Prize-based contingency management for the treatment of substance abusers: a meta-analysis

Contingency Management for Treatment of Cannabis Use Disorder in Co-Occurring Mental Health Disorders: A Systematic Review

Amongst individuals with a mental health disorder, a comorbid diagnosis of cannabis use disorder (CUD) is associated with numerous adverse consequences, including more severe symptom profiles, poorer treatment response, and reduced psychosocial functioning. Contingency management (CM), a method to specifically reinforce target behavior attainment (e.g., substance use abstinence), may provide an effective intervention in treating cannabis use in patients with a dual diagnosis of CUD and a mental health disorder. A systematic search examining the effects of CM on cannabis use, clinical, cognitive, and psychosocial outcomes in patients with a mental health disorder on PubMed, PsycINFO, and EMBASE databases up to November 2022 was performed. Six studies met inclusion criteria for our review. We found CM to be efficacious in producing cannabis use reductions and abstinence amongst individuals with a psychotic-spectrum or major depressive disorder. Additional longitudinal studies with larger sample sizes, other psychiatric populations, and longer follow-up periods are needed to evaluate the sustained effects of CM.

Hazardous drinking and alcohol use disorders

Alcohol is one of the most widely consumed psychoactive drugs globally. Hazardous drinking, defined by quantity and frequency of consumption, is associated with acute and chronic morbidity. Alcohol use disorders (AUDs) are psychiatric syndromes characterized by impaired control over drinking and other symptoms. Contemporary aetiological perspectives on AUDs apply a biopsychosocial framework that emphasizes the interplay of genetics, neurobiology, psychology, and an individual's social and societal context. There is strong evidence that AUDs are genetically influenced, but with a complex polygenic architecture. Likewise, there is robust evidence for environmental influences, such as adverse childhood exposures and maladaptive developmental trajectories. Well-established biological and psychological determinants of AUDs include neuroadaptive changes following persistent use, differences in brain structure and function, and motivational determinants including overvaluation of alcohol reinforcement, acute effects of environmental triggers and stress, elevations in multiple facets of impulsivity, and lack of alternative reinforcers. Social factors include bidirectional roles of social networks and sociocultural influences, such as public health control strategies and social determinants of health. An array of evidence-based approaches for reducing alcohol harms are available, including screening, pharmacotherapies, psychological interventions and policy strategies, but are substantially underused. Priorities for the field include translating advances in basic biobehavioural research into novel clinical applications and, in turn, promoting widespread implementation of evidence-based clinical approaches in practice and health-care systems.

Behavioral Interventions Contributing to Reducing Poverty and Inequities

Behavioral science has a long history of engaging in efforts to understand and address socially important issues. Poverty and inequities in health and development are among the most important and complex social issues facing the world today. With its Sustainable Development Goals (SDGs), the United Nations (2015) has focused attention and guidance on addressing key global challenges, including to "end poverty" (SDG 1), "ensure good health and well-being for all" (SDG3), and "reduce inequality within and among countries" (SDG 10). In this paper, we provide a framework and illustrative examples of contributions of behavioral science to these issues. We feature illustrative behavioral interventions at the individual, relationship, community, and societal levels. We highlight the diversity of issues, intervention methods, and settings reflected in applications of behavioral science. By joining methods from behavioral science, public health, and other disciplines-and the experiential knowledge of those most affected by inequities-behavioral methods can make significant contributions to collaborative efforts to assure health and well-being for all.

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.

Nondrug reinforcers contingent on alternative behavior or abstinence increase resistance to extinction and reinstatement of ethanol-maintained behavior

The effects of delivering nondrug alternative reinforcement on resistance to extinction and reinstatement of rats' ethanol-maintained lever pressing were evaluated in two experiments. In both, rats self-administered ethanol by lever pressing in a two-component multiple schedule during baseline. In the Rich component, alternative food reinforcement was made available for performing an alternative response (Experiment 1) or according to a differential-reinforcement-of-other-behavior schedule for lever pressing (Experiment 2). In the Lean component, only ethanol was available. Moreover, the frequency of alternative reinforcement was manipulated across conditions in Experiment 1. Following baseline, lever pressing was extinguished in both components by suspending ethanol reinforcement, and alternative food reinforcers were discontinued. Finally, to test for reinstatement, ethanol reinforcers were delivered independently of lever pressing in both components. In both experiments, proportion-of-baseline response rates were higher during extinction and reinstatement testing in the Rich component than in the Lean component (although differentiation was not observed at the lowest frequency of alternative reinforcement in Experiment 1). Thus, alternative nondrug reinforcers increased resistance to extinction and reinstatement of rats' ethanol-maintained lever pressing, even when those reinforcers were delivered contingently on an alternative response or on abstinence from lever pressing.

Virtual Training Is More Cost-Effective Than In-Person Training for Preparing Staff to Implement Contingency Management

Behavior therapy implementation relies in part on training to foster counselor skills in preparation for delivery with fidelity. Amidst Covid-19, the professional education arena witnessed a rapid shift from in-person to virtual training, yet these modalities' relative utility and expense is unknown. In the context of a cluster-randomized hybrid type 3 trial of contingency management (CM) implementation in opioid treatment programs (OTPs), a multi-cohort design presented rare opportunity to compare cost-effectiveness of virtual vs. in-person training. An initial counselor cohort (n = 26) from eight OTPs attended in-person training, and a subsequent cohort (n = 31) from ten OTPs attended virtual training. Common training elements were the facilitator, learning objectives, and educational strategies/activities. All clinicians submitted a post-training role-play, independently scored with a validated fidelity instrument for which performances were compared against benchmarks representing initial readiness and advanced proficiency. To examine the utility and expense of in-person and virtual trainings, cohort-specific rates for benchmark attainment were computed, and per-clinician expenses were estimated. Adjusted between-cohort differences were estimated via ordinary least squares, and an incremental cost effectiveness ratio (ICER) was calculated. Readiness and proficiency benchmarks were attained at rates 12-14% higher among clinicians attending virtual training, for which aggregated costs indicated a $399 per-clinician savings relative to in-person training. Accordingly, the ICER identified virtual training as the dominant strategy, reflecting greater cost-effectiveness across willingness-to-pay values. Study findings document greater utility, lesser expense, and cost-effectiveness of virtual training, which may inform post-pandemic dissemination of CM and other therapies.

Oxytocin and orexin systems bidirectionally regulate the ability of opioid cues to bias reward seeking

As opioid-related fatalities continue to rise, the need for novel opioid use disorder (OUD) treatments could not be more urgent. Two separate hypothalamic neuropeptide systems have shown promise in preclinical OUD models. The oxytocin system, originating in the paraventricular nucleus (PVN), may protect against OUD severity. By contrast, the orexin system, originating in the lateral hypothalamus (LH), may exacerbate OUD severity. Thus, activating the oxytocin system or inhibiting the orexin system are potential therapeutic strategies. The specific role of these systems with regard to specific OUD outcomes, however, is not fully understood. Here, we probed the therapeutic efficacy of pharmacological interventions targeting the orexin or oxytocin system on two distinct metrics of OUD severity in rats-heroin choice (versus choice for natural reward, i.e., food) and cued reward seeking. Using a preclinical model that generates approximately equal choice between heroin and food reward, we examined the impact of exogenously administered oxytocin, an oxytocin receptor antagonist (L-368,899), and a dual orexin receptor antagonist (DORA-12) on opioid choice. Whereas these agents did not alter heroin choice when rewards (heroin and food) were available, oxytocin and DORA-12 each significantly reduced heroin seeking in the presence of competing reward cues when no rewards were available. In addition, the number of LH orexin neurons and PVN oxytocin neurons correlated with specific behavioral economic variables indicative of heroin versus food motivation. These data identify a novel bidirectional role of the oxytocin and orexin systems in the ability of opioid-related cues to bias reward seeking.

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.

Real-World Reductions in Healthcare Resource Utilization over 6 Months in Patients with Substance Use Disorders Treated with a Prescription Digital Therapeutic

BACKGROUND AND AIMS

Substance use disorders (SUDs) affect approximately 40.3 million people in the USA, yet only approximately 19% receive evidence-based treatment each year. reSET® is a prescription digital therapeutic (PDT) and the only FDA-authorized treatment for patients with cocaine, cannabis, and stimulant use disorders. This study evaluated real-world healthcare resource utilization (HCRU) and associated costs 6 months after initiation of reSET in patients with SUD.

