and happy whatever day it is that you're watching this presentation. Thanks so much for joining me today while I talk about contingency management and specifically how we can use contingency management for the treatment of substance use disorders. In terms of disclosures and just a little bit about me, I don't have any conflicts to report, any financial conflicts to report. Just a little bit about me, I received both my degrees from West Virginia University a handful of moons ago, and I've been working in the mental health field since 2005. I am currently the lead commission for addiction services with the WVU's Department of Behavioral Medicine and Psychiatry. I've been here since late 2010. And then I'm also an adjunct instructor for WVU School of Counseling and Wellbeing. I teach in their addiction studies programming. And while I don't have any conflicts to report, one disclosure is that I reluctantly have a homestead farm, which at times really feels more like a glorified petting zoo. And so the way these animals earn their keep at home is by showing up in my lectures from time to time. So today they're gonna actually help me kind of illustrate the learning theories behind contingency management, and then how contingency management can work for you as a provider. So you're gonna see these critters show up in the future. In terms of our objectives for the presentation, what we're gonna do is review current substance use disorder statistics. I'm going to provide an overview of contingency management. We will review the evidence and support of contingency management. I'm going to highlight the importance of reinforcement schedules and incentive types. And then I'll end by offering recommendations for growth with contingency management policies. And so here are the desired results that hopefully you'll walk away from today after viewing this presentation. So the hope is that you're gonna understand how reinforcement theories led to the development of contingency management. You'll be able to develop a framework to implement contingency management in your own practice, and then also use your knowledge of contingency management to advocate for continued changes in policy development. I know I'm talking to an audience of addiction experts, so these numbers probably won't surprise you, but I'd still like to just start off with kind of a quick review of where we're at with current substance use disorder statistics. And so in November, 2023, the U.S. Department of Health and Human Services through SAMHSA, they released the results of the 2022 National Survey on Drug Use and Health. And what they found was that in 2022, 48.7 million people aged 12 or older had a substance use disorder in the past year. And that was including 29.5 million who had an alcohol use disorder, 27.2 million who had a drug use disorder, and 8 million people who had both an alcohol use disorder and a drug use disorder. Among the 39.7 million adults aged 18 year older in 2022 who had a substance use disorder in the past year and did not receive a substance use treatment in the past year, 94.7% didn't seek treatment or think that they should get it. And then only an estimated 0.8 of adults with a substance use disorder sought treatment and only 4.5 of adults with a substance use disorder did not seek treatment, but thought that they should get it. Here we have a chart that depicts the pattern of opioid overdose deaths over the last 25-ish years. It outlines these four distinct ways. I know you all have heard about before and it takes us to what we're dealing with now in the present day. And so the first wave began, you know, with those increased prescribing of opioids in the 1990s with overdose deaths involving prescription opioids increasing since at least 1999. That second wave began there in 2010 with rapid increases in overdose deaths involving heroin. The third wave, as you can see here, began in 2013. This is where we saw significant increases in overdose deaths involving synthetic opioids, particularly those that involved fentanyl. And then additionally, what we were seeing was that opioid involved overdose deaths also included other drugs, other substances. And so finally, this fourth wave began in 2018 when we saw a rise in deaths by methamphetamines. And so while the availability and the use of illicit fentanyl is still the major driver of these overdose deaths, many individuals are exposed to fentanyl knowingly and unknowingly through their purchase of and use of other fentanyl-laced cocaine and methamphetamine. So this chart breaks down what drugs were involved in overdose deaths from 1999 to 2021. Looking closely at those last two years here listed 2020 and 2021, we see that big spike in fentanyl, methamphetamine, and cocaine. And then data by the CDC shows that drug overdose deaths reached a record high of over 93,000 in 2020, and then another record high of over 107,000 in 2021. And since I am here from West Virginia, I'm gonna point out how much our Appalachian region is struggling, as you can see in the pitch black parts of this graphic. And again, looking specifically at our rural state here, what we've seen is what you all have seen happening all across the country, the significant rise in overdose deaths related to fentanyl and methamphetamines. Okay, I got through, I call those the bummer slides, the bummer statistics. So let's now talk about something that can help with this, and that is contingency planning. So in talking about contingency management, we have to first talk about the origins of it, and that is learning theories. And so in case any of you have your old Psych 101 textbooks lying around, you can crack those open because we're gonna get a quick refresher course here. So I'm going to talk about classical conditioning and then operant conditioning, which will lead us to the next slide. So in talking about contingency management, we're gonna talk about operant conditioning, which will lead us into how contingency management came to be a research treatment intervention. And then don't forget these guys over here are gonna help me explain just what I'm talking about. So we'll start with classical conditioning. It's a learning style that's credited to the great Ivan Pavlov for