Implementation of a Highly Effective Intervention for the Treatment of Stimulant Use Disorder and it is chaired by Dr. Larissa Mooney. Dr. Larissa Mooney is the immediate past president of AAAP. She is a professor of psychiatry at the University of California San Francisco. She leads the UCLA VA Addiction Psychiatry Fellowship and she was previously the section chief of the Substance Use Disorders at the Greater Los Angeles VA. And she's also a distinguished fellow of the APA. She's a fellow of ASAM and she's the principal investigator of the Southern California node for the NIDA CTN. Dr. Mooney, thank you. Thank you for the introduction and good morning everyone. Welcome to the first symposium of this year's AAAP annual meeting. Really happy to be here in in sunny Florida. I hope you'll have a chance to enjoy the nice weather. So the broad topic of today's symposium is contingency management which as many of you know is the most robust treatment that we have for stimulant use disorder and yet it is really widely underutilized and unavailable in most treatment settings outside of the VA which has supported use of CM for many years. However, the situation is starting to change as some states are beginning to arrange funding for contingency management and implement CM programs that utilize Medicaid reimbursement. The availability of reimbursement for CM is starting to happen in some states. So our three speakers today have hands-on experience with contingency management implementation and rollout in California, Washington, and Montana and they will be sharing those experiences with you and early pilot data from these efforts and hopefully some of you will be inspired to get more involved with CM and continue to advocate for CM locally and in ways that may be available to you and we also hope to hear from you during the discussion about your experiences and challenges that you're facing and bring your questions to this panel. So I'm going to introduce our first speaker now, Dr. Richard Rawson who is a professor emeritus at the UCLA Department of Psychiatry and a research professor at the University of Vermont. Dr. Rawson has conducted numerous clinical trials on pharmacological and behavioral treatments for individuals with stimulant use disorder. He has multiple publications on contingency management from research supported by NIDA grants. He is a founding member of the CM Contingency Management Policy Group established in 2019 to promote the use of CM for treatment of stimulant use disorder. He is a senior consultant to the California Department of Health Care Services on the design, development, and implementation of California's Recovery Incentive Program. He is currently providing consultation and technical assistance to five states on the development of CM. He was recently awarded the ASAM Presidential Award for Excellence in Teaching and Leadership in Addiction Medicine and made a Distinguished Fellow of the International Society of Addiction Medicine. And on a personal note, Dr. Rawson was my very first mentor at UCLA and has significantly influenced my career, so I'm particularly honored to be introducing him today. Morning. Larissa was the best thing I ever did at UCLA. Tom was a close second, however. And yes, Larissa just sort of reviewed what I've been doing recently and on New Year's Eve 2019, I got an email from Wesley Clark saying the Office of the National or the Inspector General for the HHS is considering allowing incentives to be used as part of a Medicaid benefit and we should be sending emails to HHS to encourage them to allow us to use Medicaid dollars for contingency management. That was New Year's Eve and I had to write the thing before midnight in order to get it in under the wire. That started a conversation with Wesley and a number of us and we've been meeting every Thursday afternoon for the last five years to work on these issues. And this issue of getting contingency management used is something that has been an interest of mine going back to the early 2000s when, after I finished a couple of NIDA studies and found that it seemed to work pretty well, we've been trying to figure out how to get it used in the real world. Disclosures. And this is my talk. Okay. So why should we be interested in this? This slide is now a little bit dated. I saw Wilson Compton's here and I need to get a hold of Wilson to get the more updated one of these. From NIDA on the current drivers of the overdose crisis and the punchline from this is that you see in the last several years and now I think they have slides through 22 that the primary drugs that are involved in the opioid or in the overdose death crisis are of course fentanyl as the primary one but second and very substantially are stimulants cocaine and methamphetamine. And one of the things that's been of interest to me watching the news and the media and over the past five years particularly is that the phrase the opioid overdose crisis. This really does go beyond opioids. Fentanyl certainly is the major killer but in some data that we've been looking at in Vermont where I now live we're looking we're talking to people who go to syringe exchanges asking what their primary drug is that's driving their injection drug use and with over 60 percent it's stimulants. Vermont's still main stimulant is cocaine but it's cocaine and methamphetamine that's what's driving their drug acquisition. Now of course they often get fentanyl mixed into the drug supply but the thing that's really pushing their drug use is their addiction to cocaine and methamphetamine. So I think it's been a really underappreciated part of the story that the stimulant use has playing a large role in putting people at very high risk for exposure to