1
|
Kock LS, Higgins ST, Heil SH. Commentary on Ussher et al.: Duration and magnitude of postpartum financial incentives for the maintenance of cigarette smoking abstinence. Addiction 2024; 119:1364-1365. [PMID: 38837806 DOI: 10.1111/add.16580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 05/17/2024] [Indexed: 06/07/2024]
Affiliation(s)
- Loren S Kock
- Vermont Center on Behavior and Health, University of Vermont, Burlington, Vermont, USA
- Department of Psychiatry, University of Vermont, Burlington, Vermont, USA
| | - Stephen T Higgins
- Vermont Center on Behavior and Health, University of Vermont, Burlington, Vermont, USA
- Department of Psychiatry, University of Vermont, Burlington, Vermont, USA
- Department of Psychological Science, University of Vermont, Burlington, Vermont, USA
| | - Sarah H Heil
- Vermont Center on Behavior and Health, University of Vermont, Burlington, Vermont, USA
- Department of Psychiatry, University of Vermont, Burlington, Vermont, USA
- Department of Psychological Science, University of Vermont, Burlington, Vermont, USA
| |
Collapse
|
2
|
Coughlin LN, Zhang L, Frost MC, Khazanov G, McKay JR, DePhilippis D, Lin LA. Contingency management for substance use disorders in the U.S. Veterans Health Administration: 2018-2022. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 163:209400. [PMID: 38735480 DOI: 10.1016/j.josat.2024.209400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/28/2024] [Accepted: 05/09/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION Contingency management (CM) is one of the most effective interventions for substance use disorders (SUDs), including stimulant use disorder. In the United States, the Veterans Health Administration (VHA) led the largest-scale rollout of CM in the US to date, but little is known about characteristics of patients treated and CM clinical practices. METHODS In this retrospective cohort study, we used VHA electronic health records data to descriptively examine CM treatment course (e.g., number of visits, time between visits, duration of treatment episode) and characteristics of patients receiving CM for SUDs from 2018 to 2022. RESULTS From January 2018 to September 2022, 2844 patients received CM at 90 VA Health Systems (including 98 VA Medical Center, 7 community-based outpatient clinics, and 15 other sites). The median number of CM visits was 8 (mean = 10.17, SD = 8.12) visits over the course of 1.5 months (median = 45 days, mean = 57.46 days, SD = 62.65). The target substance was stimulants in 86.42 % of visits. Average age of patients was 52.29 years (SD = 12.10), with 55.06 % of patients experiencing homelessness or housing instability, and 97.50 % of patients diagnosed with more than one SUD. Compared to the year prior to the COVID-19 pandemic (03/2019-02/2020; mean = 957.33, SD = 157.71 visits/month), CM visits declined by 83.20 % in the year following the pandemic (03/2020-02/2021; mean = 160.83, SD = 164.14), and have yet to return to pre-pandemic levels. CONCLUSIONS The CM rollout has been markedly successful in the VHA, with adoption across multiple VHA sites within a complex patient population, indicating the potential for effective, more widespread CM implementation. At the same time, there was a considerable reduction in CM care during the COVID-19 pandemic and CM has not yet returned to pre-pandemic levels. Moreover, only a small minority of VA patients with stimulant use disorder have received CM. Given increasing rates of overdose, including stimulant-involved overdose, it is important to increase CM provision in VHA and non-VHA settings.
Collapse
Affiliation(s)
- Lara N Coughlin
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States of America.
| | - Lan Zhang
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States of America
| | - Madeline C Frost
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, United States of America; Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America
| | - Gabriela Khazanov
- Center for Excellence in Substance Addiction Treatment and Education (CESATE), Corporal Michael J Crescenz VA Medical Center, United States of America; Department of Psychiatry, University of Pennsylvania, United States of America
| | - James R McKay
- Center for Excellence in Substance Addiction Treatment and Education (CESATE), Corporal Michael J Crescenz VA Medical Center, United States of America; Department of Psychiatry, University of Pennsylvania, United States of America
| | - Dominick DePhilippis
- Department of Psychiatry, University of Pennsylvania, United States of America; Office of Mental Health and Suicide Prevention, Veterans Affairs, United States of America
| | - Lewei Allison Lin
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States of America; VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America
| |
Collapse
|
3
|
Allami N, O'Connor K, Bagley SM. A case of severe opioid and methamphetamine use disorder in a 14 year old. Addict Sci Clin Pract 2024; 19:54. [PMID: 39030629 DOI: 10.1186/s13722-024-00487-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 07/08/2024] [Indexed: 07/21/2024] Open
Abstract
We present the case of a 14-year-old who established care at our primary care clinic after hospitalization for unintentional fentanyl overdose. They were diagnosed with severe opioid use disorder (OUD) and stimulant use disorder (StUD) and initiated buprenorphine while inpatient. They were then transitioned to the only known outpatient primary care clinic in her county who was actively providing medications for opioid use disorder (MOUD) in adolescents.At the first visit, they reported a history of 20 overdoses, struggling with adherence to buprenorphine and continued opioid cravings. An overdose safety plan was reviewed with them and their parent including providing them naloxone kits, fentanyl test strips, and education handout sheets. Due to their significant overdose history and adherence challenges with sublingual buprenorphine, they were started on long-acting injectable buprenorphine (LAIB) with weekly provider visits and urine toxicology screening. In collaboration with the treatment team, they initiated behavioral treatment with contingency management (CM), with incentives for appointment completion, expected urine results, and successful medication administration. Over the next 19 months, and to date, they have increasingly engaged with care and have remained abstinent. LAIB may be an appealing alternative for adolescents with OUD to improve adherence and reduce risk of recurrent use and overdose. Adjunctive treatment with CM may improve retention in MOUD and have the benefit of treating StUD. There is a need for further research to explore innovative, community-based treatment for youth with OUD.
Collapse
Affiliation(s)
- Nadia Allami
- Santa Cruz Community Health, 1510 Capitola Road, Santa Cruz, CA, 95062, USA.
| | - Kristen O'Connor
- Santa Cruz Community Health, 1510 Capitola Road, Santa Cruz, CA, 95062, USA
| | - Sarah M Bagley
- Chobanian & Avedisian School of Medicine and Boston Medical Center, 801 Mass Ave, Boston, MA, 02118, USA
| |
Collapse
|
4
|
Davidson RM, Brown HD, Regnier SD, DeFulio A. Incentivized collaborative care to disseminate and enhance contingency-management services. J Appl Behav Anal 2024. [PMID: 39004776 DOI: 10.1002/jaba.1099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 06/06/2024] [Indexed: 07/16/2024]
Abstract
Contingency management is especially effective in supporting medication adherence and drug abstinence among people with opioid use disorder. However, the incorporation of contingency management into clinical practice has been slow. The present study was designed to evaluate the feasibility, acceptability, and usability of incentives for providers as a means of accelerating collaborative care with contingency management. Thirteen buprenorphine prescribers served as participants in a nonexperimental study. The prescribers who referred patients to a contingency-management service received monetary incentives for reviewing patient performance data and describing their use of these data in treatment decisions. The results show that this approach is feasible, acceptable, and easy to use for everyone involved. Self-reports indicate improved prescriber-patient relationships and more informed care. However, prescriber-focused incentives did not appear to greatly enhance access to contingency-management services for patients. Thus, provider incentives may be beneficial but further research is needed to advance adoption of contingency management.
Collapse
Affiliation(s)
| | - Hayley D Brown
- Department of Psychology, Western Michigan University, Kalamazoo, MI, USA
| | - Sean D Regnier
- Department of Psychology, Western Michigan University, Kalamazoo, MI, USA
- Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Anthony DeFulio
- Department of Psychology, Western Michigan University, Kalamazoo, MI, USA
| |
Collapse
|
5
|
Acuff SF, Strickland JC, Smith K, Field M. Heterogeneity in choice models of addiction: the role of context. Psychopharmacology (Berl) 2024:10.1007/s00213-024-06646-1. [PMID: 38990313 DOI: 10.1007/s00213-024-06646-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 07/01/2024] [Indexed: 07/12/2024]
Abstract
RATIONALE Theories of addiction guide scientific progress, funding priorities, and policy development and ultimately shape how people experiencing or recovering from addiction are perceived and treated. Choice theories of addiction are heterogenous, and different models have divergent implications. This breeds confusion among laypeople, scientists, practitioners, and policymakers and reduces the utility of robust findings that have the potential to reduce the global burden of addiction-associated harms. OBJECTIVE Here we differentiate classes of choice models and articulate a novel framing for a class of addiction models, called contextual models, which share as a first principle the influence of the environment and other contextual factors on behavior within discrete choice contexts. RESULTS These models do not assume that all choice behaviors are voluntary, but instead that both proximal and distal characteristics of the choice environment-and particularly the benefits and costs of both drug use and non-drug alternatives-can influence behavior in ways that are outside of the awareness of the individual. From this perspective, addiction is neither the individual's moral failing nor an internal uncontrollable urge but rather is the result of environmental contingencies that reinforce the behavior. CONCLUSIONS Contextual models have implications for guiding research, practice, and policy, including identification of novel target mechanisms while also improving existing interventions.
Collapse
Affiliation(s)
- Samuel F Acuff
- Recovery Research Institute, Center for Addiction Medicine, Massachusetts General Hospital and Harvard Medical School, 151 Merrimac Street, Boston, MA, 02114, USA.
| | - Justin C Strickland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD, 21224, USA
| | - Kirsten Smith
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD, 21224, USA
| | - Matt Field
- Department of Psychology, University of Sheffield, Sheffield, S1 2LT, UK
| |
Collapse
|
6
|
Howell BA, Lin LA, Coughlin LN. Treatment for Co-Occurring Stimulant and Opioid Use Disorders: Overcoming Barriers in the Era of Polysubstance Use. JAMA Psychiatry 2024:2821074. [PMID: 38985457 DOI: 10.1001/jamapsychiatry.2024.1775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2024]
Abstract
This Viewpoint explores the current barriers to implementing contingency management treatment for individuals experiencing both opioid use and stimulant use disorders in the context of high numbers of US overdoses.
Collapse
Affiliation(s)
- Benjamin A Howell
- Yale Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Lewei Allison Lin
- Michigan Innovations in Addiction Care through Research and Education, Department of Psychiatry, University of Michigan, Ann Arbor
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Lara N Coughlin
- Michigan Innovations in Addiction Care through Research and Education, Department of Psychiatry, University of Michigan, Ann Arbor
| |
Collapse
|
7
|
Kasson E, Filiatreau LM, Davet K, Kaiser N, Sirko G, Bekele M, Cavazos-Rehg P. Examining Symptoms of Stimulant Misuse and Community Support Among Members of a Recovery-Oriented Online Community. J Psychoactive Drugs 2024; 56:422-432. [PMID: 37381990 PMCID: PMC10755072 DOI: 10.1080/02791072.2023.2228781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 04/28/2023] [Accepted: 06/09/2023] [Indexed: 06/30/2023]
Abstract
Misuse of prescription and non-prescription stimulants and related overdose deaths represent a growing public health crisis that warrants immediate intervention. We examined 100 posts and their respective comments from a public, recovery-oriented Reddit community in January 2021 to explore content related to DSM-V stimulant use disorder symptoms, access and barriers to recovery, and peer support. Using inductive and deductive methods, a codebook was developed with the following primary themes: 1) DSM-V Symptoms and Risk Factors, 2) Stigma/Shame, 3) Seeking Advice or Information, 4) Supportive or Unsupportive Comments. In 37% of posts community members reported taking high doses and engaging in prolonged misuse of stimulants. Nearly half of posts in the sample (46%) were seeking advice for recovery, but 42% noted fear of withdrawal symptoms or a loss of productivity (18%) as barriers to abstinence or a reduction in use. Concerns related to stigma, shame, hiding use from others (30%), and comorbid mental health conditions (34%) were also noted. Social media content analysis allows for insight into information about lived experiences of individuals struggling with substance use disorders. Future online interventions should address recovery barriers related to stigma and shame as well as fears associated with the physical and psychological impact of quitting stimulant misuse.
Collapse
Affiliation(s)
- Erin Kasson
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110
| | - Lindsey M. Filiatreau
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110
| | - Kevin Davet
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110
| | - Nina Kaiser
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110
| | - Georgi Sirko
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110
| | - Mehaly Bekele
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110
- University of Southern California, Los Angeles, CA 90007
| | - Patricia Cavazos-Rehg
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110
| |
Collapse
|
8
|
Brummer J, Thylstrup B, Melis F, Hesse M. Predictors of retention in heroin-assisted treatment in Denmark 2010-2018 - A record-linkage study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024:209449. [PMID: 38960145 DOI: 10.1016/j.josat.2024.209449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/25/2024] [Accepted: 06/26/2024] [Indexed: 07/05/2024]
Abstract
INTRODUCTION While randomized-controlled trials have shown that heroin-assisted treatment (HAT) is superior to methadone maintenance alone in treatment of refractory clients, little is known about client factors associated with retention in HAT in routine care. METHODS This retrospective cohort study assessed predictors of retention in first treatment episode among a consecutive cohort of clients admitted to HAT in Denmark from 2010 to 2018, who could be matched to the Danish population register and for whom a Short Form Health Survey (SF-36) was available at admission (N = 432). The study derived predictors from client self-reports at intake and administrative data available in national registers. Cox proportional hazards regression modelled retention in treatment. RESULTS The one-year retention rate was 69.63 % (95 % CI 65.06 %-73.74 %), and the median time in treatment was 2.45 years (95 % CI, 1.83-3.12). Bivariate analyses showed that retention was lower for clients who had recent cocaine or benzodiazepine use and among those who had experienced an overdose in the year prior to enrollment in HAT. Age below 40, recent illegal activity, poorer emotional wellbeing, previous residential treatment experience, and previous intensive outpatient treatment were also predictors of dropout from HAT. CONCLUSIONS This observational study found that retention in HAT in routine care was similar to rates observed in randomized-controlled trials conducted in other countries. The results suggest that addressing polysubstance use as part of the HAT program may promote long-term retention, as may directing resources to certain subgroups identified at intake, including clients under 40 years and those who report recent criminal activity, emotional problems, or overdoses. The findings that previous residential treatment and intensive outpatient treatment were associated with dropout were unexpected.
