Welcome, everyone, to our workshop that is entitled Contingency Management for Stimulant Use Disorder, with a focus on using contingency management with folks who are receiving medical intervention or medications for opiate use disorder. I'm Mike McDonald, and I am a professor in the College of Medicine at Washington State University and a contingency management researcher and director of our research group. I'm here today. I'm excited to talk to you today about this important topic, and with my wonderful colleagues, Dr. Amy Burns. Maybe you all could just give a wave out. Thank you, Amy, who's the Associate Program Director for the Psychiatry Residency over across the way from us, the Teach Health Clinic here in Spokane, Washington, that's affiliated with Providence. Also, one of our wonderful psychiatry fellows, Dr. Casey Collins, who's joining us and you're going to hear from later, who's a third-year resident. Then, of course, joined by my colleague who I've worked closely with, Dr. Sarah Parent, who is our lead contingency management interventionist in my research, our research that we do together, and also our lead contingency management trainer in some of the trainings we're doing. We're excited to share with you that overview of what contingency management is, the research behind contingency management, particularly for psychostimulants, and then talk to you a little bit about our experience implementing contingency management in the context of an office-based buprenorphine program in primary care, with, again, targeting stimulant use in folks who are also receiving treatment for opiate use disorder. Next slide, please. Thank you, Amy. First, our disclosures. The PRISM Collaborative, which is the group that Sarah and I are a part of, we're being paid to do trainings in Montana, Washington, and California. We just wanted to share that information. We are in just a regular Zoom meeting setting. Your chat is not disabled. You can chat to other specific group members. You can also chat to everyone. We'd ask that you chat to everyone, if possible, when you have a question. Please chat out your questions. Please keep yourself muted. You also can have your video on or off, but please keep yourself muted unless you're speaking. We're going to try to do questions via chat, and then also, we're going to take some times to stop and pause and take a couple questions at natural times to pause. If we don't answer your question right away in the chat, we'll answer it in the times when we pause to answer questions. Next slide, please. Our objectives for today, we have three objectives. The first one is to really understand contingency management and be able to describe the evidence for the intervention, especially for stimulant use disorders. Then the second objective we have is to be able to characterize how it's an effective and feasible intervention. One, it's effective. What are the parts of contingency management that really need to be there to make it contingency management and not just the use of incentives? How can you feasibly, Amy and Casey are going to talk about how you can feasibly do this in an office-based buprenorphine clinic. Our last objective is that I get to talk about the exciting topic of Medicaid compliance. That's a really important issue because about a year ago, for those of us who serve people who are, this is CARES funded by Medicaid or Medicare, we really haven't been able to use contingency management with them until about a year ago. Really excited to be here to talk to you about how you now can use contingency management with Medicaid and Medicare patients, but the specific ways that you really need to do it to make sure you're doing a great work. Then I also want to give a really quick shout out before we do our quiz, Amy, to Alice Dong, who is our wonderful medical student. Alice, maybe you're out there. Please wave your hand, who really helped us prepare this presentation. Thank you so much, Alice, and we're excited that you're here. With that, Amy, I'm turning it over to you for our pop quiz. Okay. Okay, everybody. Put on your seatbelts because it's time for a pop quiz. What we're going to do is I'm going to flip the slide to the next slide. You guys, I want you to read the question and throw your answers into the chat just to get us warmed up for the content. Okay. Here we go. This is kind of going to take you guys back to psychology 101. Oh my gosh. I'm picking up on a lot of threes. Okay. Okay. Oh, we got a four. Oh. I'm feeling the consensus for operant conditioning. Okay. So I'm going to hand it over to Sarah. Thank you, Dr. Burns. So yes, a lot of you have the right instincts. We are going to talk a little bit about operant conditioning. And like Amy said, we're bringing you back to your freshman year psych 101 class. And I'm just going to do a quick review of operant conditioning because in order to understand contingency management, you need to be reminded of how operant conditioning works. So remember, in this context, positive means adding a stimulus. And then reinforcement occurs when behavior is maintained or increased. So for instance, if you want your kiddo to do their homework, you could reinforce that behavior by providing a positive stimulus, something like screen time, when they show you they've completed their assignments. And then I also want to remind you about negative reinforcement. That one's always trickier. It's like a test question that people get wrong often. So negative reinforcement also increases or maintains a behavior, but it does that by removing an aversive stimulus. So a great example of this is a college kid at a party. They arrive. They immediately feel nervous. They don't know how to talk to anyone. And then they notice that, you know, the table of red cups and the keg and they head over there, have a few drinks. And that aversive feeling of social anxiety goes away. Now they're more likely to continue to go to more parties. So next slide, please. So why is operant conditioning important for treating addiction? First, let's acknowledge that substances themselves, substances like psychostimulant drugs, are highly reinforcing themselves. They provide positive reinforcement because they make a person immediately feel good. And that increases the chance that that person will want to use them again. And they provide negative reinforcement by removing aversive stimulus like fatigue, negative feelings, similar to what I just described about the college kid at the party. And then as substance use disorder progresses, a person may lose other reinforcers in their life, like their job or fulfilling relationships with family or friends. And so in this way, addiction, we kind of say, hijacks the brain's reward pathway. It makes it so that the drug itself is the most positive reinforcer in someone's life. Next slide, please. And so the question is, can someone who uses stimulants respond to other positive reinforcers when given the opportunity? In this classic study, people who use cocaine were brought into a lab and given the choice between a line of cocaine and a monetary reward. So you can see from the graph that when the reward was five cents, clearly most people chose the line of cocaine. But when the reward was $2, most people chose the money. So this really is a simple way to demonstrate that people who use drugs do make rational choices and will choose abstinence over use if we offer an alternative reinforcer. It also shows that the non-drug reinforcer doesn't have to be very large. I mean, this is, you know, you can see the date there. This is 1994 money, so it might need to be a little bit more than two bucks. But you can see it doesn't have to be that much. And so studies like this have been replicated over and over for many different substances. And this has set the stage for a therapeutic intervention that can offer an alternative reinforcer to encourage drug abstinence. So next slide, please. So, Q contingency management. And as a simple behavioral intervention that provides a therapeutic positive reinforcer to compete with the reinforcing nature of the substance, and to realign the brain's reward pathway toward non-drug rewards. So to do that, we need to choose a behavior to reinforce. So in this case, it's stimulant abstinence as measured by a urine drug test. And then we want to provide a positive stimulus, in this case a tangible reward, like something like a gift card. And then that will lead to maintaining that original behavior or increasing, so increasing stimulant abstinence. So CM is this simple, but we do want to describe some details and what is required to maximize its impact on outcomes. So next slide, please. So let's discuss some key elements to the design of an effective CM program to treat stimulant use disorder. We already know that the behavior we want to reinforce is stimulant abstinence, so we're going to define that a little bit more specifically as stimulant abstinence as demonstrated by the stimulant negative point of care urine drug test, collected twice a week. So let me explain why these details are important. The point of care urine drug test is an objective way to measure the behavior, right, so we don't want to rely on subjective measures like self-report. A point of care test also creates an achievable goal. So these tests have about, for stimulant use, have a detection window of about two to four days. And so two to four days of stimulant abstinence is an achievable first goal. And when used twice weekly can detect most stimulant use and provide many opportunities to offer rewards. The point of care tests are feasible because they're inexpensive enough to use twice a week, and they provide immediate results, and you'll see later that those immediate results help us provide immediate rewards. And so a twice per week urine test program is a consistent program to frequently measure and reinforce stimulant abstinence. Next slide, please. So, let's see. The other. So now we want to talk about the positive stimulus. So that's what we mean by the rewards. In order to be most reinforcing here are some important features of the reward you'll be using. So of course the reward has to be contingent, that's in the name right so we only provide a reward when the urine drug test is negative. The reward should also be immediate, so you want to reward right after you get that point of care urine drug test result. And that best helps the brain pair that behavior choice with the reward with that positive outcome. You'd like the rewards to be tangible, that means using things like