METHODS

A retrospective analysis of HealthVerity PrivateSource20 data compared the 6-month incidence of all-cause hospital facility encounters and clinician services in patients treated with reSET (re-SET cohort) before (pre-index period) and after (post-index period) reSET initiation (index). Incidence was compared using incidence rate ratios (IRR). HCRU-related costs were also assessed.

RESULTS

The sample included 101 patients (median age 37 years, 50.5% female, 54.5% Medicaid-insured). A statistically significant decrease of 50% was observed in overall hospital encounters from pre-index to post-index (IRR 0.50; 95% CI 0.37-0.67; P < 0.001), which included inpatient stays (56% decrease; IRR 0.44; 95% CI 0.26-0.76; P = 0.003), partial hospitalizations (57% decrease; IRR 0.43; 95% CI 0.21-0.88; P = 0.021), and emergency department visits (45% decrease; IRR 0.55; 95% CI 0.38-0.80; P < 0.004). Additionally, some clinician services declined significantly including pathology and laboratory services: other (54% decrease; IRR 0.46; 95% CI 0.28-0.76; P = 0.003); pathology and laboratory services: drug assays prior to opioid medication prescription (37% decrease; IRR 0.63; 95% CI 0.41-0.96; P = 0.031); and alcohol and drug abuse: medication services (46% decrease; IRR 0.54; 95% CI 0.41-0.70; P < 0.001). Reductions in facility-encounters drove 6-month reSET per-patient cost reductions of $3591 post-index compared to pre-index.

CONCLUSIONS

Use of reSET by patients with SUD is associated with durable reductions in HCRU and lower healthcare costs over 6 months compared to the 6 months before PDT treatment, after adjusting for covariates, providing an economic benefit to the healthcare system.

Willingness of people who inject drugs to participate in a randomised controlled trial involving financial incentives to initiate hepatitis C treatment

BACKGROUND

Evidence regarding the acceptability of contingency management is limited. We investigated the willingness of people who inject drugs to participate in a randomised controlled trial (RCT) involving financial incentives to initiate HCV treatment.

METHODS

ETHOS Engage is an observational cohort study of people with a history of injecting drug use who either injected in the past six months or receive opioid agonist therapy (OAT) in Australia. We assessed willingness to participate in a RCT with financial incentives and factors associated with preference for entire incentive ($60) at first clinic visit versus delayed incentive with logistic regression.

RESULTS

93% (593/635) of eligible participants agreed to participate in an RCT with financial incentives of which 24% were Aboriginal or Torres Strait Islander, 84% had completed secondary school, and 59% injected drugs in the prior month. Willingness to participate in an RCT increased by amount offered: unspecified (72%), $20 (75%), $60 (80%), and $100 (85%). The preferred incentive distribution method over three clinical visits was entire incentive at first clinical visit (32%). Among those with a preferred distribution method (n = 369), factors associated with entire incentive at first clinic visit were being Aboriginal or Torres Strait Islander (aOR 1.75; 95% CI 1.05-2.94), completion of secondary school (aOR 0.46; 95% CI 0.26-0.83) and mainly injected heroin in month prior (aOR 1.82; 95% CI 1.03-3.20).

CONCLUSION

Most participants were willing to participate in an RCT involving financial incentives to initiate treatment but differed regarding distribution. Study findings inform implementation of incentives in clinical practice.

Do financial incentives increase mental health treatment engagement? A meta-analysis

OBJECTIVE

Engagement in mental health treatment is low, which can lead to poor outcomes. We evaluated the efficacy of offering patients financial incentives to increase their mental health treatment engagement, also referred to as contingency management.

METHOD

We meta-analyzed studies offering financial incentives for mental health treatment engagement, including increasing treatment attendance, medication adherence, and treatment goal completion. Analyses were run within a multilevel framework. All study designs were included, and sensitivity analyses were run including only randomized and high-quality studies.

RESULTS

About 80% of interventions incentivized treatment for substance use disorders. Financial incentives significantly increased treatment attendance (Hedges' g = 0.49, [0.33, 0.64], k = 30, I2 = 83.14), medication adherence (Hedges' g = 0.95, [0.47, 1.44], k = 6, I2 = 87.73), and treatment goal completion (Hedges' g = 0.61, [0.22, 0.99], k = 5, I2 = 60.55), including completing homework, signing treatment plans, and reducing problematic behavior.

CONCLUSIONS

Financial incentives increase treatment engagement with medium to large effect sizes. We provide strong evidence for their effectiveness in increasing substance use treatment engagement and preliminary evidence for their effectiveness in increasing treatment engagement for other mental health disorders. Future research should prioritize testing the efficacy of incentivizing treatment engagement for mental health disorders aside from substance use. Research must also identify ways to incentivize treatment engagement that improve functioning and long-term outcomes and address ethical and systemic barriers to implementing these interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

An adaptive design to screen, treat, and retain people with opioid use disorders who use methamphetamine in methadone clinics (STAR-OM): study protocol of a clinical trial

BACKGROUND

Methamphetamine use could jeopardize the current efforts to address opioid use disorder and HIV infection. Evidence-based behavioral interventions (EBI) are effective in reducing methamphetamine use. However, evidence on optimal combinations of EBI is limited. This protocol presents a type-1 effectiveness-implementation hybrid design to evaluate the effectiveness, cost-effectiveness of adaptive methamphetamine use interventions, and their implementation barriers in Vietnam.

METHOD

Design: Participants will be first randomized into two frontline interventions for 12 weeks. They will then be placed or randomized to three adaptive strategies for another 12 weeks. An economic evaluation and an ethnographic evaluation will be conducted alongside the interventions.

PARTICIPANTS

We will recruit 600 participants in 20 methadone clinics.

ELIGIBILITY CRITERIA

(1) age 16+; (2) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) scores ≥ 10 for methamphetamine use or confirmed methamphetamine use with urine drug screening; (3) willing to provide three pieces of contact information; and (4) having a cell phone.

OUTCOMES

Outcomes are measured at 13, 26, and 49 weeks and throughout the interventions. Primary outcomes include the (1) increase in HIV viral suppression, (2) reduction in HIV risk behaviors, and (3) reduction in methamphetamine use. COVID-19 response: We developed a response plan for interruptions caused by COVID-19 lockdowns to ensure data quality and intervention fidelity.

DISCUSSION

This study will provide important evidence for scale-up of EBIs for methamphetamine use among methadone patients in limited-resource settings. As the EBIs will be delivered by methadone providers, they can be readily implemented if the trial demonstrates effectiveness and cost-effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04706624. Registered on 13 January 2021. https://clinicaltrials.gov/ct2/show/NCT04706624.

Does Treatment Readiness Shape Service-Design Preferences of Gay, Bisexual, and Other Men Who Have Sex with Men Who Use Crystal Methamphetamine? A Cross Sectional Study

Crystal methamphetamine (CM) disproportionately impacts gay, bisexual, and other men who have sex with men (gbMSM). However, not all gbMSM are interested in changing their substance use. The present study aimed to examine whether participant-preferred service characteristics were associated with their readiness to change. We surveyed gbMSM who used CM in the past six months, aged 18 plus years, on dating platforms. Participants rated service-design characteristics from “very unimportant” to “very important”. Multivariable regression tested service preference ratings across levels of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES-8D). Among 291 participants, 38.7% reported their CM use was not problematic, 19.5% were not ready to take any action to reduce or stop using CM, and 41.7% were ready to take action. On average, participants rated inclusive, culturally-appropriate, out-patient counselling-based interventions as most important. Participants with greater readiness-to-change scores rated characteristics higher than gbMSM with lesser readiness. Contingency management and non-abstinence programming were identified as characteristics that might engage those with lesser readiness. Services should account for differences in readiness-to-change. Programs that provide incentives and employ harm reduction principles are needed for individuals who may not be seeking to reduce or change their CM use.

Abstinence-contingent wage supplements to promote drug abstinence and employment: Post-intervention outcomes

BACKGROUND

Substance use disorder, unemployment, and poverty are interrelated problems that have not been addressed adequately by existing interventions. This study evaluated post-intervention effects of abstinence-contingent wage supplements on drug abstinence and employment.

METHODS

Unemployed adults enrolled in opioid agonist treatment were randomly assigned to an abstinence-contingent wage supplement group (n = 44) or a usual care control group (n = 47). All participants could work with an employment specialist throughout a 12-month intervention period. Those in the abstinence-contingent wage supplement group earned stipends for working with the employment specialist and, after gaining employment, abstinence-contingent wage supplements for working in their community job but had to provide opiate- and cocaine-negative urine samples to maximize pay. To assess post-intervention effects of abstinence-contingent wage supplements and compare those effects to during-intervention effects, we analyzed urine samples and self-reports every 3 months during the 12-month intervention and the 12-month post-intervention period.

