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

Smartphone App-Based Contingency Management and Opioid Use Disorder Treatment Outcomes

Importance

Opioid use disorder continues to be a national crisis, contributing to substantial morbidity and mortality. Medication is the only evidence-based treatment for opioid use disorder; however, improving clinical outcomes may require augmenting it with psychosocial interventions, such as contingency management (CM), specifically, smartphone app-based CM.

Objective

To evaluate whether augmenting medication for opioid use disorder (MOUD) with app-based CM is associated with fewer days of opioid use at the end of treatment and greater retention than treatment with MOUD only.

Design, Setting, and Participants

This retrospective cohort study used data from November 1, 2020, to November 30, 2023, collected from opioid treatment programs and office-based opioid treatment programs across Texas. The cohort included individuals aged 18 years or older who were uninsured or underinsured and who chose to receive MOUD only or MOUD plus CM delivered via the WEconnect smartphone app. Participants who chose to receive app-based CM received monetary incentives upon achieving their self-chosen recovery goals.

Exposure

Opioid use disorder.

Main Outcomes and Measures

Primary analyses examined differences in treatment outcomes (self-reported days of opioid use at the end of treatment and retention) between patients who chose MOUD only and those who chose MOUD plus app-based CM. Linear regression analysis was used to examine days of opioid use at the end of treatment, and Cox proportional hazards regression analysis was used to examine retention.

Results

The analytic sample comprised 600 individuals (mean [SD] age, 38.4 [8.6] years; 342 male [57.0%]), with 300 included in each treatment group. Those who chose to receive MOUD plus app-based CM reported significantly fewer days of opioid use at the end of treatment compared with those who chose to receive MOUD only (mean [SD] duration, 8.4 [12.9] vs 12.0 [13.5] days; β = -6.10; 95% CI, -8.09 to -4.10). Retention analysis showed that patients who chose to receive MOUD plus app-based CM were significantly more likely to stay in treatment longer compared with those who chose to receive MOUD only (mean [SD] duration, 290.2 [109.4] vs 236.1 [128.1] days; β = 51.91; 95% CI, 33.86 to 69.95).

Conclusions and Relevance

These findings suggest that augmenting MOUD with app-based CM may provide clinical benefits for underserved patients. Expanding the availability of app-based CM may contribute to decreasing the societal, economic, and personal burden of opioid use.

How Does Telehealth Expansion Change Access to Healthcare for Patients With Different Types of Substance Use Disorders?

BACKGROUND

Patients with substance use disorders (SUDs) exhibit low healthcare utilization despite high medical need. Telehealth could boost utilization, but variation in uptake across SUDs is unknown.

METHODS

Using Wisconsin Medicaid enrollment and claims data from December 1, 2018, to December 31, 2020, we conducted a cohort study of telemedicine uptake in the all-ambulatory and the primary care setting during telehealth expansion following the COVID-19 public health emergency (PHE) onset (March 14, 2020). The sample included continuously enrolled (19 months), nonpregnant, nondisabled adults aged 19 to 64 years with opioid (OUD), alcohol (AUD), stimulant (StimUD), or cannabis (CannUD) use disorder or polysubstance use (PSU). Outcomes: total and telehealth visits in the week, and fraction of visits in the week completed by telehealth. Linear and fractional regression estimated changes in in-person and telemedicine utilization. We used regression coefficients to calculate the change in telemedicine utilization, the proportion of in-person decline offset by telemedicine uptake ("offset"), and the share of visits completed by telemedicine ("share").

RESULTS

The cohort (n = 16 756) included individuals with OUD (34.8%), AUD (30.1%), StimUD (9.5%), CannUD (9.5%), and PSU (19.7%). Total and telemedicine utilization varied by group post-PHE. All-ambulatory: total visits dropped for all, then rose above baseline for OUD, PSU, and AUD. Telehealth expansion was associated with visit increases: OUD: 0.489, P < .001; PSU: 0.341, P < .001; StimUD: 0.160, P < .001; AUD: 0.132, P < .001; CannUD: 0.115, P < .001. StimUD exhibited the greatest telemedicine share. Primary care: total visits dropped for all, then recovered for OUD and CannUD. Telemedicine visits rose most for PSU: 0.021, P < .001; OUD: 0.019, P < .001; CannUD: 0.011, P < .001; AUD: 0.010, P < .001; StimUD: 0.009, P < .001. PSU and OUD exhibited the greatest telemedicine share, while StimUD exhibited the lowest. Telemedicine fully offset declines for OUD only.

CONCLUSIONS

Telehealth expansion helped maintain utilization for OUD and PSU; StimUD and CannUD showed less responsiveness. Telehealth expansion could widen gaps in utilization by SUD type.