Manager of Science and Dissemination at the American Society of Addiction Medicine. And I want to thank you all for joining today's webinar, Management of Stimulant Use Disorder Guideline, Behavioral Treatments for Stimulant Use Disorder, presented by Dr. Brian Hurley. Before I turn things over to Dr. Hurley, I'll go over some logistics and announcements. Next slide, please. This webinar is brought to you through a collaboration between ASAM and AAAP. ASAM, founded in 1954, is a professional medical society representing over 7,000 physicians, clinicians, and associated professionals in the field of addiction medicine. ASAM is dedicated to increasing access and improving the quality of addiction treatment, educating physicians and the public, supporting research and prevention, and promoting the appropriate role of physicians in the care of patients with addiction. Next slide, please. AAAP is a national professional society that focuses on evidence-based prevention, treatment, and recovery approaches, particularly for people with substance use disorders and co-occurring psychiatric disorders. Their primary focus is to promote high-quality evidence-based prevention, treatment, and recovery approaches, strengthen addiction psychiatry specialty training, foster careers in addiction psychiatry, and promote addiction psychiatry as a recognized specialty. Also to provide evidence-based substance use disorder education to healthcare trainees and healthcare professionals, and educate the public and influence policy on substance use, co-occurring psychiatric disorders, and related issues. Next slide. We begin our session today with a few brief announcements about how to use Zoom features. First, please note that attendees' mics are automatically set to mute. If you have any questions on the content during the presentation or comments, please type them in the Q&A box in your Zoom control panel. We'll have time for questions at the end, but you can submit your questions at any time throughout the presentation. If you experience any technical difficulties, please use the chat function to send a message and ASAM staff will help you with your technical issue. Today's webinar will include opportunities for audience members to engage through Zoom polls. So throughout the webinar, the Zoom poll function will be utilized. The poll should appear on your screen during various points of the webinar. So please participate and answer the polls in a timely manner. Next slide, please. Just a few ground rules. Please take your time to understand the cases and participate actively. Embrace diverse experiences, monitor your participation and seek clarification. Next slide. I will now turn it over to you, Dr. Hurley. Hey, everybody. I'm Brian. I'm an addiction psychiatrist. I'm also the president of ASAM. And also, Dr. Modi and I were the co-leads from ASAM and from AAAP directly on this national clinical guideline on the treatment of stimulant use disorder. So happy to be able to participate in this webinar and disseminate the guideline out into the community. So our learning objectives for our time here together now are to summarize the recommendations for behavioral treatments for stimulant use disorder. There are a number of them, but the one we're gonna spend the most time on is a behavioral treatment called contingency management. So we're gonna spend some time on actual implementation considerations. And then we have some case scenarios talking about stimulant use, both from a prevention, treatment, and harm reduction perspective. We'll briefly go through guideline methodology. We'll talk about screening, behavioral treatments, which will be the bulk of our time, some population-specific applications, and then get to case discussion. The guideline methodology is actually spelled out in the guideline itself. So I put in a link if you wanna read the guideline. I'll refer you to it for a lot of the specifics. But in short, we used, so ASAM's Quality Improvement Council had oversight over the whole process. We contracted with IRETA, the Institute for Research, Education, and Training in Addictions as our technical contractor. And then we had a guideline committee made up of 14 ASAM and AAAP members for kind of a blended representation from both ASAM and AAAP. And I should just offer my own gratitude to my addiction psychiatry colleagues for the contributions of everybody on the writing committee for this guideline. So we had the expert committee, had some key questions, did systematic literature review, developed evidence decision tables, made some, drafted some statements, rated those, then developed a draft, did some external review, including external comment, comments, reconciliation, and then ultimately was reviewed through both the AAAP and ASAM review processes and approved by both boards of directors. You wanna know who is on the writing committee? This is what's on the writing committee. This is also spelled out in the actual guideline itself. The population that we were interested in is people with stimulant use disorder, people at high risk for developing stimulant use disorder, and people experiencing stimulant intoxication and withdrawal which can include but is not specific to people with stimulant use disorder. We have webinars focused on everything from intoxication withdrawal management, prevention, pharmacotherapy, and this is a behavioral treatment for stimulant use disorder webinar. So we'll spend some time on that component of the interventions. Most comparisons, we were looking at what does the research and evidence say about interventions in pharmacotherapy, behavioral treatments, intoxication, withdrawal management, and prevention compared to TAU or treatment as usual. We were interested in stimulant abstinence and in use reduction and in other substance use, treatment retention or attrition, kind of depending on the way you look at it, any adverse events and risky behavior reductions. And we were looking not just at substance use disorder treatment settings, we were also interested in hospital settings, emergency department settings, general medical settings, you know, prenatal clinics. We're looking pretty broadly at places where stimulant use disorder prevention and treatment and recovery support could be implemented. We looked at systematic reviews and meta-analysis, some primary literature, the gray literature, and a literature extraction. And we use something called the GRADE approach. So the GRADE approach looks at the literature, but it doesn't restrict recommendations to come from it. That is to say, the guideline committee did make recommendations based on kind of expert consensus that was literature informed. We are transparent in GRADE methodology about the evidence basis for our recommendations. So is it high quality evidence with multiple systematic reviews, lower quality evidences in RCTs without