fentanyl and fentanyl overdose. These are some data from Joe Friedman and Chelsea Sober at UCLA. They've done some great epidemiologic work looking at the at the wonder data set. This is the overdose death by fentanyl and stimulant presence from 2010 to 2021 and if you look at the last bar you can see that about a third of the deaths are from fentanyl only about a third are fentanyl and stimulants cocaine and methamphetamine about almost 20 percent are stimulants only and then the top one with neither fentanyl nor stimulants but if you add up the red section of the bar in the purple section you're at about 50 percent of the overdose includes stimulants either alone or in combination with fentanyl and as we've been mustering efforts to reduce overdose overdose deaths I think the the emphasis on the role of stimulants really has been underappreciated. These are some data on which stimulant and I'm sorry this is I criticize people for putting up graphs and then saying I'm sorry you can't read this graph but that's exactly what I'm doing here but this shows some of the the states I mean in most states it goes out to of 45 to 50 percent or above are involved stimulants and I wanted to quote from the Larissa told me that she and Brian Hurley are doing a session on the stimulant guidelines that are were produced by the ASAM AAP clinical guidelines in there is the is the sentence that contingency management has demonstrated the best effectiveness in the treatment of stimulant use disorders compared to any other intervention studied and represents the current standard of care. So that's a very nicely stated I think that all of us who have been working in the area of stimulant use disorders in the last well 50 years really understand that this is the treatment that has all of the data contingency management's a behavioral technique employing the systematic delivery of positive reinforcement for desired behaviors incompatible with drug use in the treatment of stimulant use disorders vouchers or gift cards can be earned for submission of cocaine or methamphetamine free urine samples or for the completion of other target behaviors as it's currently being implemented in the trials that Tom and Sarah are going to talk about we're using this protocol of reinforcing stimulant free urines. There are some other ways of using contingency management but this seems to be the one that has when you look at the literature on this if your interest is in reducing stimulant use this is the protocol that seems to have the biggest bang for the buck. Essential ingredients of contingency management BF Skinner 1938 behavior of organisms use use positive reinforcement. It's this is entirely a positive reinforcement intervention. You define a specific behavior that is going to be reinforced. In many cases the protocols use providing a stimulant negative urine test or biological test. So that's the target behavior in many of the protocols measure the behavior frequently. So in order to provide contingency management most protocols use twice a week some use three times a week but the ones that in current use generally are using twice a week provide tangible incentives immediately after the behavior is observed and with the focus on the word immediately the reward has to occur immediately to have an effect. Again BF Skinner 1938 and would hold the incentive when the behavior is not observed while maintaining a supportive attitude. So people come in they give urine samples when they're negative for stimulants they earn gift cards or electronic gift cards or some other form of reinforcer. If they give a urine sample and it's positive for stimulants there's still a lot of encouragement. There's a lot of positive feedback to them but they just don't get the gift card. So but there's no punishment involved no scolding no kicking people out of treatment no punishing people for not providing perfect behavior. As I said it's a positive reinforcement. It offers a non-drug reinforcement in exchange for the evidence for drug abstinence. These rewards are very effective it seems may seem counterintuitive that people are spending all of their money and all of their savings and all of their resources on these drugs but yet small reinforcement can help to change the behavior. And if you I was doing a lot of CBT work back with when I was seeing patients in the 90s we were seeing gazillions of cocaine and methamphetamine users back then and we were doing CBT and motivational interviewing and educating patients and blah blah blah. And we thought we were doing a pretty good job until we ran a well first off I saw a Steve Higgins study that was published in 1992 on contingency management and I thought he I thought he was making up his data because I was treating real cocaine users and you couldn't get that kind of data with my patients. So I visited Vermont I was at UCLA at the time I visited Vermont to talk with him and he convinced me that he actually had collected these data so we ran a couple of studies with NIDA support at UCLA and we got remarkable data. One set of patients were patients in methadone outpatient opioid treatment program who were using cocaine and we got really good data from contingency management and then we used with primary stimulant users. We were individuals who use stimulants. We were we use contingency management got the same remarkably positive results. So I became a believer on the usefulness of this. Now contingency management is not simply providing incentives or rewards. There's lots of ways to add positive reinforcement into a treatment clinic and I certainly would recommend it that as much positive reinforcement as we can put into treatment is a positive thing is something that should be. And