prizes or gift cards. And of course we want those rewards to be desirable right we are trying to use operant conditioning to compete with that positive reinforcement from the substance itself so you really want something desirable something that motivates people. So, should be something that they want or need, and at a value that is motivating. So our advice is to use a magnitude for each reward that should be no less than $5 per per negative urine drug test, and should increase from there. And then totaling no less than 300 to really we would like to see a five at least a $500 possible reward earnings over the duration of their 12 week treatment period. If they were abstinent the entire 12 weeks. Next slide please. So, I mean, I just said that I want the value of the reward started at least $5, but increase from there so let me tell you what I mean by that. Any incentive system can provide rewards when somebody demonstrates a behavior achieves the goal, I'm talking about that at the, at the introduction that incentive system I think is something that a lot of people may already use or, or it's pretty But this concept of escalation reset and recovery is really what sets contingency management apart. So I want to be able to explain what we mean by each of these terms. So, escalation means that the reward gets bigger, the longer the patient is abstinence abstinent, so this gets patients literally more invested in keeping up their abstinence streak. And one way to do this is to establish a value of an initial or base reward, and then increase the magnitude of that reward by using bonuses, each time they achieve another week of abstinence. So in a program like this week of abstinence would be two consecutive stimulant negative urine drug tests. And so we also use a concept called the reset. And to explain that in contingency management we don't use punishment notice I ignored that entire side of teaching operant conditioning right because we use reinforcement and contingency management. So, so we don't use punishment, but we do emphasize accountability. So, not only are the rewards contingent right so they don't get the reward if they submit a stimulant positive urine test or if they don't show up for that visit. But also at the next visit they will reset back down to the initial base reward magnitude. Again, this isn't meant as a punisher. It's just that knowing that all those bonus dollars could be lost further motivates people to want to keep up the abstinence, and to explain this because this can be a tricky thing for people to understand it feels like punishment so what I want to, or when people first learn about it they perceive it as that. And so I want to give you a little metaphor to help you understand why we have reset as part of the program, and I have kids so I use a video game metaphor that my kids if I ever tried to tell them to turn off the, the, their video games before they finished a level, they say oh no no I'm going to lose my progress, I'm going to lose my progress and I really feel like I see that with contingency management that it's not just that the dollar value of the reward went up, but that they earned those bonus rewards and they want to keep earning the bonus rewards and they don't want to lose those bonuses and so knowing describing this about your program ahead of time actually makes those rewards that much more reinforcing. But if they do experience a reset, we don't want patients to feel discouraged. And so that's why we built in what we call recovery in this so what we mean by recovery is that we don't want, you know, our quote is we don't want to slip up to turn into giving up. So we always tell people that they will be able to recover their bonus magnitude quickly. So once they demonstrate another week of stimulant abstinence with those two consecutive negative urine drug tests, they'll immediately return to their previous previously earned bonus magnitude, without having to earn them one at a time again. So what I mean by that is if someone had achieved enough bonuses to say be earning $10 per negative urine drug test, and then they have a positive test and you don't get a reward that day. The next time they reset back down to $5, but as soon as they have another two consecutive urine drug tests remember that's demonstrating a week of stimulant abstinence, then they will immediately return to that $10 magnitude and start earning more bonuses So, next slide please. So there are a few different models of contingency management programs, there's a prize draw model and a voucher model. We've used both in our work in our research, but I'm, I've started to mainly focus on teaching people the voucher version, because it's easier to teach and it's easier to keep track of. So I'm just going to give you the details of a voucher model of contingency management. So for that you use pre arranged vouchers to, and they're provided for each stimulant negative urine drug test, and then the voucher amount escalates sort of what I just described with escalation. So for example, if you start with $5 per negative urine drug test, and you use an escalation bonus of $2 per week of abstinence. If you start with the first negative urine drug test they're able to submit, they earn that $5 voucher. Once they demonstrate two in a row, they'll be earning $7 per negative urine drug test. When they demonstrate two more tests in a row or another week of abstinence then they'll be earning $9 per sample and so forth. The escalation will continue, and that way clients know exactly what they'll get for each negative urine drug test it's easy to budget for this because you can tell exactly what they will be earning. And then the vouchers themselves can be banked, or they can be exchanged immediately, and you can offer either gift cards or tangible rewards that equate to the dollar value of those vouchers. So, I am. Next slide please and I think with that slide, we are going to show you an example of contingency management and action. So, um, this is actually going to be the price draw style contingency management which means that you'll see they're going to describe it in the video, but rather than earning pre determined vouchers, they're going to reach their hand in a bucket and draw a prize and that's going to tell them what they earned that day. And when you do a price version of contingency management then what escalates or gets larger is the number of prize draws that they earn. But the same general spirit of contingency management applies. So, um, with that, we'll hit play and let you see some contingency management. So if you don't mind, we'll just have you take this. And just head out that way. I can do that. Great. Great. So we are going to check this here. How's your day been? Pretty good. Good. Good. So now we're looking to see you are clean for cocaine, amphetamines, methamphetamines, THC, and heroin. So you've been in the study for four weeks, I think you get five draws. Sound good? Yeah, sounds good. Excellent. You're only able to... Okay, let me see what I can do. We're so focused on the sound working that we... I know, you guys need the full deal though. You guys deserve the best. Sure, Sam. Okay, I'm going to go ahead and start it over again, you guys. Let me know if you guys can see it this time too. Can you see it now? So we're going to start today by having you do a UA. So if you don't mind, we'll just have you take this and stand up and just head out that way. Okay, I can do that. Great. Great, Paul, thank you so much. So we are going to check this here. How's your day been? Pretty good. Good, good. So now we're looking to see you are clean for cocaine, amphetamines, methamphetamines, THC, and heroin. So since you've been in the study for four weeks, that means you get five draws. Sound good? Yeah, sounds good. Excellent. Okay. Okay, first draw. What do you got? Small. Good job. Nice. Now back in there. What's this? Small. Small, great. Good job. Can we get a different color? What's this? Large. Hey, alrighty. Excellent, good job. So that's two smalls and a large, so we'll stand up here and have you look at our cabinet. Okay. Alright. There we go. Sorry, we've got a closed door. Ah, hey. Grab yourself two smalls and a large product. Okay, small here? Mm-hmm. Okay. Oh, wow. What a decision. I don't need any more mac and cheese. Oh, I'll take these. Oh, what are these? Oh, no. This. The lips. I'll take lips. You can get another small, too. One more small. Is that a whole cup full of goodies? Oh, they're just one each. Just one each. Okay. Oh, well. Oops. I'll take the gloves. Great. Can you close this time of year? Okay. And a large. And a large. Is that this shelf? Yep, that's that second shelf. That's that one there. Okay. What is this here? Oh. We'll take this one. Fantastic. Okay. Perfect. And I think, Sarah, that's why Amy's pulling up the slides. This is a great opportunity for people to ask questions. Yeah, so it's just taking a moment to look in the chat, but did you want to pass them on to me? Yeah, I think the first one, we had two questions. One, I think that we could spend an hour answering for sure, but the first one was, and I think you hopefully addressed it, but Ellen asked, do you find that patients drop out after a reset? And how do you encourage them to continue in the program? And I responded that that's what the recovery is about, that we really want it to be a slip up and not a relapse. And so we really encourage you to try to always tell people, whoa, look, okay, this happened, right? You had a positive test. But remember, you can get back up to that voucher amount when you come back. I think that you can comment on this too, but it's that we do this twice a week in the standard outpatient model. We have people come in and submit a urine sample twice a week. So if you don't succeed, you can have an opportunity to succeed really soon. You don't have to wait a couple of weeks to demonstrate your success. So anything to add to that? Yeah, that last piece has been key for the folks that I do contingency management with. Twice a week program might seem somewhat daunting in some ways, but it really provides so many opportunities to get back on track and to reward frequently. So that's what happens. They just know that it's only about three days away before they have an opportunity to earn rewards again. And so it is really, well, we didn't have time to get into a lot of detail, but in my longer training sessions, we get into the spirit of contingency management, which is kind of staying encouraging. It's not, people are used to being