RESULTS

During the intervention, abstinence-contingent wage supplement participants provided significantly more opiate- and cocaine-negative urine samples than usual care control participants; abstinence-contingent wage supplement participants were also significantly more likely to become employed and live out of poverty than usual care participants during intervention. During the post-intervention period, the abstinence-contingent wage supplement and usual care control groups had similar rates of drug abstinence, similar levels of employment, and similar proportions living out of poverty.

CONCLUSIONS

Long-term delivery of abstinence-contingent wage supplements can promote drug abstinence and employment, but many patients relapse to drug use and cease employment when wage supplements are discontinued.

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.

Contingency management for treatment attendance: A meta-analysis

BACKGROUND

Treatment providers have applied contingency management (CM) treatment, an intervention that often rewards individuals for drug abstinence (i.e., ABS CM), to treatment engagement as well. However, we know little about the magnitude of treatment effects when providers target attendance behaviors (i.e., ATT CM).

METHODS

This study conducted a systematic search to identify studies that included ATT CM, either in isolation or in combination with ABS CM. The study used meta-analysis to estimate the effect size of ATT CM and ABS CM + ATT CM on treatment attendance and drug abstinence. We identified a total of 10 studies including 12 CM treatments (6 ATT CM and 6 ABS CM + ATT CM) with 1841 participants.

RESULTS

Results indicated a moderate effect (d = 0.47, 95% confidence interval (CI) [0.25, 0.69]) of ATT CM on attendance relative to non-reward active comparison conditions. Frequency of rewards was significantly associated with larger effect sizes. Results also indicated a small effect (d = 0.22, 95% CI [0.12, 0.33]) of ATT CM on abstinence outcomes relative to nonreward comparisons, p < 0.001. The study found no significant differences in attendance or abstinence between ATT CM and ABS CM + ATT CM (p's > 0.05).

CONCLUSION

Overall, the results supported ATT CM for increasing treatment engagement, with smaller effects on abstinence. Effects on abstinence were smaller than those observed in prior meta-analyses focused on ABS CM. No significant differences existed in attendance or abstinence outcomes between ATT CM and ABS + ATT CM. However, future studies are needed to experimentally compare ABS CM + ATT CM to ABS CM, and ATT CM to determine additive effects. Clinics implementing CM should consider the differential effects between ATT CM and ABS CM when selecting target behavior(s).

Patient Engagement With a Game-Based Digital Therapeutic for the Treatment of Opioid Use Disorder: Protocol for a Randomized Controlled Open-Label, Decentralized Trial

BACKGROUND

Prescription digital therapeutics are software-based disease treatments that are regulated by the US Food and Drug Administration; the reSET-O prescription digital therapeutic was authorized in 2018 and delivers behavioral treatment for individuals receiving buprenorphine for opioid use disorder. Although reSET-O improves outcomes for individuals with opioid use disorder, most of the therapeutic content is delivered as narrative text. PEAR-008 is an investigational device based on reSET-O that uses an interactive, game-based platform to deliver similar therapeutic content designed to enhance patient engagement, which may further improve treatment outcomes.

OBJECTIVE

We aim to investigate how participants interact with the prescription digital therapeutic's new content delivery format. Secondary objectives include evaluating treatment success, symptoms of co-occurring mental health disorders, recovery capital, and skill development.

METHODS

Due to the COVID-19 pandemic, this study was redesigned using a decentralized model because it was not possible to conduct medication initiation and study visits in person, as initially intended. A decentralized, randomized controlled trial design will be utilized to compare patient engagement with PEAR-008 and that with reSET-O using both subjective and objective assessments. The study population will consist of approximately 130 individuals with opioid use disorder (based on Diagnostic and Statistical Manual of Mental Disorders 5 criteria) who have recently started buprenorphine treatment for opioid use disorder. Participants will be virtually recruited and randomly assigned to receive either PEAR-008 or reSET-O. All study sessions will be virtual, and the duration of the study is 12 weeks. The primary outcome measure of engagement is operationalized as the number of active sessions per week with either PEAR-008 or reSET-O. (An active session is any session that contains some active participation in the app, such as navigating to a different screen, engaging with a learning module, or responding to a notification.) Subjective dimensions of engagement will be assessed with participant surveys. The hypothesis is that PEAR-008 will have significantly greater participant engagement than reSET-O.

RESULTS

As of February 2021, participant enrollment is ongoing.

CONCLUSIONS

This randomized controlled trial will investigate if changing the delivery format and enhancing the content of a prescription digital therapeutic for opioid use disorder will affect how participants use and interact with the prescription digital therapeutic. The study design may serve as a useful model for conducting decentralized studies in this patient population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04542642; https://clinicaltrials.gov/ct2/show/NCT04542642.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/32759.

Understanding Stimulant Use and Use Disorders in a New Era

Extending from the triple wave epidemic of opioid-related overdose deaths, a fourth wave of high mortality involving methamphetamine and cocaine use has been gathering force. This article provides a review of the published literature on stimulants including epidemiology, pharmacology, neurobiology, medical and psychiatric consequences, withdrawal management, and medical and behavioral treatments.

A SMARTTT approach to Treating Tobacco use disorder in persons with HIV (SMARTTT): Rationale and design for a hybrid type 1 effectiveness-implementation study

BACKGROUND

Tobacco use disorder is a leading threat to the health of persons with HIV (PWH) on antiretroviral treatment and identifying optimal treatment approaches to promote abstinence is critical. We describe the rationale, aims, and design for a new study, "A SMART Approach to Treating Tobacco Use Disorder in Persons with HIV (SMARTTT)," a sequential multiple assignment randomized trial.

METHODS

In HIV clinics within three health systems in the northeastern United States, PWH with tobacco use disorder are randomized to nicotine replacement therapy (NRT) with or without contingency management (NRT vs. NRT + CM). Participants with response (defined as exhaled carbon monoxide (eCO)-confirmed smoking abstinence at week 12), continue the same treatment for another 12 weeks. Participants with non-response, are re-randomized to either switch medications from NRT to varenicline or intensify treatment to a higher CM reward schedule. Interventions are delivered by clinical pharmacists embedded in HIV clinics. The primary outcome is eCO-confirmed smoking abstinence; secondary outcomes include CD4 cell count, HIV viral load suppression, and the Veterans Aging Cohort Study (VACS) Index 2.0 score (a validated measure of morbidity and mortality based on laboratory data). Consistent with a hybrid type 1 effectiveness-implementation design and grounded in implementation science frameworks, we will conduct an implementation-focused process evaluation in parallel. Study protocol adaptations related to the COVID-19 pandemic have been made.

CONCLUSIONS

SMARTTT is expected to generate novel findings regarding the impact, cost, and implementation of an adaptive clinical pharmacist-delivered intervention involving medications and CM to promote smoking abstinence among PWH. ClinicalTrials.govidentifier:NCT04490057.

Challenges to Conducting Contingency Management Treatment for Substance Use Disorders: Practice Recommendations for Clinicians

A growing empirical literature supports contingency management (CM) as an efficacious treatment for substance use disorders, especially when reinforcers are immediate, frequent, and of sufficient magnitude on escalating schedules. However, in real world-practice, CM is often conducted in ways that are inconsistent with research protocols. One reason for these inconsistencies may be due to pragmatic challenges inherent in conducting CM. In this article, we described an outpatient CM treatment program for drug use disorders and several specific challenges associated with adherence to CM parameters from research protocols. Finally, we propose possible solutions for these challenges and discuss implications for practice.

What are the ethical implications of using prize-based contingency management in substance use? A scoping review

BACKGROUND

The area of substance use is notable for its early uptake of incentives and wealth of research on the topic. This is particularly true for prize-based contingency management (PB-CM), a particular type of incentive that uses a fishbowl prize-draw design. Given that PB-CM interventions are gaining momentum to address the dual public health crises of opiate and stimulant use in North America and beyond, it is imperative that we better understand and critically analyze their implications.

PURPOSE

The purpose of this scoping review paper is to identify the characteristics of PB-CM interventions for people who use substances and explore ethical implications documented in the literature as well as emerging ethical implications that merit further consideration.