these sorts of things that you that people do in treatment centers and clinics for people with addiction all of these things are great. They're they're wonderful but they're not contingency management. So in order to do contingency management there's a few things that are important to to understand. The first is that you have to have a protocol. I just submitted a paper and said talked about the things that are needed to do contingency management and I got feedback that use of the term protocol is a research term and we should be using another word and I can't quite figure out what the right word is because to me it's a protocol. The when we work with California to set up the program that Tom is going to talk about a lot of time and effort went into the protocol of exactly what are the rules of the game. What are the what will earn you the reward. How often do you have to come in. What are the rules of you know specifics of the protocol. That took us a long time. We had a lot of provider input a lot of input from potential consumers as to what they would want in their contingency management program and the design of the protocol I think really is an underestimated part of the package. Anyway you need to have an adequate level of reinforcement. I'll talk about that in a bit an adequate duration and the term adequate is in this case is you're it's sort of throwing a dart at a dartboard as to what the adequate duration is. We don't really know. We don't have good data on how long people need to be in contingency management. Probably needs to be more than a month and probably less than a lifetime but somewhere in there in that in that range or maybe it does need to be a lifetime. I wouldn't rule that out. There need to be fraud prevention guardrails when you start handing out gift cards worth twenty five dollars or those kinds of amounts. There lots of mischief can occur and lots of things can occur with those gift cards so you have to have a very clear protocol and very clear accountability for how the the rewards are given out and for what and over what period of time and how they're recorded and who has access to them. All of that stuff is is very important. There needs to be a well-designed training and implementation plan. This is not a one afternoon training approach that there really needs to be training and ongoing coaching and fidelity monitoring and that's the last one fidelity monitoring and if you have specific populations. Sarah and her colleagues at the University at Washington State University have done a lot of work with American Indian and Alaskan Natives in tailoring protocols for that population. Tom did work with Steve Schapta on developing contingency management programs for men who have sex with men who use methamphetamine and so there are adaptations that may need to be done with the protocol. This okay this is now getting into the weeds a bit. One of the issues that blocked contingency management up through 2019. I was doing a contingency management program in California and I think about 20 2006 2007 and the state had provided some money. We had about 20 programs doing CM and it was going quite nicely. Patients were doing well. Programs liked it but the program started getting audits from their Medicaid, Medi-Cal in California auditors saying you can't do this. This is giving patients kickbacks. You can't give them tangible incentives and of course the programs contacted me and I said I don't know what they're talking about because I don't really understand the Medicaid police but they all shut down and nobody you know was gotten any had any penalties but it was clear that there was something I didn't understand about Medicaid rules that suggested you couldn't use incentives with patients. That pretty much shut everything down for for about 10 years except in the VA as Larissa mentioned Nancy Petri did some really remarkable work getting contingency management into the VA starting in about 2014 and they've been using it for about 10 years but anyway I was interested in seeing contingency management used out in the larger system outside the VA and this issue that Wesley and I started working on in 2019 dealt with the Office of the Inspector General and the definition of a safe harbor for how much money you could use in this process of contingency management and one of they came up with a set of guidelines that Wesley, Wesley is a lawyer and so he was able to interpret the 200 page document that they wrote on this and boiled it down into some specific recommendations and these are those recommendations that outline kind of what you're expected to do in order to be able to use contingency management, provide incentives, reinforcers to patients for for reduced stimulant use and we have these slides will certainly be made available to you but there are some clear guidelines at this point that are important to make sure that you're operating within the guidelines of the Office of the Inspector General for HHS. Now contingency management as I mentioned is the application of positive reinforcement and the actual delivery of it and the the way in which it is provided to patients is a very positive experience. Tom will talk more about what he's done in California within the training and implementation activities to emphasize this and it it I have to say it has been interesting I've sat in on a bunch of the coaching calls that they do and it's not immediately sort of intuitive to many of our workforce in the substance use area that positive reinforcement it needs to stay positive to keep people coming in to keep them staying connected even if they're continuing to use which many of them do for for some time but that's been an interesting development we certainly