1
|
Khazanov GK, McKay JR, Rawson R. Should contingency management protocols and dissemination practices be modified to accommodate rising stimulant use and harm reduction frameworks? Addiction 2024; 119:1505-1514. [PMID: 38627885 DOI: 10.1111/add.16497] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 03/15/2024] [Indexed: 08/03/2024]
Abstract
BACKGROUND Stimulant-related overdoses have increased dramatically, with almost 50% of overdoses in the United States now involving stimulants. Additionally, harm-reduction approaches are increasingly seen as key to reducing the negative impact of substance use. Contingency management (CM), the provision of financial incentives for abstinence, is the most effective treatment for stimulant use disorder, but historically has not been widely implemented. Many recent, large-scale implementation efforts have relied upon foundational CM protocols that may not sufficiently account for recent increases in the prevalence and lethality of stimulant use nor the growing preference for harm reduction versus abstinence-only frameworks. ARGUMENT We argue the need to (1) consider whether and how CM protocols might be modified to address rising stimulant use and harm reduction frameworks and (2) make CM widely accessible so that it can reduce population-level stimulant use while ensuring that it is delivered with fidelity to its basic principles. Proposed changes include changing CM reinforcement schedules to emphasize treatment engagement and reductions in use in addition to abstinence, changing guidelines on the duration of and re-engagement in CM, investing in research on virtual CM, incentivizing providers and health systems to deliver CM, making it easier to purchase and use point-of-care drug screens, using direct-to-consumer marketing to increase demand for CM and adapting CM to the community in which it is being implemented. CONCLUSIONS Our proposed modifications to contingency management (CM) protocols and accessibility may more effectively address rising stimulant use and align CM more closely with harm-reduction frameworks. Given the urgent need to reduce overdose deaths, developing and testing modified CM protocols may need to rely upon methods other than randomized controlled trials. Efforts to disseminate CM widely to reduce population-level stimulant use must be balanced with the need to maintain fidelity to CM's basic principles.
Collapse
Affiliation(s)
- Gabriela Kattan Khazanov
- Center of Excellence for Substance Addiction Treatment and Education, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - James R McKay
- Center of Excellence for Substance Addiction Treatment and Education, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Richard Rawson
- University of California Geffen School of Medicine, Los Angeles, CA, USA
- University of Vermont Center for Behavioral Health, Burlington, VT, 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
|
Forster SE, Torres TM, Steinhauer SR, Forman SD. Telehealth-Based Contingency Management Targeting Stimulant Abstinence: A Case Series From the COVID-19 Pandemic. J Stud Alcohol Drugs 2024; 85:26-31. [PMID: 37796622 PMCID: PMC10846603 DOI: 10.15288/jsad.23-00016] [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] [Received: 01/19/2023] [Accepted: 07/31/2023] [Indexed: 10/07/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Sarah E. Forster
- Veterans Affairs Pittsburgh Healthcare System, VISN 4 Mental Illness Research, Education, & Clinical Center (MIRECC), Pittsburgh, Pennsylvania
| | - Taylor M. Torres
- Veterans Affairs Pittsburgh Healthcare System, VISN 4 Mental Illness Research, Education, & Clinical Center (MIRECC), Pittsburgh, Pennsylvania
| | - Stuart R. Steinhauer
- Veterans Affairs Pittsburgh Healthcare System, VISN 4 Mental Illness Research, Education, & Clinical Center (MIRECC), Pittsburgh, Pennsylvania
- University of Pittsburgh, Department of Psychiatry, Pittsburgh, Pennsylvania
| | - Steven D. Forman
- Veterans Affairs Pittsburgh Healthcare System, VISN 4 Mental Illness Research, Education, & Clinical Center (MIRECC), Pittsburgh, Pennsylvania
- University of Pittsburgh, Department of Psychiatry, Pittsburgh, Pennsylvania
| |
Collapse
|
4
|
DePhilippis D, Khazanov G, Christofferson DE, Wesley CW, Burden JL, Liberto J, McKay JR. History and current status of contingency management programs in the Department of Veterans Affairs. Prev Med 2023; 176:107704. [PMID: 37717740 DOI: 10.1016/j.ypmed.2023.107704] [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: 03/28/2023] [Revised: 09/05/2023] [Accepted: 09/13/2023] [Indexed: 09/19/2023]
Abstract
OBJECTIVE This article describes the Department of Veterans Affairs (VA) national implementation of contingency management within VA substance use disorder (SUD) treatment programs. METHODS The rationale for implementing CM, role of VA leadership, and training and supervision procedures are detailed. The role of the Veterans Canteen Service (VCS) in sustaining the CM implementation through the donation of incentives is outlined. Updated outcomes from the primary program, CM to incentivize stimulant abstinence, are provided. Data presented were gathered from June 2011 to January 2023, from VA facilities across the country. RESULTS More than 6000 Veterans from 119 VA facilities have received CM in a 12-week program in which two urine samples are obtained per week, with 92% of the samples negative for the targeted substance. Two other CM pilot projects are described. The first incentivizes adherence to injectable medications for opioid and alcohol use disorders, with over 580 veterans from 27 VA sites participating to date. The second incentivized smoking cessation in 312 patients from four sites. A new initiative in which CM is implemented in smaller community-based VA facilities through use of onsite prize cabinets is presented and the possibility of providing CM remotely in VA is discussed. CONCLUSIONS It has proved feasible to implement abstinence CM and several other CM pilot programs at many VA facilities. Factors that contributed to the success of the VA CM rollout, challenges that were encountered along the way, and lessons learned that may facilitate wider use of CM outside VA are discussed.