necessarily a consistent signal in randomized controlled trials is an expert opinion. But we were clear in the way that we put together the recommendation statements of the process and the evidence foundation that we used. So that's a bit about the process. Excited for you to review the guideline, including if you want to get into the specifics of our evidence to decision tables, you're welcome to look more at how we've put this together. So screening and assessment. How do you know when to offer somebody treatment? So for a general population, I do not mean for the population of people who've already been identified to have stimulant use problems that then get linked to treatment. Screening at that point doesn't make much sense. People are already kind of differentiated as needing care. Before a general population where you don't know which of your patients would benefit from stimulant use disorder prevention, treatment and recovery support, we deferred to US Preventive Services Task Force guidelines. This would be in the, it's both in the peer review literature and the GRADE literature that includes screening for stimulant misuse. So when screening for risky substance use includes stimulants is our recommendation. Clinicians should consider more frequently screening patients for stimulant misuse who take psychostimulant medications. That's a risk factor. There was low certainty evidence. There was a strong recommendation, just logically, if somebody has access to prescribed psychostimulants, want to check in to make sure that they're using those psychostimulants appropriately. And then review the PDMP, which is actually an evidence-based strategy to support informing medication decisions for patients. When somebody screens positive for stimulant misuse, we should assess what's the context of their stimulant misuse, right? Is it only in the context of certain situations or behaviors or is it more generalized? When is it associated with trauma? When is it associated with intimate partner violence? Evaluate complications using a history and physical exam. So if somebody has stimulant misuse that's creating cardiac problems, then do a cardiac workup. If somebody is stimulant use because of the route that they're using is causing wound infections, right? Then evaluate somebody's wounds, right? We do a history and physical and then focus medical care based on what we find in doing that history and physical and then conduct lab testing based on clinical assessment. So it isn't, if somebody misuses stimulants, everyone gets an HIV test. Are you using stimulants? What's stimulants using? What's the context that would then, as an example, inform screening for infectious diseases, cardiac conditions, and other medical conditions. Again, it's based on the history and physical. Now, there are some conditions that are more risky than others, right? So the clinical priority is any urgent or emergent biomedical or psychiatric signs and complications, such as if somebody's having acute chest pain, suggestive, or supportive that somebody could be having a cardiac event, that's emergent. If somebody's having acute psychosis and behavioral decompensation where they are threatening themselves or others, that's emergent, right? So to, and that can all emerge in response to stimulant intoxication. So to make sure when we're assessing patients with stimulant use disorder, making sure we're not missing any medically emergent or psychiatrically emergent conditions and providing appropriate treatment. Here's some of our urgent biomedical and psychiatric signs and symptoms that we talked about. So, you know, a stimulant use disorder focused history and physical, mental status exam, and conduct whatever laboratory testing and or workup is medically indicated, and don't omit diagnostic assessment for stimulant use disorder based on the current DSM criteria, right? So when somebody is using stimulants, if we ask about the 11 set of criteria that form the basis of the DSM diagnosis of stimulant use disorder, that can then be the foundation for what we might do next. And in addition to understanding whether somebody meets criteria for stimulant use disorder, what's the frequency amount of use? What do they use? Do they use in a binge pattern, daily pattern, you know, use of stimulants alone versus when nobody else is present, concurrent use of prescribed and not prescribed intoxicants such as alcohol, opioids, and other CNS presence and a history of overdose are all pretty important things to know when you're working with somebody who has screened positive for stimulant use and has been diagnosed with a stimulant use disorder. Other assessment recommendations, know somebody's history of stimulated ED visits and hospitalizations, route of administration, risky sexual behaviors, and non-medical use of prescription stimulants. Non-medical use of prescription stimulants might, it although is not inevitably, associated with ADHD. So consider a diagnostic assessment for co-occurring attention deficit disorder, not because everyone with stimulant use disorder has attention deficit disorder, but because it is a, the risk, I'll call it the prevalence of ADHD is higher in people with stimulant use disorder. And I'll say, as a psychiatrist myself, oftentimes it is always unclear, right, exactly. Does somebody meet criteria for ADHD based on their current presentation? That is oftentimes a historically informed diagnostic assessment. Comprehensive assessment includes, people who've been using stimulants for a long time, elevated degree of suspicion for cardiac disorders. We don't recommend routine ECG or EKG testing, but to consider that testing based on the history and physical, a lower threshold for considering muscle breakdown testing, such as creatine kinase for rhabdo. And again, this is again, based on history and then an elevated degree of suspicion for renal disorders, which are, these are medical conditions that with chronic stimulant use are at higher risk. Now, there were no studies that actually said, okay, like a stimulant intoxication withdrawal must be treated in X or Y setting. That is to say, unlike opioid or alcohol use disorders, where there are clear medical protocols for withdrawal management, there are not medical protocols for stimulant intoxication withdrawal specific in the ASAM criteria. So what you do is you screen for other medical conditions that indicate somebody might need to go to a hospital, might need to go to a residential, might need to go to, and the ASAM criteria is one multidimensional assessment that can help guide level of care placement over connecting a patient based on their clinical presentation to the appropriate level of care. So poll time, poll question number one. There is a 32-year-old who presents somewhere, wherever you are, with signs of stimulant intoxication. The first clinical priority