researching. And so classical conditioning is an example of an unconscious learning method. And it's really the most straightforward way in which we humans and animals can learn. So classical conditioning is the process in which an automatic conditioned response is paired with a very specific stimuli to install that connection within the person or animal. Apparently classical conditioning was stumbled upon by accident, which I actually didn't remember until I was freshening up my own classical conditioning knowledge. So Pavlov was conducting research on the digestion of dogs when he noticed that the dog's physical reactions to food suddenly changed over time. So at first the dogs would only salivate when the food was placed in front of them. However, later they salivated slightly before their food arrived. And so Pavlov realized that what they were doing was salivating at the noises that were pretty consistently present before that food arrived. And so to test this out, what he did was set up an experiment in which he would ring a bell shortly before presenting food to the dogs. At first, the dogs elicited no response to the bells, didn't really mean anything to them. However, eventually the dogs began to figure out that that bell meant their breakfast was coming pretty soon and so they would start to salivate. And so again, let's review what's happened here. There's a neutral stimulus, which is a stimulus that at first elicits no response. And so Pavlov introduced the ringing of the bell as that neutral stimulus. An unconditioned stimulus is a stimulus that leads to an automatic response. And so in Pavlov's experiment, the food was that unconditioned stimulus. An unconditioned response is an automatic response to a stimulus. And so the dogs salivating for food is the unconditioned response in Pavlov's experiment. And then that conditioned stimulus is a stimulus that can eventually trigger that conditioned response. And so in that experiment above, the conditioned stimulus was the ringing of the bell and then the conditioned response was that salivation. And so from a teaching perspective, it's really important to note that the neutral stimulus becomes the conditioned stimulus. Now, if you take a look at this at the upper right-hand corner here, you'll see a collection of little piglets. So those kids learned pretty early that when they hear the sound of the food barrel lid being opened, that they're gonna be met with a pile of food soon. So regardless of where they're at in the pasture, they come run into the fence line and park themselves right in the spot where that food is always dumped. So they have learned to respond to that sound. So here's some classical conditioning examples from a substance use disorder treatment perspective. And so what our patients will tell us is that they can experience a physical craving when they're faced with visual cues of the previous drugs they used to use, or if they're placed back in a drug-related environment or around people that they used to use with, it will bring about those cravings within them. If a patient was treated badly by previous healthcare providers, they can develop maybe an anxious or angry response to being faced with new healthcare providers. I don't know if you all have experienced this, but I see that sometimes in my office, if a new patient is coming in for an assessment, sometimes I'll notice they immediately have their walls up potentially because they have been conditioned to expect that, a stigmatizing attitude from me. In aversion therapy, a person learns to associate something negative with a behavior that they wanna stop. So for example, if a person misuses alcohol, they could be given a medication like antabuse that causes them to get sick every time they drink it. And so the hope is, or the goal is for that negative response, getting sick, to condition them to no longer want alcohol. And finally, this picture depicts a twofer of classical conditioning. So both my chickens and dog have learned to come running when they hear the Cheerios box being shaken. Moving on, let's now talk about the other big learning theory associated with contingency management, and that is operant conditioning. So you may remember the name B.F. Skinner, who was a behavioralist. He believed that the best way to understand behavior is to look at the causes of an action and its consequences. And so he called this approach operant conditioning. Operant conditioning or instrumental conditioning, it's a theory of learning where behavior is influenced by its consequences or reinforcements. So behavior that is reinforced or rewarded will likely be repeated, and behavior that is punished will hopefully occur less frequently. And so these reinforcements can fall into three categories. So first is positive reinforcement. Positive reinforcement is meant to increase the frequency of a behavior when it's given. So for example, if a child cleans their room, they get to have a treat afterwards. Negative reinforcement is meant to increase the frequency of a behavior when it's removed. So for example, when my alarm went off this morning, I got up out of bed so that I could turn my alarm off and stop having to hear that awful sound that it makes. And lastly, we have adversive reinforcement or punishment. So adversive reinforcement or punishment is meant to decrease the frequency of a behavior when it's implemented. And so if I get pulled over speeding on my way home from work today, the speeding ticket I may be given is meant to encourage me to not speed in the future. That's never happened, by the way, I just wanna go on record saying that. So over here on the right-hand screen, we have Barry, who is demonstrating the core definition of positive reinforcement. When he pushes on that lever with his tongue, he gets a nice shot of water. On a good day, it's a nice shot of cold water. Speaking of, I'm gonna take a little water break myself. Okay. So we talked about the types of reinforcement, now let's talk about the schedules of reinforcement. This feels eerily like math to me, so hang in there with me. Behaviorists discovered that different patterns or schedules of reinforcement had different effects on the speed of learning and extinction. And so