Collapse
Affiliation(s)
- Dominick DePhilippis
- Department of Psychiatry, University of Pennsylvania, 3535 Market St., Suite 500, Philadelphia, PA 19104, United States of America; Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, Washington, DC 20420, United States of America
| | - Gabriela Khazanov
- Crescenz Veterans Affairs Medical Center, 3900 Woodland Ave., Philadelphia, PA 19104, United States of America; Department of Psychiatry, University of Pennsylvania, 3535 Market St., Suite 500, Philadelphia, PA 19104, United States of America
| | - Dana E Christofferson
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, Washington, DC 20420, United States of America
| | - Carl Wayne Wesley
- Crescenz Veterans Affairs Medical Center, 3900 Woodland Ave., Philadelphia, PA 19104, United States of America
| | - Jennifer L Burden
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, Washington, DC 20420, United States of America
| | - Joseph Liberto
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, Washington, DC 20420, United States of America
| | - James R McKay
- Crescenz Veterans Affairs Medical Center, 3900 Woodland Ave., Philadelphia, PA 19104, United States of America; Department of Psychiatry, University of Pennsylvania, 3535 Market St., Suite 500, Philadelphia, PA 19104, United States of America.
| |
Collapse
|
5
|
Reid N, Buchman D, Brown R, Pedersen C, Kozloff N, Stergiopoulos V. The acceptability of financial incentives to support service engagement of adults experiencing homelessness and mental illness: a qualitative study of key stakeholder perspectives Authorship. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2022; 49:1060-1071. [PMID: 36071341 DOI: 10.1007/s10488-022-01217-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 08/11/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Evidence suggests financial incentives may effectively support service engagement among people experiencing homelessness, but literature related to their acceptability in this population is limited. This study used qualitative methods to explore stakeholder perspectives on the acceptability of using financial incentives to promote service engagement among homeless adults with mental illness. METHODS As part of a larger mixed-methods pragmatic trial of a community-based brief case management program in Toronto, Canada, twenty-two trial participants were purposefully recruited to participate in semi-structured qualitative interviews, and five service providers and seven key informants were purposefully recruited to participate in a focus group and interviews, respectively. Topics included perspectives of acceptability and lived experiences of using financial incentives to support engagement, health and well-being. Data collection occurred between April 2019 and December 2020. Data was audio-recorded and transcribed. Coding and interpretation of data was informed by grounded theory and inductive thematic analysis. RESULTS Stakeholders held diverse views on the acceptability of financial incentives to promote service engagement in this population. Main themes across groups included moralizing recipient motivation; tensions in how best to define and respect autonomy; and consideration of potential unintended consequences for both individuals and the service system. Significant group differences within some themes emerged. CONCLUSION Results highlight ongoing debates over using financial incentives to facilitate service engagement among adults experiencing homelessness and mental illness. Differences in stakeholder perspectives suggest the need for person-centredness in health and research settings, and balancing theoretical risks and long-term goals with likely potential for immediate benefits.
Collapse
Affiliation(s)
- Nadine Reid
- Centre for Addiction and Mental Health, 1000 Queen St. W, M6H 1H4, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St, M5T 3M6, Toronto, ON, Canada
| | - Daniel Buchman
- Centre for Addiction and Mental Health, 1000 Queen St. W, M6H 1H4, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, 155 College St, M5T 3M7, Toronto, ON, Canada
- Joint Centre for Bioethics, University of Toronto, 155 College St, M5T 1P8, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, 60 Leonard Ave, M5T 0S8, Toronto, ON, Canada
| | - Rebecca Brown
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond St, M5B 1W8, Toronto, ON, Canada
| | - Cheryl Pedersen
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond St, M5B 1W8, Toronto, ON, Canada
| | - Nicole Kozloff
- Centre for Addiction and Mental Health, 1000 Queen St. W, M6H 1H4, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St, M5T 3M6, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, 250 College St, M5T 1R8, Toronto, ON, Canada
| | - Vicky Stergiopoulos
- Centre for Addiction and Mental Health, 1000 Queen St. W, M6H 1H4, Toronto, ON, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St, M5T 3M6, Toronto, ON, Canada.
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond St, M5B 1W8, Toronto, ON, Canada.
- Department of Psychiatry, University of Toronto, 250 College St, M5T 1R8, Toronto, ON, Canada.
| |
Collapse
|