Collapse
Affiliation(s)
- Julie Brummer
- Centre for Alcohol and Drug Research, Emdrup Campus, Aarhus BSS, Aarhus University, Tuborgvej 164, Building A, 2(nd) Floor, 2400 Copenhagen NV, Denmark.
| | - Birgitte Thylstrup
- Centre for Alcohol and Drug Research, Emdrup Campus, Aarhus BSS, Aarhus University, Tuborgvej 164, Building A, 2(nd) Floor, 2400 Copenhagen NV, Denmark.
| | - Francesca Melis
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, Norway.
| | - Morten Hesse
- Centre for Alcohol and Drug Research, Emdrup Campus, Aarhus BSS, Aarhus University, Tuborgvej 164, Building A, 2(nd) Floor, 2400 Copenhagen NV, Denmark.
| |
Collapse
|
9
|
Stidham Ba J, Jon-Emefieh Ba C, Carrano PhD J, Wenzel PhD K, Fishman Md M. Characteristics of mHealth therapy app engagement by young adults with OUD. J Addict Dis 2024:1-6. [PMID: 38914005 DOI: 10.1080/10550887.2024.2363027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
While rates of opioid use disorder (OUD) continue to rise across the country, young adults with OUD are at particular risk as they have poorer treatment outcomes and lack developmentally appropriate treatment options. The introduction of mobile applications for OUD present a new avenue to improve treatment outcomes for young adults. One such app, reSET® provides app users with weekly cognitive behavioral therapy lessons focusing on addiction with built in contingency management for completion of lessons and negative urine drug screens. This exploratory study aimed to identify the characteristics of patients who engaged with the application, reSET®, as well as to describe potential differences in treatment outcomes between engagers and non-engagers. This observational cohort study analyzed clinical and other program data from 35 young adults between the ages of 20-28 that were involved in the care and prescribed medications for OUD in Baltimore, Maryland during the 12-week period of app prescription. Results indicated that young adults had dichotomous levels of engagement, with almost 30% engaging highly with the app, completing >90% of lessons, and approximately 70% having low engagement, completing <25% of lessons. There were no differences in mental health outcomes, but engagers were more likely to be retained in care at the end of the 12-week prescription as compared to non-engagers. Overall, results suggest that mHealth apps targeted for OUD treatment offer potential treatment benefits for young adults, especially regarding treatment retention. Future studies should investigate the treatment and mental health impacts of reSET® and other mHealth apps within this population.
Collapse
|
10
|
Coleman SR, Higgins ST, Smyth JM, Rodriguez BL, Loganathan M, Gaalema DE. Extending contingency management for smoking cessation to patients with or at risk for cardiovascular disease: A preliminary trial of a home-based intervention. Exp Clin Psychopharmacol 2024; 32:270-276. [PMID: 37602999 PMCID: PMC10879453 DOI: 10.1037/pha0000677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
Cigarette smoking puts individuals with or at risk for developing cardiovascular disease (CVD) in jeopardy of experiencing a major cardiovascular event. Contingency management (CM) for smoking cessation is an intervention wherein financial incentives are provided contingent on biochemically verified smoking abstinence. Conventional CM programs typically require frequent clinic visits for abstinence monitoring, a potential obstacle for patients with medical comorbidities who may face barriers to access. This preliminary study examined the feasibility and comparative efficacy of (a) usual care (UC; advice to quit smoking, self-help materials, quitline referral) versus (b) UC plus home-based CM for smoking cessation (UC + HBCM). HBCM entailed earning monetary-based vouchers contingent on self-reported 24-hr smoking abstinence biochemically verified by a breath carbon monoxide (CO) sample ≤ 6 ppm. Participants were 20 outpatients with a CVD diagnosis or qualifying CVD risk factor randomly assigned 1:1 to the two conditions. Intervention participants received 14 in-home abstinence visits over 6 weeks. Voucher monetary value started at $10 and escalated by $2.50 for each subsequent negative sample (maximum earnings: $367.50). Positive samples earned no vouchers and reset voucher value to $10, but two negative samples following a positive allowed participants to continue earning vouchers at the prereset value. Primary outcome was point-prevalence smoking abstinence at Week 6 assessment. More participants assigned to UC + HBCM than UC were smoking abstinent at that Week 6 assessment (90% vs. 30%), χ²(1, N = 20) = 7.5, p < .01. These results provide initial evidence that HBCM can effectively promote smoking abstinence in CVD outpatients. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
Collapse
Affiliation(s)
- Sulamunn R.M. Coleman
- Vermont Center on Behavior and Health, University of Vermont
- Departments of Psychiatry, University of Vermont
- Psychological Science, University of Vermont
| | - Stephen T. Higgins
- Vermont Center on Behavior and Health, University of Vermont
- Departments of Psychiatry, University of Vermont
- Psychological Science, University of Vermont
| | - Joshua M. Smyth
- The Pennsylvania State University, Department of Biobehavioral Health, University of Vermont
| | | | | | - Diann E. Gaalema
- Vermont Center on Behavior and Health, University of Vermont
- Departments of Psychiatry, University of Vermont
- Psychological Science, University of Vermont
| |
Collapse
|
11
|
Jalali A. Informing evidence-based medicine for opioid use disorder using pharmacoeconomic studies. Expert Rev Pharmacoecon Outcomes Res 2024; 24:599-611. [PMID: 38696161 DOI: 10.1080/14737167.2024.2350561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/29/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION The health and economic consequences of inadequately treated opioid use disorder (OUD) are substantial. Healthcare systems in the United States (US) and other countries are facing a growing healthcare crisis due to opioids. Although effective medications for OUD exist, relying solely on clinical information is insufficient for addressing the opioid crisis. AREAS COVERED In this review, the role of pharmacoeconomic studies in informing evidence-based medication treatment for OUD is discussed, with a particular emphasis on the US healthcare system, where the economic burden is significantly higher than the global average. The scope/objective of pharmacoeconomics as a distinct scientific research program is briefly defined, followed by a discussion of existing evidence informed by data from systematic reviews, in addition to a convenience sample of recently published pharmacoeconomic studies and protocols. The review also explores the need for methodological advancements in the field. EXPERT OPINION Despite the potential of pharmacoeconomic research in shaping evidence-based medicine for OUD, significant challenges limiting its real-world application remain. How to address these challenges are explored, including how to combine cost-effectiveness and budget impact analyses to address the needs of the healthcare system as a whole and specific stakeholders interested in adopting new OUD treatment strategies.
Collapse
Affiliation(s)
- Ali Jalali
- Department of Population Health Sciences, Division of Comparative Effectiveness & Outcomes Research, Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| |
Collapse
|
12
|
Pfund RA, Ginley MK, Boness CL, Rash CJ, Zajac K, Witkiewitz K. Contingency Management for Drug Use Disorders: Meta-Analysis and Application of Tolin's Criteria. CLINICAL PSYCHOLOGY-SCIENCE AND PRACTICE 2024; 31:136-150. [PMID: 38863566 PMCID: PMC11164545 DOI: 10.1037/cps0000121] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
Several professional organizations and federal agencies recommend contingency management (CM) as an empirically supported treatment for drug use disorder. However, the release of the "Tolin criteria" warrants an updated recommendation. Using this methodology, five meta-analyses (84 studies, 11,000 participants) were reviewed. Two meta-analyses were rated moderate quality, and three were rated low or critically low quality. Comparator conditions included active treatment, placebo, treatment as usual, and no treatment. The primary outcome was abstinence. Considering only the moderate quality meta-analyses, the effect of CM versus control on posttreatment abstinence was d = 0.54 [0.43, 0.64] and follow-up abstinence was d=0.08 [0.00, 0.16]. A "strong" recommendation was provided for CM as an empirically supported treatment for drug use disorder.
Collapse
Affiliation(s)
- Rory A. Pfund
- Center on Alcohol, Substance use, And Addictions, University of New Mexico
| | | | | | - Carla J. Rash
- Calhoun Cardiology Center, University of Connecticut School of Medicine
| | - Kristyn Zajac
- Calhoun Cardiology Center, University of Connecticut School of Medicine
| | - Katie Witkiewitz
- Center on Alcohol, Substance use, And Addictions, University of New Mexico
| |
Collapse
|
13
|
The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder. J Addict Med 2024; 18:1-56. [PMID: 38669101 PMCID: PMC11105801 DOI: 10.1097/adm.0000000000001299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
The American Society of Addiction Medicine/American Academy of Addiction Psychiatry (ASAM/AAAP) Clinical Practice Guideline on the Management of Stimulant Use Disorder provides guidance on evidence-based strategies for the treatment of stimulant use disorders (StUDs), stimulant intoxication, and stimulant withdrawal, as well as secondary and tertiary prevention of harms associated with stimulant use. The Clinical Guideline Committee (CGC) comprised experts from ASAM and AAAP representing a range of clinical settings and patient populations. The guideline was developed following modified GRADE methodology. The process included a systematic literature review as well as several targeted supplemental searches. The CGC utilized Evidence to Decision tables to review available evidence and rate the strength of each recommendation. The clinical practice guideline was revised based on external stakeholder review. Key takeaways included: Contingency management represents the current standard of care for treatment of StUDs; Pharmacotherapies may be utilized off-label to treat StUDs; Acute stimulant intoxication can result in life-threatening complications that should be addressed in an appropriate level of care; Secondary and tertiary prevention strategies should be used to reduce harms related to risky stimulant use.
Collapse
|
14
|
Durpoix A, Rolling J, Coutelle R, Lalanne L. Psychotherapies in opioid use disorder: toward a step-care model. J Neural Transm (Vienna) 2024; 131:437-452. [PMID: 37987829 PMCID: PMC11055728 DOI: 10.1007/s00702-023-02720-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/01/2023] [Indexed: 11/22/2023]
Abstract
Opioid use disorder (OUD) is characterized by a lack of control in opioid use, resulting in psychological distress and deficits in interpersonal and social functioning. OUD is often associated with psychiatric comorbidities that increase the severity of the disorder. The consequences of OUD are dramatic in terms of increased morbi-mortality. Specific medications and psychotherapies are essential tools not only in the treatment of OUD but also in the prevention of suicide and overdoses. In our review, we assess the different types of psychotherapies (counseling, motivational interviewing, contingency management, cognitive-behavioral therapy, and dialectical-behavior therapy) that are delivered to opioid users, either associated or un-associated with OUD medications and/or medications for psychiatric disabilities. We describe the application of these therapies first to adult opioid users and then to adolescents. This work led us to propose a stepped-care model of psychotherapies for OUD which provided information to assist clinicians in decision-making regarding the selection of psychotherapeutic strategies according to patients' OUD severity.
Collapse
Affiliation(s)
- Amaury Durpoix
- Addictology Department, Strasbourg University Hospital, 1, place de l'Hôpital, 67091, Strasbourg, France
- Strasbourg University, Faculty of Medicine, Strasbourg, France
| | - Julie Rolling
- Psychiatry, Mental Health and Addictology Department, Strasbourg University Hospital, Strasbourg, France
- Regional Center for Psychotrauma Great East, Strasbourg, France
- Centre National de la Recherche Scientifique Unité Propre de Recherche 3212 (CNRS UPR 3212), Institute for Cellular and Integrative Neurosciences (INCI), Strasbourg, France
| | - Romain Coutelle
- Psychiatry, Mental Health and Addictology Department, Strasbourg University Hospital, Strasbourg, France
- INSERM U1114, Cognitive Neuropsychology, and Pathophysiology of Schizophrenia, Strasbourg, France
| | - Laurence Lalanne
- Addictology Department, Strasbourg University Hospital, 1, place de l'Hôpital, 67091, Strasbourg, France.
- INSERM U1114, Cognitive Neuropsychology, and Pathophysiology of Schizophrenia, Strasbourg, France.
- Strasbourg University, Faculty of Medicine, Strasbourg, France.
- Fédération de Médecine translationnelle de Strasbourg, Strasbourg, France.
| |
Collapse
|
15
|
Incze MA, Kelley AT, James H, Nolan S, Stofko A, Fordham C, Gordon AJ. Post-hospitalization Care Transition Strategies for Patients with Substance Use Disorders: A Narrative Review and Taxonomy. J Gen Intern Med 2024; 39:837-846. [PMID: 38413539 PMCID: PMC11043281 DOI: 10.1007/s11606-024-08670-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/30/2024] [Indexed: 02/29/2024]
Abstract
Hospitalizations represent important opportunities to engage individuals with substance use disorders (SUD) in treatment. For those who engage with SUD treatment in the hospital setting, tailored supports during post-discharge transitions to longitudinal care settings may improve care linkages, retention, and treatment outcomes. We updated a recent systematic review search on post-hospitalization SUD care transitions through a structured review of published literature from January 2020 through June 2023. We then added novel sources including a gray literature search and key informant interviews to develop a taxonomy of post-hospitalization care transition models for patients with SUD. Our updated literature search generated 956 abstracts not included in the original systematic review. We selected and reviewed 89 full-text articles, which yielded six new references added to 26 relevant articles from the original review. Our search of five gray literature sources yielded four additional references. Using a thematic analysis approach, we extracted themes from semi-structured interviews with 10 key informants. From these results, we constructed a taxonomy consisting of 10 unique SUD care transition models in three overarching domains (inpatient-focused, transitional, outpatient-focused). These models include (1) training and protocol implementation; (2) screening, brief intervention, and referral to treatment; (3) hospital-based interdisciplinary consult team; (4) continuity-enhanced interdisciplinary consult team; (5) peer navigation; (6) transitional care management; (7) outpatient in-reach; (8) post-discharge outreach; (9) incentivizing follow-up; and (10) bridge clinic. For each model, we describe design, scope, approach, and implementation strategies. Our taxonomy highlights emerging models of post-hospitalization care transitions for patients with SUD. An established taxonomy provides a framework for future research, implementation efforts, and policy in this understudied, but critically important, aspect of SUD care.