we're looking at fixed versus variable and then ratio versus interval. And so a fixed ratio schedule of reinforcement means that you receive that reinforcement after a specific number of correct responses, which could just be one correct response. And this has a very high response rate. So back to Barry, every time he presses on that lever, he gets water. A variable ratio schedule of reinforcement, that means the behavior is reinforced after an unpredictable number of times. And so gambling is an example of that. Also fishing is an example of this. I told my husband that after completing the slide, I now have a little bit more understanding of why he decides to keep fishing. A fixed interval schedule of reinforcement means that one reinforcement is given after a fixed time interval, as long as at least one correct response has been made during that time. So an example of that would be being paid by the hour or if we're thinking about our treatment setting. So another example would be every 15 minutes, pain meds are delivered through a pain pump, providing at least one press has been made to that pain pump. And then the pain pump is automatically shut off. And a variable interval schedule of reinforcement means that as long as one correct response has been made, reinforcement is given after an unpredictable amount of time has passed, for example, on average every five minutes. So an example of that would be a self-employed person maybe being paid at unpredictable times. As we're talking about using reinforcement to help change behaviors with our patients, it's important to highlight that we don't want to just focus on decreasing undesired behaviors. For example, like using stimulants, we also wanna help them increase desired behaviors. And so differential reinforcement of other behavior or DRO is an ABA technique used to reduce or eliminate challenging behaviors by reinforcing any behavior other than the negative behavior. And so the goal is to increase more desirable and appropriate behaviors, instead of just focusing on extinguishing the one undesirable behavior. And so in our clinical world, examples of that would be encouraging attendance to individual therapy sessions or group therapy sessions, encouraging the patients to attend peer recovery meetings outside of their treatment, encouraging them to complete assignments or activities that we've attached to their treatment plan. And so by encouraging these other treatment engagement activities, the hope is that engagement is going to help with that initial goal that we have for our patient, for example, to stop using the stimulants. So back on the farm, we wanted to get our rooster TR to stop flying out of the fenced in pasture and eating all the berries in the garden as he's doing so lovingly on the left side of the screen. And so while we wanted him to decrease that behavior, we also wanted him to increase the behaviors of staying around the chickens and protecting them. And so with a lot of extra food and treats, we eventually were able to make that happen. Okay, folks, now that we have refreshed our memories on a few learning styles and reinforcement schedules, we can now talk about how that specifically applies to contingency management. So contingency management is sometimes called motivational incentives, the prize method, the carrot and stick methods, behavioral contracting, and to contingency contracting, it's got all kinds of names. You're gonna hear me mostly call it contingency management or just CM for short. So no other intervention, behavioral or pharmacological for the treatment of stimulant use disorder has as strong an evidence base as contingency management. And you're gonna hear me repeat that point again later. So contingency management is based on the principle of operant conditioning that behavior is shaped by its consequences. Contingency management is designed to increase desired behaviors by providing immediate reinforcement consequences in the form of incentives when that target behavior occurs and withholding those incentives when the target behavior does not occur. It's comprised of a broad group of behavioral interventions that either provide or withhold rewards and negative consequences quickly in response to at least one measurable behavior. It is a well-known behavioral intervention, though it is still underutilized, and we're going to talk about why that is later on. So the overarching goal of contingency management is to help the patient learn to consistently act in effective ways, even when experiencing difficult or disruptive inner experiences. So back on the farm, I wanted to assist Squeak to stop biting me. So while she didn't get punished when she did so, what she did was get extra treats when she did other things like balance on my back. So researchers began studying contingency management as an intervention for alcohol use disorder in the 1960s. In the 1990s, dozens of studies showed that contingency management is a helpful intervention for increasing abstinence among individuals with cocaine use disorder. And there is now an abundance of research, including large clinical trials on contingency management, being helpful with stimulant use disorder. And it is more effective than any medication out there. So the assumptions in contingency management are based on the operant conditioning principles that we've talked about today. And so the first assumption is the idea that addiction is maintained and reinforced by a combination of the rewarding biochemical effects of the substance and of the environmental influences. And so what we can do is target specific behavioral change by systematically applying immediate and certain rewards and consequences. We also assume that individuals will be able to initiate and sustain abstinence, or maybe reductions in substance use, as long as the rewards of the abstinence are greater than the neurobiologically mediated rewarding effects of substance use. And so this will also be able to initiate and sustain abstinence as long as the consequences of substance use are greater than any perceived consequences of abstinence. I want you to keep that last assumption in mind when we talk further about rewards or incentives in the future. So from a clinical