should be to, A, conduct a urine drug screen, B, assess for rickety sexual behaviors, C, evaluate for accompanying psychiatric disorders, and D, identify and address any urgent medical needs. The poll is up. Oh my goodness. It's like the fastest I think I've seen people vote. Almost there. We got about 600 people here, a little over 600 people here, and we've got just under 500 voting. So I'll give it another moment or two. All right, excellent. So the results are in. Identify and address any urgent medical needs. That is correct. Urine drug screening is always something that you request patient consent around, right? So we don't generally catheterize patients unless there's a medical reason to do so, and wanting to know what somebody has used is not inevitably a reason for that, particularly if there are other urgent medical needs. So the answer is, and 93% of you voted this way, identify and address any urgent medical needs. Of course, the other assessing behaviors, psychiatric disorders, and urine drug screens are things that you might offer to somebody as part of the workup, but urgent medical needs take precedence. Thank you for participating in poll number one. Behavioral treatments. Let's see. So this is gonna be the bulk of the way I spend our time. Contingency management, also called a recovery incentive, where you provide somebody a reward when they exhibit an objectively observable behavior that is desired, is the primary component of a treatment plan to treat stimulant use disorder. And I'm gonna say two things. One, CM, the strongest evidence base in terms of effect size of all behavioral treatments listed, And one of the trickiest to get paid for. I live in California. California is using its Medicaid program called Medi-Cal to pay for contingency management in non-residential settings of care that are certified by the state to bill Medi-Cal for a substance use treatment. It's a wonderful access point that we have a payer that will pay for a CM for a stimulant use disorder. But I just, I cannot make the, you know, it is strongly evidence-based with high certainty and the clinical guideline committee said it's a strong recommendation. Contingency management. We recognize that not every jurisdiction has equivalent access to contingency management. Nonetheless, it is from ASAM and AAAP's vantage point, the treatment of choice for stimulant use disorder. The community reinforcement approach is also evidence-based treatment. Not everyone does the community reinforcement approach. It requires a fair amount of patient participation and motivation, but it is an effective, it's an evidence-based treatment. CBT, CBT or cognitive behavioral therapy. There's some moderate certainty that it improves outcomes, that the outcomes on stimulant absence, reduction of stimulant use, treatment retention. But CBT is an evidence-based treatment. And then there's a manualized intensive outpatient curriculum called the matrix model that does a combination of toxicology monitoring, CBT, 12-step facilitation therapy, recovery support. That is a free version from a while back that's posted online. And then there's a paid version that is available. The matrix institute updates this periodically and there's also a paid version available. So clinicians can consider offering evidence-based interventions via digital therapeutics. The guideline committee did not sort of say, oh, this digital therapeutic compared to X versus Y is better than any other. And the truth is it's more about the modality than the delivery, right? So we did not, there was not enough evidence to support from the clinical guideline committee's perspective, digital therapeutics as a standalone platform, but they are very helpful modalities for delivering components of evidence-based treatments, particularly ones that can't otherwise be available in the context where somebody is, and to absolutely use telemedicine, telehealth to treat stimulant use disorder, particularly for patients who face challenges in accessing in-person care. It is better for somebody to have a level of connection, right, into the community than it is that they are exactly at one particular physical location. When I say if somebody can't get to a physical location, it's better they get some care than no care at all, is sort of the point I'm making. So CM, the fundamentals of contingency management is that behavior can be changed to incentives. The behaviors have to be modifiable. By modifiable, it's, you know, somebody uses or doesn't use or participates in some objective behavior versus not, but it has to be modifiable and observable. And CM actually, out of all the other interventions, has the highest levels of treatment retention and highest levels of supporting patients towards abstinence. It increases abstinence, right, so it increases the number of urine toxicology verified negative samples, and it also increases treatment retention. The behavior has to be modifiable and objectively measured. So it isn't, oh, I'm telling you I didn't use methamphetamine this week. That's not objective. Objective is somebody's urine that you have reasonable assurance that their urine in a cup negative for simulants. So California's program, where I work, it has to be negative for amphetamines, methamphetamine, and cocaine. Reinforcement must be immediate for the effect to be strongest. The more time between when you observe the behavior and when somebody gets the incentive, the less effective CM is. Now, I don't mean to suggest that, you know, it has to, like, 10 versus 20 seconds, but I mean, if you send a urine to a lab and get the results back three days later, and that's when the incentive is delivered, you're kind of missing your, you know, that's not immediate enough. Ideally, it's sort of like within, so this is where point-of-care testing is really helpful, because point-of-care testing usually results between five and 10 minutes, depending on the brand of cup you're using or, you know, methodology you're using. Immediate response is important, and the penalties for, let's say, hypothetically, a positive urine drug screening include withholding the reinforcer, right? So, if somebody gets an incentive each time they produce a urine that's negative for stimulants in a hypothetical protocol twice a week, if, let's say, their fourth visit on their second week or their fifth visit on their third week, it's positive they don't get the reinforcer that week. Now, it doesn't just have to be toxicology-verified abstinence. Options that have been studied include, did you show up to counseling? Did you pick up your medications? Did you take your medications? Did you participate in components of your behavioral plan, right? Those are all, it doesn't have to be necessary toxicology-verified abstinence from substance use. If any of you work at opiate treatment programs, there's kind of some seem built in