punished when they submit a urine drug test that is positive, but instead we say we're patient, but we have three days and you can try again. And so you just stay positive. And that really helps people not feel ashamed and stay engaged in the program. Great. And then the other question was just about, have there been any studies using a different, an escalation that's based on like another behavior. So it only escalate, I think, to understand the question. And, and in my response to that, as we segue sort of into research is, I don't think that's been done, but that probably could have been done because there's hundreds of studies on contingency management, especially by our, our colleagues who are really interested in how we change the maximum way to use contingency management to get people to change their behaviors. And certainly we've done some research in that area too, but it's a great idea, I think. And then also Karen shared about some work at the VA in Minneapolis, where there was sort of an approach like that. I suggested that, yeah, based on, you know, especially Ken Silverman's work and his team at Hopkins, that, that changing that, that, that, that, that focusing on one behavior and then moving to another behavior once that behavior is acquired is another strategy that's been successful in research. And, and I know that there's some colleagues from the VA on here too. You know, the VA being the only system of care right now that's fully implemented contingency management across their system. And so you all have done some really cool stuff in the Veterans Administration. Excellent. I think I see another chat example of, we talked about tangible rewards in our program and they talked about their reward being take-home doses of the buprenorphine. And that of course has been, has been studied several times as a, as also a very kind of motivating reward as well. For sure. And something that is convenient and makes people's lives better. And you don't have to fund that reward because it does cost money. So that's nice. All right. So now we're going to switch gears and talk about the, I'm going to share a little bit about the, you know, the over an overview of research. And really that's not what this talk is about. Most of all, most of us know already that contingency management is an effective intervention for stimulant use disorders. It's probably, it is the most evidence-based and maybe the only reliably evidence-based intervention for methamphetamine use disorders. And that is, of course, a problem that all of us are dealing with, especially those of us who are treating people with buprenorphine or in methadone with, in a methadone maintenance program. The effects, although this is, you know, not universally true in studies, the effects of contingency management can last up to a year and can be comparable. I've been found in some studies to be comparable to cognitive behavioral therapy, for instance. And then our group really focuses on alcohol. Sarah and I do a lot of contingency management research on the effectiveness of contingency management as an intervention for alcohol use disorder. And our work, we found that it's the effect of contingency management is comparable for alcohol to the work in stimulants. So it works for alcohol. Of course, many other people have investigated the efficacy of contingency management for tobacco use and found that it works as well. And it also works for a number of other substances. So next slide, please. So we wanted to just highlight a couple of things. First of all, this is a really interesting meta-analysis that was recently completed, or was recently published in JAMA Psychiatry. And this is a meta-analysis. And when we think about sort of the evidence for stimulant use disorder treatments, and for any treatment really, you can, you know, this is pretty amazing to look at. This is 60 studies looking at contingency management for MOUD. They're not all included in this figure, but there have been 60 studies that looked at contingency management in the context of buprenorphine treatment, or in methadone maintenance, or even in naltrexone, or like injectable naltrexone. And what they find across the board in these studies that targeted stimulant use, so again, these are MOUD patients who then are being, contingency management is being used to target stimulant abstinence in folks who are co-using stimulants and also involved in MOUD. And what you find is an effect size of 0.7, which is a large effect size, which is, right, it's not an effect size we typically see in psychiatry. It's not in behavioral health. And when you think about the wonderful presentations that have been at this conference and are around sort of around on trying to, for us trying to find a medication that works for stimulant use, all the really interesting research that's happening, and you compare the effect sizes that they're seeing in those studies, you know, you could see that contingency management really for stimulants is a really great bet in terms of helping patients acquire abstinence from stimulants. So that's the take-home point there of that slide. Next slide, please. Okay, and to go back to the past, I want to sort of the initial seminal studies in contingency management for stimulants. This is a study that was done by Steve Higgins and team back in 1994, and this was with 40 patients who are receiving community reinforcement approach or receiving community reinforcement as a sort of standard care. And so everybody in this study was receiving community reinforcement and evidence-based psychotherapy, right, for stimulants. And then they were randomized then to either just receive that, that's the standard group, or to receive contingency management. And the intervention with the contingency management was 12 weeks, but the study period here that these figures are displayed is really are focused on 24 weeks, so 12 weeks of the incentives and then a follow-up period of 12 weeks. And what you can see is retention throughout the 12 weeks and the contingency management group and the incentive group is 75%. Well, in the community reinforcement, the standard therapy that was being offered, it's only about 40%. When you look at the number of folks who attained or the percentage of folks who attained eight weeks of abstinence during that 24 weeks, which is a really, you know, a great period of abstinence, a clinically meaningful period of abstinence, you can see that it's statistically higher in the contingency management group in that 60% to 70% range versus only about a quarter of folks in the standard group attained that. So that just is one initial example of, and many studies have followed, showing that, you know, contingency management really does seem to work for people with stimulant use disorders. Next slide. Okay, so this is a study that, actually, that video was shot, that we showed you was shot by Dr. Rick Reese, who many of you know, in Seattle in our, the first study that I was involved with contingency management, and that was a study where Rick, who is an expert in co-occurring disorders, got together with John, Dr. John Rolb, here at WSU, who is an expert in meth, in, in stimulant contingency management, and they thought, well, what's one way that we could bring evidence-based addiction treatment to a community mental health center? So what, for folks who have co-occurring disorders, for people who have serious mental illness, illnesses such as schizophrenia, schizophrenia spectrum disorders, bipolar disorder, major depression, you know, the typical, in a community mental health center, the people who are serving a community mental health center, many of them, right, have, half of them, at some point in their life, will develop a substance use disorder. What if we brought contingency management to that group? And let's see if it works. And so what, I, I was lucky enough to get to work with this team, and oversee this study, and what we found in this, in this study, was that, that red line there, are folks who received treatment as usual at their community mental health center, and this is, that's, this is their stimulant abstinence by week across the 12-week intervention, and you could see that, that, that's, that group just received rewards for showing up, and the other group, as demonstrated in the video, received rewards for being abstinent from stimulants, and so you can see about two and a half times higher odds of having, submitting a stimulant negative sample throughout the 12 weeks, so an effect size that was pretty comparable to, to, you know, studies of contingency management in folks with just stimulant use disorders. So next slide, please. So the reason I wanted to share the, this, the results of this study with you are this slide, and what this slide demonstrates is, you know, is what we really were hoping to find, or interested to investigate, which is in this group of people with co-occurring disorders, if we add contingency management to treatment as usual, do we not only see an impact on substance use, but do we see an impact on psychiatric functioning, and not only just psychiatric functioning, but on important psychiatric outcomes. So this is the number of days, the number of people, and number of days that folks were hospitalized before and after randomization. The before, the pre-randomization is just there to show you that one person was hospitalized in each group in the three months before folks were randomized, so really please focus on the, on the bars on the right, and what those bars show you is that there's a really large difference, there was a really large difference for six months post-randomization in the contingency management group versus our control group, which is the non-contingent group. So in that non-contingent group, nine people were hospitalized for a total of 152 days, and in the contingency management group, only two folks were hospitalized for a total in that, in that entire group of 14 days. I think our end in this, our randomized end in this study was 176 individuals. So if you think about the cost of just one of those days of hospitalization, and the cost of delivering contingency management, this cost savings of course offset that cost of contingency management, and indeed we did an economic evaluation that was published in 2015 that showed that definitely this version of contingency management, this population was cost effective, and that's been replicated by a number of groups, but the economic benefits of contingency management have been replicated multiple times. So that, I