practice standpoint, here's another way to kind of show us the basic principles of contingency management. So first, what we want to do is frequently monitor for that target behavior. We want to provide incentive when target behavior occurs and provide it as soon as possible. We want to remove that incentive when the target behavior does not occur. And then we want to keep repeating this habit loop. In contingency management interventions in the substance use disorder treatment world, patient's receiver will reward for meeting a treatment goal. In the most common types of contingency management, patients will either receive a cash or a voucher or another prize in response to a measurable behavior. So for example, when they're able to produce a negative urine toxicology screen. Many of these prize reinforcement contingency management strategies have built in bonuses also, such that with the accumulation of negative toxology screens over time, the patient can then actually earn even greater and greater rewards for each subsequent negative screen that is completed. And so research has shown that rewarding appointment attendance is actually equally effective to rewarding abstinence with respect to treatment engagement. And one study found that rewarding appointment attendance was actually superior to rewarding abstinence which I find interesting. So it boils down to when we are rewarded for things that motivates us to want to continue doing that thing and maybe even get better at that thing. I don't know about you all, but I didn't come to work today just out of the goodness of my heart. I came because I get the rewarding of helping people. And then also I happened to get a paycheck, which helps. So how do incentives work, you ask? Well, here's an easy peasy chart that will help show us that. And so the way it works is patient attends treatment, they are given an incentive and the hope is that's going to help them retain them in treatment. Patient also engages in additional desired behavior like a negative urine drug screen. They get that incentive and the hope is over time it helps reduce their substance use. And so that's the way it works. And so this process addresses that impulsivity and the reward center of the brain by providing that immediate gratification that is necessary for learning. And so let's talk even more specifically about incentives. So incentives come in the form of vouchers, points or tokens that can then be exchanged for money, prizes, excuse me, or privileges. So an example of a privilege could be maybe earning take-home doses of methadone for people in an opioid treatment program. Some research suggests that people with substance use disorders respond better to receiving concrete incentives like an actual prize in the moment or money in the moment rather than a voucher or a token, which is only an incentive in the abstract and is not in and of itself valuable. However, other publications recommend sticking with vouchers for items that relate to the patient's wellbeing. And so incentives can be administered regularly. If you remember from my psych reviews, that's a fixed schedule. So like an example would be every time the patient achieves a target behavior, let's say they remained abstinent as documented by a negative drug screen or they can also be given intermittently. So that's called a variable schedule. There's what's called a fishbowl procedure, which is common in contingency management programs. You can also call that a variable magnitude of reinforcement. It's the idea that slips of paper are placed in a fishbowl, half indicating that an incentive has been won and then half offering the positive reinforcement, reinforcing statement, something like good job. And so this method prevents patients from being able to predict when they will and will not get that sort of concrete money-based incentive. Incentives can also be dispersed on an escalating schedule with that incentive gradually increasing every time a target behavior is occurred. So if a target behavior is ever not achieved, then what happens is the incentive value resets back to that original value and the escalating schedule begins again. So an example would be we use contingency management in one of our treatment groups and it's a four-week program. And the first week when they produce a negative toxicology screen or they come to their appointments, they're given X amount of dollars. The second week that they do those behaviors, coming to their appointments, giving a negative urine screen, that X number of dollars increases to a higher number and it increases all throughout those four weeks. Some research suggests that people with substance use disorders respond better to contingency management that uses both immediate and delayed incentives, wherein patients earn an incentive right after meeting a target behavior, but then also win the opportunity to potentially earn an even larger incentive in the future as that target behavior is continually met. It's important to educate the patient ahead of time on what they can expect. So what that schedule of giving incentives will be. So for example, are they gonna get them right away? Is it gonna be following a brief delay? For example, giving vouchers that can then be exchanged for prizes in the moment or potentially exchanged in later at the week. It's just really important for them to know that so they know what to expect. Asking their preference could also be really helpful here because you're going to find out what they find motivating, but that might not be doable just given what your program needs are, given what your team has decided on for that. But that's an option to consider is having your patients in on the conversation of what would they find motivating. So here we have baby girl Piglet. Now, if I try to give her a paper voucher, do you think that would be very motivating to her? Nope, not at all. She would immediately chew it up and then spit it right back out. So for her, I happen to know that she is motivated by fresh fruits and vegetables. And so that is her incentive here. Well, let's talk about size. So the size of the individual incentives may be important in generating positive results with higher value cash incentives