to historically the way that patients who were more clinically stable got more take-homes, right? That is a type of, you know, more evidence clinical stability in terms of participation, attendance, you know, urine toxicology, the more privileges somebody got. So, it doesn't necessarily always have to be like monetary reinforcers, but the standard CM program is money, gift cards, and vouchers are all pretty effective, and it's fully acceptable to give patients a menu of choices. You know, a gift card to Y versus X vendor can be helpful. As setting of the U privileges, people can respond to that, and I mentioned the OTP example of take-home doses are all examples of the way contingency management can be operationalized. Now, because not every payer has currently launched a contingency management program, there's a lot of contingency management programs that are, for lack of a better term, grant-funded, right? You're not building the health plan. You've got a grant to run a CM program, and when you run a grant to do a CM program, you want to make that money last as long as you can. So, how do you do that in a setting where you don't have a ton of money to spread, say, monetary reinforcers for a ton of patients? There's something called the fishbowl method, and I have to give credit to Nancy Petri, who really published a lot of the fishbowl method approach to contingency management. The reinforcer is a draw from the fishbowl. The fishbowl itself has some of them, like about half of the slips, are affirmative statements with no monetary value. The other half have, you know, most of them have low monetary values, then some have slightly higher, and then there's like one or two that are like, you know, relatively big dollar amounts. And one way to do this is if you, let's say, exhibit the desired behavior, your reinforcer is a draw from the fishbowl. Then maybe the second time you exhibit the desired behavior, it's two draws from the fishbowl. You can do escalating behaviors where people get greater chances of getting higher value slips that are in the fishbowl, and this is a way to save money. Now, there's all kinds of considerations with this, right? So fixed incentives have the advantage of people know what they're getting, but the fishbowl method is also evidence-based and helpful. Incentive values escalating with ongoing successful behavior is itself a reinforcer. Incentive value resets with unsuccessful behavior is also a reinforcer against kind of not adhering to the recommended behavior on which the reinforcer is contingent. There's always setting considerations. You have staff to deploy this program, and not every healthcare setting is equipped, is sort of equivalently staffed. But if you're wondering, like, why am I spending so much time on CM, this is a study from, what, 30 years ago? So it's not new, but it looks at the percentage of subjects with cocaine abstinent urines. Behavioral is the CM, or so urine verified cocaine abstinence with the behavioral treatment, that CM versus standard treatment, which is not CM. Like, it was not a subtle, like, this was a significant finding, right? This is not a subtle finding. And so we've known about the effectiveness of CM now for a long time. What we haven't done is, like, optimize a health system to deliver it. So contingent management reduces stimulant use. Longer intra-test intervals allow use to go undetected. That's why I suggested you might want to start CM using twice a week, because stimulants usually metabolize out within a few days, right? So two to three days detection window, depending on the technology you're using. The longer, the better, and that's true with almost all treatments, right? The longer somebody is doing a treatment, the better. But there's actually this great study looking at, you know, treatment as usual versus one or two months of CM. One to two months of CM were about equivalent in terms of abstinence following the end of the contingency, right? So we sort of, one thing to look at was, compared to standard treatment, after treatment was done, who resumed using and how quickly? And there seemed to be something about four, I'll call it at least, four months of CM. And this, I'll say, makes intuitive sense. The intuitive part of this is, how long does it take somebody to learn either reduction in stimulant use or abstinence of stimulant use, right? Like, either are relevant conditions, but how long does it take somebody to really learn their own version of recovery, right? And as it turns out, four months is, looks like close to a minimum effective dose. Now, I say minimum effective dose, you see improvements with one to two months, but four months really seems to have the strongest effect of then sustained stimulant abstinence. And then again, 22% greater likelihood of stimulant abstinence over 20 weeks on average after reinforcement ended compared to comparison treatments. And for those of you that treat patients with stimulant use disorder, 24 weeks, it's really good, right? I mean, like six months, that is a huge win, even if there are instances of return to use, which is part of recovery, relapse is part of recovery. But that is, for that to be the modal response on a cohort is an excellent finding. Again, longer duration of reinforcement, longer duration of abstinence after the reinforcement ends. And CM appears to work regardless of age, race, gender. It is a strongly evidence-based approach for treating stimulant use disorder. Okay. We've got about 10 minutes left to do everything else. So that's, I'm now going to put a coda on contingency management. We'll talk about CBT. You could do a whole course on CBT. Like there's like, you know, eight hour webinars, one week webinar, you know, one week seminars. I mean, you could do, there's a whole like curriculum around this. I'm not going to go through everything about CBT, but the highlights of CBT are how we think affects how we act, how we feel affects how we think and what we do and our behavior is affected by how we think and feel. So CBT looks at our emotions, thoughts, and behaviors and trains people to look at distorted ways of thinking and maladaptive behaviors. What are you doing? That's getting in your way. And there are a whole, what is the right word? Like a curriculum of skills to look at cognitive distortions, maladaptive behavior, emotional self-regulation that people can learn in order to have a more effective triangle of thoughts, behaviors, and emotions. Because it is a learning psychotherapy, it's therapeutic sessions tend to last like with CM, it's okay, here's your urine, here's your incentive, right? It can, the whole thing can last 10, 15 minutes. With CBT, it takes, you know, a standard session is like a 45, 50 minute session and a standard course of CBT or dose of CBT is like five to 10 months. Like for, again, for most patients. Now, are there more