturally relevant treatment and prevention messages.

Methamphetamine abuse: issues for special populations

Methamphetamine (MA) abuse has been a problem in the western United States for decades. However, recently the incidence of MA abuse has risen to epidemic levels in some regions and among particular subgroups of the population. Recognizing the need to develop effective treatments for MA dependence, the Center for Substance Abuse Treatment (CSAT) established a multisite Methamphetamine Treatment Program (MTP) that compares the Matrix Model treatment program for MA to the treatments as usual at seven community-based clinics in California, Montana and Hawaii. Examination of the clients receiving services though this project provides an opportunity to explore particular issues of diverse special populations who are impacted by the problem of MA dependence. These groups include rural Americans, Native Americans, Hawaiians, gay and bisexual males and drug court participants. Specifically, this article examines cultural, geographic and situational barriers to accessing and completing treatment and presents strategies that have been used to overcome these barriers.

Sexual risk behavior and condom use among street youth in Hollywood

A study of 610 street youth aged 13-23 who attended drop-in centers in Hollywood, Calif., reveals that 96% are sexually experienced. One-half of the young men and one-third of the young women have engaged in sex for food, money, shelter, drugs or other items needed. Twenty-five percent of the men and 15% of the women have injected drugs at some time in their life. Some 45% of the men and 30% of the women used condoms at last intercourse. A logistic regression analysis found that among men, those who have completed 10th grade or higher are nearly three times as likely to use condoms as are those who have less education. Young men who have been tested for the human immunodeficiency virus are nearly twice as likely to use condoms as are those who have not been tested. Among women, condom use declines with age, and young women who have engaged in sex for food, money or lodging are more likely to use condoms than those who have not.

Ontogeny of selective attention effects on event-related potentials in attention-deficit hyperactivity disorder and normal boys

A longitudinal study of young attention-deficit hyperactivity disorder (ADHD) boys has found clear evidence for developmental abnormalities in event-related potential (ERP) waves that reflect cognitive processes associated with selective attentional tasks. Boys alternated attention to auditory or visual modalities in a train of stimuli, in an attempt to detect target stimuli in the attended modality. Results suggest that ADHD boys' attentional difficulties are due to insufficient facilitation of responses to the attended stimuli and not to an inability to block ignored stimuli. Abnormalities in ERPs reflecting cognitive processes associated with both interchannel selection mechanisms (processing negativity) and intrachannel selection mechanisms (P3b) were found. The degree of abnormality in the P3b responses to target stimuli in ADHD boys (lower than normal boys) was found to increase with age. It is suggested that the abnormally low P36 response to attended target stimuli found in ADHD boys may be due in part to insufficient LC noradrenergic activity normally triggered by attended task-relevant or novel stimuli.