affecting more positive behavioral changes. Here's where the research is mixed. So some research found no difference in behavioral outcomes. The SAMHSA Treatment Improvement Protocol 33, I'm going to talk about that even later. They referenced a study that looked at comparing incentives that were averaged at $300 with larger incentives with an average of $900. And they didn't find a difference in outcomes. The bigger issue, however, is the size of the cap. So currently, SAMHSA limits contingency management payments to $75 per year using any federal funds, including grant funds. And so in relation to the behavioral target of drug abstinence, what some folks have found is $75 is an ineffectual reinforcer magnitude. So researchers Dalian Company, they wrote an article I'm going to reference in a little bit. They pointed out that programs that offer such limited value incentives are potentially counterproductive to the development and the dissemination of effective treatment for substance use disorders. The concern is that program evaluators or other relevant stakeholders, they may incorrectly conclude that contingency management is ineffective when program failure is really instead a product of just that low reinforcement magnitude. And so ultimately to help maintain target behaviors, the longer a patient maintains a target behavior, such as remaining abstinent, the greater that incentive should be. And so for example, a patient could earn more draws from that fishbowl for sequential stimulant negative urine drug screens, for example. I'm going to take a quick little library. So listed here are recent manuals and protocols that discuss the use of contingency management specifically for stimulant use disorder. So first up, I've already mentioned it once before, the Substance Abuse and Mental Health Services Administration, they have their treatment for stimulant use disorder improvement protocol, which was last updated in 2021. And there is a whole section on contingency management. The U.S. Department of Health and Human Services released a report just this past November, 2023 on strategies to support contingency management. And then finally, the American Society of Addiction Medicine and the American Academy of Addiction Psychiatry recently released their own clinical practice guidelines on the management of substance use disorder. They all state that there is strong evidence that contingency management is an effective intervention for increasing treatment engagement and reducing stimulant use. They reference a well-known systematic review that evaluated reviews covering various psychosocial and pharmacological interventions for stimulant use disorder. And they found that contingency management was the only effective intervention. Let me drive this point home, in case you haven't heard me say it a few times already. There's over three decades of research that shows us that contingency management is more effective than any other behavioral intervention we have out there for stimulant use disorder. And contingency management is also more effective than any pharmacological interventions for stimulant use disorder. And since I'm talking to a group of addiction medicine experts, you already also know that there are no current FDA approved medications for stimulant use disorder. Let's also talk about contingency management for opioid use disorder. So we know that treatment involving medications for opioid use disorder has proven to be highly effective, but unfortunately that comorbid stimulant use and other behavioral health problems can often undermine these treatments. And so there was a systematic review and meta-analysis done that examined 74 reports that looked at contingency management being used in conjunction with MOUD treatment. Their primary outcome was whether contingency management was associated with positive outcomes at end of treatment assessments for the following six clinical problems. So they looked at stimulant use, polysubstance use, illicit opioid use, cigarette smoking, therapy attendance, individual or group therapy attendance, and then medication adherence. And ultimately their systematic review and meta-analysis provides supports for the efficacy of contingency management for addressing a wide range of clinical problems that are common among people receiving medications for opioid use disorder. Here is where the research splits when looking at contingency management for stimulants and contingency management for opioid use disorder. So the follow-up results in this meta-analysis indicate that treatment effects often dissipate after contingency management is discontinued. So supporting our patients in developing relapse prevention strategies is key in the treatment planning process here, but I know you all know that. So using technologies, you know, we're talking digital health tools or apps, there's sort of various ways that we can use technology out there. That's where the current contingency management research is focusing on. We do know that using technology can be an effective way to get quick data and also actually give quick incentives. And in our telehealth world, this is a really nice addition. So although contingency management protocols can be high or low or no tech, there's a number of emerging technological solutions such as patient-facing mobile apps combined with provider-facing dashboards. Those can facilitate the tracking progress towards recovery goals and the overall program level management of the selected reward system. Let's chat honestly about the struggles with in-person programming these days. So a lot of contingency management programs out there, they require in-person visits to collect drug samples, to deliver reinforcers and to provide additional therapeutic support. These in-person treatment models can also create several potential barriers, right? So from a program perspective, issues that we see are maybe a lack of personnel, a lack of personnel that have the expertise in contingency management or contingency management programs that put too much burden on staff. Clinics may also lack the time necessary to provide specialized training in contingency management in its underlying theoretical framework. Then from a patient