in the training that's been done in in all the sites motivational interviewing is a big part of the implementation of how to deliver these and how to interact with the patient in a way that is supportive and retains them in treatment even when they're not doing well even when they're not earning the incentives but we keep them coming back in and Tom was talking about a patient in in California this morning that went through the first entire 24 weeks of contingency management and gave positive tests the whole time all the way through but continued to participate in the in the activities and then in a later subsequent in episode of treatment it took and and the use went down but maintaining the person's involvement with these kinds of strategies is a part of contingency management that gets doesn't get talked about a lot but is an important component for it read there's a ton of research support as suggested by the the guideline statement when I used to do these presentations I would put up graphs and show bar graphs but now in there seems to be a cottage industry now and doing a meta analyses I think there have been nine meta analyses in the last five years and interestingly they all say the same thing when it comes to the treatment for stimulant use disorders this one was one led by this was a group affiliated with the W.H.O. most of these folks on comparative efficacy and acceptability of psychosocial interventions for cocaine and methamphetamine addiction, a review and meta-analysis. They looked at 50 studies, combination of contingency management and community reinforcement approach was the most efficacious and most acceptable in the short and the long term. They actually looked at the work Higgins had done with a behavioral treatment called community reinforcement that seemed to extend the benefits of contingency management. This study published in 2020 came up with a slightly different conclusion. While contingency management interventions showed the strongest evidence, they detected some benefit from some tailored CBT interventions. This is one of the more recent one by Bensley et al. with patients for cocaine use. His conclusion, the meta-analysis contingency management programs were associated with reduction in cocaine use, only contingency management. Steve Higgins' group at UVM did an analysis of interventions with patients on MOUD, methadone and buprenorphine, and their conclusions provide evidence supporting the use of contingency management with that population on MOUD who also use stimulants. This is a study that looked at 27 studies using CM for treatment of methamphetamine use disorder. They looked at a whole variety of other outcomes. Does contingency management for the treatment of stimulant use disorder do anything other than reduce their stimulant use? They found that in 26 of the 27 studies, there was reduced methamphetamine use, but also that there was evidence that people with CM were retained longer in treatment, received more other behavioral therapy treatments or sessions while in treatment, reduced risky sexual behavior, and they felt better, increased positive affect, decreases in negative affect. You get effects that are beyond just reducing stimulant use disorder. That's true whether you're using it together with other behavioral therapies or not. The study I did really compared using CM alone, CM together with cognitive behavioral therapy, cognitive behavioral therapy alone, or no additional treatment. What I found was in the two contingency management groups, we got very substantially better results than in the other two groups, but no difference between CM with or without CBT. So it really is a very potent intervention. Current challenges. The big one is there's a $75 cap. The federal government has a $75 cap on the amount you can use with an individual patient. $75 is not adequate. It would be similar to saying you can use buprenorphine, but you can only use two milligrams per day per patient. You would say, well, that's not using buprenorphine. Ditto with using $75. It's inadequate. It's not. Carla Rash from the University of Connecticut just put together a big review of the amounts, what is an adequate amount, and it's all over the place, but it's certainly the floor is somewhere in the neighborhood of $300 or $400 per patient, maximum earnings all the way up to $2,000 depending on the study. So you're really looking at a much different range than $75. People using $75, they're using an incentive program, but it's not really evidence-based contingency management. The California program Tom's going to talk about has a $599 maximum amount people earn. When we set that up with California, we recommended $1,200 for the California protocol, but the California lawyers said, we're not sure if this is taxable income. So if you give more than $600 or more, you'll have to give patients 1099 forms. Our providers decided they didn't want to give 1099 forms, so we stopped at a maximum of 599. There's nothing about 599 that's magical. There's no like, that's the best number you should use. The only reason we stopped with 599 is because of the potential for tax issues. The other ones, there really have been, I think what Tom and Sarah are going to talk about are two of the most robust training and implementation plans for this. What's been done to date has been sort of random activity around training people to do this, and if you're going to do this and you're going to get people to follow a protocol and to do it with fidelity, it's not a small effort. It takes a good deal of guidance. We don't really know what the optimal parameters are, how much we should use, how long we should go, or anything else. So that's, those are some of our current