just wanted to share that with you all, especially at this, this, this, this, in this, in this group who are, I mean if you are a psychiatrist, I think these are really important outcomes. So that's a quick overview of contingency management research. Next slide, Sarah. Or, I'm sorry, Amy. So we're gonna maybe, are we taking a quick break to talk about, talk about, take any questions on research? Yeah, do you guys want to, I think we have some time now, would be a great time if there's anything in the chat that you guys want to talk about before we move on to implementation. Sure, so there's a couple questions in the chat about using some of the apps that are available for contingency management, and some of them are paired with CBT, so they can monitor their activity with the CBT modules, and again, giving that sort of a way to deliver contingency management remotely, especially during a pandemic. So Dr. McDonald, do you want to speak to any of that? Well, this is a rapidly evolving situation. There are a number of CM apps out there, or apps that incorporate CM. I think we need to be careful about what, like, CM is a specific intervention that, in our studies, we added to treatment as usual, we might add it to other approaches, but it's really the CM that the researchers are interested in. And of course, there's studies combining it with other cognitive behavioral therapies, so I think it's a good idea. I think cognitive behavioral therapy is great. I think that a lot of these apps, though, don't just do CM, they do a number of things. So there's a couple things that I think are important. I think these are likely to change with some of the statewide rollouts of contingency management. I think some of these apps are interested in modifying their approaches. I think the main thing that I'd point out with many of the apps is that their incentive amounts, we typically recommend, based on the research, about, you know, $500, a maximum of $500 of incentives be available to a continuously abstinent individual over 12 weeks. And for RESET, for instance, their amount of incentives, I think, is much lower than that. DYNAMICARE, I think, has a lower, a little bit of a lower incentive amount. And so that's one thing to just be mindful of, that in some of the apps, while they may, like this, for instance, RESET O is FDA approved, the dose of contingency management's, I think, lower than what we would recommend typically. I do know that there is interest from all those app companies in changing that. So that's one thing. I think apps are great. I also agree with, I think, Sheila sent out that question. Oh, no, it's a different question. So I think that, you know, the one issue we have with apps, and Sarah, you know this really well from our co-occurring disorders research, is that some people just can't maintain their smartphone. And they certainly can't maintain the data part of their smartphone, much less the minutes. And so for a lot of folks we work with, that could be a challenge, and is keeping them engaged on an app. And also, I think apps are wonderful, especially for people who can't come in regularly to a clinic. Or people, right, most people, I think it's 85% of people with a substance use disorder never receive any treatment. So that, to me, that's fantastic. Apps are a fantastic way to reach those folks. I also think that a lot of our apps, although RESET isn't one, and also I know Dynamic Care also does do this too. So I think it's important if we're talking about abstinence and contingency management for abstinence, that there is an objective way to assess abstinence. So some of the, RESET does that, and so does Dynamic Care. I know some of the other app companies, though, have chosen to reinforce other behaviors and not abstinence. So that's just important to think about. I think that's great, but it's just important to think about. I think there's a couple other questions here. Yes, Mike, some of the other questions are around the Medicaid, Medicare population and the cap. So I think I'm going to put a pin in that question because we'll be getting to that in another slide. And then another question was about the sustained effect up to 12 months after the intervention, and asking whether it faded at 12 months or whether the maximum follow-up 12 months, and that it worked at every time point after that. So I kind of think, you know, in my, so this is a meta point, and I don't, and I think we're doing research right now on ways to maximize the long-term impacts of contingency management, and I know other groups are too. I think the main thing is to remember that, well, you know, sort of in cognitive behavioral therapy or other skills-based interventions, we sort of have this idea that if we treat someone for six months, they're going to be well forever, which doesn't fit with like the way that we treat most chronic psychiatric conditions or most chronic medical conditions, right? If you stop someone's blood pressure, you don't expect their blood pressure to, if you put a person on blood pressure medicine for 12 weeks and you take it away, you don't expect them to still have their blood pressure down, right? The blood pressure is going to go up. So I think that's sort of one meta point I'd have in response to that question. But what we, so what we do see is that that effect does fade over time, which makes sense given that substance use disorders are a chronic remitting disorder, and so we see that, we see that sort of it goes up down over time, but it doesn't go down as quickly or as much as folks who didn't receive contingency management at all, and I think what we know, and I don't think this is unique to contingency management, but that long-term abstinence is best predicted by the amount of abstinence the person receives in the intervention. So for people who respond to the contingency management, of course, they're more likely to maintain long-term abstinence as opposed to people who didn't. So I think contingency management does have that benefit. I do think that we have to, though, as a field, work hard and keep working to make sure that the benefits of contingency management last and maximize our ability to do that. So I don't know if that, hopefully, is a satisfying answer. I think there's been all kinds, 12 months is the longest, really, that I think anyone's looked at this. Usually, we have like a three-month follow-up period, and so we're also kind of a little bit behind our psychotherapy research friends and colleagues because long follow-up periods and contingency management research has not been something we've done, so I feel like we need more research in this area, too. Great, and I think we've covered most of the questions that have come up in the, oh, one more before we move on to the implementation. Any specific recommendations or things that we should be mindful of when we implement CM with the psychosis, schizophrenia, SPMI population? Yeah, that is a population we work with in our work, so I can just tell you from delivering contingency management that it's really fun, and that's where I may have a personal bias toward an in-person model of contingency management because my folks with schizophrenia really love showing up. We're really kind of positive to visits in their week, and they provide the structure that they seem to respond to in a great way. Really, we are sort of a positive social interaction for them, again, twice a week, so Dr. McDonald, do you want to speak more to working with folks with schizophrenia? No, I mean, I think you have the most recent experience, certainly on a day-to-day basis. I really think I agree with that. We're studying this now, trying to characterize. I think Sarah pinged back on a question on this, really that this is the classical conditioning part of contingency management, that the positive area, the positive valence or the positive sort of aspect of receiving those rewards then creates a bond between you as the clinician and that person, and so it's really cool to see that a person who has a lot of negative symptoms, who really doesn't get out of the house much, maybe drinks alone or uses alone, starts coming in and starts smiling, making more eye contact, sort of to see those kind of changes happen because of the contingency management, because of that frequent contact, and then also the reduction in substance use is pretty cool, so I would honestly, as a person who's been doing co-occurring disorders work for the last 12 years with contingency management, I really don't feel like the model is very different. I feel like it's pretty darn similar and it works pretty darn well and in the same ways that it would work with folks. I also will just put a plug in for the idea that it's such a simple intervention, as you could see in that example, that doesn't require a lot of cognition. It doesn't require psychotherapy homework. It doesn't require some of those other challenging things that we see with CBT, so not that those things aren't, you know, those can be overcome and certainly people have overcome them in developing models for people with serious mental illness, but I think the nice, it's so simple contingency management and it's so positive that really is something that folks with serious and persistent mental illness respond to. Yeah, I really love to watch trust build over time, so in the beginning there's, you know, there's a little bit of guardedness for their interactions and then contingency management, I mean, we're literally providing this positive reinforcement over and over again and so when you see the trust build, the relationship changes with that. It's really, really kind of fun. So to make sure we stay on track, I think that we should pass it on to Dr. Burns and Dr. Collins, but please keep putting the questions in the chat. We'll try to get to them as we go and then we'll have some more time for questions at the end. Okay, great. So what I'd like to suggest is that we shift gears a little bit to implementation and the reason why I feel like this is so important is, and the reason why I got really involved in contingency management in my practice, is that, you know, I really think of myself as an evidence-based psychiatrist and I noticed that a lot of my patients with methamphetamine use disorder weren't getting the evidence-based treatment for it and so it was that incongruity internally that really kind of pushed me to consider implementing contingency management in a clinic and I really feel like the rep, you know, we've heard a lot about the evidence-based and I think we're