focused CBT protocols that are abbreviated? Absolutely. Like I'm not, and actually like there's so many different versions of CBT including like more dynamic focused therapies. But this is CBT in a nutshell. This is kind of like the saying nothing else. This is kind of the standard approach. The community reinforcement approach starts with a functional analysis of substance use. What do stimulants do? What do they do? What do they like? What don't they do? What don't you like? How does it affect your relationships? How is it affecting your job? How is it affecting, you know, other components of your life? And it's focused on relationship counseling, job guidance, and vacation guidance and skills. Therapy focused on building social, like non-using social connections, kind of like network therapy and drug refusal skills, and then new recreational activities and social networks. So this is the community reinforcement approach again in a nutshell. And then I also mentioned the matrix model. This is a manualized treatment that is for patients admitted to an intensive outpatient level of care that has skills groups, relapse prevention, psychoeducation, social supports, mutual self-help, family education, individual counseling, and typically toxicology testing. It is a nine hour a week curriculum. The standard curriculum as I recall it is a 12 week curriculum with sort of ongoing modules for people that need longer levels of IOP care. There is a newer version available again through the Matrix Institute and a freer version, so older, on the SAMHSA website that you can download and review. So matrix model of care, evidence-based treatment. And the clinical guideline committee did not talk about motivational interviewing. So I'm going to talk about motivational interviewing because it's a fundamental communication style that I use with patients. But I'm just going to say motivational interviewing, although was not elevated as having a differential difference on stimulant use disorder, I should say is a fundamental communication style I use in my practice to help evoke change talk from individuals who might be ambivalent about ongoing stimulants use and help resolve that ambivalence in the direction of positive change. It means the interviewer selectively responds to change talk and it is not, there's not like there are three minute versions, 30 minute versions, one hour versions, years of versions, brief versions, there's so many different ways of doing motivational interviewing. And conflict of interest alert, as the president of ASAM, we run a motivational interviewing course at ASAM. You're welcome to take it, but I will step down off of my sales pitch to say motivational interviewing does not seem to have a differential effect on stimulant use disorder, but as an addiction physician myself and for other addiction medicine clinicians, recommend knowing about it. Okay, so poll question number two, contingency management for stimulant use disorder is associated with A, no impact on rates of abstinence, B, compromised contingency reinforcement with shorter test intervals, C, better outcomes with interventions of less than four weeks or D, increased likelihood of absence 24 weeks after the reinforcement ends. 400 in, we'll give it another few moments. All right, excellent. So, nobody said no impact related to abstinence. That's exactly right. About 80% of you said increased likelihood of abstinence 24 weeks after the reinforcement ends. Yes, that's true. You get, and this is, again, across a cohort. Some people learn abstinence-based recovery and just stop using altogether. Some people do return to use, but we see, again, a mean response after the reinforcement ends of 24 weeks with four or more months of CM. With B, I think there was 5% of you that said compromised contingency reinforcement with shorter test intervals. Actually, shorter test intervals are better, right? The more testing and then reinforcement is done, the stronger the effect of CM. The longer inter-test intervals, the more likelihood, the less reinforcing it is. And there are better outcomes with interventions that are greater than four weeks, not less than four weeks. So, thank you for participating in poll number two. Poll number three. Which key component of treatment for stimulant use disorder focuses on resolving an individual's ambivalence about change? All right. So it's actually motivational interviewing. It's focused on helping people resolve ambivalence about change. CBT, which 16 percent of you guessed or voted on, is focused on changing thoughts, feelings, and behaviors. I suppose you could consider resolution of ambivalence as cognitive distortion, but MI is directly focused on supporting resolving an individual's ambivalence about change. All right. We'll get to population-specific applications and then to our case. So lots of people use stimulants, have what's called co-occurring disorders. Co-occurring disorders are where we treat both the stimulant use disorder and a co-occurring mental health condition concurrently. The idea is integrated care is best. Now, if it's not possible to do an integrated psychiatric treatment along with stimulant use disorder treatment in the same setting, ideally, you're tailoring recommended behavioral therapy to address the interaction between the patient's stimulant use disorder and co-occurring disorders. So CBT is an evidence-based treatment for a whole host of mood and anxiety conditions. With co-occurring disorders, you're reviewing the patient's treatment plan, ideally in coordination with the patient's existing treating providers, and then continuing current medications when those medications are appropriate. For adolescents and young adults, we actually avoid routine drug testing to screen adolescents and young adults for a stimulant use disorder, unless it's part of a treatment program. Our recommendation is not if there are youth at risk of using stimulants to start with drug screening, but drug screening can be a vital component offered to patients as part of a treatment program. When considering drug testing of patients under the age of 18, it's actually the parent or guardian that needs to consent, not just the patient's assent. But that said, again, I don't run around with a catheter. If the patient won't assent even if the patient's parents do consent, I treat a non-participation of drug test as itself clinically meaningful information. I had to pay particular attention to signs or symptoms of ADHD and eating disorders, which are at higher rates in people with stimulant use disorder, and to make sure that the adolescents and young adult patients are supported in age-specific treatment, and to consider, again, behavioral interventions that are developmentally appropriate. Counsel parents and guardians not to default to home drug tests. Home drug tests are usually cheaper immunoassays with