Adaptation of contingency management for stimulant use disorder during the COVID-19 pandemic

Telehealth-Based Contingency Management Targeting Stimulant Abstinence: A Case Series From the COVID-19 Pandemic

OBJECTIVE

Contingency management (CM) is the gold standard treatment for stimulant use disorder but typically requires twice- to thrice-weekly in-person treatment visits to objectively verify abstinence and deliver therapeutic incentives. There has been growing interest in telehealth-based delivery of CM to support broad access to this essential intervention--a need that has been emphatically underscored by the COVID-19 pandemic. Herein, we present observations from initial efforts to develop and test a protocol for telehealth-based delivery of prize-based CM treatment incentivizing stimulant abstinence.

METHOD

Four participants engaged in hybrid courses of CM, including one or more telehealth-based treatment sessions, involving self-administered oral fluid testing to confirm abstinence. Observations from initial participants informed iterative improvements to telehealth procedures, and a 12-week course of telehealth-based CM was subsequently offered to two additional participants to further evaluate preliminary feasibility and acceptability.

RESULTS

In most cases, participants were able to successfully join telehealth treatment sessions, self-administer oral fluid testing, and share oral fluid test results to verify stimulant abstinence. However, further improvements in telehealth-based toxicology testing may be necessary to interpret test results accurately and reliably, especially when colorimetric immunoassay results reflect substance concentrations near the cutoff for point-of-care testing devices.

CONCLUSIONS

Preliminary findings suggest that telehealth-based CM is sufficiently feasible and acceptable to support future development, in particular through improved methods for remote interpretation and verification of test results. This is especially important in CM, wherein accurate and reliable detection of both early and sustained abstinence is crucial for appropriate delivery of therapeutic incentives.

Integrated Care Models: HIV and Substance Use

PURPOSE OF REVIEW

Behaviors and practices associated with substance use contribute to lack of HIV virologic suppression and onward transmission. In the USA, many recent HIV outbreaks have been connected with substance use. Evidence-based strategies for integrating care of those at risk for and living with HIV and who use substances continue to evolve. This review, based on scientific and medical literature through March 2023, provides an overview and evaluation of initiatives for integrated care aimed to serve patients at risk for and with HIV and a substance use disorder.

RECENT FINDINGS

Integrated care services can improve health outcomes for patients at risk for and with HIV and a substance use disorder; for instance, treatment for an opioid use disorder can help improve HIV viral suppression. Brick-and-mortar facilities can provide successful care integration with appropriate clinic leadership to support multidisciplinary care teams, up-to-date provider training, and sufficient pharmacy stock for substance use treatment. Delivering healthcare services to communities (e.g., mobile healthcare clinics and pharmacies, telehealth) may prove to be an effective way to provide integrated services for those with or at risk of HIV and substance use disorders. Incorporating technology (e.g., mobile phone applications) may facilitate integrated care. Other venues, including harm reduction programs and carceral settings, should be targets for integrated services. Venues providing healthcare should invest in integrated care and support legislation that increases access to services related to HIV and substance use.

A qualitative study of people who use methamphetamine during the early COVID-19 pandemic to inform future ED harm reduction strategies

BACKGROUND

Morbidity and mortality rates related to methamphetamine are on the rise. Simultaneously, social-distancing guidelines were issued in March 2020 to decrease transmission of COVID-19. The aim of this study was to explore concerns regarding methamphetamine use during the COVID-19 pandemic and subsequent harm reduction strategies with patients who use methamphetamine to inform emergency department (ED)-based harm reduction approaches.

METHODS

A mixed-methods study of adults residing in Washington with high-risk methamphetamine use and a recent ED visit from April-September 2020 was performed. Participants completed a survey and a semi-structured interview on perceptions and experiences of COVID-19. Descriptive statistics were used for survey responses. Interview transcripts were analyzed and guided by modified grounded theory using an iterative approach to refine the guide and codebook. Interviews were independently coded by 2 investigators and discussed until consensus.

RESULTS

Twenty-five participants completed the survey; 20 participants were interviewed (45% recently used heroin, 40% unstably housed). Thirty-five percent was worried about COVID-19 infection. Three themes emerged from the interviews: (1) increase in meth use, (2) interplay of meth obtention and COVID-19, and (3) interactions with healthcare and social services.