all, there's consensus that the evidence is there, but I think where the cutting edge is is implementation and that's why I really feel like it's critical to talk a little bit about that in this presentation to help clinicians support each other and how we're going to figure out how to implement this and how to operationalize this important work. So my story started about two years ago where I decided that I really wanted to start and implement a contingency management project inside of a primary care clinic that also had an addiction clinic a couple days a week in it. So it's kind of like a side project. And what's been kind of surprising about this pet project is that it has become my favorite part of my job. It's brought me so much joy, meaning, and purpose. And I think that the other people who've been involved in the project could say the same thing. And so I'm hoping that as we kind of share the story that it might inspire other people to consider rolling this thing out and seeing if it could do some good things for your patients too. So this first slide is just about talking about a few of the challenges that you can see when you're trying to implement contingency management. Sometimes you may run into co-workers or other people that you're going to need to collaborate with that are resistant to the idea of incentives. And so in a minute here, Dr. Parent and I are going to role play a potential way of approaching those kinds of arguments. You'll have to come up with some kind of tracking device to keep track of patients, how many vouchers they've earned, how many gift cards, or however you want to set up your system. But most electronic medical records don't have this as a built-in tool. So you're going to have to figure that out. You're going to have to figure out how to fund the program and the reinforcers that you're going to use. In my experience, it hasn't been a ton of money, you guys. It's been, I think, we are one year, we spent like six thousand dollars or less our first year. And so this isn't, we're not talking about needing huge, huge money to get this off the ground. Obviously, you'll need staff time and you're in drug screen cups, and sometimes some clinics, at one point we experimented with billing nursing visits, so $25 a pop for, so that we could get reimbursed for the nurse's time to do these short visits. And then you're in drug screen cups. You could experiment with looking at billing insurance companies for the cups, but sometimes there's some limitations to that and it would be dependent on your setting. Obviously, you'll have to come up with figuring out who's going to staff it, and you guys set up appointments, can patients drop in, and then obviously navigating all the regulations is really, really hard, and Dr. McDonald's going to talk a little bit about that later. Okay, so this, at this point, I'd like to invite Dr. Perrin to unmute, and what we are going to attempt to do is demonstrate some rebuttals to common criticisms and obstacles to implementing contingency management, and see how we do. So, Sarah's going to bring her A-game at me, and I'm going to try to do what I can to make an argument for implementation. So, Dr. Burns, I heard that your clinic is doing this contingency management thing, where you pay people to not use methamphetamines, so they give a urine test and then they get paid for that. Why would we pay for someone to do something that I think they should be doing anyway? Yeah, yeah, I hear your concern. Yeah, well, one of the reasons why it's really critical is that our treatments that we've been doing, our alternative treatments, aren't really working, and we're really struggling with a crisis in overdose deaths associated with stimulants. And so, it's really important that we be open to new alternative ways of doing things. And just keep in mind, even how you and I feel about doing the right thing. Like, for instance, even though I feel like my job is totally the right thing to do, and it's really meaningful, I still require a little bit of financial encouragement to show up on Monday morning. All right, I get it, I get it. So, you know, that incentive works for you, it might help work for other people, and obviously there's a huge need. So, all right, I kind of get it, but I can't wrap my head around what would stop somebody from taking these gift cards that you're giving them, and just going out and trading them for meth. Yeah, you're right, they could. They totally could. In fact, I've had one patient do that, and he came and told us. Now, the thing is, when he came after he used meth, it was a self-limiting deal, right? Because his urine had methamphetamine in it, and so he didn't get any more. So, it shut itself down. Negative feedback loop, you know? So, that doesn't happen very much, because you don't get reinforced for doing that. Oh, that makes sense. So, I guess you thought about that when you set up your program. So, okay, but as I understand it, people have to be abstinent to get the rewards. They have to stop using substances, and in this day and age, we're really starting to think a lot about harm reduction, and is a program that focuses on abstinence compatible with the idea of harm reduction? Is it the wrong approach? I don't know. Yeah, yeah. Well, just keep in mind that contingency management is a tool that can be offered in the context of a harm reduction culture, and so, and also, you know, it's like if a patient chooses that this is what they want to do, we want to support them, and also keep in mind that rewards or reinforcers are given in proportion to negative urines, and they're not kicked out of treatment full stop if they relapse, and instead, they're just reminded of their next opportunity to earn a reward, and I know Dr. McDonald could probably speak more to this, but it's my understanding that new studies are looking at non-abstinent targets as well, so there's probably going to be, we're going to learn more and more about harm reduction and contingency management. That's great, and it is good to know that people aren't kicked out of the program, and not, you know, it's not punishment focused, so I could see how that would be compatible with the culture of harm reduction, but you know, what's the use? So, you know, we can maybe get people to stop using substances for the period of time that they're doing this 12-week program, but when it's over, do people just go right back to using? Yeah, yeah, that is a real concern, and you know, what I kind of, the way that I kind of think about this, that we're using, we have a chronic disease that we're treating, a use disorder that we're treating with a short-term treatment, and we all know that that's a mismatch. I think we're, we are all in this, in the specialty, realize that there's a problem with that, and so I kind of like to think of contingency management as a way of kick-starting abstinence, and then at the end of treatment, shifting to alternative treatments that have more longevity, and so I kind of see this time during contingency management as an opportunity for patients to develop the recovery capital, to set up sober support systems, to allow their frontal lobes to heal, so that they're able to make more and more wise decisions that make sense for their life, and so you're right, like, that this isn't the golden ticket that's going to solve everything, but it's the best thing that we have now for our patients. Wow, thanks, Dr. Burns. I wanted to poke holes in this whole contingency management thing, but it sounds like you are going to be able to help some people with it, so you win. Thank you, Sarah, for bringing it at me today. Okay, let's go on to this next slide. Okay, so, you know, there are some, trying to integrate contingency management into a private practice, it can be a little bit different than other appointments and treatments that are common in a primary care clinic, like, for instance, a primary care clinic is pretty unusual to have twice a week visits, and so in our project, we do have some nurses that do nursing visits where they'll take patients' blood pressures a couple times a week, or they may do wound changes a couple times a week, and so we really took advantage of that system that was already in place and put it into the nursing visits, so that way we didn't have to reinvent the wheel in that way. Keep in mind that if you're using a urine drug specimen cup that's CLIA waived, that means the FDA says it's okay to even use at your house. You could have a non-clinical staff read that if it's a CLIA waived cup, is what I'm thinking. One of the things that's been really, really apparent is this positive experience that patients have come to have around treatment, that coming to see the doctor, coming to treatment is a really exciting and happy thing to come and do, and this isn't really common for a lot of people with substance use disorders that are used to being punished, and so it's a real change in the vibe in the clinic. It's been really, really fun, and as patients continue to escalate in their rewards, they continue to build self-confidence and self-efficacy that they can cash out in other aspects of their life, going for a job interview that they didn't previously wouldn't have had confidence for, for example, and one of the most surprising things about contingency management and implementation for me has been provider satisfaction. For instance, when our patients give a negative urine drug screen, the results come into my electronic in-basket, and it's so exciting to see good news in my in-basket that it raises my spirit, and then I get to share it with all their other providers, and there's some electronic high fives going around, and you know that I think we're, like, all of us are in short supply of some good news, and so it's really exciting to integrate that into our clinics, and in fact, I think that it would be an interesting area of research to look at contingency management for provider burnout as an intervention. I just came up with a study. Okay, so what I'd like to do is, you know, one of my motivations is to try to challenge other providers to consider implementing contingency management in your setting. From the looks of the chat, it looks like a lot of you already are doing this, and so I might, you might not have to reinvent something you already have, but what I'd like to do is to challenge everyone that's in the presentation to do a thought experiment about if you were to implement contingency management in your practice, what it might look like. What I'd like you to do is to share