challenges. Okay, so the major, one of the major obstacles right now is where does the money come from to provide this? If federal dollars can only be used up to $75, how else can we fund this? Well, one is through 1115 waivers that states have to do with the federal government to determine how they're going to use their Medicaid dollars. California, Washington, Montana, Michigan, Delaware, and several other states are in the process, there may be ones I don't know about, have these waivers and are using the protocols that you'll hear described. So the waiver is one mechanism to go above the $75. Several states, Michigan, Vermont, Rhode Island, are using opioid settlement money together with the $75, and if you set it up properly, you can pay for staffing and urine testing and everything except the incentive out of federal dollars, and you pay $75. So you only are really looking for money above $75. That's all you need from some other source, and opioid settlement funds, I think, are an excellent idea. Some states are funding it with state funds, and the state of Maine is doing some work with foundations. These are some of the protocol questions as people try to start to use CM. There's a couple of different models, what's been called voucher-based CM, which is the protocol Steve Higgins developed in the 90s, or prize-based CM, which involves, you may know it as the fishbowl method, where you draw slips of paper, and it's a variable schedule of reinforcement that Nancy Petri designed. Which ones are those? What are the pluses and minuses? That hasn't really been determined. Duration, target behavior, are you going to look at negative urinalyses, or are you going to look at attendance? I won't go into it, but there's some issues around attendance and whether or not that's kosher vis-a-vis the OIG. Often when you implement this, the treatment programs will say, well, we want to make it contingent on any drug use, alcohol, cannabis, opioids, anything. To which we say, no, let's focus it on stimulants. That's where we have the data. We know it's a treatment for stimulant use disorder, and if you ask for total abstinence, you're likely not going to give many reinforcers. We have great medicines for opioid use disorder, but that often is a discussion that takes some time to work through. Incentive magnitude, as I said, we're looking at anything from per patient, maximum earnings of anywhere from neighborhood of $500 up. There's a technique in the protocol where the amount escalates over time, and if the person gives a positive test, it resets back to a lower amount. Now I'm not crazy about that because that's a punisher, and we're discussing whether or not that's something we want to continue. The idea of escalating with people give consecutive negative urines is great, but the reset often I've had patients in my study say, hell with you, I'm not going to start all over again. That's a decision, whether you want that in your protocol, and do you use it together with other behavioral techniques? Again, lots of people do. The evidence is not strong on the value of that. These are some of the references, and I will wrap up, and I did it in 30 minutes. Thank you. Larissa told me that I should mention this, and I forgot. There are at least five companies delivering contingency management using apps that I think have great potential, and if you're thinking about how to use this, I certainly would suggest that these apps maybe have potential for development, for delivery of contingency management. Thanks. Great. Thank you so much, Dr. Rawson. I'm going to introduce our next speaker now, Dr. Thomas Freese. He is an adjunct professor in the UCLA Department of Psychiatry and director of the UCLA Integrated Substance Use and Addiction Programs. Additionally, he serves as the director of training and dissemination for the UCLA Division of Addiction Psychiatry. He is the co-PI of the training and dissemination contract with the California Department of Healthcare Services for the Recovery Incentives Program, and he is the co-director of the SAMHSA-funded Pacific Southwest Addictions Technology Transfer Center, PSATTC. Previously, Dr. Freese served as ISAP director of training for 20 years. He has conducted trainings on a wide variety of topics, including addressing the stimulant and opioid epidemics, the intersection of HIV and substance use, and culturally responsive care. Dr. Freese has developed and conducted trainings across the U.S. and internationally. Thank you. Thank you very much, Larissa. Hi, everyone. Rick, it's nice to be number two to Larissa. I look up to her a great deal, and she's officially my supervisor, so nice to be here today with all of you. Oh, there's my slides. So I'm going to focus specifically on the work that we're doing in California. I want to emphasize specifically, though, this is not a research study. This is a publicly funded implementation in real world settings, which means out in the wild, where people do all kinds of things that you never expect and that you can't necessarily control for as you can in a research study. And so one of the big challenges that we were given is, how do you implement what's been shown in research to be effective with all of these tight controls that we can implement when we don't have those controls? And the state of California said, oh, yeah, and you have to be able to demonstrate research levels of fidelity. So we're going to talk about kind of what we did and how we think we're getting pretty close to that, and some of the lessons learned along the way. And then we have some preliminary data from the evaluation that I'd like to share with you just to kind of get a sense of how things are going so far. As a forecast to where