perspective, attending in-person treatment can be difficult. We're asking people to show up in-person frequently, but they may have transportation issues or childcare issues or jobs that don't want to excuse them every week. And testing for, if you're using testing as a part of your contingency management sort of incentive process, that testing can be required anywhere from several times per day to several times per week. And that's a lot to ask. If in-person verification is required, clinics really need staffing and resources to conduct these tests and patients need to be able to travel to the clinic regularly. And so implementing in-person contingency management requires programs and policies to mitigate these barriers. One way to mitigate these barriers is to employ remote internet and smartphone-based treatment delivery. So these methods entail remote detection of drug status using biochemical sensing. There's remote delivery of incentives. There's ways to use video or photo evidence to verify the end user's identity. And then remote methods, what they could do is supplement, extend, or replace in-person treatments when appropriate. So digital contingency management also reduces the staff needed for individual monitoring, which is helpful. Drug testing procedures, automatic incentive delivery, and accounting can all be conducted remotely. So for our contingency management program I talked about earlier, it is done in our group-based therapy setting that's done virtually that takes place on Zoom. And so the way it works is our patients have reloadable gift cards. And so when we're signing in for their group therapy session that day, the minute they're signing in, that's them attending their appointment. Then we just, thankfully, we have staff that are able to go in and then just load money onto that gift card. So they get it in the moment, even though they're not coming here in person. There are several digital health tools and apps in the news and research. I have just a few listed here, but there's really more, there's a lot out there. But on here, for example, there's Dynamic Care, WeConnect, the Connections app. I also really encourage you to check out this article by Dallery, DiFulio, and Reif, titled Digital Contingency Management in the Treatment of Substance Use Disorders. They review research that's been done using digital contingency management for tobacco, alcohol, and illicit substances. And they report on the positive outcomes using those digital measures. I'd also like to take this moment to thank my husband for helping to take these pictures of the animals with my phone. He is a trooper. I will admit it's hard to talk about contingency management without talking about the community reinforcement approach, but alas, I only have a good one hour with you good folks. So I still wanna mention it here because it comes up in the research frequently as being a good partner to contingency management. And so community reinforcement approach is a behavioral therapy model, and it's based on the operant conditioning theory that we talked about earlier. So the focus is how can we help individuals find healthier, more adaptive ways to meet their social and emotional needs rather than using substances? So it's comprised of a broad group of behavioral interventions that provides or withhold rewards and negative consequences quickly in response to at least one measurable behavior. So during the treatment, patients learn practical skills to meet their goals. So examples of that would be maybe healthy communication, problem solving, conflict resolution, relapse prevention, things like that. The community reinforcement approach may also incorporate things like job hunting skills, social recreational counseling as ways to identify sober activities. And the, excuse me, the clinician is likely to take a very active role in their treatment that can include role-playing to help the patient learn and practice these skills and then encouraging the patient to try out new activities. In SAMHSA's Treatment Improvement Protocol for Simulant Use Disorder, I talked about that earlier, their section about contingency management references community reinforcement approach and recognizes that the combination of those two of both contingency management and community reinforcement approach was the most effective treatment in both the short and long-term follow-up for people using simulants. When I say effective treatment, I'm referring to the fact that they saw both a decreased treatment dropout rate and increased rates of abstinence by the end of treatment at both that short-term and long-term follow-up. The ASAM, AAAP Clinical Practice Guideline book, they also discussed community reinforcement approach and they shared that moderate evidence does exist that shows community reinforcement approach can help with treatment retention along with those abstinence rates and abstinence duration. Unfortunately, it hasn't been widely implemented because of its barriers. So CRA requires a lot of resources on the part of the staff and the program. We're talking costly services, it's labor intensive and there's some significant training that goes along for it. So that coupled with significant patient commitment really means that it's just not often used as regularly. So the overall strengths and weaknesses of a contingency management program is that it is proven to increase retention rates, increase abstinence rates and overall engagement and treatment. So there are some weaknesses and variabilities or vulnerabilities, excuse me, that we wanna talk about. So it could appear to mimic gambling. Some programs object to implementing contingency management on the grounds that it could be classified as this game of chance. So for example, in some contingency management interventions, we talked about that fishbowl process. So participants pull tickets out of a fishbowl after a negative toxicology screen and some of the tickets have prizes and those can range in value. And so that feels like gambling to some folks. That said, there's currently no evidence that contingency management increases gambling behavior or problematic gambling in folks. It does require staff involvement in tracking which could feel like a burden