your thoughts in the chat, and here are some specific concepts that you could consider addressing in your chat, like, for instance, in your CM project, who would do the work of reading the urine specimen cups and giving out the reinforcers? How would you get your hand on these cups, and what kind of rewards might you consider? So I'm going to go ahead and just give you guys some time to ponder that. As people are pondering it, I don't know if, Dr. Burns, if you want to answer this one question that came up in the chat, or I'm happy to take it, and the question is, based on the UDS cups that you use, are there specific medications that you tell patients to make sure not to take to avoid false positives for meth? You know, we haven't, well, specifically, I know Dr. Collins is going to talk about this later, but as an exclusion criteria for the program, we don't let people come in that are prescribed stimulants, and so that's the only one that we do, and otherwise, we don't put any other obstacles to treatment in our inclusion criteria. And I might add that most, or at least the UDS cups that I work with, have a separate test for amphetamines and methamphetamines, and so that would certainly, you know, stimulant medications like, you know, Ritalin may test positive for amphetamines, but they don't generally cross-react with the methamphetamines, so if you did focus on that, it may work for you, but if you are worried about amphetamine misuse, then you might need to be mindful of that in terms of who you're signing up for your contingency management program. Yeah, and I think we used to be worried about Sudafed and some of those other, you know, medications that were used to make methamphetamine, but access to those is more, is limited now, and what we find, and so in our stimulant studies, we've recommended people avoid those, so you could recommend that, but I don't think that people are routinely accessing those or using those cold medications relative to others, and frankly, I've always been underwhelmed by the positive, false positives that have, I just don't see a lot of false positives even for that, so. Yeah, you know, that hasn't been a problem in our study either. Yeah. It hasn't, it just hasn't come up. I don't know if, I guess I wouldn't, that hasn't been an issue. Yeah, especially because, you know, a lot of us are involved in work in the criminal legal system and the, you know, or in some other sort of punitive system, and so we're used to, or you know, in our suboxone, people's suboxone work, they do UDTs, and we're used to, like, really being concerned about those false positives. Again, for a small amount of a voucher, like a ten dollar voucher, we really just, I, it rarely, rarely ever happens that someone's going to fake a UA. We still do things to be smart, but, or to, you know, or to claim one of these false positive results. It happens every once a while, but for the most part, it just doesn't happen, and everything goes pretty smoothly. Yeah, I want to respond to, it looks like Ellen in the chat is talking about that she's stumped as far as what specific gift card reward should be, and I wanted to give a shout out for the Tango reward system, because I, we haven't been able to use it. We are using Walmart gift cards, but I think Tango is, is dreamy, and in a private practice scenario, you might be able to get away with it, and Tango, for those of you guys who don't know, is an electronic gift card system where you could transfer a cash amount to a patient's account, and they can decide how, what type of gift card they want to cash out, and they have over 300 different vendors, and I, and you could even donate your money to charity, and so it's like incredibly, what I think about it, what I really like about it, it's completely individualized, because as we know, what's reinforcing one for one person could be not enforcing at all to another, and so this Tango situation, I think really addresses that individuality component of it. Okay, guys, let's move on. So, okay, Dr. McDonald, will you spend a little bit of time talking about the Office of Inspector General? Sure, my pleasure. I talk about this every day or two. So, first of all, these answers are great. Yeah, yeah, you're talking about, you know, the nods talking about the billing for urine tests twice a week. So, when we're doing like statewide implementations or pilots of people now, we're actually having them talk to Medicaid or this, into the, to the state, you know, Medicaid branch to say, hey, this is what we're going to do. Is this okay with you? And these are the seven clinics in Montana that are going to pilot the program. That means they're going to do 24 urine tests per participant in those clinics. Is that going to be fine with you? And then they've made exceptions. And I know California and Montana, for sure, have worked, I think, worked in the urine testing to their waiver that's going to, that's been submitted. That includes contingency management. So, I'm hopeful in that sense. I don't know about private insurance because really most of our work has been with non-private insurance. But that's certainly an important thing to think about. The reward thing is Tango is the ticket. That's the easiest thing to use. There's, there's other products out there like that. But really when it worst comes to worst, ask your patients. And if you're going to use the prize-based version of this, you know, be, you really have to be cautious because you don't want, you could see in our, our version there, there was our video. There's a lot of Seattle Mariners stuff because despite the fact that it was in Seattle, nobody wanted any Mariners stuff. So, that's why we do advocate for the gift cards because, and especially something as flexible as Tango. So, okay. I was trying to avoid talking about Medicaid fraud. But now I'll just jump in and talk about it. So, Dr. Burns came up with this great analogy, dropping the anchor in the OIG safe harbor. We, so we have on this, on the webinar right now, I think one of, at least one of the experts and leaders of the Veterans Administration implementation, implementation, Dr. Dom DePhillips. And so, Dom is, and their team has really along with some other collaborators pushed out contingency management across the VA. And the reason that that could be done in the VA is because the VA does not build Medicaid for services, at least that I'm aware of. And so, it's been great to see the VA. They've really broken the ground for the rest of us. But again, a year ago, we'd be talking to you about this and, you know, we'd get you all excited. And then you'd go out and you'd figure out that if you see Medicaid patients or Medicare patients, you really can't do contingency management. And that's because in the context of Medicaid incentives in, in Medicaid, in terms of how they've been used to commit fraud, contingency management has been a really small piece of the puzzle. So, many of you know about this, all of us who have had to do our, you know, training for around the Stark law and the anti-kickback regulations. We, we understand this already. So, not only can I be in trouble for referring someone to Dr. Burns and her paying me, you know, we could both get in trouble for that referral, but also you can be in trouble for paying people to come to your clinic or to engage in a Medicaid billable encounter. So, what happened in, especially in California, was there billions of dollars of Medicaid fraud where clinics offered a hundred dollars of gift cards to come in and get a health assessment. And those folks will come in, they get their health assessment, that health assessment would include hundreds and thousands of dollars of fraudulent Medicaid assessments, medically unnecessary things. And so, those, those cases, again, are billions of dollars. Contingency management is a small piece and it could be construed by some, it was potentially construed by many people, including the CMS and the office of the inspector general as being potentially fraudulent. So, until last December, when the Trump administration revised the office, the office of inspector general safe harbors around the use of incentives with Medicare and Medicaid enrollees, before that, it was really something that wasn't widely done outside of the VA. But in December, I think AAP, ASAM, a number of our colleagues who are world experts in contingency management advocated because of the methamphetamine epidemic, advocated strongly to the Trump administration that they revise the rule and provide a safe harbor for contingency management, so that we could use contingency management as the best way to get people to stop using methamphetamine and other stimulants, that we could use it as clinicians with our Medicaid and Medicare patients. The response was, no, we're not going to do that. But we, we get the problem. It's a big problem. We want to do something about it, or we really care. And so, we have these other five exemptions or other five safe harbors. And if you do contingency management with, with Medicaid enrollees around these other safe harbor rules, as long as you follow these other rules, you can totally do contingency management. So it was a no, but yes, not just free reign for all of us to do contingency management, just like we could do other things like buprenorphine or cognitive behavioral therapy and bill for it. I'm not this isn't about billing for it. Sorry, I don't want to confuse you and do it without being in trouble with Medicaid. But they said, yeah, you could do it. You could do it with these following these rules. So really quick, these rules are in these, this has not been challenging case law. But we have worked with a national group of individuals, California is doing a lot of work in this area right now, where we really feel like these are the best practices in terms of making sure that you're doing contingency management right. The first one is you cannot advertise that you're giving out prizes for for for drug treatment. Like you can't just go out and say, Oh, look, there's a big billboard. We're giving out prizes, we're giving out cash to everybody. Of course, you're not going to do that. You can totally talk about the fact that you're doing contingency management as part of your evidence based program or, or in talk about it, you can be frank about it. And you can, you can tell other providers that might refer to you and your clients about it. So you can advertise, but you can't advertise that as a way to make money, right, you have to be you to defraud to bill Medicaid. So