a false positive and false negative rate. A lot of general population folks don't always know those things, so that's why testing really should be done in the context of a treatment program as opposed to recommending families try to navigate that directly. Be familiar with state laws on consent to treatment, and while parental consent is not needed for young adults, offering youth and transitional, both like children age 17 and younger, and transitional age youth, kind of ages 18 to 25-ish, oftentimes involving families in treatment is really helpful. For pregnant and postpartum patients, make sure that people are connected to prenatal care, understand what biopsychosocial programs are related to pregnancy and parenting, so childcare, WIC programs can all be really helpful when treating patients who are pregnant and postpartum, might have stimulant use disorder, and coordination of prenatal care with treatment of stimulant use disorder is strongly encouraged. When screening for acute issues in a pregnant and postpartum people, just pay attention to the pregnancy. Make sure, and this is, ASAM actually has a public policy statement on drug testing in people who are or could be pregnant. Understand that drug testing actually has to be consented to. We recommend a written consent when a patient is pregnant, because oftentimes health systems have reactive policies and procedures around adhering to mandatory reporting requirements. Just weigh the risks and benefits around utilizing drug testing in a population of people who's pregnant, and including informed consent. Risk versus benefits to the infant or fetus should be considered when medications are used. There are certain teratogenic medications that we have listed. This is not a medication talk, but just understand like you're individualizing care, taking into consideration the risks and benefits of medication treatments and consider contingency management. For sexual and gender minoritized patients, sometimes also called LGBTQ plus patients, understand that there's no evidence that LGBT identified or sexual gender minoritized patients have to go to a LGBT or equivalent specific program to respond. There are certain contexts of stimulant use, particularly what is sometimes called chem sex or people whose stimulant use is associated with sexual activity. We're discussing that in a group of people who might be reactive to hearing that information, might be uncomfortable. What I would say, the clinical guideline committee said, consider connecting sexual gender minoritized patients to sexual gender affirming programs when there are clinical reasons why they might not be comfortable participating in a gender population setting. That said, head-to-head trials, if you take a lot of the studies from the 90s and 2000s, looked at gay men using methamphetamine and connected them to like a gay men group versus gender population group. The truth is the outcomes were similar between both treatments. For patients involved in the criminal and cross-rural system, initiating treatment for stimulant use disorder is recommended even when people are currently in cross-rural system custody. For people experiencing homelessness, unstable housing, and poverty, everything from income support, housing, resolving food insecurity, case management, but addressing the many drivers that keep people experiencing homelessness homeless and unsheltered are critically important. This is not just specific stimulant use disorder. These are strategies that people who are unhoused, unsheltered, that income have poor outcomes than people without when they're not provided with housing and other supports to address the social determinants of health. When initiating, I'm a little bit behind, but that's okay, we'll get through this. When initiating a treatment for stimulant use disorder in an adolescent patient, parental guardian consent is A, always required, B, sometimes required depending on state laws, C, never required, or D, only required for medication treatments but not for counseling. All right. About 430 respondents, it actually depends on state laws. The age of consent for substance use disorder treatment in California is age 12. The age of consent for psychotropic medications is age 18. There's a navigation of state laws. I always seek consent when somebody has a parent or guardian that's available and accessible from the parent or guardian, just to be clear. There are instances where an adolescent might not have an involved parent or guardian to consent. That then is on my problem list, but I'm allowed to initiate medically appropriate treatment, including counseling for youth and case management and coordination of care in accordance with state laws. Let's see. We're going to get to the case, and then we'll get to Q&A, and I promise there's a number of questions teed up, I will get to them. Let's talk about case number 1, Mr. Brown. Mr. Brown is 23 years old. He is cisgender. He's using methamphetamine, nicotine, and cannabis. He smokes methamphetamine in two to three-day binges, typically two to four times a month. He's not necessarily a daily methamphetamine. Somebody uses methamphetamine. But again, for two to three days, two to four times a month. It's typically concurrent with group sexual activity. He'll go to events where there are multiple people participating in sexual activity, and he's sexually active with both men and women. He goes to a sexually transmitted infection clinic and receives a PrEP, which is a medication that when taken can prevent the acquisition of HIV and he reports no history of chronic medical conditions. He's not taking any medications other than PrEP or pre-exposure prophylactic antiretroviral therapy. During his methamphetamine binge episodes, he typically doesn't sleep. That means staying awake for 48 plus hours at a time. Then after they end, he'll sleep for a full day, 20 plus hours, and he feels depressive symptoms including deflated self-attitude. Every day, he vapes about five milligrams of nicotine, so a 20 milligram pod. He vapes and doesn't smoke. A 20 milligram pod lasts four days and he smokes cannabis every day. He doesn't drink, he doesn't use opioids, and he denies any other substance use. He is not ready to stop using methamphetamine, he is not ready to vape, and he's not ready to stop using cannabis. That is his clinical history. Ordinarily, we do an interactive case discussion with 673 people. I'm trying to think of how to do that effectively. What I'll go ahead and do is I will offer some of my own thoughts, and then please put your thoughts on the QA of how you would approach this. Is he appropriate for a contingency management program? The answer is it depends on the contingency management program. The contingency management program that I run, or that I work with a contracted network here in California to run, is a focus on stimuli