Collapse
Affiliation(s)
- Michael A Incze
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA.
| | - A Taylor Kelley
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Patient-Aligned Care Team, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Hannah James
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Seonaid Nolan
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Andrea Stofko
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA
| | - Cole Fordham
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA
| | - Adam J Gordon
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Patient-Aligned Care Team, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| |
Collapse
|
16
|
Fredericksen RJ, Baker R, Sibley A, Estadt AT, Colston D, Mixson LS, Walters S, Bresett J, Levander XA, Leichtling G, Davy-Mendez T, Powell M, Stopka TJ, Pho M, Feinberg J, Ezell J, Zule W, Seal D, Cooper HLF, Whitney BM, Delaney JAC, Crane HM, Tsui JI. Motivation and context of concurrent stimulant and opioid use among persons who use drugs in the rural United States: a multi-site qualitative inquiry. Harm Reduct J 2024; 21:74. [PMID: 38561753 PMCID: PMC10985853 DOI: 10.1186/s12954-024-00986-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 03/12/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND In recent years, stimulant use has increased among persons who use opioids in the rural U.S., leading to high rates of overdose and death. We sought to understand motivations and contexts for stimulant use among persons who use opioids in a large, geographically diverse sample of persons who use drugs (PWUD) in the rural settings. METHODS We conducted semi-structured individual interviews with PWUD at 8 U.S. sites spanning 10 states and 65 counties. Content areas included general substance use, injection drug use, changes in drug use, and harm reduction practices. We used an iterative open-coding process to comprehensively itemize and categorize content shared by participants related to concurrent use. RESULTS We interviewed 349 PWUD (64% male, mean age 36). Of those discussing current use of stimulants in the context of opioid use (n = 137, 39%), the stimulant most used was methamphetamine (78%) followed by cocaine/crack (26%). Motivations for co-use included: 1) change in drug markets and cost considerations; 2) recreational goals, e.g., seeking stronger effects after heightened opioid tolerance; 3) practical goals, such as a desire to balance or alleviate the effects of the other drug, including the use of stimulants to avoid/reverse opioid overdose, and/or control symptoms of opioid withdrawal; and 4) functional goals, such as being simultaneously energized and pain-free in order to remain productive for employment. CONCLUSION In a rural U.S. cohort of PWUD, use of both stimulants and opioids was highly prevalent. Reasons for dual use found in the rural context compared to urban studies included changes in drug availability, functional/productivity goals, and the use of methamphetamine to offset opioid overdose. Education efforts and harm reduction services and treatment, such as access to naloxone, fentanyl test strips, and accessible drug treatment for combined opioid and stimulant use, are urgently needed in the rural U.S. to reduce overdose and other adverse outcomes.
Collapse
Affiliation(s)
| | - R Baker
- Oregon Health & Science University, Portland, USA
| | - A Sibley
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - A T Estadt
- The Ohio State University, Colombus, USA
| | - D Colston
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | | | | | - J Bresett
- Southern Illinois University School of Medicine, Springfield, USA
| | - X A Levander
- Oregon Health & Science University, Portland, USA
| | | | - T Davy-Mendez
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - M Powell
- University of Washington, Seattle, USA
| | - T J Stopka
- Tufts University School of Medicine, Department of Public Health and Community Medicine, Medford, USA
| | - M Pho
- University of Chicago, Chicago, USA
| | - J Feinberg
- West Virginia University, Morgantown, USA
| | - J Ezell
- Cornell University, Ithaca, USA
| | - W Zule
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - D Seal
- Tulane University, New Orleans, USA
| | | | | | | | - H M Crane
- University of Washington, Seattle, USA
| | - J I Tsui
- University of Washington, Seattle, USA
| |
Collapse
|
17
|
Kim YG, Brandt L, Cheung K, Nunes EV, Roll J, Luo SX, Liu Y. Optimizing Contingency Management with Reinforcement Learning. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.28.24305031. [PMID: 38585900 PMCID: PMC10996730 DOI: 10.1101/2024.03.28.24305031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Contingency Management (CM) is a psychological treatment that aims to change behavior with financial incentives. In substance use disorders (SUDs), deployment of CM has been enriched by longstanding discussions around the cost-effectiveness of prized-based and voucher-based approaches. In prize-based CM, participants earn draws to win prizes, including small incentives to reduce costs, and the number of draws escalates depending on the duration of maintenance of abstinence. In voucher-based CM, participants receive a predetermined voucher amount based on specific substance test results. While both types have enhanced treatment outcomes, there is room for improvement in their cost-effectiveness: the voucher-based system requires enduring financial investment; the prize-based system might sacrifice efficacy. Previous work in computational psychiatry of SUDs typically employs frameworks wherein participants make decisions to maximize their expected compensation. In contrast, we developed new frameworks that clinical decision-makers choose actions, CM structures, to reinforce the substance abstinence behavior of participants. We consider the choice of the voucher or prize to be a sequential decision, where there are two pivotal parameters: the prize probability for each draw and the escalation rule determining the number of draws. Recent advancements in Reinforcement Learning, more specifically, in off-policy evaluation, afforded techniques to estimate outcomes for different CM decision scenarios from observed clinical trial data. We searched CM schemas that maximized treatment outcomes with budget constraints. Using this framework, we analyzed data from the Clinical Trials Network to construct unbiased estimators on the effects of new CM schemas. Our results indicated that the optimal CM schema would be to strengthen reinforcement rapidly in the middle of the treatment course. Our estimated optimal CM policy improved treatment outcomes by 32% while maintaining costs. Our methods and results have broad applications in future clinical trial planning and translational investigations on the neurobiological basis of SUDs.
Collapse
Affiliation(s)
- Young-Geun Kim
- Mailman School of Public Health, Department of Biostatistics, New York, NY, USA
- Columbia University Irving Medical Center, Department of Psychiatry, New York, NY, USA
| | - Laura Brandt
- City College of New York, Department of Psychology, New York, NY, USA
| | - Ken Cheung
- Mailman School of Public Health, Department of Biostatistics, New York, NY, USA
| | - Edward V Nunes
- Columbia University Irving Medical Center, Department of Psychiatry, New York, NY, USA
- New York State Psychiatric Institute, Division on Substance Use Disorders, New York, NY, USA
| | - John Roll
- Washington State University, Department of Community and Behavioral Health, Spokane, WA, USA
- Washington State University, Program of Excellence in Addictions Research, Spokane, WA, USA
| | - Sean X Luo
- Columbia University Irving Medical Center, Department of Psychiatry, New York, NY, USA
- New York State Psychiatric Institute, Division on Substance Use Disorders, New York, NY, USA
| | - Ying Liu
- Columbia University Irving Medical Center, Department of Psychiatry, New York, NY, USA
| |
Collapse
|
18
|
Jett JD, Beck R, Tyutyunnyk D, Sanchez J, Weeks DL, Javors MA, Hill-Kapturczak N, Lopez-Cruzan M, Kriegel L, Ginsburg BC, Cabassa L, McDonell MG. Feasibility of a telehealth-based contingency management intervention for alcohol use disorders using the phosphatidylethanol (PEth) 16:0/18:1 alcohol biomarker: a pilot randomized trial. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2024; 50:162-172. [PMID: 38284925 PMCID: PMC11228813 DOI: 10.1080/00952990.2023.2283691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 11/11/2023] [Indexed: 01/30/2024]
Abstract
Background: Phosphatidylethanol (PEth) is a blood-based biomarker for alcohol consumption that can be self-collected and has high sensitivity, specificity, and a longer detection window compared to other alcohol biomarkers.Objectives: We evaluated the feasibility and acceptability of a telehealth-based contingency management (CM) intervention for alcohol use disorder (AUD) using the blood-based biomarker PEth to assess alcohol consumption.Methods: Sixteen adults (7 female, 9 male) with AUD were randomized to Control or CM conditions. Control participants received reinforcers regardless of their PEth levels. CM participants received reinforcers for week-to-week decreases in PEth (Phase 1) or maintenance of PEth consistent with abstinence (<20 ng/mL, Phase 2). Blood samples were self-collected using the TASSO-M20 device. Acceptability was assessed by retention in weeks. Satisfaction was assessed with the Client Satisfaction Questionnaire (CSQ-8) and qualitative interviews. The primary efficacy outcome was PEth-defined abstinence. Secondary outcomes included the proportion of visits with PEth-defined heavy alcohol consumption, negative urine ethyl glucuronide results, and self-reported alcohol use.Results: Retention averaged 18.6 ± 8.8 weeks for CM participants. CM participants reported high levels of satisfaction (CSQ-8, Mean = 30.3 ± 1.5). Interview themes included intervention positives, such as staff support, quality of life improvement, and accountability. 72% of PEth samples from CM participants were consistent with abstinence versus 34% for Control participants (OR = 5.0, p = 0.007). PEth-defined heavy alcohol consumption was detected in 28% of CM samples and 52% of Control samples (OR = 0.36, p = 0.159). CM participants averaged 1.9 ± 1.7 drinks/day versus 4.2 ± 6.3 for Control participants (p = 0.304).Conclusion: Results support the acceptability and satisfaction of a telehealth PEth-based CM intervention, though a larger study is needed to assess its efficacy [NCT04038021].
Collapse
Affiliation(s)
- Julianne D Jett
- PRISM Collaborative, Department of Community and Behavioral Health, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Rachael Beck
- PRISM Collaborative, Department of Community and Behavioral Health, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Diana Tyutyunnyk
- PRISM Collaborative, Department of Community and Behavioral Health, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Jesus Sanchez
- Department of Psychiatry and Behavioral Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Douglas L Weeks
- PRISM Collaborative, Department of Community and Behavioral Health, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Martin A Javors
- Department of Psychiatry and Behavioral Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Nathalie Hill-Kapturczak
- Department of Psychiatry and Behavioral Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Marisa Lopez-Cruzan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Liat Kriegel
- PRISM Collaborative, Department of Community and Behavioral Health, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Brett C Ginsburg
- Department of Psychiatry and Behavioral Sciences, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Leopoldo Cabassa
- Brown School, Washington University St. Louis, St Louis, MO, USA
| | - Michael G McDonell
- PRISM Collaborative, Department of Community and Behavioral Health, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| |
Collapse
|
19
|
Appa A, Baral S, Stein B, Knight K, Gandhi M, Coffin P, Martin M. The IMPACT (Infection Management Plus Addiction Care Together) Pilot: A Case Series of Combined Contingency Management for Substance Use Disorders and Antibiotic Adherence in the Hospital Setting. J Addict Med 2024; 18:138-143. [PMID: 38109334 PMCID: PMC10939948 DOI: 10.1097/adm.0000000000001254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
OBJECTIVES Psychostimulant-related mortality is rising alongside increasing substance use-related hospitalizations, which are commonly complicated by patient-directed (or "against medical advice") discharges. Contingency management (CM) is an underused evidence-based treatment for substance use disorders with proven efficacy to support medication adherence. Our objective was to describe feasibility and preliminary effectiveness of a novel CM intervention incentivizing both drug use reduction and antibiotic adherence in the hospital setting. METHODS We conducted a pilot intervention of twice weekly CM for stimulant and/or opioid use disorder and antibiotic adherence conducted on inpatient wards and/or an embedded skilled nursing facility in an urban public hospital. Based on point-of-care urine drug test results and objective antibiotic adherence review, participants earned increasing opportunities to receive incentives. We measured feasibility via number of visits attempted and cost of gift cards dispensed. We evaluated effectiveness via antibiotic completion, discharge type, and participant perception of intervention effectiveness collected via structured survey. RESULTS Of 13 participants enrolled, most had opioid use disorder (fentanyl in 10/13) and stimulant use disorder (methamphetamine in 7/13). Almost all were receiving treatment for osteomyelitis and/or endocarditis (12/13). Feasibility challenges included competing demands of acute care with variable range of completed visits per participant (1-12 visits). Despite this, antibiotic completion was high (92%, 12/13 participants) with only two patient-directed discharges. Participants described CM as very effective in aiding infection treatment but had greater variability in beliefs regarding CM facilitation of reduced drug use. CONCLUSIONS Providing CM in the hospital setting may represent an effective approach to improving health outcomes by increasing antibiotic adherence and addressing substance use.
Collapse
Affiliation(s)
- Ayesha Appa
- Department of Medicine, University of California, San Francisco, San Francisco, USA
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins University, Baltimore, USA
| | - Brianna Stein
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, USA
| | - Kelly Knight
- Department of Medicine, University of California, San Francisco, San Francisco, USA
| | - Monica Gandhi
- Department of Medicine, University of California, San Francisco, San Francisco, USA
| | - Phillip Coffin
- San Francisco Department of Public Health, San Francisco, USA
| | - Marlene Martin
- Department of Medicine, University of California, San Francisco, San Francisco, USA
| |
Collapse
|
20
|
Cooke ME, Knoll SJ, Streck JM, Potter K, Lamberth E, Rychik N, Gilman JM, Evins AE, Schuster RM. Contingency management is associated with positive changes in attitudes and reductions in cannabis use even after discontinuation of incentives among non-treatment seeking youth. Drug Alcohol Depend 2024; 256:111096. [PMID: 38277735 PMCID: PMC10923125 DOI: 10.1016/j.drugalcdep.2024.111096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/12/2024] [Accepted: 01/13/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND It is important to identify interventions that reduce harm in youth not motivated to change their cannabis use. This study evaluated how short-duration contingency management (CM) impacts cannabis use attitudes and behavior after abstinence incentives are discontinued among non-treatment seeking youth. METHODS Participants (N=220) were randomized to 4 weeks of abstinence-based CM (CB-Abst; n=126) or monitoring (CB-Mon; n=94). Participants completed self-report and provided biochemical measures of cannabis exposure at baseline, end-of-intervention, and 4-week follow-up. Changes in self-reported cannabis use frequency (days/week; times/week) and biochemically verified creatinine-adjusted 11-nor-9-carboxy-tetrahydrocannabinol concentrations (CN-THCCOOH) were analyzed between groups from baseline to follow-up. In CB-Abst, cannabis use goals at end-of-intervention were described and changes in cannabis use at follow-up were explored by goals and cannabis use disorder (CUD) diagnosis. RESULTS There was a group by visit interaction on cannabis use (days: beta=0.93, p=0.005; times: beta=0.71, p<0.001; CN-THCCOOH: beta=0.26, p=0.004), with reductions at follow-up detected only in CB-Abst. Following 4 weeks of abstinence, 68.4% of CB-Abst participants wanted to reduce or abstain from cannabis use following completion of CM. Those in CB-Abst who set end-of-intervention reduction goals and were without CUD had greater decreases in cannabis use frequency at follow-up (Goals*time on days/week: beta=-2.27, p<0.001; CUD*time on times/week: beta=0.48, SE=0.24, t=2.01, p=0.048). CONCLUSIONS Findings support the utility of brief incentivized abstinence for generating motivation to reduce cannabis use and behavior change even after incentives end. This study supports CM as a potentially viable harm reduction strategy for those not yet ready to quit.