if it's not implemented in a way that fits your program and fits your staffing needs. And there is a stigma, there's still a stigma about using contingency management to help people develop sobriety. And we're gonna talk more about that in the next slide. So in terms of program considerations when utilizing contingency management, I wanna drive a few points home here. So the program you design has to be simple. It has to be simple for the staff to understand and for the patients to understand. If it's confusing or the incentive schedule or the schedule process isn't clear, it might not really create the momentum within folks that is needed to stick with it. Making the target behaviors clear to everyone and easy to track is really, really helpful. So for example, a negative drug screen is a very clear behavior that your program is likely also tracking anyhow. So that's a sort of another part of this is how can we double dip in a good way? How can we figure out what are we already doing and use that as a part of the incentive process? If it's a simple program with easy to track behaviors and easy to deliver, then the hope is that it's not a burden on staff to implement this program. And so lastly, let's talk about staff buy-in which is really important. So there is definitely some stigma around contingency management. While it does seem that that resistance to contingency management is declining as more people are educated on its effectiveness, the resistance is still there. So some people feel that you shouldn't have to quote unquote pay people to get sober, that we're bribing people and that recovery should be the reward. And so providing those staff with the evidence behind contingency management is incredibly helpful so they can see firsthand what the research has shown us why we're deciding to bring it into our treatment agencies and really reframing it with them that this is an engagement and a retention tool and that what we're doing is trying to help patients retrain their brain to allow them to continue sobriety on their own. So not necessarily, certainly not punishing them for have that stigmatizing attitude but really help them have an opportunity to see it from a different perspective. So to summarize on how and why contingency management works, I took these straight from that DHHR report I mentioned previously. So it works by helping people to make health promoting changes in their lives that would otherwise be very difficult because of the impacts of the addiction on the brain. And so contingency management does this by helping to recalibrate that brain's reward system towards recovery-related behaviors. It holds people accountable for meeting their recovery goals, right? We're reinforcing recovery-related behaviors which is a positive kind of accountability and we're withholding incentives when they aren't meeting those goals but not doing so in a shaming, punishing way. Abstinence-based contingency management protocols mitigate the likelihood of diversion because clients who use a substance won't receive an incentive. I also wanna point out here that the risk of clients diverting their incentives towards obtaining other substances is low. That also wasn't found in the research. The abstinence effects, the stimulants abstinence effects of contingency management come last even after treatment is completed. In studies that were referred to in the report, they consistently found that contingency management is among the most effective treatments for promoting lengthier periods of abstinence during treatment, which is associated with a greater likelihood for long-term abstinence following treatment. And so to summarize contingency management programming, the important variables to remember are that we want to identify the target behavior. We want to design the monitoring schedule that is motivating to the patient and also doable for us staff. And we wanna land on a delivery of the reinforcement that is accessible to the patient. And so frequency of the incentive is really important. Getting the incentive to the patient immediately and consistently is really important. And again, finally making sure it is an incentive that the patient will find meaningful. So Spork over here is showing us just how much he loves a fresh mud bath and Billy is demonstrating how impactful fresh leaves are for her. These two would not like to switch those out. Billy wants nothing to do with a mud bath and Spork really couldn't care about some tree limbs if we tried to give them to him. As we're finishing up here, I'd like to address the barriers that exist with current contingency management programs and what the experts are recommending for future changes or research. So let's talk about those barriers that exist with implementing contingency management. I already addressed the financial caps as a barrier to effective contingency management, but I have those points here repeated on the slide as well is that that $75 limit is just really seen as not an effective reinforcer and possibly counterproductive. Let's next talk about regulatory barriers. So treatment providers have to be mindful of the federal anti-kickback statute, which I really had to learn about as well getting this presentation ready. And so this prohibits getting paid for patient referrals or generation of business involving medical services billed to the federal government. And so in December, 2020, the Office of the Inspector General published clarification known as the OIG Final Rule. And they found that contingency management, while they weren't necessarily considered a safe harbor, they're not inherently in violation of the anti-kickback statute, and they can really be analyzed on a case-by-case basis. However, implementation of contingency management in compliance with that OIG Final Rule, it's not well-defined. Programs can seek guidance from the OIG. They're not required to do so, but that also takes some time. A recent report by the Motivational Incentives Policy Group, so that's a stakeholder coalition of contingency management experts in policy research, legal analysis. They outline those guardrails that serve as unofficial guidelines for the use of contingency management incentives, making sure that they're