absence. Putting him in a program that requires him to not use a methamphetamine to get an incentive, only makes sense if he's in agreement with that. One question is, is he interested in receiving recovery incentives if he stops using methamphetamine? If he says, no, I'm going to continue to use methamphetamine, I have no need to change that. Then I'm going to be more focused on harm reduction or risk reduction techniques. What are the ways that he uses? Is it smoking, injecting, insufflation? There's different ways that they're swallowing. There's different ways that people use methamphetamine. Then I'm providing him with tools to help prevent the risk of, well, he's on PrEP, so that helps manage the risk of HIV infection. Hepatitis or other types of infections or wounds that can happen with injection drug use if that's his route of administration. The other thing that I would probably start with is with motivational interviewing, which again, did not elevate itself in the guideline as like a evidence-based strategy specific to stimulant use disorder, but is an evidence-based strategy to support people resolving ambivalence to get a sense of what about a stimulant use is he not liking. For example, he binges, sleeps for a full day. What way is that getting in the way of his quality of life is a relevant consideration. Then making sure that he has access to dental care, medical care. I'm doing a history of physical to look at any medical comorbidities that he might be experiencing is how I would start. If he was interested in changing his methamphetamine use, CM, if he'll do an IOP program, but focused on giving him the skills and strategies to change the substance use in a way that is more healthy to him. Three minutes and then I get to Q&A. Case number 2. This is a 32-year-old cisgender woman who's using cocaine. Ms. Green is a 32-year-old HIV negative cisgender woman. She was living with a romantic partner, the relationship ended and she became homeless. She was not independently employed, doesn't have her own income. She was in an encampment and somebody offered her cocaine so that she could stay awake because she was concerned that if she fell asleep, she would be at risk for violence or theft. She was brought in by ambulance to an emergency room with symptoms of acute agitation. She was brought in by paramedics who brought her into the emergency room after she became behaviorally disruptive after using cocaine at her encampment. On an interview, she says, everyone in the encampment was plotting against her and it was this broadly systematized feeling of being persecuted. She was also feeling the sensation of insects crawling under her skin. Those of you that know the term will recognize that as formication, with an M, formication, which is again that sensation of insects either on or underneath your skin. She says that she has this feeling of paranoia and formication. After she uses cocaine, it usually goes away. She's in the ER now. She's able to now talk. She's like, well, I'm having this experience, but it goes away after a few hours. She gets labs in the emergency room and it is positive benzococcaline, which is a ureometabolite of cocaine. It is also positive for human chorionic genetotropin, which those of you may recognize as a positive pregnancy test. What might I do with Ms. Green? Again, welcome your thoughts on case 2. But a few thoughts out of the gate. Talk to her about whether she wants to continue to use cocaine. Are there other? Well, first of all, she's experiencing homelessness. She is now experiencing pregnancy. Does this open up, at the very least, interim shelter opportunities for pregnant people? When I'm already thinking from a social services perspective, how do I resolve her immediate homelessness as a foundation for any other health intervention that I might provide? Is she interested in changing her use of cocaine? Are there other ways now that she's housed, or if we can get her housed, that she might be able to maintain her safety without such a high-risk strategy? Immediately, and I'm a psychiatrist, so take this with a grain of salt, but connect her to prenatal care. I don't do prenatal care, so make sure she's connected to look at the health of her pregnancy. Talk to somebody about her intentions for her pregnancy. I mean, all of that I think would be helpful. Then similarly as before, like motivational interviewing, is she interested in changing her cocaine use? If so, contingency management, and again, in combination with matrix model, CBT, cumulative reinforcement, depending on the results of a more extensive level of care assessment. Those are a couple of cases and some immediate thoughts. I am now going to pivot to Q&A, and what I'm going to do is I'm going to start with the chat Q&A and would welcome if there's additional thoughts of getting through the chat as quickly as possible. I see some people have their hand raised. If you can go and put in your thoughts in the chat, I'm happy to respond. Grace says, regarding CM, does the new ACM guideline recommend using psychostimulants as a type of CM? No. I'm unaware of any evidence to support psychostimulants being the incentive. CM is mostly focused on vouchers, take-home doses or privileges in like OTPs, residential settings or other places where there's like milieu privileges and then monetary enforcers. That's not to say that it couldn't be a way of doing that in a way that's helpful. But I know for a lot of us, the prescribed controlled substances treat substance use such as buprenorphine to treat opioid use is just one example. We do this all the time. You show up to your visits consistently, you might get more take-home doses, more longer duration prescription is what I meant. Potentially with refills depending on how somebody is doing. When somebody is showing signs of like missing appointments, if you're doing your intoxicology testing, more worrisome toxicology testing results, I might do shorter prescriptions with more frequent visits. We do that with other meds already. Our recommendation is if you're going to treat stimulant use disorder with a psychostimulant, one, you should really be a board-certified addiction physician that knows what you're doing or be a physician that's working with a board-certified physician because that is a sometimes fraught higher risk medication strategy. But this is not a med talk, this is a behavioral talk. Any resources on examples of how to implement a CM program? I'll refer you to, we don't have a ton of implementation guidance in this guideline. There's a whole literature on implementing contingency management programs, including in OTPs. I do think we'd love to see you do more. Chris, by just on this point, starting with a grant to be able to give you some financial flexibility of designing a program to your patient's needs, I think would be helpful. Dimitri, do you put