Collapse
Affiliation(s)
- Megan E Cooke
- Department of Psychiatry, Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ, USA
| | - Sarah J Knoll
- Department of Psychiatry, Massachusetts General Hospital, USA
| | - Joanna M Streck
- Department of Psychiatry, Massachusetts General Hospital, USA; Harvard Medical School, Boston, MA, USA
| | - Kevin Potter
- Department of Psychiatry, Massachusetts General Hospital, USA; Harvard Medical School, Boston, MA, USA
| | - Erin Lamberth
- Department of Psychiatry, Massachusetts General Hospital, USA
| | - Natali Rychik
- Department of Psychiatry, Massachusetts General Hospital, USA
| | - Jodi M Gilman
- Department of Psychiatry, Massachusetts General Hospital, USA; Harvard Medical School, Boston, MA, USA
| | - A Eden Evins
- Department of Psychiatry, Massachusetts General Hospital, USA; Harvard Medical School, Boston, MA, USA
| | - Randi M Schuster
- Department of Psychiatry, Massachusetts General Hospital, USA; Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
21
|
Acuff SF, Ellis JD, Rabinowitz JA, Hochheimer M, Hobelmann JG, Huhn AS, Strickland JC. A brief measure of non-drug reinforcement: Association with treatment outcomes during initial substance use recovery. Drug Alcohol Depend 2024; 256:111092. [PMID: 38266572 PMCID: PMC10922801 DOI: 10.1016/j.drugalcdep.2024.111092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/19/2023] [Accepted: 01/09/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Translational research demonstrates that drug use is inversely associated with availability and engagement with meaningful non-drug reinforcers. Evaluation of non-drug reinforcement in treatment-receiving clinical populations is limited, likely owing to the time intensive nature of existing measures. This study explores the association of non-drug reinforcers with treatment outcomes using a novel, brief measure of past month non-drug reinforcement quantifying three elements: relative frequency, access, and enjoyability. METHODS Respondents enrolled in substance use treatment (residential, intensive outpatient, and medically managed withdrawal) in clinics across the United States (N = 5481) completed standardized assessments of non-drug reinforcement and treatment outcomes (i.e., return to use and life satisfaction) one-month after treatment discharge. Non-drug reinforcement measures (availability, engagement, enjoyability) were used as predictors of return to use and life satisfaction using generalized linear models. RESULTS Non-drug reinforcement indices were associated with return to use and life satisfaction in unadjusted models (e.g., 12.4 % versus 58.3 % return to use for those with the highest and lowest availability, respectively). Consistent results were observed in models adjusted for sociodemographic variables and risk factors (i.e., sleep disturbance, anhedonia, stress). Comparisons by drug class generally showed lower non-drug reinforcement among patients reporting heroin or methamphetamine as their primary drug. CONCLUSIONS Results highlight the importance of non-drug reinforcement during the first month following treatment. Rapid measurement of non-drug reinforcement in stepped care settings may illuminate critical deficits in early stages of behavior change, identify those at greatest risk for return to use, and provide targets for treatment to improve recovery trajectories.
Collapse
Affiliation(s)
- Samuel F Acuff
- Recovery Research Institute, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jennifer D Ellis
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA; Ashley Addiction Treatment, Havre de Grace, MD, USA
| | - Jill A Rabinowitz
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Martin Hochheimer
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - J Gregory Hobelmann
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA; Ashley Addiction Treatment, Havre de Grace, MD, USA
| | - Andrew S Huhn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA; Ashley Addiction Treatment, Havre de Grace, MD, USA
| | - Justin C Strickland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA; Ashley Addiction Treatment, Havre de Grace, MD, USA.
| |
Collapse
|
22
|
Thakarar K, Appa A, Abdul Mutakabbir JC, Goff A, Brown J, Tuell C, Fairfield K, Wurcel A. Frame Shift: Focusing on Harm Reduction and Shared Decision Making for People Who Use Drugs Hospitalized With Infections. Clin Infect Dis 2024; 78:e12-e26. [PMID: 38018174 DOI: 10.1093/cid/ciad664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Indexed: 11/30/2023] Open
Affiliation(s)
- Kinna Thakarar
- Tufts University School of Medicine, Boston, Massachusetts, USA
- Center for Interdisciplinary Population & Health Research, MaineHealth Institute for Research, Portland, Maine, USA
- Department of Medicine, Maine Medical Center, Portland, Maine, USA
| | - Ayesha Appa
- Division of HIV, Infectious Diseases, and Global Medicine at San Francisco General Hospital, University of California-San Francisco, San Francisco, California, USA
| | - Jacinda C Abdul Mutakabbir
- Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California-San Diego, La Jolla, California, USA
- Division of the Black Diaspora and African American Studies, University of California-San Diego, La Jolla, California, USA
| | - Amelia Goff
- Section of Addiction Medicine, Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Jessica Brown
- Department of Care Management, Oregon Health and Science University, Portland, Oregon, USA
| | | | - Kathleen Fairfield
- Tufts University School of Medicine, Boston, Massachusetts, USA
- Center for Interdisciplinary Population & Health Research, MaineHealth Institute for Research, Portland, Maine, USA
- Department of Medicine, Maine Medical Center, Portland, Maine, USA
| | - Alysse Wurcel
- Tufts University School of Medicine, Boston, Massachusetts, USA
- Department of Medicine, Division of Geographic Medicine and Infectious Diseases, Tufts Medicine, Boston, Massachusetts, USA
| |
Collapse
|
23
|
Incze MA, Garland EL. Mobilizing Primary Care Against the Opioid Crisis in the Post X-Waiver Era. J Gen Intern Med 2023; 38:3618-3620. [PMID: 37653205 PMCID: PMC10713878 DOI: 10.1007/s11606-023-08382-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/16/2023] [Indexed: 09/02/2023]
Affiliation(s)
- Michael A Incze
- Division of General Internal Medicine, University of Utah, Salt Lake City, USA.
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, USA.
| | - Eric L Garland
- Center On Mindfulness and Integrative Health Intervention Development, College of Social Work, University of Utah, Salt Lake City, USA
- Veterans Health Care Administration VISN 19 Whole Health Flagship Site Located at the VA Salt Lake City Health Care System, Salt Lake City, USA
| |
Collapse
|
24
|
Parent SC, Peavy KM, Tyutyunnyk D, Hirchak KA, Nauts T, Dura A, Weed L, Barker L, McDonell MG. Lessons learned from statewide contingency management rollouts addressing stimulant use in the Northwestern United States. Prev Med 2023; 176:107614. [PMID: 37451553 PMCID: PMC10787039 DOI: 10.1016/j.ypmed.2023.107614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 07/01/2023] [Accepted: 07/08/2023] [Indexed: 07/18/2023]
Abstract
Increases in stimulant drug use (such as methamphetamine) and related deaths creates an imperative for community settings to adopt evidence-based practices to help people who use stimulants. Contingency management (CM) is a behavioral intervention with decades of research demonstrating efficacy for the treatment of stimulant use disorder, but real-world adoption has been slow, due to well-known implementation barriers, including difficulty funding reinforcers, and stigma. This paper describes the training and technical assistance (TTA) efforts and lessons learned for two state-wide stimulant-focused CM implementation projects in the Northwestern United States (Montana and Washington). A total of 154 providers from 35 community-based service sites received didactic training in CM beginning in 2021. Seventeen of these sites, ten of eleven in Montana (90.9%) and seven of 24 in Washington (29.2%), went on to implement contingency management programs adherent to their state's established CM protocol and received ongoing TTA in the form of implementation coaching calls. These findings illustrate that site-specific barriers such as logistical fit precluded implementation in more than 50% of the trained sites; however, strategies for site-specific tailoring within the required protocol aided implementation, resulting in successful CM program launch in a diverse cross-section of service sites across the states. The lessons learned add to the body of literature describing CM implementation barriers and solutions.
Collapse
Affiliation(s)
- Sara C Parent
- Department of Community and Behavioral Health, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA; Promoting Research Initiatives in Substance Use and Mental Health Collaborative, Spokane, WA, USA.
| | - K Michelle Peavy
- Department of Community and Behavioral Health, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA; Promoting Research Initiatives in Substance Use and Mental Health Collaborative, Spokane, WA, USA
| | - Diana Tyutyunnyk
- Department of Community and Behavioral Health, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA; Promoting Research Initiatives in Substance Use and Mental Health Collaborative, Spokane, WA, USA
| | - Katherine A Hirchak
- Department of Community and Behavioral Health, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA; Promoting Research Initiatives in Substance Use and Mental Health Collaborative, Spokane, WA, USA
| | - Tammera Nauts
- Montana Primary Care Association, Helena, MT, United States of America
| | - Amy Dura
- Washington State Health Care Authority, Olympia, WA, United States of America
| | - Lora Weed
- Washington State Health Care Authority, Olympia, WA, United States of America
| | - Linda Barker
- Washington State Health Care Authority, Olympia, WA, United States of America
| | - Michael G McDonell
- Department of Community and Behavioral Health, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA; Promoting Research Initiatives in Substance Use and Mental Health Collaborative, Spokane, WA, USA
| |
Collapse
|
25
|
Liao S, Jang S, Tharp JA, Lester NA. Relationship between medication adherence for opioid use disorder and health care costs and health care events in a claims dataset. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 154:209139. [PMID: 37574167 DOI: 10.1016/j.josat.2023.209139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 05/29/2023] [Accepted: 08/09/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION Medication for opioid use disorder (MOUD) has well-documented benefits for treating OUD, though its efficacy depends on patient adherence. We know little about outcomes of MOUD nonadherence compared to treatment regimens without MOUD, and this article aims to address the gap. This analysis focused on office-based MOUD treatment (buprenorphine and naltrexone) to evaluate the long-term impact of adherence on subsequent health care costs and health care events. METHODS With claims data from 2017 to 2019, we used propensity score (PS) weighting to create three comparable cohorts of patients: 1) Adherent: filled MOUD prescription & ≧80 % of days covered by MOUD (N = 1045); 2) Nonadherent: filled MOUD & < 80 % of days covered (N = 1116), 3) did not fill MOUD (N = 16,784). The study defined three time intervals based on a patient's most recent MOUD episode: A 6-month baseline period before initiation of MOUD or random index date for those with MOUD; a 6-month treatment period, during which adherence or nonadherence was established; and a 12-month follow-up period to evaluate outcome measures. The study used generalized PS methodology to examine the effect of proportion of days covered (PDC) as a continuous measure of adherence. RESULTS Among patients who filled MOUD, adherence to MOUD was significantly predicted by having less severe OUD, being older, having fewer inpatient visits and lower outpatient costs before the start of treatment. Adherent patients displayed significantly lower health care costs in the follow-up period compared to nonadherent MOUD patients, and lower odds of experiencing health care events. The nonadherent MOUD group displayed significantly higher odds of health care events compared to patients who had no evidence of receiving MOUD in claims data (NO-MOUD). Among patients prescribed MOUD, each 10 % increase in PDC was associated with a significant decrease in inpatient/outpatient costs and in odds of health care events. CONCLUSIONS This analysis aligns with previous findings about the importance of maintaining long-term adherence to MOUD in supporting patient outcomes. The results also suggest a novel finding that despite confounder control via PS methods, nonadherent patients display poorer outcomes compared to similar NO-MOUD patients.
Collapse
Affiliation(s)
- Shirley Liao
- Verily, 269 E Grand Ave, South San Francisco, CA, United States of America.
| | - Steve Jang
- Verily, 269 E Grand Ave, South San Francisco, CA, United States of America
| | - Jordan A Tharp
- Verily, 269 E Grand Ave, South San Francisco, CA, United States of America
| | - Natalie A Lester
- Verily, 269 E Grand Ave, South San Francisco, CA, United States of America; OneFifteen, 6636 Longshore St, Dublin, OH, United States of America
| |
Collapse
|
26
|
Andraka-Christou B, Williams M, Buksbaum S, Karkkainen J, Stein BD, Batchelder SR, Peck K, Heil SH, Rawson R, Sigmon SC. US state laws relevant to incentives for health behavior: A qualitative analysis. Prev Med 2023; 176:107645. [PMID: 37494973 PMCID: PMC10805957 DOI: 10.1016/j.ypmed.2023.107645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/19/2023] [Accepted: 07/23/2023] [Indexed: 07/28/2023]
Abstract
Contingency management (CM) involves provision of incentives for positive health behaviors via a well-defined protocol and is among the most effective treatments for patients with substance use disorders (SUDs). An understanding of laws affecting incentives for health behaviors and outcomes, including contexts in which incentives are already permitted, could inform efforts to disseminate CM. We conducted a systematic NexisUni legal database review of state statutes and regulations effective during 2022 to identify (a) laws that explicitly permit or prohibit delivery of incentives to patients, employees, or insurance beneficiaries for SUD-specific behaviors or outcomes, and (b) laws that explicitly permit delivery of incentives for any health behaviors or outcomes. We identified 27 laws across 17 jurisdictions that explicitly permit delivery of incentives for SUD-related behaviors or outcomes, with most occurring in the context of wellness programs. No state laws were identified that explicitly prohibit SUD-specific incentives. More broadly, we identified 57 laws across 29 jurisdictions permitting incentives for any health outcomes (both SUD- and non-SUD-related). These laws occurred in the contexts of wellness programs, K-12/early childhood education, government public health promotion, and SUD treatment provider licensing. Considering the urgent need to expand evidence-based SUD treatment in rural and underserved areas throughout the US, these findings could inform efforts to develop laws explicitly permitting provision of incentives in SUD care and enhance efforts to disseminate CM more broadly.
Collapse
Affiliation(s)
| | - Michelle Williams
- University of Central Florida, 525 W Livingston Ave, Suite 401, Orlando, FL 32801, USA
| | - Scott Buksbaum
- University of Central Florida, 525 W Livingston Ave, Suite 401, Orlando, FL 32801, USA
| | - Josie Karkkainen
- University of Central Florida, 525 W Livingston Ave, Suite 401, Orlando, FL 32801, USA
| | - Bradley D Stein
- RAND Corporation, 4570 Fifth Avenue, Pittsburgh, PA 15238, USA
| | - Sydney R Batchelder
- The Vermont Center on Behavior and Health, University of Vermont, 1 South Prospect St, Burlington, VT 05401, USA
| | - Kelly Peck
- The Vermont Center on Behavior and Health, University of Vermont, 1 South Prospect St, Burlington, VT 05401, USA
| | - Sarah H Heil
- The Vermont Center on Behavior and Health, University of Vermont, 1 South Prospect St, Burlington, VT 05401, USA
| | - Richard Rawson
- The Vermont Center on Behavior and Health, University of Vermont, 1 South Prospect St, Burlington, VT 05401, USA
| | - Stacey C Sigmon
- The Vermont Center on Behavior and Health, University of Vermont, 1 South Prospect St, Burlington, VT 05401, USA
| |
Collapse
|
27
|
Becker SJ, DiClemente-Bosco K, Rash CJ, Garner BR. Effective, but underused: lessons learned implementing contingency management in real-world practice settings in the United States. Prev Med 2023; 176:107594. [PMID: 37385413 PMCID: PMC10753028 DOI: 10.1016/j.ypmed.2023.107594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/19/2023] [Accepted: 06/24/2023] [Indexed: 07/01/2023]
Abstract
Despite being one of the most effective adjunctive behavioral interventions in combination with medication for opioid use disorder, contingency management (CM) is one of the least available interventions in opioid treatment programs. This paradoxical state of affairs is perhaps the greatest example of the research-to-practice gap in the behavioral health field. Implementation science, a discipline that aims to identify replicable methods that can be used across settings and populations to bridge the gap between research and practice, can potentially help. Based on our team's experience implementing CM in opioid treatment programs, we detail five key lessons for researchers, clinicians, policy makers, and others seeking to implement and sustain CM in real-world settings. First, multiple barriers to CM implementation exist at both the counselor- and organization-levels, requiring multi-level solutions. Second, one-shot CM training alone is not sufficient for successful implementation: ongoing support is essential to achieve levels of intervention fidelity that will benefit patients. Third, assessing an organization's capacity for implementation prior to support provision can prevent costly mistakes. Fourth, implementors should plan for high staff turnover rates and expect the unexpected by developing detailed contingency plans. Finally, implementors should remember that the goal is to implement evidence-based CM and not simply incentives. We encourage colleagues to consider these lessons to increase the likelihood that CM can be implemented and sustained in a manner that improves the quality of care in opioid treatment programs.