hope that makes sense. You can't make, you know, don't make billboards that look like lottery billboards and advertisements. You need to document that you're only using contingency management with people who have the medical necessity. And that typically is a stimulant use disorder. For right now, we're encouraging people to focus on that. And our implementation, for example, we're asking people to, we're talking about stimulant use disorders. So you know, you could say this person has a stimulant use disorder, therefore, we're using this evidence based intervention called contingency management. We strongly encourage you in the current sort of landscape to use a research based contingency management program and not just make it up yourself. We think that if there ever was a investigation, if you ever were subject to a Medicaid investigation, that you'd be able to defend yourself even more strongly if you used a research-based program. The main take-home point though for this whole thing, for this whole slide is don't tie the incentives with that you're giving out to the client, especially gift cards, do not tie them to a Medicaid billable encounter. So although there is lots of research to suggest that contingency management is an effective way to get people to attend more of their outpatient addiction treatment sessions, or their IOP, right? Intensive outpatient addiction treatment, that we really want to, we're discouraging people from doing that as like a first implementation. Because if you're billing Medicaid for that outpatient addiction treatment session, and then you're paying the person to come to that, that could be construed as Medicaid fraud by CMS. So we are really encouraging you to focus on patient outcomes. And the patient outcome that we're encouraging you to focus on is that negative urine drug test for stimulants, let's say. So if you have a patient outcome, which is negative urine drug test, you can't argue that that's a patient outcome when you're treating someone with a stimulant use disorder. We want you to reinforce that. So even if a person comes into their group therapy session, attends that, you bill for that, you bill Medicaid for that, or Medicare for that, then in addition to that, you can separately document that you're doing contingency management, and that you're doing contingency management for the negative urine drug test, right? So that's an important take-home point. I hope it makes sense. I'm glad to talk more about that. We're generally recommending that you not use more than $500 with incentives, because that revision talks about that limit, although California is asking for a Medicaid waiver to do more than that. You want to do some QI on this topic. That's really going to be important to, again, show to Medicaid if they ever get interested in this, and want to look at your contingency management program. You can demonstrate that you've looked at your whole panel of patients, your whole clinic, and you've shown that it's reduced stimulant use across your patient population. And we really want everyone to adhere to these rules right now, because it's been 30 years of evidence for contingency management. We're finally able to move out into clinics and do it outside of the VA, and really help people during this current methamphetamine epidemic, and again, for everybody with stimulus disorders. But if one of us does it wrong, if one of us, if somebody does have a Medicaid investigation and is found to be doing it fraudulently, that could have dire consequences for everyone else who wants to implement the program. So I will leave it at that. Yeah, but no pressure, guys. Yeah, exactly. That's why we're passionate about doing these trainings, and getting the word out. Again, it's not been challenging case law, but we really think this is sort of a best practice implementation. Okay, so now we're going to shift gears to a little bit about how we decided to implement in our clinic. And Dr. Collins, I'm going to have you take over here. Thank you, Dr. Burns. So my involvement in our clinic's implementation of contingency management was in the implementation and quality improvement phase of the last year and a half at this point. So to start, I'm going to talk about patient criteria, eligibility criteria. There's only a few criteria needed to be eligible. It includes patients who have a stimulant use disorder on their problem list, have had a positive urine drug screen for that substance in the past month, and are interested in quitting stimulants. Additional use disorders are not an exclusion criteria. Next slide. As Dr. Burns mentioned a little bit earlier, the only criteria that renders a patient ineligible is current use of a prescribed stimulant, which we, because of the concern of confounding the results of the urine drug screen. So as mentioned already, the patients are asked to come in twice a week, prepared to provide a sample for a urine drug screen, and they meet with one of our contingency management nurses for that visit. They get enrolled in a consistent schedule of either Tuesday, Friday, or Monday, Thursday, primarily depending on patient preference. Next slide. The duration of the program in total is 16 weeks. The first 12 are contingency management. And so that's patients coming in twice weekly to provide a sample and get their reimburser. And so the second part of the treatment is the cool-down phase. And this was recently implemented, where patients come in once weekly for four weeks to do CBT-based relapse prevention worksheets. And the idea behind this recent implementation was alluded to a little bit earlier, that based on neurophysiologic studies, there's an increased frontal lobe activity after a period of abstinence. And so ideally, patients are more in a better position to engage in CBT, and which could hopefully be an additive or synergistic psychological benefit to enhance abstinence. The reward or reinforcer that our patients receive currently is in the form of Walmart gift cards. The first week is a $5 reward, and for every week of abstinence, a reward increases by $5. Recently, we implemented a cap of $390 to maintain consistency with the OIG recommendations. This is a little bit in progress. But overall, you can anticipate spending about half of the maximum amount per patient because of the high dropout rate. So I remember initially when we started this, we were really worried about the number of patients that were gonna be involved. All of them, if they all get to the 12 weeks, how much is that going to cost? And what we ended up finding is that there was, we ended up spending much less than anticipated. If the patient doesn't come to the appointment or their urine is positive for a stimulant, they don't receive a reinforcer. And if their urine is positive for other substances, for example, if they're negative for stimulants, and positive for opiates, that's essentially disregarded and the patient receives a reinforcer. Next slide. So as mentioned, the literature indicates a $300 to $500 maximum reward is an effective dose. Additional costs, as mentioned previously, are overhead, staff, and urine and drug screen cups. Our program initially and continues to be funded by Providence Healthcare Community Benefit Funds through the Providence Health System. So this is a copy of my poster, which was presented at a regional conference. Essentially was just looking at the implementation, specifically like recruitment and retention of patients, a little bit of outcomes in the first, maybe seven months of the project. And I think the primary takeaway from the slide is that identifying patients is not easy, and you shouldn't worry about being overwhelmed with high patient volume after implementing contingency management. To enroll an adequate number of patients in our program, we initially started by opening referrals to our primary care and psychiatry clinic. This is followed by opening referrals to our inpatient medical and psychiatry units at our local tertiary hospital and the emergency department. So we educated referring individuals, mostly the social work teams at the hospital and emergency department, in addition to the clinic referring providers. And the last, using a program in our electronic medical record, we could identify patients within the system that were eligible based on those criteria mentioned earlier and send messages directly to their primary care doctors notifying them, hey, this patient would be eligible and might be a candidate for contingency management. And after all this, we got 22 referrals over the course of that timeframe. As you can see on the graph there, from July to February, and about eight of those patients actually attended four or more visits. So yeah, as mentioned, we had a high dropout rate, which is consistent with the literature. Next slide. So just reporting a brief outcome measure that we were tracking, which was the average duration of abstinence, which was for patients who attended those four or more appointments, getting four, they're getting on average about six and a half weeks of abstinence, which is also consistent with the available literature on CM. Next slide. So this is a slide that just has a few quotes of feedback from patients who have been enrolled in contingency management. And I think the summary is that they feel rewarded, more motivated, building that self-efficacy that Dr. Burns mentioned. And then I just want to share a couple of brief patient stories from our clinic. The first one is that a patient enrolled in our program came to all 16 weeks of appointments despite his urine being positive every single time he came in. And the reason why he did this, he says, is that because he enjoyed seeing and talking to the staff. And then a second patient brought in his newborn baby to show the staff. So those are just a few fun experiences that we had with patients. And I think they highlight a point that Dr. Burns mentioned a bit earlier, which is this idea of creating a positive, like a recurrent, unconditional positive environment for these patients that come in too. These patients have been stigmatized by the healthcare providers and healthcare system. And I think Dr. McDonald mentioned this earlier, 85% of patients don't seek treatment at all. And essentially what's happening here is a negative reinforcement for healthcare seeking behaviors, which is a big issue to overcome with a lot of these patients. This slide I think is about, I think it's gonna answer some of the chats I'm seeing in the chat. This is a little plug for the Contingency