we're heading, when Rick thought that Steve Higgins was making up his data because of how positive it was, when I saw our first set of evaluation data, I'm like, can't possibly be that. And so we think we're doing a pretty good job, and I think we have some good lessons to learn. So to set the context of where we are, California's been dealing, I can't see my slides if the mics are over there, so, California has been dealing with a stimulant use problem for 30 years. And as methamphetamine, cocaine's been pretty stable in the eastern seaboard, methamphetamine made its way to you and then kind of rolled back, and then it rolled back again. Cocaine kind of rolled to the west coast and then rolled back again. We've never lost the methamphetamine problem out west. And in fact, if you go further west than California, the problem gets even more significant as you get to Hawaii and the U.S.-affiliated Pacific jurisdictions. So some very straightforward thinkers, including Kelly Pfeiffer, who's no longer with the Department of Healthcare Services, but really was one of the brains behind this whole process, said we need to do something about this. And so having never done it before, she said, let's just try to get CMS to pay for it. And so she worked with a team of people and put together the 1115 waiver. Now, you all are probably much more expert in Medicaid than I am, but in case you don't know what an 1115 waiver is, it's designed to change the rules in how Medicaid funding is spended so that you can do a pilot project and demonstrate through that pilot project that if we do this instead of this, we get better results. And much to everyone's surprise, CMS said, sure, let's do that. So over the course of about two years, and it did take all of that time to get the protocol in place, get CMS approval, and then begin to recruit and implement sites, we were charged with figuring out how do we roll this out. And so we went back to implementation science and the work of Dr. Sarah Becker, and she demonstrated that by implementing specifically contingency management in one of her studies actually with people who use opioid medicines, that she got pretty good results. And so her science to service lab had a didactic workshop, ongoing performance feedback, external facilitation and coaching, as Rick had mentioned. And for this particular protocol, because we were doing it out in the wild, she did hers in a research trial, we wanted to make sure that the sites really understood what they were getting into. And so we created a readiness process for them to be able to demonstrate, I know the protocol. Now, back at our sites where our bathrooms don't conform to what you talked about and our clinic flow is entirely different, and we don't have half the staff that you talked about, this is how we're going to implement it in our particular site. And then we, I'll tell you about that process later. And then because we're required to show that we're getting research levels of fidelity to the model, we do ongoing fidelity monitoring as well. So the key elements of the program are, we decided in California to take some of the original seminal work, which was based on a 12-week model, and replicate that model. Rick was really influential in helping the state see that 12 weeks is really short to keep someone engaged in treatment. So what if we extended it for another 12 weeks as a sustainment period and got people to try to stay engaged for a longer period of time? What would that do to our results? We have some early indicators of that that I'll share with you in just a little bit. We do test for either 12 or 14 substances, depending on which of the approved urine drug tests that people use. But the incentives are only based on stimulants. And again, that's based on the research that Rick reviewed, that if we try to test for everything, no one gets any reinforcers because they don't do it well enough often enough, and you get no impact. But that research also says that if we do one drug at a time, not only do you get an impact on that and all the other quality of life stuff that Rick talked about, but you also get some associated impact on other substance use as well as they continue to improve. So stimulants only. Rick already talked about the 599 maximum. And we were promised a ruling by the IRS to determine whether this was taxable income or not. And they said it would come to us no later than June of 2023. So we're right on time with that, and we don't know that we'll ever get it. And as you'll see in just a minute, it sounds pretty straightforward. They pee in a cup, it's negative, they get an incentive. It's not that easy. And it involves a great deal of math and a great deal of tracking. So the state of California decided to put out a call for proposals, and they funded a company, Q2I in our case, to develop an incentive manager to oversee that. So they developed a web-based portal that basically all the sites have to do is simply put in a positive or negative result. It calculates the appropriate incentive for that individual, and then it delivers the incentive, preferably by text or email, because they can hang on to those. But if they don't have the technology in order to be able to manage that, they can get them printed. The big downside to printing gift cards is it's cash, basically. So if they lose that, they lose the incentive as well. So I'm going to skip that one for one second. So we do use that escalation reset and recovery protocol that Rick talked about, that, yeah, the punishing element of the reset is really awful, right? You get up to $16 or $20, and then you have a no-show or a positive test, and you get no incentive that day, and you drop all the way down to baseline again. But