METHODS

The PRISMA-ScR checklist was used in conjunction with Arksey and O'Malley's methodological framework to guide this scoping review. We completed a two-pronged analysis of 52 research articles retrieved through a comprehensive search across three key scholarly databases. After extracting descriptive data from each article, we used 9 key domains to identify characteristics of the interventions followed by an analysis of ethical implications.

RESULTS

We analyzed the characteristics of PB-CM interventions which were predominantly quantitative studies aimed at studying the efficacy of PB-CM interventions. All of the interventions used a prize-draw format with a classic magnitude of 50%. Most of the interventions combined both negative and positive direction to reward processes, behaviors, and/or outcomes. One ethical implication was identified in the literature: the risk of gambling relapse. We also found three emerging ethical implications by further analyzing participant characteristics, intervention designs, and potential impact on the patient-provider relationship. These implications include the potential deceptive nature of PB-CM, the emphasis placed on the individual behaviors to the detriment of social and structural determinants of health, and failures to address vulnerability and power dynamics.

CONCLUSIONS

This scoping review offers important insights into the ethics on PB-CM and its implications for research ethics, clinical ethics, and public health ethics. Additionally, it raises important questions that can inform future research and dialogues to further tease out the ethical issues associated with PB-CM.

The profound heterogeneity of substance use disorders: Implications for treatment development

A single treatment approach will never be sufficient to address the diversity of individuals with substance use disorders (SUDs). SUDs have historically defied definition through simple characterizations or models, and no single characterization has led to the development of broadly effective interventions. The range of dimensions of heterogeneity among individuals with SUDs, including severity, type of substance, and issues that frequently co-occur underscore that highly tailored approaches are needed. To approach personalized medicine for individuals with SUDs; two major developments are needed. First, given the diversity of individuals with SUDs, multivariate phenotyping approaches are needed to identify the particular features driving addictive processes in any individual. Second, a wider range of interventions that directly target core mechanisms of addiction and the problems that co-occur with them are needed. As clinicians cannot be expected to master the full range of interventions that may target these core processes, developing these so that they can be delivered easily, flexibly, and systematically via technology will facilitate our ability to truly tailor interventions to this highly complex and challenging population. One such technology-delivered intervention, computer-based training for cognitive behavioral therapy (CBT4CBT), is used as an example to illustrate a vision for the future of highly-tailored interventions for individuals with SUDs.

Remotely delivered incentives to promote buprenorphine treatment engagement in out-of-treatment adults with opioid use disorder

BACKGROUND

Opioid overdose remains a leading cause of death. Office-based buprenorphine could expand access to treatment to the many opioid users who are not in treatment and who are at risk for opioid overdose. However, many people in need of buprenorphine treatment do not enroll in treatment. This randomized pilot trial evaluated efficacy of a remotely delivered incentive intervention in promoting engagement in buprenorphine treatment in out-of-treatment adults with opioid use disorder.

METHODS

Participants (N = 41) were offered referrals to buprenorphine treatment and randomly assigned to Control or Incentive groups for 6 months. Incentive participants were offered incentives for enrolling in buprenorphine treatment, verified by providing documentation showing that they received a buprenorphine prescription, and providing videos taking daily buprenorphine doses. Participants used a smartphone application to record and submit a video of their buprenorphine prescription and daily buprenorphine administration. Incentive earnings were added remotely to reloadable credit cards.

RESULTS

Incentive participants were significantly more likely to enroll in treatment compared to control participants (71.4 % versus 30.0 % of participants; OR [95 % CI]: 6.24 [1.46-26.72], p = .014). Few participants in either group adhered to buprenorphine treatment, and the two groups continued to use opioids, including fentanyl at high and comparable rates. The two groups did not differ in the percentage of urine samples that were positive for buprenorphine, opiates, fentanyl, or methadone at monthly assessments conducted during the 6-month intervention.

CONCLUSIONS

Remotely delivered incentives can connect out-of-treatment adults with opioid use disorder to treatment, but additional supports are needed to promote buprenorphine adherence.

Voucher Reinforcement Decreases Psychiatric Symptoms in Young People in Treatment for Drug Use Disorders - A Post Hoc Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

This multicenter, parallel randomized, open study examined the effect of using vouchers and session reminders as an added element to outpatient treatment for drug use disorders in youth. It was hypothesized that being randomly assigned to a contingency management condition would lead to a reduction of psychiatric symptoms, and that this reduction would be mediated through abstinence and treatment completion.

METHODS

A total of 460 participants aged 15 to 25 years from nine outpatient sites were randomized to one of four treatment conditions (standard treatment alone [STD], i.e., 12 sessions using motivational interviewing and cognitive behavioral therapy, STD plus vouchers for attendance [VOU], STD plus text reminders [REM], or STD plus vouchers and text reminders [REM + VOU]). Participants' symptoms of psychological distress were assessed using the YouthMap 12 instrument at intake, and at 3, 6, and 9 months post-treatment initiation. Interviewers were blinded to interventions.

RESULTS

114 participants were randomized to STD, 112 to REM, 113 to VOU, and 121 to VOU + REM. 69 clients were never interviewed for follow-up, leaving 391 for analysis (n = 90, n = 94, n = 99, n = 108). The mean age was 20.5 years (SD = 2.6), 23% were female, and 34% reported having a psychiatric diagnosis. Random effects regression showed that participants randomized to one of the two voucher-based conditions experienced significantly steeper declines in symptoms compared with STD (p < .01). Structural equation modeling results indicated that the effects of contingency management on symptoms were mediated through abstinence, but not sessions attended.

CONCLUSIONS

Adding contingency management to interventions for drug use disorders can reduce symptoms of psychological and emotional distress among populations of treatment-seeking youth, in part due to indirect effects through abstinence at follow-up. The data is collected from a clinical trial registered as ISRCTN27473213, at https://www.isrctn.com/.

Digital delivery of a contingency management intervention for substance use disorder: A feasibility study with DynamiCare Health

Digital health tools can provide convenient delivery of evidence-based treatments. The DynamiCare Health smartphone app delivers a contingency management intervention for substance use disorder consisting of remote self-testing for alcohol (breath) and drugs (saliva) with remote test validation and delivery of financial incentives for negative test results. This study examined feasibility, engagement (duration and consistency of app utilization), and impact on usual care treatment participation when a community substance use treatment program implemented this digital therapy among its patients. The study randomly assigned patients with alcohol use disorder (N = 61) to receive either DynamiCare along with treatment-as-usual (TAU; N = 29) or TAU only (N = 32) during a 90-day evaluation period. Mean duration between first and last app use was 64 (±35) days, with mean earnings of $248 (±$209, out of $600 maximum). Among those with any app use (n = 25), compliance was 68% and 74%, respectively for requested breath and saliva samples. Overall, two thirds of patients (66%) assigned to the app used it for at least 57 days and with high rates of self-testing compliance. Those completing the assessment (n = 13; 45% of sample) endorsed high satisfaction ratings. DynamiCare versus TAU participants were more likely to be retained in usual care treatment at 90 days (24% vs 3%; (χ2 (1, 61) = 5.9, p < 0.05), but sustained app utilization was associated with a wide range of usual care treatment participation. These data suggest that DynamiCare Health is feasible and potentially beneficial as a complement to community substance use treatment programs.

Electrophysiological predictors and indicators of contingency management treatment response: Rationale and design for the ways of rewarding abstinence project (WRAP)

Background

Electrophysiological measures can predict and reflect substance use treatment response. Veterans are disproportionately affected by disorders of addiction; cocaine use disorder (CUD) being particularly problematic due to high relapse rates and the absence of approved pharmacotherapies. Prize-based Contingency Management (PBCM) is an evidence-based behavioral intervention for CUD, involving incentives for cocaine abstinence but treatment response is variable. Measurement-based adaptation of PBCM has promise to improve effectiveness but remains to be usefully developed.

Methods

This trial aims to determine if individuals with distinct neurocognitive profiles differentially benefit from one of two existing versions of PBCM. CUD patients will be randomized into treatment-as-usual or 12-weeks of PBCM using either monetary or tangible prize incentives. Prior to randomization, EEG will be used to assess response to monetary versus tangible reward; EEG and cognitive-behavioral measures of working memory, cognitive control, and episodic future thinking will also be acquired. Substance use and treatment engagement will be monitored throughout the treatment interval and assessments will be repeated at post-treatment.