Management Training Program called the PROSM Collaborative here in Washington State. And this is a group that provides comprehensive training and technical assistance, including didactics, a manual, an Excel spreadsheet that can help you track vouchers, support calls, fidelity assessments, and trainings. And so this is the group that helped me. They have been with me every step of the way and Sarah and Mike are part of the PROSM or the lead the PROSM actually, Dr. McDonald does. And so I just wanna put in a plug that it's been really fun working with them. And not only did I get help getting contingency management but I got some new friends out of the deal too. So it's been really nice. The other thing I wanted to mention in the question chat that I saw come up was brainstorming ideas for funding. And I think we're at the cutting edge of how are we gonna make consistent structural funding available for all people, for all different insurers. Right now we're seeing several states in the West, the Medicaid programs start to fund contingency management. And I'm hoping that that will continue to spread throughout the country. In the meantime, I'm getting really creative you guys. Okay, so one of the ideas, I went on my organization has a foundation. So I went and asked them and they are so excited to be a part of this that they gave me money pretty easy. But some of my most recent ideas have included hitting up my administrators for my colleagues unused CME dollars because during COVID nobody's traveling to go to hotels for conferences. And so they're saving a ton of money. And so I've asked if my colleagues would consider donating those funds to my project. And another thing that I've done is I've sent out donation requests to my family when they asked me what I want for Christmas. So that's another strategy that I've been using. And because I don't need very much money, that's been about all I need. And so that's how I'm doing this thing on the side while I'm waiting for the rest of society to catch up. So, so there you have it. Can I just add Amy? And so we are gonna be training 26 sites throughout all of Washington, 26 opiate treatment network clinics and 20 of those, it doesn't matter. And then a bunch of hub and spokes sites. So a lot of buprenorphine providers and how to implement contingency management statements. And the only reason we're doing that is because of Dr. Burns, because she reached out to the healthcare authority here and she said, hey, I'm a psychiatrist. I run a training clinic. I do buprenorphine. We're overwhelmed by stimulants. We need to do contingency management. And because of her advocacy that got us connected to healthcare authority. And that's why we're gonna be rolling out this training in Washington. And some of our decriminalization legislation that just was passed, where we're changing the way that what happens to you when you're arrested for possession or you could be arrested for possession now includes contingency management because folks knew about it through Dr. Burns' advocacy and some other advocates. So I just wanna put a plug in for you all, especially as psychiatrists and other mental, as a provider, psychiatrist, physicians, you all have a big voice in this space. And I'm just so excited that there's physicians asking me as a psychologist how to do this in their private practice. Like you're even considering this is just amazing to me. And so I wanna thank you, Amy, especially for all your advocacy and also for you all for being here, because I think it's a big deal to have, especially physicians really interested and excited about this intervention. Yeah, I wanted to just let the other psychiatrists out there on this call know that my advocacy wasn't very hard. It was basically like one meeting that I asked to have a meeting and I told them why I think we should do it and why it's important. And people start getting out their checkbooks. Like it is right now, the wind is at our back. So this is an easy lift in comparison to some other initiatives that I've pushed on. This one happened, I can't believe, you know, like I just, anyway, I just wanted to let you guys know, don't be intimidated on this one. Everybody sees the problem and everybody's trying to figure out how to fix it. And so all you have to do is point them to the evidence and it seems like they give you money. That's my experience. It's that easy, huh? Yeah. I got, one time I had a 30 minute phone call and I got $5,000. And I remember coming out of my office thinking like, I am in the wrong profession. I mean like- For sure, you definitely are. Yeah, it's crazy. Maybe I should be a fundraiser. So anybody wants to put Amy on their grant application because you're guaranteed to get it if you just put her on it. I was like, I'll definitely do that now. Thank you for the kind comments. It's a pretty high praise. So please feel free to reach out to us. We have another few minutes. Feel free to either chat questions if you have them at this point, if there's questions we've missed, or go ahead and unmute yourself if you'd like to ask a question. I wanted to bring up a chat question that was mentioned earlier that I'm not sure we addressed from Jack Blaine. He says, I'm a psychiatrist in private practice with no staff. I have access to urine test cups and read them myself. I have difficulty figuring out how to finance the cash rewards or gift cards. I think we mostly, or I guess we mostly addressed that, which is you, Dr. Burns, just being creative with and looking into funding options. Yeah, and I think also talking to private insurers, if you do have any connections to private insurance companies, there are some who have, like I mentioned in my response, have approved dynamic care for their enrollees. And so that would mean you wouldn't need to do it or pay for it, but for sure, I've talked with a couple of my psychology friends about, who are in private practice, about doing contingency management and having models where, yeah, that person would give you that money upfront. This particularly worked for people who are not even insured or just paying you for their care, just cash. And then you would give those back out as reinforcers. We've also been creative about sort of thinking about people, like if you have a client who has a plan to go to Mexico for a trip, remember before the pandemic, we used to all travel places. So if you have a client who's got a big goal, like maybe they're gonna buy a new car if they do have those financial resources or something like that, you could set up a contingency management program like that where they got to earn increments or vouchers towards that. And then you oversaw those with the urine tests. And so you could do some tricky, some creative things like that. But I think, you know, you gotta be pretty creative. Dr. McDonald, what do you think? I'm not sure if this is legal or legitimate, so I'm just gonna throw it out, but it just came to me. Okay, so like this person's asking about their private practice. Like what if they earned, and you're gonna waive their co-pays? That's one that I've thought a lot about, but I don't, this is where it's totally out of my league. You all are way more informed on this than I. I don't know if that's allowed. I don't know if you're allowed to apply that. Yeah, I don't know either. I just know that when I talk to even the managed care companies that work with Washington State Medicaid, they are very interested in this intervention. It's perfect for like a setting like Kaiser or any other payer, like it's safe. So we can save a lot of money on those inpatient costs on, you know, especially on inpatient costs. And so I think it just makes sense. I think, so I think, yeah, but you have to be creative. Glad to talk to you more. I think it is coming though. I think that's the main thing I wanna tell you all who are in private practice. This is coming. So somebody asked Dom, oh, Dom's the best physician to answer this. I don't know how many VA clinics are actually implementing it. It's a lot though. There you go, 111. So the California pilot, my understanding is the California pilot of contingency management is gonna touch as many as 350 clinics over the next year. So I think that will be, it's gonna be a huge lift. And so I think it's coming, as it comes to Medicaid, just like anything else, I think it's gonna hopefully come to private insurers and others as well. For those of you, I think that is worth mentioning that right now the Medicaid programs in Washington State, Montana, and California are currently working with PRISM to bring contingency management to their Medicaid patient populations. And so if you live in those states, you may be able to make some connections there. And you may be able to use that information to approach your Medicaid payer in your state and say, hey, all the cool kids are doing it. You guys are off the back. They're gonna be saving the money and you're gonna be paying it out. So that's a little sample of how I advocate. Yeah, we have so much business. I know we really would love to respond to every training request, but at this point I think there's a, because contingency management has been used in research and really the VA group is the only group that's really pushed it out at a large scale, there's not that many people out there like Sarah, frankly, that just have the experience. And so we're trying to continue to build that expertise and coordinate across the country to meet needs because we often get, I mean, I get contacted at least once a week by a different state asking us about training. And some of those states don't follow up because they have a lot going on. But we really, I really appreciate the advocacy and we really need more of you doing this work because we need your help training people to do this work. So we're excited to partner anyway with you all to do that. Because I've seen other cool ideas about residency and training, how to integrate this into residency training. And yeah, maybe Amy next year we could do a whole talk on that. Yeah, that's exactly what I'm doing. Well, you guys, 1215 is our end time. So I think we should wrap it up and say goodbye until next year. Well, at least until our next talk anyway. Okay. Bye everyone. Thank you.

contingency management

stimulant use disorder

Mike McDonald

Washington State University

psychostimulants

primary care setting

opiate use disorder

Medicaid compliance

evidence-based psychiatry

co-occurring mental illness

addiction clinic

funding strategies

training and technical assistance programs