CONCLUSIONS

People who use methamphetamine noted an increase in use along with the social distancing guidelines put in place for COVID-19 and employed a variety of harm reduction profiles when obtaining methamphetamine. Also, the pandemic brought difficulties in accessing care and amplified mistrust in healthcare instructions and public health messages. Based on these qualitative interviews, further work should consider aligning methamphetamine and COVID-19 harm reduction messages and working with trusted community resources to improve harm reduction strategies for methamphetamine use and COVID-19. IRB: Informed Consent by the University of Washington Human Subjects Division (approval number, STUDY00009277).

Associations between Circumstances Surrounding Overdose and Underlying Classes of Polysubstance Overdose Deaths

BACKGROUND

The overdose crisis is worsening, with polysubstance overdose deaths involving psychostimulants increasing in the U.S. Substance-specific prevention and intervention activities may not be as effective for polysubstance use, so we sought to classify substances used among overdose decedents to identify unique factors related to these classes.

METHODS

We used data from the Nevada State Unintentional Drug Overdose Reporting System, Jan 2019-Jun 2021, which comes from death certificates, coroner/medical examiner reports, and postmortem toxicology. Latent class analysis, multinomial logistic regression, and Chi-squared tests determined underlying drug use classes, differences in characteristics and circumstances surrounding overdose, and assessed relationships between circumstances and drug use classes.

RESULTS

We identified four latent classes: (1) prescription drugs (19.1%), (2) predominately methamphetamine (31.4%), (3) multi-drug (28.9%), and (4) opioid and stimulant (20.6%). Compared to other classes, the prescription drug class had a higher percentage of female decedents, from rural counties, with mental health diagnoses, who died at home. The predominately methamphetamine class had a higher percentage of decedents experiencing homelessness. The multi-drug use class had higher percentage of younger and Hispanic decedents. Those in the opioid and stimulant class had higher odds of being recently released from an institutional setting, compared to the multi drug class.

CONCLUSIONS

These underlying classes were associated with several characteristics and circumstances that can prove useful for prevention, treatment, and harm reduction agencies when designing programs and interventions to target specific groups of people at-risk for drug overdose.

A randomized controlled trial of contingency management for smoking cessation in substance use treatment patients

Background/Objective

Contingency management (CM) is one of the most effective interventions for smokers with substance use disorder (SUD), and no empirical assessment of its long-term efficacy has been conducted so far in a real-world context. The objectives were: (1) examine the additive effectiveness of CM on cognitive-behavioral treatment (CBT) for smoking cessation, and (2) examine the relationship between smoking cessation and substance use abstinence.

Method

A total of 80 participants (75.8% males; M_age = 45.31; SD = 9.64) were assigned to two smoking cessation treatments: CBT or CBT+CM. A set of generalized estimating equations were conducted to examine the effect of treatment condition on smoking outcomes, as well as the effect of smoking status on substance abstinence.

Results

Adding CM to CBT for smoking cessation improved tobacco abstinence rates at the end-of-treatment (p = .049). Tobacco abstinence rates declined over time (p = .012), but no significant effects of treatment condition were observed across follow-ups (p = .260). Smoking cessation was not significantly related to substance abstinence (p ≥ .488).

Conclusions

CM facilitates early abstinence in smokers with SUD, although effects subside after treatment termination. The lack of association between smoking abstinence and substance use suggests no jeopardizing effects as a result of quitting smoking.

Addiction and COVID: Issues, Challenges, and New Telehealth Approaches

In recent decades, the United States has seen a substantial increase in the number of people diagnosed with substance use disorder (SUD). Both SUDs and COVID-19 separately have had, and continue to have, a widespread impact on our society. While they are two distinct entities, they are intricately related and have been shown to influence one another. Lockdown mandates intended to enhance public safety produced unintended consequences for people with SUDs by decreasing access to treatment and disrupting their current care. Telehealth could offer a solution to this disruption as its utilization expands the provider’s reach and increases access to treatment in underserved populations, including those with SUDs. The use of telemedicine seems to result in higher rates of patient satisfaction, compliance, and treatment retention rates while maintaining the need for social distancing. Even when pandemic restrictions resolve, telehealth can continue to provide invaluable benefits to individuals with addiction, particularly those in rural America. In summary, ongoing research regarding telehealth delivery and the expansion of telehealth is a byproduct of the pandemic and can advance the American healthcare system beyond the days of COVID-19. This manuscript will review studies regarding the use of telehealth in SUD with the hope that further research within and beyond the COVID-19 pandemic will lead to the increased use of telehealth by those involved in and those receiving care for SUDs.