Discussion

Results of this trial may elucidate individual differences contributing to PBCM treatment response and reveal predictors of differential benefits from existing treatment variants. The design also affords the opportunity to evaluate treatment-related changes in neurocognitive functioning over the course of PBCM. Our model posits that PBCM scaffolds future-oriented goal representation and self-control to support abstinence. Individuals with poorer functioning may be less responsive to abstract monetary reward and will therefore achieve better outcomes with respect to abstinence and treatment engagement when tangible incentives are utilized.

Pilot Study of an Integrated Smartphone and Breathalyzer Contingency Management Intervention for Alcohol Use

INTRODUCTION

Monitoring devices provide a platform for assessing alcohol use and implementing alcohol interventions. This pilot study focused on assessing the early-stage feasibility and usability of a smartphone-based application and breathalyzer used in a contingency management intervention for alcohol use.

METHODS

Six nontreatment-seeking participants completed a 9-week ABA within-subjects designed intervention targeting alcohol use. Participants submitted 2 to 8 alcohol breathalyzer samples per day and completed self-report drinking measures and usability assessments. During the A phases (weeks 1-3 and 8-9), participants received reinforces for submitting breathalyzer samples, regardless of their results. During the contingency management, B phase (weeks 4-7), and received reinforcers only when negative breathalyzer samples were submitted. Usability assessment of the application was also conducted during weeks 2 and 9.

RESULTS

Participants in the contingent B phase (49%) were more likely to submit alcohol-negative breathalyzer samples compared with the noncontingent A phases (27%; P < 0.001). Usability assessment of the application varied, and participants noted several technical concerns.

CONCLUSION

The use of smartphones and breathalyzers may be a practical solution to extend the reach of contingency management during and after treatment.

Mixed-methods trial of a phosphatidylethanol-based contingency management intervention to initiate and maintain alcohol abstinence in formerly homeless adults with alcohol use disorders

BACKGROUND

Contingency management (CM) is an intervention where incentives are provided in exchange for biochemically confirmed alcohol abstinence. CM is effective at initiating alcohol abstinence, but it is less effective at maintaining long-term abstinence. Phosphatidylethanol (PEth), collected via a finger-stick, can detect alcohol use for 14-28 days. PEth allows for the development of a CM model that includes increasingly less frequent monitoring of abstinence to assist high risk groups, such as formerly homeless individuals, maintain long-term abstinence.

AIMS

Investigate whether PEth-based CM intervention targeting alcohol abstinence in formerly homeless, currently housed individuals with alcohol use disorders is: (1) acceptable and feasible for housing program tenants and personnel; and is associated with increased (2) alcohol abstinence and (3) housing tenure.

METHODS

Acceptability and feasibility will be assessed using a QUAL+quant mixed-methods design using qualitative interviews and quantitative measures of satisfaction and attrition. Effectiveness will be evaluated through a randomized pilot trial of 50 study participants who will receive 6 months of either treatment as usual (TAU) including incentives (e.g., gift cards) for providing blood samples (Control Condition) or TAU and incentives for negative PEth results (PEth-CM Condition). Outcomes will be assessed during the intervention and at a three-month follow-up visit. The trial will be conducted via telehealth as a result of COVID-19.

DISCUSSION

This protocol seeks to utilize a novel alcohol biomarker to evaluate the acceptability, feasibility, and initial effectiveness of a CM model that encourages long-term abstinence in a high-risk group.

Patients' beliefs towards contingency management: Target behaviours, incentives and the remote application of these interventions

INTRODUCTION

Contingency management interventions are among the most efficacious psychosocial interventions in promoting abstinence from smoking, alcohol and substance use. The aim of this study was to assess the beliefs and objections towards contingency management among patients in UK-based drug and alcohol services to help understand barriers to uptake and support the development and implementation of these interventions.

METHODS

The Service User Survey of Incentives was developed and implemented among patients (N = 181) at three UK-based drug and alcohol treatment services. Descriptive analyses were conducted to ascertain positive and negative beliefs about contingency management, acceptability of different target behaviours, incentives and delivery mechanisms including delivering incentives remotely using technology devices such as mobile telephones.

RESULTS

Overall, 81% of participants were in favour of incentive programs, with more than 70% of respondents agreeing with the majority of positive belief statements. With the exception of two survey items, less than a third of participants agreed with negative belief statements. The proportion of participants indicating a neutral response was higher for negative statements (27%) indicating greater levels of ambiguity towards objections and concerns regarding contingency management.

DISCUSSION AND CONCLUSIONS

Positive beliefs towards contingency management interventions were found, including high levels of acceptability towards a range of target behaviours, incentives and the use of technology devices to remotely monitor behaviour and deliver incentives. These findings have implications for the development and implementation of remote contingency management interventions within the UK drug treatment services.

Long-term efficacy of contingency management treatment based on objective indicators of abstinence from illicit substance use up to 1 year following treatment: A meta-analysis

OBJECTIVE

Contingency management (CM) is often criticized for limited long-term impact. This meta-analysis focused on objective indices of drug use (i.e., urine toxicology) to examine the effects of CM on illicit substance use up to 1 year following treatment.

METHOD

Analyses included randomized trials (k = 23) of CM for stimulant, opioid, or polysubstance use disorders that reported outcomes up to 1 year after the incentive delivery had ended. Using random effects models, odds ratios (OR) were calculated for the likelihood of abstinence. Metaregressions and subgroup analyses explored how parameters of CM treatment, namely escalation, frequency, immediacy, and magnitude of reinforcers, moderated outcomes.

RESULTS

The overall likelihood of abstinence at the long-term follow-up among participants who received CM versus a comparison treatment (nearly half of which were community-based comprehensive therapies or protocol-based specific therapies) was OR = 1.22, 95% confidence interval [1.01, 1.44], with low to moderate heterogeneity (I² = 36.68). Among 18 moderators, longer length of active treatment was found to significantly improve long-term abstinence.

CONCLUSIONS

CM showed long-term benefit in reducing objective indices of drug use, above and beyond other active, evidence-based treatments (e.g., cognitive-behavioral therapy, 12-step facilitation) and community-based intensive outpatient treatment. These data suggest that policymakers and insurers should support and cover costs for CM, which is the focus of hundreds of studies demonstrating its short-term efficacy and, now, additional data supporting its long-term efficacy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A pilot randomized controlled trial of assertive treatment including family involvement and home delivery of medication for young adults with opioid use disorder

BACKGROUND AND AIMS

Although medications for opioid use disorder (OUD), including extended-release naltrexone (XR-NTX), have demonstrated effectiveness, adherence is often low. We tested the preliminary efficacy of youth opioid recovery support (YORS), a multi-component intervention designed to improve engagement and medication adherence for young adults with OUD.

DESIGN

Single-site randomized controlled trial with 24-week follow-up.

SETTING

Community substance use disorder treatment program in Baltimore, MD, USA.

PARTICIPANTS

Young adults aged 18-26 years enrolled in inpatient/residential OUD treatment intending to pursue outpatient OUD treatment with XR-NTX. Twenty-one participants were randomized to YORS and 20 to treatment as usual (TAU). The analyzed sample was 65.8% male.

INTERVENTION AND COMPARATOR

Components of YORS include: (1) home delivery of XR-NTX; (2) family engagement; (3) assertive outreach; and (4) contingency management for receipt of XR-NTX doses. The comparator was TAU, which consisted of a standard referral to outpatient care following an inpatient stay.

MEASUREMENTS

Primary outcomes were number of XR-NTX doses received over 24 weeks and relapse to opioid use (defined as ≥ 10 days of use within 28 days) at 24 weeks.

FINDINGS

Participants in the YORS condition received more XR-NTX doses [mean = 4.28; standard deviation (SD) = 2.3] compared with those in TAU (mean = 0.70; SD = 1.2), P < 0.01. Participants in the YORS group compared with TAU had lower rates of relapse (61 versus 95%; P < 0.01). Survival analyses revealed group differences on time to relapse with participants in TAU being more likely to relapse sooner compared with participants in the YORS condition [hazard ratio (HR) = 2.72, 95% confidence interval (CI) = 1.26-5.88, P < 0.01].

CONCLUSIONS

The youth opioid recovery support intervention for extended-release naltrexone adherence and opioid relapse prevention among young adults with opioid use disorder appeared to improve treatment and relapse outcomes compared with standard treatment.