Collapse
Affiliation(s)
- Sara J Becker
- Center for Dissemination and Implementation Science, Northwestern Feinberg School of Medicine, 633 N St Clair Street, Chicago, IL 60611, United States of America.
| | - Kira DiClemente-Bosco
- Center for Dissemination and Implementation Science, Northwestern Feinberg School of Medicine, 633 N St Clair Street, Chicago, IL 60611, United States of America.
| | - Carla J Rash
- Calhoun Cardiology Center - Behavioral Health, UConn Health, 263 Farmington Avenue, Farmington, CT 06030, United States of America.
| | - Bryan R Garner
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, 2050 Kenny Road, Columbus 43221, United States of America.
| |
Collapse
|
28
|
Klemperer EM, Evans EA, Rawson R. A call to action: Contingency management to improve post-release treatment engagement among people with opioid use disorder who are incarcerated. Prev Med 2023; 176:107647. [PMID: 37499918 PMCID: PMC10808263 DOI: 10.1016/j.ypmed.2023.107647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 07/29/2023]
Abstract
People with opioid use disorder (OUD) are overrepresented in US correctional facilities and experience disproportionately high risk for illicit opioid use and overdose after release. A growing number of correctional facilities offer medication for OUD (MOUD), which is effective in reducing these risks. However, a recent evaluation found that <50% of those prescribed MOUD during incarceration continued MOUD within 30 days after release, demonstrating a need to improve post-release continuity of care. We describe available evidence on contingency management (CM), an intervention wherein patients receive incentives contingent on behavior change, to achieve this goal. A prior systematic review reported strong evidence in support of CM for increasing treatment adherence in MOUD programs, but the trials reviewed did not include incarcerated participants. Research on CM to increase treatment adherence among participants in the criminal justice system is limited with mixed findings. However, in comparison to the trials that supported CM's efficacy in the community, CM trials in the criminal justice system provided smaller rewards with greater delays in the delivery of rewards to patients, which likely contributed to null findings. Indeed, a prior meta-analysis demonstrates a dose-response relationship between the magnitude and immediacy of reward and CM effectiveness. Thus, CM involving larger and more immediately delivered rewards are likely necessary to improve MOUD adherence during the critical period following release from incarceration. Future research on the effectiveness and implementation of CM to improve MOUD retention after release from incarceration is warranted.
Collapse
Affiliation(s)
- Elias M Klemperer
- University of Vermont, College of Medicine, Department of Psychiatry, United States of America.
| | - Elizabeth A Evans
- University of Massachusetts Amherst, School of Public Health & Health Sciences, United States of America
| | - Richard Rawson
- University of Vermont, College of Medicine, Department of Psychiatry, United States of America
| |
Collapse
|
29
|
Error in Quiz Answer. JAMA Psychiatry 2023; 80:1176. [PMID: 37755813 PMCID: PMC10534986 DOI: 10.1001/jamapsychiatry.2023.3833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
|
30
|
Higgins ST. Behavior change, health, and health disparities 2023: Contingency management for treating substance use disorders and promoting health in vulnerable populations. Prev Med 2023; 176:107746. [PMID: 37898183 DOI: 10.1016/j.ypmed.2023.107746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/30/2023]
Abstract
This Special Issue (SI) of Preventive Medicine is the 10th in a series on behavior change, health, and health disparities. This issue focuses on Contingency Management (CM), a highly efficacious behavior-change intervention for substance use disorders (SUDs) and other behavioral health conditions wherein patients receive material incentives (e.g., vouchers exchangeable for retail items) contingent on objectively verified behavior change. Despite substantial support for its efficacy, CM remains largely unavailable in U.S. community SUD treatment facilities and other healthcare settings. This is especially concerning regarding stimulant use disorder for which CM is the only reliably efficacious intervention in controlled studies and yet is unavailable to the vast majority of those in need. This SI details recent promising developments in efforts to surmount longstanding implementation obstacles while also detailing other promising advances from meta-analyses and controlled trials examining CM's efficacy in treating other difficult-to-treat problems including smoking among pregnant women and mothers of young children as well among those as those experiencing homelessness and alcohol use disorder, the promise of digital CM, and a potential new application in promoting adherence with SUD medications.
Collapse
Affiliation(s)
- Stephen T Higgins
- Vermont Center on Behavior and Health, Departments of Psychiatry and Psychological Science, University of Vermont, 1 South Prospect St., UHC, MS482 Burlington, VT 05401, USA.
| |
Collapse
|
31
|
Higgins ST, Plucinski S, Orr E, Nighbor TD, Coleman SRM, Skelly J, DeSarno M, Bunn J. Randomized clinical trial examining financial incentives for smoking cessation among mothers of young children and possible impacts on child secondhand smoke exposure. Prev Med 2023; 176:107651. [PMID: 37527730 PMCID: PMC10825067 DOI: 10.1016/j.ypmed.2023.107651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/27/2023] [Accepted: 07/28/2023] [Indexed: 08/03/2023]
Abstract
This randomized clinical trial examined whether financial-incentives increase smoking cessation among mothers of young children and potential impacts on child secondhand-smoke exposure (SHSe). 198 women-child dyads were enrolled and assigned to one of three treatment conditions: best practices (BP, N = 68), best practices plus financial incentives (BP + FI, N = 63), or best practices, financial incentives, and nicotine replacement therapy (BP + FI + NRT, N = 67). The trial was completed in Vermont, USA between June 2015 and October 2020. BP entailed staff referral to the state tobacco quitline; financial incentives entailed mothers earning vouchers exchangeable for retail items for 12 weeks contingent on biochemically-verified smoking abstinence; NRT involved mothers receiving 10 weeks of free transdermal nicotine and nicotine lozenges/gum. Baseline, 6-, 12-, 24-, and 48-week assessments were conducted. Primary outcomes were maternal 7-day point-prevalence abstinence and child SHSe through the 24-week assessment with the 48-week assessment exploratory. Results were analyzed using mixed model repeated measures for categorical data. Odds of maternal abstinence were greater among mothers in BP + FI and BP + FI + NRT compared to BP at the 6- and 12-week assessments (ORs ≥ 7.30; 95% CIs: 2.35-22.71); only abstinence in BP + FI remained greater than BP at the 24-week assessment (OR = 2.95; 95% CIs: 1.06-8.25). Abstinence did not differ significantly between treatment conditions at the 48-week assesssment. There was a significant effect of treatment condition (F[2109] = 3.64, P = .029) on SHSe with levels in BP and BP + FI significantly below BP + FI + NRT (ts[109] ≥ -2.30, Ps ≤ 0.023). Financial incentives for smoking abstinence are efficacious for increasing maternal cessation but that alone was insufficient for reducing child SHSe. ClinicalTrials.gov:NCT05740098.
Collapse
Affiliation(s)
- Stephen T Higgins
- Vermont Center on Behavior and Health, University of Vermont, United States of America; Department of Psychiatry, University of Vermont, United States of America; Department of Psychological Science, University of Vermont, United States of America.
| | - Shirley Plucinski
- Vermont Center on Behavior and Health, University of Vermont, United States of America; Department of Psychiatry, University of Vermont, United States of America
| | - Eva Orr
- Vermont Center on Behavior and Health, University of Vermont, United States of America; Department of Psychiatry, University of Vermont, United States of America
| | - Tyler D Nighbor
- Vermont Center on Behavior and Health, University of Vermont, United States of America; Department of Psychiatry, University of Vermont, United States of America
| | - Sulamunn R M Coleman
- Vermont Center on Behavior and Health, University of Vermont, United States of America; Department of Psychiatry, University of Vermont, United States of America
| | - Joan Skelly
- Vermont Center on Behavior and Health, University of Vermont, United States of America; Department of Medical Biostatistics, University of Vermont, United States of America
| | - Michael DeSarno
- Vermont Center on Behavior and Health, University of Vermont, United States of America; Department of Medical Biostatistics, University of Vermont, United States of America
| | - Janice Bunn
- Vermont Center on Behavior and Health, University of Vermont, United States of America; Department of Medical Biostatistics, University of Vermont, United States of America
| |
Collapse
|
32
|
Bahji A, Danilewitz M, Crockford D. Navigating Evidence, Challenges, and Caution in the Treatment of Stimulant Use Disorders. Brain Sci 2023; 13:1416. [PMID: 37891785 PMCID: PMC10605120 DOI: 10.3390/brainsci13101416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/26/2023] [Accepted: 10/01/2023] [Indexed: 10/29/2023] Open
Abstract
Amidst the opioid epidemic, harm reduction-oriented approaches have gained traction, including interventions that focus on prescribing pharmaceutical-grade psychoactive substances, such as opioids, instead of illicit versions, intending to mitigate fatal overdose risks arising from the variability in potency and additives found in illicit drugs. Stimulants have increasingly been found in the victims of opioid overdoses, further prompting some to argue for the prescription of stimulant medications for individuals with stimulant use disorders. Yet, the evidence supporting this practice remains insufficient. In this communication, we critically examine the existing evidence, challenges, and cautions surrounding the treatment of stimulant use disorder.
Collapse
Affiliation(s)
- Anees Bahji
- Department of Psychiatry, University of Calgary, Calgary, AB T2R 0N2, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB T2R 0N2, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2R 0N2, Canada
| | - Marlon Danilewitz
- Department of Psychiatry, University of Toronto, Toronto, ON M5T 1R7, Canada;
- Ontario Shores Center for Mental Health Sciences, Whitby, ON L1N 5S9, Canada
| | - David Crockford
- Department of Psychiatry, University of Calgary, Calgary, AB T2R 0N2, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2R 0N2, Canada
| |
Collapse
|
33
|
Becker SJ, DiClemente-Bosco K, Scott K, Janssen T, Salino SM, Hasan FN, Yap KR, Garner BR. Implementing contingency management for stimulant use in opioid treatment programs: protocol of a type III hybrid effectiveness-stepped-wedge trial. Implement Sci 2023; 18:41. [PMID: 37705093 PMCID: PMC10498624 DOI: 10.1186/s13012-023-01297-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/28/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Contingency management (CM) is an evidence-based intervention for stimulant use and is highly effective in combination with medication for opioid use disorder. Yet, uptake of CM in opioid treatment programs that provide medication for opioid use disorder remains low. This paradox in which CM is one of the most effective interventions, yet one of the least available, represents one of the greatest research-to-practice gaps in the addiction health services field. Multi-level implementation strategies are needed to address barriers to CM implementation at both the provider- and organization-level. This type III hybrid effectiveness-implementation trial was funded by the National Institute on Drug Abuse to evaluate whether a multi-level implementation strategy, the Science of Service Laboratory (SSL), can effectively promote CM implementation in opioid treatment programs. Specific aims will test the effectiveness of the SSL on implementation outcomes (primary aim) and patient outcomes (secondary aim), as well as test putative mediators of implementation outcomes (exploratory aim). METHODS Utilizing a fully powered type III hybrid effectiveness-implementation trial with a stepped wedge design, we propose to randomize a cohort of 10 opioid treatment programs to receive the SSL across four steps. Each step, an additional 2-3 opioid treatment programs will receive the SSL implementation strategy, which has three core components: didactic training, performance feedback, and external facilitation. At six intervals, each of the 10 opioid treatment programs will provide de-identified electronic medical record data from all available patient charts on CM delivery and patient outcomes. Staff from each opioid treatment program will provide feedback on contextual determinants influencing implementation at three timepoints. DISCUSSION Between planning of this protocol and receipt of funding, the landscape for CM in the USA changed dramatically, with multiple Departments of Health launching state-wide CM initiatives. We therefore accelerated the protocol timeline and offered some cursory training resources to all sites as a preparation activity. We also began partnering with multiple Departments of Health to evaluate their rollout of CM using the measures outlined in this protocol. TRIAL REGISTRATION This study protocol is registered via ClinicalTrials.gov Identifier: NCT05702021. Date of registration: January 27, 2023.
Collapse
Affiliation(s)
- Sara J Becker
- Center for Dissemination and Implementation Science, Northwestern University Feinberg School of Medicine, 633 N St Clair Street, Chicago, IL, 60611, USA.
| | - Kira DiClemente-Bosco
- Center for Dissemination and Implementation Science, Northwestern University Feinberg School of Medicine, 633 N St Clair Street, Chicago, IL, 60611, USA
| | - Kelli Scott
- Center for Dissemination and Implementation Science, Northwestern University Feinberg School of Medicine, 633 N St Clair Street, Chicago, IL, 60611, USA
| | - Tim Janssen
- Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 S Main Street, Providence, RI, 02906, USA
| | - Sarah M Salino
- Center for Dissemination and Implementation Science, Northwestern University Feinberg School of Medicine, 633 N St Clair Street, Chicago, IL, 60611, USA
| | - Fariha N Hasan
- Center for Dissemination and Implementation Science, Northwestern University Feinberg School of Medicine, 633 N St Clair Street, Chicago, IL, 60611, USA
| | - Kimberly R Yap
- Center for Dissemination and Implementation Science, Northwestern University Feinberg School of Medicine, 633 N St Clair Street, Chicago, IL, 60611, USA
| | - Bryan R Garner
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, 2050 Kenny Road, Columbus, 43221, USA
| |
Collapse
|
34
|
Joudrey PJ, Chen K, Oldfield BJ, Biegacki E, Fiellin DA. Drive Time to Addiction Treatment Facilities Providing Contingency Management across Rural and Urban Census Tracts in 6 US States. J Addict Med 2023; 17:615-617. [PMID: 37788621 PMCID: PMC10591456 DOI: 10.1097/adm.0000000000001170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
OBJECTIVE We examined drive times to outpatient substance use disorder treatment providers that provide contingency management (CM) and those that integrate CM with medication for opioid use disorder (MOUD) services in 6 US states. METHODS We completed cross-sectional geospatial analysis among census tracts in Delaware, Louisiana, Massachusetts, North Carolina, New York, and West Virginia. We excluded census tracts with a population of zero. Using data from the 2020 Shatterproof substance use treatment facility survey, our outcome was the minimum drive time in minutes from the census tract mean center of population to the nearest outpatient CM provider, outpatient CM provider with MOUD services, and federally qualified health centers (FQHC). We stratified census tracts by 2010 Rural-Urban Commuting Area codes and by state. RESULTS The population was greater than zero in 11,719 of 11,899 census tracts. The median drive time to the nearest CM provider was 12.2 [interquartile range (IQR), 7.0-23.5) minutes and the median drive time to the nearest CM provider increased from 9.7 (IQR, 6.0-15.0) minutes in urban census tracts to 38.8 (IQR, 25.4-53.0) minutes in rural ( H = 3683, P < 0.001). The median drive time increased to the nearest CM provider with MOUD services [14.2 (IQR, 7.9-29.5) minutes, W = 18,877, P < 0.001] and decreased to the nearest FQHC [7.9 (IQR, 4.3-13.6) minutes, W = 11,555,894, P < 0.001]. CONCLUSIONS These results suggest limited availability of CM, particularly within rural communities and for patients needing concurrent CM and MOUD treatment. Our results suggest greater adoption of CM within FQHCs could reduce urban-rural disparities in CM availability.