just in alignment with that OIG Final Rule. Additionally, some programs don't have the system to set up to track the incentive process. So for example, we here provide mentorship to an addiction treatment program in West Virginia. They've been attempting to give out incentives for a couple of years, and they keep kind of consistently getting passed around from person to person within their larger system, because they can't figure out how to get that money and then be able to give out that money. And then there's the IRS issue. So if programs use contingency management at evidence-based incentive amounts, or if they're using those much larger amounts, they also have to now consider tax-related issues. So the Internal Revenue Service currently considers money that is earned in a contingency management protocol to be taxable income. And if the amount earned is more than $599 per calendar year, this income must be reported to the IRS by the treatment provider. It's not clear how reporting of this income to the IRS impacts federal confidentiality regulations for individuals in SUD treatment. And so to avoid this added complication, many current contingency management programs just use an incentive amount of $599 or less. A related risk is that if incentives are considered by the IRS to be taxable income, this income could potentially impact the benefits cliff issue. So the benefits cliff issue refers to the fact that if an individual's earned income exceeds a specific amount, the household is rendered ineligible for public benefits. And so a lot of our patients with similarly disorder, they rely on other public benefits and safety net programs. And so if the money they're earning in our contingency management program is considered taxable, is their now income eligibility going to be jeopardized? So if that is a possibility, that result is gonna, that's going to result in reluctance by individuals who receive public benefits to want to participate in contingency management treatments. We talked earlier about staff buy-in and ways to address that stigma around contingency management. And that really applies to all of your stakeholders as well. And then finally, let me review the general barrier of program resources or rather the lack thereof that I mentioned previously. So contingency management interventions require programs to develop protocols around its use and to also dedicate resources, including staff training and time towards its implementation. Some programs have the resources for this, but many don't. And so if that's you, for example, a good place to start would really be to utilize the already published protocols that exist for voucher and prize-based interventions, as well as introductory trainings, they're out there. And so start with that framework. Effective contingency management interventions need to be attentive to the schedule, the magnitude, the timing, and the type of reinforcement. This can be cumbersome in some busy treatment settings. And so really it's about using the other members of your agency, of your treatment team to figure out a plan that, you know, everybody's different perspective is going to help decide if that plan is going to work for the patients and for the staff. Technology can be a strength or a barrier based on your program's availability to use that technology. And so I have that listed here. And so finally, let me share some recommendations that I found in the literature on contingency management. Bolivar and colleagues, I hope I'm saying that last name right, the folks that completed that systematic review on contingency management for MOUD, they strongly suggest that policies are needed to facilitate integration of contingency management into community MOUD services. In an editorial put out by Johns Hopkins in 2023, they interviewed Dr. Richard Rawson who suggested that the opioid litigation dollars, those could be used in a number of ways to support implementation of effective contingency management programs. Dr. Rawson and company also published an article last year titled Contingency Management for Stimulant Use Disorder, Progress, Challenges, and Recommendations that discussed these recommendations listed above. Oh, you know what? I think I'm on the wrong slide. So sorry, I just realized that. Other recommendations, can we raise the incentive amount available to each patient in a way that's also being mindful of the IRS limitations that we discussed earlier? And then also can we consider ways to encourage private insurances to provide reinforcement for contingency management, both in the incentives paid to the patients, but also to the staff time used to implement those interventions. And then finally, there's debate about how long contingency management needs to be delivered before those abstinence related benefits it offers are going to carry on without the rewards in place. And so we really wanna continue that research. Hey, you already saw the first half of the slide. And so finally, I mentioned this report a few different times, but I really wanna remind you, this is a great guide as you're learning more about contingency management and figuring out how to bring it into your practice. And so DHHR put out this report last November. It's really your best guide on all things related to contingency management. It provides thorough education on contingency management. It lists out the evidence for it. It also looks sort of as a case study at a contingency management program that the VA system implemented. It reviews the barriers to implementing contingency management, including current laws, insufficient reimbursement, stigma, and program accessibility. And it discusses the opportunities to improve access to contingency management and improve the quality of those programs. So finally, thank you so much for your time and your compassionate care of our addiction population. I very much appreciate all that you do. And my references are attached here at the end. Thanks so much for your time. I hope you have a good rest of your day.

contingency management

substance use disorders

reinforcement schedules

incentive types

treatment engagement

abstinence promotion

barriers to implementation

program resources

policy recommendations