Meta-Analysis on the Effect of Contingency Management for Patients with Both Psychotic Disorders and Substance Use Disorders

Background: Substance use disorders (SUD) are highly prevalent among psychotic patients and are associated with poorer clinical and functional outcomes. Effective interventions for this clinical population are scarce and challenging. Contingency management (CM) is one of the most evidence-based treatments for SUD’s, however, a meta-analysis of the effect of CM in patients with a dual diagnosis of psychotic disorder and SUD has not been performed. Methods: We searched PubMed and PsycINFO databases up to December 2020. Results: Five controlled trials involving 892 patients were included. CM is effective on abstinence rates, measured by the number of self-reported days of using after intervention (95% CI −0.98 to −0.06) and by the number of negative breath or urine samples after intervention (OR 2.13; 95% CI 0.97 to 4.69) and follow-up (OR 1.47; 95% CI 1.04 to 2.08). Conclusions: Our meta-analysis shows a potential effect of CM on abstinence for patients with SUD and (severe) psychotic disorders, although the number of studies is limited. Additional longitudinal studies are needed to confirm the sustained effectivity of CM and give support for a larger clinical implementation of CM within services targeting these vulnerable co-morbid patients.

Setting a goal could help you control: Comparing the effect of health goal versus general episodic future thinking on health behaviors among cigarette smokers and obese individuals

Episodic Future Thinking (EFT) reduces delay discounting (DD; preference for smaller, immediate rewards) and various maladaptive behaviors. Exploring potential personalization of EFT to optimize its ability to alter DD and demand for unhealthy reinforcers is important for the development of interventions targeting long-term improvement and maintenance of health. In this investigation, using 2 separate studies, we examined the effects of EFT with and without a health goal on rates of discounting, demand, and craving for cigarettes and fast food among cigarette smokers and obese individuals, respectively. Using data collected from Amazon Mechanical Turk (mTurk), Study 1 (N = 189) examined the effect of EFT on DD and measures of cigarette demand and craving in cigarette smokers who were randomly assigned to 1 of 3 conditions: EFT-health goal, EFT-general, or Episodic Recent Thinking (ERT)-general. Study 2 (N = 255), using a 2x2 factorial design, examined the effects of health goals and general EFT on DD and measures of fast food demand and craving in obese individuals who were randomly assigned to 1 of 4 conditions: EFT-health goal, EFT-general, ERT-health goal or ERT-general. Health goal EFT was not more effective than general EFT in reducing monetary discounting. However, the addition of a health goal to general EFT was significantly associated with higher effect on intensity and elasticity of demand for cigarettes and fast food compared to EFT without a health goal. These findings suggest that the amplification of future thinking through the inclusion of a health goal may promote healthy decisions and result in positive behavior changes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Addressing unmet needs in opiate dependence: supporting detoxification and advances in relapse prevention

Despite record-breaking numbers of opiate related deaths in the UK in 2019, pharmacological management of opiate dependence has evolved little since the advent of methadone in 1965. Along with harm minimisation and psychosocial interventions, the mainstay of pharmacological treatment remains opioid substitution therapy (OST) using methadone or buprenorphine, with many patients receiving OST for many years. Even with these treatments, opiate users continue to face mortality risks 12 times higher than the general population, and emerging evidence suggests that individuals who remain on long-term OST present with a range of physical and cognitive impairments. Therefore, with a growing ageing opiate dependent population who would benefit from detoxification from OST, this article provides an overview of the current state of opiate dependence in clinical practice, explores the reasons why availability and acceptability of detoxification pathways are declining, and discusses emerging pharmacological therapies that could provide benefit in relapse prevention.

Alcohol Use Disorder in the Age of Technology: A Review of Wearable Biosensors in Alcohol Use Disorder Treatment

Biosensors enable observation and understanding of latent physiological occurrences otherwise unknown or invasively detected. Wearable biosensors monitoring physiological constructs across a wide variety of mental and physical health conditions have become an important trend in innovative research methodologies. Within substance use research, explorations of biosensor technology commonly focus on identifying physiological indicators of intoxication to increase understanding of addiction etiology and to inform treatment recommendations. In this review, we examine the state of research in this area as it pertains to treatment of alcohol use disorders specifically highlighting the gaps in our current knowledge with recommendations for future research. Annually, alcohol use disorders affect approximately 15 million individuals. A primary focus of existing wearable technology-based research among people with alcohol use disorders is identifying alcohol intoxication. A large benefit of wearable biosensors for this purpose is they provide continuous readings in a passive manner compared with the gold standard measure of blood alcohol content (BAC) traditionally measured intermittently by breathalyzer or blood draw. There are two primary means of measuring intoxication with biosensors: gait and sweat. Gait changes have been measured via smart sensors placed on the wrist, in the shoe, and mobile device sensors in smart phones. Sweat measured by transdermal biosensors detects the presence of alcohol in the blood stream correlating to BAC. Transdermal biosensors have been designed in tattoos/skin patches, shirts, and most commonly, devices worn on the ankle or wrist. Transdermal devices were initially developed to help monitor court-ordered sobriety among offenders with alcohol use disorder. These devices now prove most useful in continuously tracking consumption throughout clinical trials for behavioral treatment modalities. More recent research has started exploring the uses for physical activity trackers and physiological arousal sensors to guide behavioral interventions for relapse prevention. While research has begun to demonstrate wearable devices' utility in reducing alcohol consumption among individuals aiming to cutdown on their drinking, monitoring sustained abstinence in studies exploring contingency management for alcohol use disorders, and facilitating engagement in activity-based treatment interventions, their full potential to further aid in understanding of, and treatment for, alcohol use disorders has yet to be explored.

Contingency management for individuals with chronic health conditions: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Contingency management (CM) interventions involve providing reinforcement for engaging in a desired behavior, and have been shown to increase treatment adherence and promote abstinence in the treatment of substance use disorders. This review was conducted to systematically review the literature on the effectiveness of CM when applied to a range of medical conditions outside of substance use disorders.

METHOD

The authors identified a total of 24 randomized studies examining the effects of CM on four outcomes: weight change, physical activity, medication/device adherence, and viral load that were included in the qualitative summary, and 20 studies included in the meta-analysis.

RESULTS

CM was associated with positive outcomes for physical activity and medication/device adherence compared to control conditions. Findings with weight loss and viral load were more mixed, and evidence for publication bias was found for both outcomes. The effects of CM tend to dissipate when the contingency is removed. Heterogeneity was observed across most outcomes.

LIMITATIONS AND CONCLUSIONS

This review provides preliminary support for the use of CM in increasing physical activity and improving adherence to medication for chronic health conditions while reinforcement is ongoing. Future studies should examine potential moderators and identify strategies to maintain these changes over time.

The rewarding recovery study: a randomized controlled trial of incentives for alcohol and drug abstinence with a rural American Indian community

AIMS

To test if contingency management (CM) interventions for alcohol and drug abstinence were associated with increased alcohol and drug abstinence among American Indian adults with alcohol dependence who also use drugs.

DESIGN

In this 2 × 2 factorial randomized controlled trial, American Indian adults with alcohol dependence who also used drugs were randomized to four conditions: (1) incentives for submission of urine samples only (control condition), (2) CM incentives for alcohol abstinence, (3) CM incentives for drug abstinence or (4) CM incentives for abstinence from both alcohol and drugs.

SETTING

A Northern Plains Reservation in the United States.

PARTICIPANTS

A total of 114 American Indian adults aged 35.8 years (standard deviation = 10.4); 49.1% were male.

INTERVENTION AND COMPARATOR

Participants received incentives if they demonstrated abstinence from alcohol (CM for alcohol, n = 30), abstinence from their most frequently used drug (CM for drugs, n = 27) or abstinence from both alcohol and their most frequently used drug (CM for alcohol and drugs, n = 32) as assessed by urine tests. Controls (n = 25) received incentives for submitting urine samples only.

MEASUREMENTS

Primary outcomes were urine ethyl glucuronide (alcohol) and drug tests conducted three times per week during the 12-week intervention period. Data analyses included listwise deletion and multiple imputation to account for missing data.

FINDINGS

The three CM groups were significantly (P < 0.05) more likely to submit alcohol-abstinent urine samples compared with the control condition, with odds ratios ranging from 2.4 to 4.8. The CM for drugs (OR = 3.2) and CM for alcohol and drugs (OR = 2.5) were significantly more likely to submit urine samples that indicated drug abstinence, relative to the control condition (P < 0.05). However, these differences were not significant in multiple imputation analyses (P > 0.05).

CONCLUSIONS

Contingency management (CM) incentives for abstinence were associated with increased alcohol abstinence in American Indian adults diagnosed with alcohol dependence who also used drugs, living on a rural reservation. The effect of CM incentives on drug abstinence was inconclusive.