COVID-19 Lockdown and Consumption Patterns among Substance Use Disorder Outpatients: A Multicentre Study

INTRODUCTION

COVID-19 has had a great impact on mental health in the general population. However, few studies have focused on patients with substance use disorders (SUDs). This research aimed to compare the clinical status and substance use patterns of SUD outpatients, before and during confinement due to the COVID-19 pandemic.

METHODS

This multicentre study recruited 588 patients (29.2% women; M age = 47.4 ± 11.7 years) in thirteen centres for addiction treatment in Catalonia, Spain. All subjects were evaluated with validated instruments and ad hoc questionnaires. The sample was divided into 3 groups according to how the substance consumption pattern changed during lockdown (maintained pattern, worsened pattern, and improved pattern).

RESULTS

More than 62% of the patients maintained or worsened their consumption pattern during confinement, and about 38% improved throughout this time. Diverse factors were associated with the changes in pattern like age, addiction severity, psychological distress during lockdown, social and familial issues, and therapeutic variables.

CONCLUSION

The home lockdown during the COVID-19 pandemic was associated with major implications for substance consumption and psychiatric distress among SUD outpatients. Considering this, the need to plan appropriate interventions in cases of similar health crises is highlighted.

Addictions en temps de pandémie

L’Organisation mondiale de la santé a déclaré la maladie causée par le coronavirus 2 comme pandémie en mars 2020. Via les différentes mesures prises, un phénomène stressant psychosocial induit par cette épidémie a, dès lors, émergé en raison des difficultés financières, de l’isolement social et du caractère incertain du futur. L’ensemble des études nationales et internationales a mis en évidence une augmentation des usages de tabac, d’alcool et de substances illicites. Outre les comportements de consommation excessive, voire les décompensations addictives liées aux substances, il faut également prendre en considération l’usage excessif de la pornographie, des jeux de hasard et d’argent, des jeux vidéo essentiellement via Internet et l’exercice physique. La COVID-19 peut être à l’origine d’un certain nombre de conséquences et de complications chez les personnes souffrant de troubles liés à l’usage de substances licites ou illicites, population particulièrement vulnérable. Dans cette revue de la littérature narrative, nous analyserons les données concernant les comportements de consommation excessive et les addictions aux substances psychoactives licites et illicites et à certains types de comportements de la vie quotidienne. Nous avons, pour ce faire, utilisé les combinaisons de mots-clés pour sélectionner les articles scientifiques de langue anglaise et française publiés entre 2019 et 2021 en consultant les bases de données Medline, Embase, PsycInfo, Google Scholar.

Non-pharmaceutical interventions during the COVID-19 pandemic: A review

Infectious diseases and human behavior are intertwined. On one side, our movements and interactions are the engines of transmission. On the other, the unfolding of viruses might induce changes to our daily activities. While intuitive, our understanding of such feedback loop is still limited. Before COVID-19 the literature on the subject was mainly theoretical and largely missed validation. The main issue was the lack of empirical data capturing behavioral change induced by diseases. Things have dramatically changed in 2020. Non-pharmaceutical interventions (NPIs) have been the key weapon against the SARS-CoV-2 virus and affected virtually any societal process. Travel bans, events cancellation, social distancing, curfews, and lockdowns have become unfortunately very familiar. The scale of the emergency, the ease of survey as well as crowdsourcing deployment guaranteed by the latest technology, several Data for Good programs developed by tech giants, major mobile phone providers, and other companies have allowed unprecedented access to data describing behavioral changes induced by the pandemic. Here, I review some of the vast literature written on the subject of NPIs during the COVID-19 pandemic. In doing so, I analyze 348 articles written by more than 2518 authors in the first 12 months of the emergency. While the large majority of the sample was obtained by querying PubMed, it includes also a hand-curated list. Considering the focus, and methodology I have classified the sample into seven main categories: epidemic models, surveys, comments/perspectives, papers aiming to quantify the effects of NPIs, reviews, articles using data proxies to measure NPIs, and publicly available datasets describing NPIs. I summarize the methodology, data used, findings of the articles in each category and provide an outlook highlighting future challenges as well as opportunities.