the slips back in after someone draws? Yes. The idea is they draw and then after they draw, they get whatever they get and the slips go back in. The ratio is pretty consistent each time that you draw. Could the fishbowl, could you also give tickets and then draw a single name for a larger prize? Yeah, I think that that would be if you're doing now names as opposed to incentives on the slips, I think that that makes sense, Terry. How long should CM be continued? Four months or longer? Are there any studies about when CM would be discontinued? CM should be discontinued if the patient's not doing well. If the patient is getting worse, you might need to do another type of intervention such as residential containment. If somebody is not responding to CM. The fishbowl method appears to have gambling behavior. It is based on that probabilistic intermittent reinforcement. Intermittent reinforcement is a type of reinforcement with gambling for sure. Scratch tickets, lottery tickets are a type of gambling behavior. I think with the fishbowl, the idea is you're leveraging that same type of incentive in the direction of positive health as opposed to feeding the profits of people that sell, the people that do gambling exercises. Is there any research showing CM is helpful for ongoing meth use? Yes. Whole literature on that. I would put in a search term into like PubMed, continued management of methamphetamine. But you go and look at the literature that we have identified in the meta-analysis we have identified with our guideline because the short answer is yes. There is a strong evidence for it. How many times do you need to do CM to be effective? I'll name the California protocol. The California protocol is twice a week for 12 weeks, once a week for 12 weeks, so it's a 24-week protocol. If you do it less frequently than that, it will probably be less effective. But that doesn't mean it's ineffective. Having people come into the office, if you can get them in weekly, great. One thing about that though, is this is where hiring somebody to do this. They don't have to see the doc or the prescribing clinician or the clinician that's very heavily subscribed to another work. A lot of the programs that I work in California that we contract with actually have like CM coordinator staff to do this. What value amounts of CM rewards are paid for by Medi-Cal? So it's up to $599 in total over a 24-week program. And that's true for a fiscal year. So the state's not issuing 1099s to anybody. The OIG had set like a limit of $15 per reward and $75 per year, which is I think clinically too low to be effective. But Medi-Cal, and you can actually, if you Google like DHCS, which is the California Healthcare Authority contingency management, you can read about the whole protocol and the amounts that they're using. But it's typically starts in like the $20 range and goes up over time. I didn't hear anything about anonymous support groups. What are the roles and evidence behind 12-step groups for stimulant use disorder? So when we looked at 12-step facilitation therapy specifics of stimulant use disorder, and we didn't see a differential response for those treatments for stimulant use disorder compared to a 12-step facilitation therapy for other substance use disorders. There's a Cochran review of 12-step facilitation therapy for alcohol use disorder, showing it generates more absence for alcohol use disorder. But the evidence, it was examined, but the clinical guideline committee did not see a response for stimulant use disorder separate from other substance use disorders. And so it didn't, calling out 12-step facilitation therapy or mutual self-help as a standalone treatment was not an emphasis in the behavioral section. That said, 12-step treatments have been vitally and lifesaving for like millions of people. And for patients that participate in 12-step programs, I think all the evidence on 12-step is if you are actually participating in 12-step programs, it can be a huge resource. We see a ton of evidence specific to methamphetamine, cocaine, or I should call it stimulant use disorder, amphetamine type, and cocaine use disorder. So Vadip says, CM is most effective for stimulant use disorder. We offer it the least. Yes. And technology CM interventions can help bridge treatment. How do we navigate this? I think ACM supports there being more, and NAAAP supports there being more options available to people with stimulant use disorder. Any suggestion to the administration on when somebody is continuing CM, but with only small tokens of good, not cash equivalents, it's better to do CM with what you have than what you don't have. So I would not let perfect to be the enemy of the good. And then it's critical to say people who regularly, depending on drug screening results with clear consequences, the person is adequately trained to understand them. Yes. Thank you, Alan. Yes. Margaret, how much money do you have to make to make CM successful? There's a bunch of different models. Forgive me for hawking the California one. Let's see. And I think with this, I know that there's more questions, but I regret I am going to have to sign off. Okay. Thank you, Garrett, for correcting me. It's not that OIG doesn't limit it. It had been in the SAMHSA grants, and I think you're right. Follow the guidance that you have available through your single state authority and the payers you have. Okay. With that, I'm going to go ahead and turn it back to our staff to close us out. So, Taylene, do you want me to cover this or do you want to cover it? I can cover it. Thank you, Dr. Hersey. So before we close, I did want to mention how to claim CE credit. You'll need to log into your ASAM account and complete the valuation through our e-learning center in order to claim the credit. You'll also receive an email tomorrow regarding claiming credit. Should you have any questions, you can always reach out to the education department at education at ASAM.org or 301-656-3920. Next slide, please. And I did want to remind you all that this webinar today is a series of four. We've already had two webinars previously, which are available on demand on ASAM's e-learning center. And then we have another webinar coming up in two weeks on medication management for stimulant use disorder. Next slide, please. And here's our contact information if you have any questions. And thank you all so much for coming and we hope to see you at our next webinar. Take care. Deeply appreciate it for everyone's participation in the robust Q&A. So this gives us inspiration to do more at CM because clearly there's a lot of questions on that and deeply, again, appreciative of everyone's time and attention. Thank you.

Dr. Brian Hurley

Management of Stimulant Use Disorder Guideline

Behavioral Treatments

Contingency Management

CM

Fishbowl Method

Case Studies

Tailored Interventions

Audience Engagement