Working memory training improves emotion regulation in drug abstainers: Evidence from frontal alpha asymmetry

Drug addiction has been associated with unsuccessful emotion regulation, which can be improved by working memory training (WMT) in healthy populations. This study aimed to assess the effect of WMT on emotion regulation in drug abstainers. We divided 40 male drug abstainers into two groups: (i) the training group (n=20) participated in a running memory task for 20 days, and (ii) the control group (n=20) did not participate in any training task. We assessed the emotion regulation questionnaire (ERQ) and frontal electroencephalographic (EEG) activity while viewing pictures (including neutral, positive, negative and drug-related contents) for all participants before and after the training. After WMT for 20 days, the training group adopted more spontaneous emotion regulation strategies compared with control group. The asymmetry scores of training group improved while viewing negative and drug-related pictures compared to pretest, which suggests that they converted from right-brain asymmetry to left-brain asymmetry. However, the control group declined both in the ERQ scores and the asymmetry scores. These results suggest that WMT improves the emotion regulation of drug abstainers.

More behavioral recommendations produce more change: A meta-analysis of efficacy of multibehavior recommendations to reduce nonmedical substance use

Death and morbidity associated with substance use have risen continuously over the last few decades, increasing the need for rigorous examination of promising programs. Interventions attempting to change multiple behaviors have been designed to address interconnected problems such as use of both alcohol and drugs. This meta-analysis aimed to examine the efficacy of multibehavior interventions to curb nonmedical substance use in relation to the theoretical relation among different substance use behaviors. Specifically, our synthesis aimed to estimate the optimal number of recommendations for intervention efficacy and evaluate the impact of different combinations of recommendations on intervention efficacy. A synthesis of multibehavior interventions addressing nonmedical substance use was conducted to measure behavioral changes between the pretest and the follow-up. These changes were then compared across different numbers of recommendations. Sixty-nine reports and 233 effect sizes (k of conditions = 155, n = 28,295) were included. A positive linear relation was found between the number of targeted behaviors and intervention efficacy, which was stronger for drug use than alcohol use. Furthermore, recommendations on drug use worked better when paired with recommendations targeting other behaviors, whereas recommendations on alcohol use worked more independently. Lastly, multibehavior interventions were especially efficacious when delivered by experts. Overall, our synthesis indicated that targeting multiple substances is beneficial for changing drug use outcomes, but less so for alcohol use outcomes. Therefore, in the current substance use epidemic, innovative multibehavior programs appear to hold promise, especially to combat nonmedical drug use. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A contingency management intervention to reduce cannabis use and time to relapse in early psychosis: the CIRCLE RCT

BACKGROUND

Cannabis is the most prevalent illicit substance among people with psychosis, and its use is associated with poorer clinical and social outcomes. However, so far, there has been limited evidence that any treatment is effective for reducing use. Contingency management (CM) is an incentive-based intervention for substance misuse that has a substantial evidence base across a range of substances and cohorts. However, to date there have been no randomised controlled trials (RCTs) of CM as a treatment for cannabis use specifically in psychosis.

OBJECTIVE

To conduct a RCT investigating the clinical effectiveness and cost-effectiveness of CM in reducing cannabis use among Early Intervention in Psychosis (EIP) service users.

DESIGN

The CIRCLE (Contingency Intervention for Reduction of Cannabis in Early Psychosis) trial was a rater-blinded, multicentre RCT with two arms. Participants were randomised 1 : 1 to either an CM arm, in which participants received CM for cannabis use alongside an optimised treatment-as-usual programme including structured psychoeducation, or a control arm in which participants received the treatment as usual only.

SETTING

EIP services across the Midlands and the south-east of England.

PARTICIPANTS

The main eligibility criteria were EIP service users with a history of psychosis, aged 18-36 years, and having used cannabis at least once per week during 12 of the previous 24 weeks.

INTERVENTION

The CM intervention offered financial incentives (i.e. shopping vouchers) for cannabis abstinence over 12 once-weekly sessions, confirmed using urinalysis. The maximum value in vouchers that participants could receive was £240.

MAIN OUTCOME MEASURES

The main outcome was time to relapse, operationalised as admission to an acute mental health service or hospital. The primary outcome was assessed at 18 months post inclusion using electronic patient records. Secondary outcomes assessed the clinical effectiveness and cost-effectiveness of the intervention, for which data were collected at 3 and 18 months.

RESULTS

A total of 278 participants were randomised to the CM arm and 273 were randomised to the control arm. In total, 530 (96%) participants were followed up for the primary outcome. There was no significant difference in time to admission between trial arms by 18 months following consent (hazard ratio 1.03, 95% confidence interval 0.76 to 1.40). There were no statistically significant differences in most secondary outcomes, including cannabis use, at either follow-up assessment. There were 58 serious adverse events, comprising 52 inpatient episodes, five deaths and one arrest.

LIMITATIONS

Participant retention was low at 18 months, limiting the assessment of secondary outcomes. A different CM intervention design or reward level may have been effective.

CONCLUSIONS

The CM intervention did not appear to be effective in reducing cannabis use and acute relapse among people with early psychosis and problematic cannabis use.

FUTURE WORK

Cannabis use is still a significant clinical concern in this population. A pressing need remains to identify suitable treatments. A wider perspective on the social circumstances of young people with psychosis may be needed for a successful intervention to be found.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN33576045.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 45. See the NIHR Journals Library website for further project information.

12- and 18-month follow-up after residential treatment of methamphetamine dependence: Influence of treatment drop-out and different treatment concepts

This study investigates the effects of two different residential treatments and of treatment drop-out in a German methamphetamine (MA) dependent sample. 108 subjects from two addiction treatment concepts were recruited at treatment begin and followed-up at 12 (T2) and 18 (T3) months after treatment. Based on follow-up samples (n = 38 at T2, n = 25 at T3), 77.1% at T2 and 68.0% at T3 were MA abstinent. Classifying everyone, who did not participate at follow-ups as having had a relapse, showed MA-abstinence rates of 25.0% (at T2) and 15.7% (at T3). There was no difference in MA-use between treatment conditions nor between treatment completers and drop-outs. Having injected any substance predicted MA-use at T2 (p = .03). The median time of relapse was 1.5 days after hospital release. Depression scores at T2 predicted MA-use at T3 (p = .02). T2 participants that dropped out of treatment had higher craving scores at T2, than T2 subjects who completed treatment (p = .03). The results show positive effects of current inpatient treatment programs without differences between different concepts. More research is needed to clarify the impact of treatment drop-out. Attention should be paid to a successful transition from residential to outpatient services and to a reduction of study attrition.

Treatment of stimulant use disorder: A systematic review of reviews

AIMS

Stimulant use disorder contributes to a substantial worldwide burden of disease, although evidence-based treatment options are limited. This systematic review of reviews aims to: (i) synthesize the available evidence on both psychosocial and pharmacological interventions for the treatment of stimulant use disorder; (ii) identify the most effective therapies to guide clinical practice, and (iii) highlight gaps for future study.

METHODS

A systematic database search was conducted to identify systematic reviews and meta-analyses. Eligible studies were those that followed standard systematic review methodology and assessed randomized controlled trials focused on the efficacy of interventions for stimulant use disorder. Articles were critically appraised using an assessment tool adapted from Palmeteer et al. and categorized for quality as 'core' or 'supplementary' reviews. Evidence from the included reviews were further synthesized according to pharmacological or non-pharmacological management themes.

RESULTS

Of 476 identified records, 29 systematic reviews examining eleven intervention modalities were included. The interventions identified include: contingency management, cognitive behavioural therapy, acupuncture, antidepressants, dopamine agonists, antipsychotics, anticonvulsants, disulfiram, opioid agonists, N-Acetylcysteine, and psychostimulants. There was sufficient evidence to support the efficacy of contingency management programs for treatment of stimulant use disorder. Psychostimulants, n-acetylcysteine, opioid agonist therapy, disulfiram and antidepressant pharmacological interventions were found to have insufficient evidence to support or discount their use. Results of this review do not support the use of all other treatment options.

CONCLUSIONS

The results of this review supports the use of contingency management interventions for the treatment of stimulant use disorder. Although evidence to date is insufficient to support the clinical use of psychostimulants, our results demonstrate potential for future research in this area. Given the urgent need for effective pharmacological treatments for stimulant use disorder, high-quality primary research focused on the role of psychostimulant medications for the treatment of stimulant use disorder is needed.