Collapse
Affiliation(s)
- Paul J. Joudrey
- Division of General Internal Medicine, University of Pittsburgh School of Medicine
| | - Kevin Chen
- Office of Ambulatory Care and Population Health, New York City Health and Hospitals Corporation, New York, NY
- Division of General Internal Medicine and Clinical Innovation, New York University Grossman School of Medicine, New York NY
| | - Benjamin J. Oldfield
- Fair Haven Community Health Care, New Haven, CT
- Yale Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Emma Biegacki
- Yale Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - David A. Fiellin
- Yale Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
| |
Collapse
|
35
|
Frohe T, Janssen T, Garner BR, Becker SJ. Examining Changes in Pain Interference via Pandemic-Induced Isolation Among Patients Receiving Medication for Opioid Use Disorder: A Secondary Data Analysis. RESEARCH SQUARE 2023:rs.3.rs-3158420. [PMID: 37609151 PMCID: PMC10441456 DOI: 10.21203/rs.3.rs-3158420/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Background Early in the pandemic, the United States population experienced a sharp rise in the prevalence rates of opioid use, social isolation, and pain interference. Given the high rates of pain reported by patients on medication for opioid use disorder (MOUD), the pandemic presented a unique opportunity to disentangle the relationship between opioid use, pain, and social isolation in this high-risk population. We tested the hypothesis that pandemic-induced isolation would partially mediate change in pain interference levels experienced by patients on MOUD, even when controlling for baseline opioid use. Such work can inform the development of targeted interventions for a vulnerable, underserved population. Methods Analyses used data from a cluster randomized trial (N = 188) of patients on MOUD across eight opioid treatment programs. As part of the parent trial, participants provided pre-pandemic data on pain interference, opioid use, and socio-demographic variables. Research staff re-contacted participants between May and June 2020 and 133 participants (71% response rate) consented to complete a supplemental survey that assessed pandemic-induced isolation. Participants then completed a follow-up interview during the pandemic that again assessed pain interference and opioid use. A path model assessed whether pre-pandemic pain interference had an indirect effect on pain interference during the pandemic via pandemic-induced isolation. Results Consistent with hypotheses, we found evidence that pandemic-induced isolation partially mediated change in pain interference levels among MOUD patients during the pandemic. Higher levels of pre-pandemic pain interference and opioid use were both significantly associated with higher levels of pandemic-induced isolation. In addition, pre-pandemic pain interference was significantly related to levels of pain interference during the pandemic, and these pain levels were partially explained by the level of pandemic-induced isolation reported. Conclusions Patients on MOUD with higher use of opioids and higher rates of pain pre-pandemic were more likely to report feeling isolated during COVID-related social distancing and this, in turn, partially explained changes in levels of pain interference. These results highlight social isolation as a key risk factor for patients on MOUD and suggest that interventions promoting social connection could be associated with reduced pain interference, which in turn could improve patient quality of life.
Collapse
Affiliation(s)
| | - Tim Janssen
- Brown University School of Public Health Providence
| | - Bryan R Garner
- Ohio State University, The Ohio State University College of Medicine
| | | |
Collapse
|
36
|
Kalmin MM, Nicolo C, Long W, Bodden D, Van Nunen L, Shoptaw S, Ipser J. A Systematic Review of the Efficacy of Contingency Management for Substance Use Disorders in Low and Middle Income Countries. Int J Behav Med 2023:10.1007/s12529-023-10197-8. [PMID: 37532862 DOI: 10.1007/s12529-023-10197-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND The impact of illicit substance use is especially devastating in low-resourced countries where factors such as poverty, unemployment, and inadequate services impede successful treatment. Contingency management (CM) is a treatment for substance use disorders that has shown to be effective in eliciting behaviour change. The efficacy of CM interventions in low and middle income countries (LMICs) has been under explored. METHODS The aim of this systematic review of randomized controlled trials was to assess measures of CM efficacy in addressing substance use disorders, while also considering contextual moderators of CM in LMICs. A search of PubMed, Scopus, and Cochrane library databases yielded 18 studies for inclusion, from which relevant data were extracted using modified versions of the Cochrane Characteristics of Studies tool. RESULTS Two studies were located in a low-income country, two in lower-middle income countries, and fourteen in upper middle-income countries. Overall, estimated efficacy estimates were similar to those from higher income countries. However, context-specific challenges that warrant further investigation included limited access to trained staff and structural and financial constraints. CONCLUSIONS While CM in LMICs is in its early stages of development, efficacy estimates were not substantially different compared to high income countries. Challenges such as costs, willingness to implement, and the stigma associated with addiction sets the stage for further research in these contexts.
Collapse
Affiliation(s)
- Mariah M Kalmin
- Department of Family Medicine, University of California, Los Angeles 1800 Wilshire Blvd., Suite 1800, 90024, Los Angeles, CA, US.
| | - Candice Nicolo
- Department of Psychology, University of Cape Town, Cape Town, South Africa
| | - Wahbie Long
- Department of Psychology, University of Cape Town, Cape Town, South Africa
| | - David Bodden
- Department of Environmental Health, University of North Carolina, Chapel Hill, Chapel Hill, North, CA, US
| | - Lara Van Nunen
- Department of Neuroscience, University of Cape Town, Cape Town, South Africa
| | - Steven Shoptaw
- Department of Family Medicine, University of California, Los Angeles 1800 Wilshire Blvd., Suite 1800, 90024, Los Angeles, CA, US
| | - Jonathan Ipser
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
37
|
Edelman EJ, Dziura J, Deng Y, DePhilippis D, Fucito LM, Ferguson T, Bedimo R, Brown S, Marconi VC, Goetz MB, Rodriguez-Barradas MC, Simberkoff MS, Molina PE, Weintrob AC, Maisto SA, Paris M, Justice AC, Bryant KJ, Fiellin DA. Contingency management with stepped care for unhealthy alcohol use among individuals with HIV: Protocol for a randomized controlled trial. Contemp Clin Trials 2023; 131:107242. [PMID: 37230168 PMCID: PMC10460633 DOI: 10.1016/j.cct.2023.107242] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/22/2023] [Accepted: 05/22/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Although unhealthy alcohol use is associated with increased morbidity and mortality among people with HIV (PWH), many are ambivalent about engaging in treatment and experience variable responses to treatment. We describe the rationale, aims, and study design for the Financial Incentives, Randomization, with Stepped Treatment (FIRST) Trial, a multi-site randomized controlled efficacy trial. METHODS PWH in care recruited from clinics across the United States who reported unhealthy alcohol use, had a phosphatidylethanol (PEth) >20 ng/mL, and were not engaged in formal alcohol treatment were randomized to integrated contingency management with stepped care versus treatment as usual. The intervention involved two steps; Step 1: Contingency management (n = 5 sessions) with potential rewards based on 1) short-term abstinence; 2) longer-term abstinence; and 3) completion of healthy activities to promote progress in addressing alcohol consumption or conditions potentially impacted by alcohol; Step 2: Addiction physician management (n = 6 sessions) plus motivational enhancement therapy (n = 4 sessions). Participants' treatment was stepped up at week 12 if they lacked evidence of longer-term abstinence. Primary outcome was abstinence at week 24. Secondary outcomes included alcohol consumption (assessed by TLFB and PEth) and the Veterans Aging Cohort Study (VACS) Index 2.0 scores; exploratory outcomes included progress in addressing medical conditions potentially impacted by alcohol. Protocol adaptations due to the COVID-19 pandemic are described. CONCLUSIONS The FIRST Trial is anticipated to yield insights on the feasibility and preliminary efficacy of integrated contingency management with stepped care to address unhealthy alcohol use among PWH. CLINICALTRIALS gov identifier: NCT03089320.
Collapse
Affiliation(s)
- E Jennifer Edelman
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA.
| | - James Dziura
- Yale Center for Analytic Sciences, Yale University School of Public Health, New Haven, CT, USA; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Yanhong Deng
- Yale Center for Analytic Sciences, Yale University School of Public Health, New Haven, CT, USA
| | - Dominick DePhilippis
- Veterans Affairs Office of Mental Health and Suicide Prevention, US Department of Veterans Affairs, Washington, DC, USA; Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa M Fucito
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Tekeda Ferguson
- Department of Epidemiology, Louisiana State University School of Public Health, New Orleans, LA, USA; Comprehensive Alcohol-HIV/AIDS Research Center, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Roger Bedimo
- Veterans Affairs North Texas Health Care System and UT Southwestern Dallas, TX, USA
| | - Sheldon Brown
- James J. Peters Veterans Affairs Medical Center and Manhattan VA Medical Center and Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vincent C Marconi
- Atlanta VAMC, Emory University School of Medicine, Rollins School of Public Health, Atlanta, GA, USA
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Michael S Simberkoff
- VA NY Harbor Healthcare System and New York University Grossman School of Medicine, New York, NY, USA
| | - Patricia E Molina
- Comprehensive Alcohol-HIV/AIDS Research Center, Louisiana State University Health Sciences Center, New Orleans, LA, USA; Department of Physiology, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Amy C Weintrob
- Washington D.C. Veterans Affairs Medical Center and George Washington University, Washington, DC, USA
| | - Stephen A Maisto
- Department of Psychology, Syracuse University, Syracuse, NY, USA
| | - Manuel Paris
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Amy C Justice
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, Veterans Aging Cohort Study, West Haven, CT, USA
| | - Kendall J Bryant
- National Institute on Alcohol Abuse and Alcoholism HIV/AIDS Program, Bethesda, MD, USA
| | - David A Fiellin
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
38
|
Dellazizzo L, Potvin S, Giguère S, Landry C, Léveillé N, Dumais A. Meta-review on the efficacy of psychological therapies for the treatment of substance use disorders. Psychiatry Res 2023; 326:115318. [PMID: 37356250 DOI: 10.1016/j.psychres.2023.115318] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/16/2023] [Accepted: 06/17/2023] [Indexed: 06/27/2023]
Abstract
This meta-review aimed to summarize the current state of knowledge provided by meta-analyzes on the efficacy of psychotherapies for substance use disorders. A systematic search was performed in PubMed, PsycINFO, Web of Science and Google Scholar. Meta-analyzes were included if they quantitatively examined the efficacy of a psychotherapy on substance use. Among the 6866 potential articles that were screened for eligibility, 23 meta-analyzes were eligible (78 effect sizes). Each meta-analysis included 2-156 studies, with samples ranging between approximately 130 to over 33,000 individuals. The quality of evidence was evaluated as being globally of low to moderate quality. Substances were categorized as: alcohol (k = 12), cannabis (k = 7), stimulants (k = 4), opioids (k = 3) and benzodiazepines (k = 1). Interventions comprised brief intervention, cognitive-behavioral therapy, contingency management, voucher-based reinforcement therapy, motivational interview, motivational enhancement therapy, significant other people involved in the treatment, and cue-expose therapy. Concerning solely significant results, small benefits were observed for significant other people involved in treatment, motivational interviewing, and the combination of cognitive-behavioral therapy with motivational interviewing for alcohol use disorder. Likewise, small-to-moderate effects were found for motivational approaches, and cognitive-behavioral therapy as well as the combination of cognitive-behavioral therapy and motivational enhancement therapy in the case of cannabis use disorder. Small effects were observed for contingency management as well as cognitive behavioral-therapy for amphetamine-type use disorder. Small effects were similarly found for contingency management for cocaine use disorder. Concerning opioid use disorder, moderate effects were observed for contingency management and voucher-based reinforcement intervention. For benzodiazepine use disorder, small effects were noted for cognitive-behavioral therapy with taper. Results often displayed small to moderate heterogeneity when reported and were generally compared to inactive controls, such as treatment-as-usual. In all, the psychosocial treatments for substance use disorders included in this meta-review have shown to be at best moderately effective over inactive controls in the short term. Nevertheless, further trials are needed as well as meta-analyzes on interventions not included in this meta-review.
Collapse
Affiliation(s)
- Laura Dellazizzo
- Research Center of the Institut Universitaire en Santé Mentale de Montréal, Montreal, Canada; Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Stéphane Potvin
- Research Center of the Institut Universitaire en Santé Mentale de Montréal, Montreal, Canada; Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Sabrina Giguère
- Research Center of the Institut Universitaire en Santé Mentale de Montréal, Montreal, Canada; Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Clara Landry
- Research Center of the Institut Universitaire en Santé Mentale de Montréal, Montreal, Canada; Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Nayla Léveillé
- Research Center of the Institut Universitaire en Santé Mentale de Montréal, Montreal, Canada; Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Alexandre Dumais
- Research Center of the Institut Universitaire en Santé Mentale de Montréal, Montreal, Canada; Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montreal, Canada; Institut National de Psychiatrie Légale Philippe-Pinel, Montreal, Canada.
| |
Collapse
|
39
|
Buono FD, Larkin K, Pham Q, De Sousa D, Zempsky WT, Lalloo C, Stinson JN. Maintaining Engagement in Adults with Neurofibromatosis Type 1 to Use the iCanCope Mobile Application (iCanCope-NF). Cancers (Basel) 2023; 15:3213. [PMID: 37370823 PMCID: PMC10296339 DOI: 10.3390/cancers15123213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION Neurofibromatosis Type 1 (NF1) is an autosomal dominant genetic condition in which chronic pain is a predominant issue. Given the rarity of the disease, there are limited psychosocial treatments for individuals with NF1 suffering with chronic pain. Using mobile applications can facilitate psychosocial treatments; however, there are consistent issues with engagement. Utilizing a mixed methodology, the current study evaluated the customized iCanCope mobile application for NF1 on increasing engagement through the usage of contingency management. METHODS A mixed methods study from a subset of data coming from a randomized clinical trial that occurred from January 2021 to August 2022 was undertaken. Two groups (iCC and iCC + CM) were exposed to the customized iCanCope mobile application in which engagement data were captured in real-time with daily check-ins for interference, sleep, mood, physical activity, energy levels, goal setting, and accessing article content (coping strategies). Additionally, semi-structured interviews were conducted to gain insight into the participants' experience at the end of the trial. RESULTS Adults (N = 72) were recruited via NF patient advocacy groups. Significant differences were noted between the groups in total articles read (p = 0.002), goals achieved (p = 0.017), and goals created (p = 008). Additionally, there were significant differences observed between user-generated goals and those that were app recommended (p < 0.001). Both groups qualitatively reported positive feedback on the customized mobile application, indicating that continued usage and engagement of the mobile application were acceptable. CONCLUSIONS Employing customized mobile applications for adults with NF1 along with contingency management can leverage self-managed pain treatments while providing auxiliary resources to this population.
Collapse
Affiliation(s)
- Frank D. Buono
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06510, USA;
| | - Kaitlyn Larkin
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06510, USA;
| | - Quynh Pham
- Centre for Digital Therapeutics, University Health Network, Toronto, ON M5G 2C4, Canada; (Q.P.); (D.D.S.)
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada;
| | - Diane De Sousa
- Centre for Digital Therapeutics, University Health Network, Toronto, ON M5G 2C4, Canada; (Q.P.); (D.D.S.)
| | - William T. Zempsky
- Department of Pain and Palliative Medicine, Connecticut Children’s Medical Center, Hartford, CT 06106, USA;
- Department of Pediatrics and Nursing, University of Connecticut School of Medicine, Stores, CT 06032, USA
| | - Chitra Lalloo
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada;
- The Research Institute, The Hospital of Sick Children, Toronto, ON M5G 1X8, Canada;
| | - Jennifer N. Stinson
- The Research Institute, The Hospital of Sick Children, Toronto, ON M5G 1X8, Canada;
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON M5T 1P8, Canada
| |
Collapse
|
40
|
Walton KM, Herrmann ES. Medication Adherence in Tobacco Cessation Clinical Trials. ADDICTION NEUROSCIENCE 2023; 6:100069. [PMID: 36817408 PMCID: PMC9934057 DOI: 10.1016/j.addicn.2023.100069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Adherence is a critical mediator of treatment outcome across health conditions and low rates of adherence undermine success in smoking cessation treatment. This narrative review provides an overview of different techniques that can be used to measure adherence to smoking cessation treatments and outlines strategies to address treatment adherence. Techniques to measure adherence include conducting pill counts, collecting self-reports of adherence, directly observed therapy, biochemical verification methods, and electronic data collection via medication events monitoring systems. Techniques examined for increasing tobacco cessation treatment adherence include counseling, automated adherence calls, feedback from electronic monitors, contingency management and directly observed therapy. Adherence monitoring and optimization should be a standard component of smoking cessation treatment research.
Collapse
Affiliation(s)
- Kevin M. Walton
- Division of Therapeutics and Medical Consequences, National Institute on Drug Abuse, NIH
| | - Evan S. Herrmann
- Division of Therapeutics and Medical Consequences, National Institute on Drug Abuse, NIH
| |
Collapse
|
41
|
Rash CJ. Implementing an evidence-based prize contingency management protocol for stimulant use. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023:209079. [PMID: 37230390 DOI: 10.1016/j.josat.2023.209079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 03/29/2023] [Accepted: 05/18/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Contingency management (CM) is an efficacious treatment for stimulant use disorders. Research has developed support materials for the clinical delivery of prize-based CM and they are widely accessible, but few resources are available to support design and preparation for CM implementation. This guide aims to fill that gap. METHOD/RESULTS The article outlines a suggested prize CM protocol and discusses the best practices most aligned with evidence-based practices and acceptable-if-necessary modifications. The article also highlights modifications that are not evidence-based and not recommended. In addition, I discuss practical and clinical aspects of preparing for CM implementation. CONCLUSIONS Deviations from evidence-based practices are common, and poorly designed CM is unlikely to impact patient outcomes. This article provides planning stage guidance to support programs' adoption of evidence-based prize CM for the treatment of stimulant use disorders.
Collapse
|
42
|
Verdejo-Garcia A, Rezapour T, Giddens E, Khojasteh Zonoozi A, Rafei P, Berry J, Caracuel A, Copersino ML, Field M, Garland EL, Lorenzetti V, Malloy-Diniz L, Manning V, Marceau EM, Pennington DL, Strickland JC, Wiers R, Fairhead R, Anderson A, Bell M, Boendermaker WJ, Brooks S, Bruno R, Campanella S, Cousijn J, Cox WM, Dean AC, Ersche KD, Franken I, Froeliger B, Gamito P, Gladwin TE, Goncalves PD, Houben K, Jacobus J, Jones A, Kaag AM, Lindenmeyer J, McGrath E, Nardo T, Oliveira J, Pennington CR, Perrykkad K, Piercy H, Rupp CI, Schulte MHJ, Squeglia LM, Staiger P, Stein DJ, Stein J, Stein M, Stoops WW, Sweeney M, Witkiewitz K, Woods SP, Yi R, Zhao M, Ekhtiari H. Cognitive training and remediation interventions for substance use disorders: a Delphi consensus study. Addiction 2023; 118:935-951. [PMID: 36508168 PMCID: PMC10073279 DOI: 10.1111/add.16109] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022]
Abstract
AIMS Substance use disorders (SUD) are associated with cognitive deficits that are not always addressed in current treatments, and this hampers recovery. Cognitive training and remediation interventions are well suited to fill the gap for managing cognitive deficits in SUD. We aimed to reach consensus on recommendations for developing and applying these interventions. DESIGN, SETTING AND PARTICIPANTS We used a Delphi approach with two sequential phases: survey development and iterative surveying of experts. This was an on-line study. During survey development, we engaged a group of 15 experts from a working group of the International Society of Addiction Medicine (Steering Committee). During the surveying process, we engaged a larger pool of experts (n = 54) identified via recommendations from the Steering Committee and a systematic review. MEASUREMENTS Survey with 67 items covering four key areas of intervention development: targets, intervention approaches, active ingredients and modes of delivery. FINDINGS Across two iterative rounds (98% retention rate), the experts reached a consensus on 50 items including: (i) implicit biases, positive affect, arousal, executive functions and social processing as key targets of interventions; (ii) cognitive bias modification, contingency management, emotion regulation training and cognitive remediation as preferred approaches; (iii) practice, feedback, difficulty-titration, bias modification, goal-setting, strategy learning and meta-awareness as active ingredients; and (iv) both addiction treatment work-force and specialized neuropsychologists facilitating delivery, together with novel digital-based delivery modalities. CONCLUSIONS Expert recommendations on cognitive training and remediation for substance use disorders highlight the relevance of targeting implicit biases, reward, emotion regulation and higher-order cognitive skills via well-validated intervention approaches qualified with mechanistic techniques and flexible delivery options.
Collapse
Affiliation(s)
- Antonio Verdejo-Garcia
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Clayton, VIC, Australia
| | - Tara Rezapour
- Department of Cognitive Psychology, Institute for Cognitive Science Studies, Tehran, Iran
| | - Emily Giddens
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Clayton, VIC, Australia
| | - Arash Khojasteh Zonoozi
- Iranian National Center for Addiction Studies, Tehran University of Medical Sciences, Tehran, Iran
| | - Parnian Rafei
- Iranian National Center for Addiction Studies, Tehran University of Medical Sciences, Tehran, Iran
| | - Jamie Berry
- Faculty of Medicine and Health Sciences, Macquarie University, Macquarie Park, NSW, Australia
| | - Alfonso Caracuel
- Mind, Brain and Behavior Research Center, Universidad de Granada, Granada, Spain
| | | | - Matt Field
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - Eric L Garland
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah, Salt Lake City, UT, USA
| | - Valentina Lorenzetti
- Neuroscience of Addiction and Mental Health Program, Healthy Brain and Mind Research Centre, School of Behavioral Sciences, Faculty of Health Sciences, Australian Catholic University, Melbourne, VIC, Australia
| | - Leandro Malloy-Diniz
- Mental Health Department, Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Victoria Manning
- Turning Point Drug and Alcohol Centre and Monash Addiction Research Centre (MARC), Monash University, Melbourne, VIC, Australia
| | - Ely M Marceau
- School of Psychology and Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW, Australia
| | - David L Pennington
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Justin C Strickland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Reinout Wiers
- Addiction Development and Psychopathology (ADAPT) Laboratory, Department of Psychology, Centre for Urban Mental Health, University of Amsterdam, Amsterdam, the Netherlands
| | - Rahia Fairhead
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Clayton, VIC, Australia
| | - Alexandra Anderson
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Clayton, VIC, Australia
| | - Morris Bell
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Wouter J Boendermaker
- Addiction, Development, and Psychopathology (ADAPT) Laboratory, Department of Psychology, University of Amsterdam, Amsterdam, the Netherlands
| | - Samantha Brooks
- Research Centre for Brain and Behaviour, School of Psychology, Faculty of Health, Liverpool John Moores University, UK
| | - Raimondo Bruno
- School of Psychology, University of Tasmania, TAS, Hobart, Australia
| | - Salvatore Campanella
- Laboratoire de Psychologie Médicale et d'Addictologie, ULB Neuroscience Institute (UNI), CHU Brugmann-Université Libre de Bruxelles, Bruxelles, Belgium
| | - Janna Cousijn
- Department of Psychology, Education and Child Studies, Erasmus University Rotterdam, the Netherlands
| | - W Miles Cox
- School of Human and Behavioural Sciences, Bangor University, Bangor, UK
| | - Andrew C Dean
- Department of Psychiatry and Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, CA, USA
| | - Karen D Ersche
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Ingmar Franken
- Department of Psychology, Education and Child Studies, Erasmus University Rotterdam, the Netherlands
| | - Brett Froeliger
- Department of Psychiatry and Psychological Sciences, University of Missouri, Columbia, MO, USA
| | | | | | - Priscila D Goncalves
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Katrijn Houben
- Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Joanna Jacobus
- Department of Psychiatry, University of California San Diego, CA, USA
| | - Andrew Jones
- Department of Psychology, University of Liverpool, UK
| | - Anne M Kaag
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, the Netherlands
| | | | - Elly McGrath
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Talia Nardo
- School of Psychological Sciences, Macquarie University, NSW, Australia
| | | | | | - Kelsey Perrykkad
- Cognition and Philosophy Laboratory, Monash Centre for Consciousness and Contemplative Studies, Monash University, Melbourne, VIC, Australia
| | - Hugh Piercy
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - Claudia I Rupp
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, University Clinics of Psychiatry I, Medical University Innsbruck, Innsbruck, Austria
| | - Mieke H J Schulte
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, the Netherlands
| | - Lindsay M Squeglia
- Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA
| | - Petra Staiger
- School of Psychology, Deakin University, Melbourne, VIC, Australia
| | - Dan J Stein
- SAMRC Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Jeff Stein
- Center for Health Behaviors Research, Fralin Biomedical Research Institute at Virginial Tech, VA, USA
| | - Maria Stein
- Department for Clinical Psychology and Psychotherapy, University of Bern, Switzerland
| | - William W Stoops
- Department of Behavioral Science, University of Kentucky, Lexington, KY, USA
| | - Mary Sweeney
- Behavioral Pharmacology Research Unit, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Katie Witkiewitz
- Department of Psychology and Center on Alcohol, Substance Use and Addictions, University of New Mexico, NM, USA
| | - Steven P Woods
- Department of Psychology, University of Houston, Houston, TX, USA
| | - Richard Yi
- Department of Psychology, University of Kansas, Lawrence, KS, USA
| | - Min Zhao
- Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hamed Ekhtiari
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
43
|
Rawson RA, Erath TG, Chalk M, Clark HW, McDaid C, Wattenberg SA, Roll JM, McDonell MG, Parent S, Freese TE. Contingency Management for Stimulant Use Disorder: Progress, Challenges, and Recommendations. J Ambul Care Manage 2023; 46:152-159. [PMID: 36745163 DOI: 10.1097/jac.0000000000000450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
Collapse
Affiliation(s)
- Richard A Rawson
- Motivational Incentive Policy Group (Drs Rawson, Erath, Chalk, Clark, Wattenberg, and Roll, and Ms McDaid); Department of Psychiatry, Vermont Center on Behavior and Health, University of Vermont, Burlington, Vermont (Drs Rawson and Erath); Community and Behavioral Health Department, College of Medicine, Washington State University, Pullman, Washington (Drs Roll, McDonell, and Parent); and UCLA Integrated Substance Abuse Programs, Los Angeles, California (Drs Rawson and Freese)
| | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Acuff SF, MacKillop J, Murphy JG. A contextualized reinforcer pathology approach to addiction. NATURE REVIEWS PSYCHOLOGY 2023; 2:309-323. [PMID: 37193018 PMCID: PMC10028332 DOI: 10.1038/s44159-023-00167-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 03/24/2023]
Abstract
Behavioural economic accounts of addiction conceptualize harmful drug use as an operant reinforcer pathology, emphasizing that a drug is consumed because of overvaluation of smaller immediate rewards relative to larger delayed rewards (delay discounting) and high drug reinforcing value (drug demand). These motivational processes are within-individual determinants of behaviour. A third element of learning theory posits that harmful drug use depends on the relative constraints on access to other available activities and commodities in the choice context (alternative reinforcers), reflecting the substantial influence of environmental factors. In this Perspective, we integrate alternative reinforcers into the contemporary behavioural economic account of harmful drug use - the contextualized reinforcer pathology model - and review empirical literature across the translational spectrum in support of this model. Furthermore, we consider how increases in drug-related mortality and health disparities in addiction can be understood and potentially ameliorated via a contextualized reinforcer pathology model in which lack of alternative reinforcement is a major risk factor for addiction.