Perception of treatment need among adults with substance use disorders: Longitudinal data from a representative sample of adults in the United States

BACKGROUND

Most individuals with substance use disorders (SUDs) do not seek treatment. Lack of perceived treatment need (PTN) is one contributing factor, but little is known about PTN over time. We estimated whether PTN changed over three years among those with SUDs in the United States and identified select variables, including sociodemographics and symptom burden, that predict malleability vs. stability of PTN.

METHODS

Data were from Waves 1 (collected 2001-2002) and 2 (collected 2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC); 1695 adults who met DSM criteria for alcohol or non-alcohol SUD at Wave 1 and maintained ≥1 diagnostic symptom at Wave 2 were included.

RESULTS

Most individuals with SUDs (77.2%) did not perceive a need for treatment at Wave 1 baseline. Only about 1 in 8 individuals not perceiving a need for treatment in Wave 1 came to perceive a need in Wave 2 (adjusted odds ratio = 0.18, 99% confidence interval = 0.11-0.29). In contrast, about half the individuals who perceived a need for treatment in Wave 1 no longer did so in Wave 2, despite maintaining ≥1 SUD symptom. Married respondents, and respondents with more SUD symptoms, were more likely to transition from low- to high-PTN status three years later. Respondents with incomes >$35,000 were less likely to transition to high-PTN status three years later.

CONCLUSIONS

PTN was more likely to decline than increase over time. Low PTN appears to be stable among adults with SUDs in the United States, presenting a potentially enduring barrier to treatment-seeking.

COVID-19 and Substance Use Disorders: Recommendations to a Comprehensive Healthcare Response. An International Society of Addiction Medicine Practice and Policy Interest Group Position Paper

Coronavirus Disease 2019 (COVID-19) is escalating all over the world and has higher morbidities and mortalities in certain vulnerable populations. People Who Use Drugs (PWUD) are a marginalized and stigmatized group with weaker immunity responses, vulnerability to stress, poor health conditions, high-risk behaviors, and lower access to health care services. These conditions put them at a higher risk of COVID-19 infection and its complications. In this paper, an international group of experts on addiction medicine, infectious diseases, and disaster psychiatry explore the possible raised concerns in this issue and provide recommendations to manage the comorbidity of COVID-19 and Substance Use Disorder (SUD).

Canadian Guidelines on Opioid Use Disorder Among Older Adults

BACKGROUND

In Canada, rates of hospital admission from opioid overdose are higher for older adults (≥ 65) than younger adults, and opioid use disorder (OUD) is a growing concern. In response, Health Canada commissioned the Canadian Coalition of Seniors' Mental Health to create guidelines for the prevention, screening, assessment, and treatment of OUD in older adults.

METHODS

A systematic review of English language literature from 2008-2018 regarding OUD in adults was conducted. Previously published guidelines were evaluated using AGREE II, and key guidelines updated using ADAPTE method, by drawing on current literature. Recommendations were created and assessed using the GRADE method.

RESULTS

Thirty-two recommendations were created. Prevention recommendations: it is key to prioritize non-pharmacological and non-opioid strategies to treat acute and chronic noncancer pain. Assessment recommendations: a comprehensive assessment is important to help discern contributions of other medical conditions. Treatment recommendations: buprenorphine is first line for both withdrawal management and maintenance therapy, while methadone, slow-release oral morphine, or naltrexone can be used as alternatives under certain circumstances; non-pharmacological treatments should be offered as an integrated part of care.

CONCLUSION

These guidelines provide practical and timely clinical recommendations on the prevention, assessment, and treatment of OUD in older adults within the Canadian context.

Stimulant safe supply: a potential opportunity to respond to the overdose epidemic

Background

Occurring against the backdrop of an overdose crisis, stimulant use and stimulant-involved deaths in North America are increasing at an alarming rate. Many of these deaths are being attributed to fentanyl and related analogs, which have been increasingly found within street-level stimulant supplies. Within this, people experiencing socio-economic marginalization are at the greatest risk of overdose and other harms from adulterated stimulants. Current treatments for stimulant use disorder have limited effectiveness, and even less applicability to the lived realities of marginalized stimulant users. Emerging technologies, such as drug checking, are being implemented to support safer stimulant use, but the accessibility and utility of these technologies to stimulant users are framed by experiences of vulnerability that render them largely ineffective.

Stimulant safe supply

Solutions that provide a legal and safe supply of non-adulterated stimulants of known quality, and within a health care framework, are needed to directly address the risk of an increasingly adulterated stimulant supply. Similar innovative opioid-focused interventions are being piloted with medications that have a similar pharmacological effect as their illicit counterparts. While there are currently no approved pharmacotherapies for stimulant use, research has demonstrated a number of stimulant medications that are promising substitutes for cocaine and methamphetamine use. Much like with opioid-focused pharmacotherapies, having a consistent and safe supply of stimulants can lead to improved health outcomes and will drastically reduce overdose risk. However, for a stimulant safe supply intervention to be a success, it must provide the high and performance-enhancing effects that people seek from the illicit market, which requires doses and user agency that trials to date have not provided.

Conclusion

Efforts are needed to investigate the feasibility of pharmacological stimulant-based interventions that address safe supply needs. The promise of similar opioid-focused approaches in addressing both overdose-related risks and experiences related to vulnerability underscores the need to advance safe supply approaches targeted towards people who use stimulants. Given the current overdose crisis and rising stimulant use across North America, the implementation and evaluation of such novel stimulant-focused interventions should be a public health priority.

A Reinforcer Pathology perspective on relapse

The Reinforcer Pathology theory proposes conditions under which drugs emerge as excessively preferred reinforcers compared to other available reinforcers among drug users. The theory highlights 2 key variables as important determinants of drug preference: (a) excessive preference for immediate rewards (high discounting of future rewards); and (b) excessive valuation for addictive reinforcers (e.g., drugs). Two iterations of the Reinforcer Pathology theory exist with the latest iteration (i.e., Reinforcer Pathology 2.0) specifying that the temporal window of reinforcer integration (measured by delay discounting) is a determinant of reinforcer value. The 2 iterations of the Reinforcer Pathology theory are described. A novel insight and understanding of abstinence and relapse from a Reinforcer Pathology perspective, limitations, and future directions are discussed. The Reinforcer Pathology theory continues the long-standing efforts to scientifically understand and better define novel concepts and methods to further translational research and improve treatment outcomes. Exploring the complementary relation between the Reinforcer Pathology perspective and other current approaches could have a valuable effect.

Building a Group-Based Opioid Treatment (GBOT) blueprint: a qualitative study delineating GBOT implementation

BACKGROUND

Group-Based Opioid Treatment (GBOT) has recently emerged as a mechanism for treating patients with opioid use disorder (OUD) in the outpatient setting. However, the more practical "how to" components of successfully delivering GBOT has received little attention in the medical literature, potentially limiting its widespread implementation and utilization. Building on a previous case series, this paper delineates the key components to implementing GBOT by asking: (a) What are the core components to GBOT implementation, and how are they defined? (b) What are the malleable components to GBOT implementation, and what conceptual framework should providers use in determining how to apply these components for effective delivery in their unique clinical environment?

METHODS

To create a blueprint delineating GBOT implementation, we integrated findings from a previously conducted and separately published systematic review of existing GBOT studies, conducted additional literature review, reviewed best practice recommendations and policies related to GBOT and organizational frameworks for implementing health systems change. We triangulated this data with a qualitative thematic analysis from 5 individual interviews and 2 focus groups representing leaders from 5 different GBOT programs across our institution to identify the key components to GBOT implementation, distinguish "core" and "malleable" components, and provide a conceptual framework for considering various options for implementing the malleable components.

RESULTS

We identified 6 core components to GBOT implementation that optimize clinical outcomes, comply with mandatory policies and regulations, ensure patient and staff safety, and promote sustainability in delivery. These included consistent group expectations, team-based approach to care, safe and confidential space, billing compliance, regular monitoring, and regular patient participation. We identified 14 malleable components and developed a novel conceptual framework that providers can apply when deciding how to employ each malleable component that considers empirical, theoretical and practical dimensions.

CONCLUSION

While further research on the effectiveness of GBOT and its individual implementation components is needed, the blueprint outlined here provides an initial framework to help office-based opioid treatment sites implement a successful GBOT approach and hence potentially serve as future study sites to establish efficacy of the model. This blueprint can also be used to continuously monitor how components of GBOT influence treatment outcomes, providing an empirical framework for the ongoing process of refining implementation strategies.