Collapse
Affiliation(s)
| | - James MacKillop
- Peter Boris Centre for Addictions Research, Department of Psychiatry and Behavioural Neurosciences, McMaster University/St Joseph’s Healthcare Hamilton, Hamilton, Ontario Canada
- Homewood Research Institute, Guelph, Ontario, Canada
| | - James G. Murphy
- Department of Psychology, University of Memphis, Memphis, TN USA
| |
Collapse
|
45
|
Breland H, Larkins S, Antonini V, Freese T, McGovern M, Dunn J, Rawson R. Stimulant use among patients in opioid treatment settings: Provider perspectives. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023:209012. [PMID: 36931604 DOI: 10.1016/j.josat.2023.209012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 01/20/2023] [Accepted: 03/05/2023] [Indexed: 03/17/2023]
Abstract
INTRODUCTION Methadone maintenance therapy (MMT) has been a pillar of opioid addiction treatment. Opioid treatment programs (OTPs) have been faced with an escalating threat of stimulant use and related overdose deaths among patients. We know little about how providers currently address stimulant use while maintaining treatment for opioid use disorder. METHODS We conducted 5 focus groups with 36 providers (n = 11 prescribers; 25 behavioral health staff), and collected an additional 46 surveys (n = 7 prescribers; 12 administrators; 27 behavioral health staff). Questions focused on perceptions of patient stimulant use and interventions. We applied inductive analysis to identify themes relevant to identification of stimulant use, use trends, intervention approaches, and perceived needs to improve care. RESULTS Providers indicated a trend of rising stimulant use among patients, especially those experiencing homelessness or comorbid health conditions. They reported a range of approaches to patient screening and intervention, including medication and harm reduction, improving treatment engagement, increasing level of care, and providing incentives. Providers expressed less agreement as to which of these interventions were effective, and though providers saw stimulant use as a common and severe problem, they reported little problem recognition and interest in treatment from their patients. A particular concern of providers was the prevalence and danger of synthetic opioids, such as fentanyl. They sought more research and resources to identify effective interventions and medications to address these issues. Also notable was an interest in contingency management (CM) and use of reinforcements/rewards to encourage stimulant use reduction. CONCLUSION Providers face challenges in treating patients who use both opioids and stimulants. Although methadone is available to treat opioid use, no such "silver bullet" exists for stimulant use disorder. The rise in stimulant and synthetic opioid (e.g., fentanyl) combination products is presenting an extraordinary challenge for providers whose patients are at unprecedented risk for overdose. Providing OTPs with more resources to address polysubstance use is critical. Existing research indicates strong support for CM in OTPs, but providers reported regulatory and financial barriers to implementation. Further research should develop effective interventions that are accessible to providers in OTPs.
Collapse
Affiliation(s)
- Haley Breland
- Integrated Substance Abuse Programs, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Sherry Larkins
- Integrated Substance Abuse Programs, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
| | - Valerie Antonini
- Integrated Substance Abuse Programs, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Thomas Freese
- Integrated Substance Abuse Programs, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Mark McGovern
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Julia Dunn
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Richard Rawson
- Integrated Substance Abuse Programs, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
46
|
Ware OD, Sweeney MM, Cunningham C, Umbricht A, Stitzer M, Dunn KE. Bupropion Slow Release vs Placebo With Adaptive Incentives for Cocaine Use Disorder in Persons Receiving Methadone for Opioid Use Disorder: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e232278. [PMID: 36920397 PMCID: PMC10018324 DOI: 10.1001/jamanetworkopen.2023.2278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
IMPORTANCE Opioid-stimulant co-use is a common problem with few evidence-based treatments. OBJECTIVE To examine bupropion slow release (SR) enhancement of a tailored abstinence incentive program for stimulant use in persons with opioid use disorder. DESIGN, SETTING, AND PARTICIPANTS This 26-week, double-blind, placebo-controlled randomized clinical trial with a 4-week follow-up period was conducted at 4 methadone treatment programs in Baltimore, Maryland. Included participants were persons receiving methadone for the treatment of opioid use disorder with past 3-month cocaine use and current cocaine use disorder between March 2015 and September 2019. Data were analyzed from November 2020 through August 2022. INTERVENTIONS A 6-week incentive induction period with monetary incentives for evidence of cocaine abstinence during thrice-weekly urine testing was conducted. Persons achieving 2 weeks of consecutive abstinence during induction were assigned to the relapse prevention group (20 individuals); otherwise, individuals were assigned to the abstinence initiation group (60 individuals). Participants were randomized within incentive groups to bupropion SR (150 mg oral twice daily; 40 participants) or placebo (40 participants). Incentives were available until week 26, and study medication ended week 30. MAIN OUTCOMES AND MEASURES The mean percentage of participants with cocaine abstinence (by negative urinalysis or self-report) during weeks 7 to 26 (ie, the incentive intervention period) and 27 to 30 (ie, the follow-up period) and the percentage of participants testing negative for cocaine at weeks 26 and 30 were assessed. Main effects of medication collapsed across incentive conditions and sensitivity analyses of medications within incentive conditions were assessed. Analyses were conducted in the modified intention-to-treat sample (ie, 80 individuals who received ≥1 dose of study medication) and completers (ie, 52 individuals who completed ≥1 visit during week 30). RESULTS Among 80 participants (42 Black [52.5% ] and 35 White [43.8%]; mean [SD] age, 45.7 (9.4) years; 52 males [65.0%]) receiving methadone for opioid use disorder, 40 participants were randomized to receive bupropion SR and 40 participants to receive placebo. No significant difference on urinalysis or self-reported cocaine use was observed between medication groups. Sensitivity analyses revealed differential patterns for incentive subgroups. Participants in the relapse prevention group had high abstinence (>80%; eg, during weeks 7-26 in the modified intention-to-treat analysis, 410 of 456 samples [89.9%] from participants in the bupropion SR group tested negative for cocaine) throughout the trial regardless of whether they were randomized to bupropion SR or placebo. Participants in the abstinence initiation group had better outcomes with bupropion SR than placebo throughout the trial (mean [SD] total number of samples testing negative for cocaine, 30.3 [21.6] samples for bupropion SR vs 17.1 [14.9] samples for placebo; P = .05) and more participants receiving bupropion SR than placebo were abstinent at the end of the study (20 of 30 participants [66.7%] vs 9 of 30 participants [30.0%]; P = .04). CONCLUSIONS AND RELEVANCE In this randomized clinical trial, an overall benefit for bupropion SR vs placebo when combined with a financial abstinence incentive program was not observed. Results among incentive subgroups suggest that continued evaluation of medications, including bupropion SR, for stimulant treatment using a tailored approach that factors early abstinence into study design and interpretation may be needed. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02111798.
Collapse
Affiliation(s)
- Orrin D. Ware
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- School of Social Work, University of North Carolina at Chapel Hill
| | - Mary M. Sweeney
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- Now with National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland
| | - Colin Cunningham
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Annie Umbricht
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Maxine Stitzer
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- Friends Research Institute, Baltimore, Maryland
| | - Kelly E. Dunn
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
47
|
Bray BC, Watson DP, Salisbury-Afshar E, Taylor L, McGuire A. Patterns of opioid use behaviors among patients seen in the emergency department: Latent class analysis of baseline data from the POINT pragmatic trial. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 146:208979. [PMID: 36880900 PMCID: PMC9992925 DOI: 10.1016/j.josat.2023.208979] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 11/09/2022] [Accepted: 02/05/2023] [Indexed: 02/11/2023]
Abstract
INTRODUCTION The nation's overdose epidemic has been characterized by increasingly potent opioids resulting in more emergency department (ED) encounters over time. ED-based opioid use interventions are growing in popularity; however, they tend to treat people who use opioids as a homogenous population. The current study sought to understand heterogeneity among people who use opioids who encounter the ED by identifying qualitatively different subgroups among participants in an opioid use intervention clinical trial at baseline and examining associations between subgroup membership and multiple correlates. METHODS Participants were from a larger pragmatic clinical trial of the Planned Outreach, Intervention, Naloxone, and Treatment (POINT) intervention (n = 212; 59.2 % male, 85.3 % Non-Hispanic White, mean age = 36.6 years). The study employed latent class analysis (LCA) using five indicators of opioid use behavior: preference for opioids, preference for stimulants, usually use drugs alone, injection drug use, and opioid-related problem at ED encounter. Correlates of interest included participants' demographics, prescription histories, health care contact histories, and recovery capital (e.g., social support, naloxone knowledge). RESULTS The study identified three classes: (1) noninjecting opioid preferers, (2) injecting opioid and stimulant preferers, and (3) social nonopioid preferers. We identified limited significant differences in correlates across the classes: differences existed for select demographics, prescription histories, and recovery capital but not for health care contact histories. For example, members of Class 1 were the most likely to be a race/ethnicity other than non-Hispanic White, oldest on average, and most likely to have received a benzodiazepine prescription, whereas members of Class 2 had the highest average barriers to treatment and members of Class 3 were the least likely to have been diagnosed with a major mental health illness and had the lowest average barriers to treatment. CONCLUSIONS LCA identified distinct subgroups among POINT trial participants. Knowledge of such subgroups assists with the development of better-targeted interventions and can help staff to identify the most appropriate treatment and recovery pathways for patients.
Collapse
Affiliation(s)
- Bethany C Bray
- Institute for Health Research and Policy, The University of Illinois at Chicago, 1747 W Roosevelt Road, Chicago, IL 60608, United States.
| | - Dennis P Watson
- Chestnut Health Systems, Lighthouse Institute, 221 W Walton Street, Chicago, IL 60610, United States.
| | - Elizabeth Salisbury-Afshar
- Department of Family Medicine and Community Health, University of Wisconsin Madison School of Medicine and Public Health, 1100 Delaplaine Court, Room 3835, Madison, WI 53715, United States.
| | - Lisa Taylor
- Chestnut Health Systems, Lighthouse Institute, 221 W Walton Street, Chicago, IL 60610, United States; Jane Addams School of Social Work, The University of Illinois at Chicago, 1040 W Harrison Street, Chicago, IL 60607, United States
| | - Alan McGuire
- Department of Social and Behavioral Sciences, Richard M. Fairbanks School of Public Health, Indiana University, 1050 Wishard Boulevard, Indianapolis, IN 46202, United States; Center for Health Information and Communication, Health Services Research and Development, Richard L. Roudebush Veterans Affairs Medical Center, 1481 W 10th Street, Indianapolis, IN 46202, United States; Department of Psychology, School of Science, Indiana University Purdue University Indianapolis, 402 N Blackford Dr., Indianapolis, IN 46202, United States.
| |
Collapse
|
48
|
Orme S, Zarkin GA, Luckey J, Dunlap LJ, Novak MD, Holtyn AF, Toegel F, Silverman K. Cost and cost-effectiveness of abstinence contingent wage supplements. Drug Alcohol Depend 2023; 244:109754. [PMID: 36638680 PMCID: PMC10207811 DOI: 10.1016/j.drugalcdep.2022.109754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Substance use disorders are correlated with unemployment and poverty. However, few interventions aim to improve substance use, unemployment, and, distally, poverty. The Abstinence-Contingent Wage Supplement (ACWS) randomized controlled trial combined a therapeutic workplace with abstinence-contingent wage supplements to address substance use and unemployment. The ACWS study found that abstinence-contingent wage supplements increased the percentage of participants who had negative drug tests, who were employed, and who were above the poverty line during the intervention period. This study presents the cost of ACWS and calculates the cost-effectiveness of ACWS compared with usual care. METHODS To calculate the cost and cost-effectiveness of ACWS, we used activity-based costing methods to cost the intervention and calculated the costs from the provider and healthcare sector perspective. We calculated incremental cost-effectiveness ratios and cost-effectiveness acceptability curves for negative drug tests and employment. RESULTS ACWS cost $11,310 per participant over the 12-month intervention period. Total intervention and healthcare costs per participant over the intervention period were $20,625 for usual care and $30,686 for ACWS. At the end of the intervention period an additional participant with a negative drug test cost $1437 while an additional participant employed cost $915. CONCLUSIONS ACWS increases drug abstinence and employment and may be cost-effective at the end of the 12-month intervention period if decision makers are willing to pay the incremental cost associated with the intervention.
Collapse
Affiliation(s)
- Stephen Orme
- RTI International, Research Triangle Park, NC, United States.
| | - Gary A Zarkin
- RTI International, Research Triangle Park, NC, United States
| | - Jackson Luckey
- RTI International, Research Triangle Park, NC, United States
| | - Laura J Dunlap
- RTI International, Research Triangle Park, NC, United States
| | - Matthew D Novak
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - August F Holtyn
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Forrest Toegel
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kenneth Silverman
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| |
Collapse
|
49
|
Dorey L, McGarrigle J, May R, Hoon AE, Dymond S. Client Views of Contingency Management in Gambling Treatment: A Thematic Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:17101. [PMID: 36554983 PMCID: PMC9778966 DOI: 10.3390/ijerph192417101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/21/2022] [Accepted: 12/06/2022] [Indexed: 06/17/2023]
Abstract
Low levels of treatment access and poor retention among those with gambling problems suggests a need to improve treatment. Contingency management (CM) is a behavioural intervention involving the identification of target behaviours and the provision of incentives when targets are met. There exists a substantial evidence base for CM increasing abstinence and attendance in substance misuse treatment, but this has not been widely extended to gambling treatment setting. This study sought to explore the views of clients about CM for the treatment of problematic and disordered gambling. We conducted semi-structured interviews with 25 gambling treatment clients who were, or had previously been, engaged in treatment in Great Britain. Participants were provided with an explanation of CM, two hypothetical scenarios, and two structured questionnaires to facilitate discussion. Thematic analysis was used to interpret findings. Some participants felt that clients could manipulate CM while in treatment to obtain money to gamble, and that mechanisms of CM could trigger recovering clients into relapse. Participants also identified potential benefits of CM to achieve treatment goals, by enhancing motivation and engagement while in treatment, and helping bring people into treatment earlier. Gambling treatment clients broadly supported the use of incentives for treatment. CM is seen as a facilitator of extended engagement in treatment, and an encouragement for clients to make progress in the treatment process.
Collapse
Affiliation(s)
- Lucy Dorey
- School of Psychology, Swansea University, Singleton Campus, Swansea SA2 8PP, UK
| | - Jack McGarrigle
- School of Psychology, Swansea University, Singleton Campus, Swansea SA2 8PP, UK
| | - Richard May
- School of Psychology and Therapeutic Studies, University of South Wales, Pontypridd CF37 1DL, UK
| | - Alice E. Hoon
- Swansea University Medical School, Singleton Campus, Swansea SA2 8PP, UK
| | - Simon Dymond
- School of Psychology, Swansea University, Singleton Campus, Swansea SA2 8PP, UK
- Department of Psychology, Reykjavík University, Menntavegur 1, Nauthólsvík, 101 Reykjavík, Iceland
| |
Collapse
|
50
|
Abstract
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.
Collapse
Affiliation(s)
- Steven L Proctor
- Thriving Mind South Florida, Miami, FL, USA.,PRO Health Group, Miami Beach, FL, USA.,Department of Psychiatry and Behavioral Health, Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| |
Collapse
|