we wanted to recognize that they've made a lot of gains along the way. So for that first test in our protocol, in the work that they're doing in Washington, their protocol's a little bit different than ours. But in our protocol, that first test, you get $10. The next test, you get everything you had before. So if you're at $16, you go back to $16, plus the next escalation along the way. So it puts them back on track very quickly in order to be able to get the incentive. And so this is actually the incentive schedule that we utilize. And you can see we start at $10 for every two consecutive tests. You escalate by $1.50. And if you test negative during the entire 24-week period, you'll earn a total of $599 by the end of that period. So how the heck do you do this? This is the program that we laid out and got approved by the Department of Healthcare Services. We start with a two-hour overview training. That is a self-paced recorded training using a recorded PowerPoint presentation broken up into small modules so people can do it at whatever pace they want to. We encourage everyone in the agency to do that training. But it's required for the people who are going to be responsible for implementing the Contingency Management Service. By the way, that's in the public domain. It's open to everybody. And we've had people from across the nation take that. So if you want just sort of a basic overview, which is what it is, of what is Contingency Management, it's a really great low-barrier way to do that. And we offer continuing education, including continuing medical education for that. And it's free. Was that an advertisement? You're welcome. After that, the people who are implementing the protocol, and we've narrowed this down to a small group of people, a CM coordinator, a backup person for that coordinator, and a supervisor at each site. The supervisor can also provide backup for the CM coordinator. As Rick said, this is not an intervention that's for everybody. Not everyone has the kind of attitude to keep everything all positive on an ongoing basis. And the worst thing that can happen is for someone to come in, test positive, and be criticized for that using the old-school way of doing urine drug testing, as opposed to praised for coming in and giving the test, and then supported to move to their next test along the way. So agencies have identified specific people in their site that they think will be good at implementing this protocol. So those people are required to take the two-hour overview, and then they participate in two sessions totaling three hours each, six hours total of training in the protocol itself. We go over the details of the protocol, how to use the urine drug tests that have been approved, why the urine drug tests that were there were selected. I'll talk about that in a second. And then all of the specific nuance of using the incentive manager, but most importantly, what happens when the clients disagree? What happens when they say, I haven't used, and the test says that they're positive? How does the provider handle those kinds of clinical interactions? And so we work on those in the training. We then move on to the readiness assessment. The readiness assessment, as I said, is really, can you do this in your site? So we've developed a Qualtrics-based self-study that walks the person through all of the requirements of the protocol and says, how are you doing this in your local site? As they do that, they talk about what their plan is, but we also then evaluate that to see are there areas where we need to talk about more to make sure they're in line with the protocol. They also, each staff person is required to enter three practice cases, really challenging, clinically difficult practice cases into a sandbox version of the incentive manager portal so that we can make sure that they understand how to enter those data and that they can enter them error-free in that particular case. Once they submit all of that, we schedule an interview with them, walk through any questions that came up with the self-study, and then walk through their decision-making process for all of those clinical scenarios. You put in this answer, how did you come to that decision, and do some role-playing along the way as appropriate. You have to do steps one, two, and three before you're given the go to launch. Once they do that, the Department of Healthcare Services approves them to implement the service and they can begin enrolling clients into the service. We thought they were going to hate us because we're not done with them yet. So on a monthly basis, we ask them every single one of those key staff people, those three, at least three staff people to come to a coaching call. And right now, those are going on in perpetuity. The coaching calls are an hour. They can select among 10 different calls that are available during the course of the month. And they have to attend one, not even as a team. We'd like them to, but we know that schedules don't allow that a lot of times. Those coaching calls are really problem solving calls, group learning kinds of processes, strategies for recruiting patients, and just dealing with kind of the day-to-day stressors associated with managing this. And Sarah does these calls with us as well. We just get to sit and listen to really amazing stories about the impact that this service has done. And one of the things that we've noticed is that providers are saying they feel less burned out who are implementing this service. And most notably, providers who've been doing treatment based firmly in 1970 and never moved beyond that and said, this is not going to work. We don't want to do it, kind of forced into it in their agency. And they're among our biggest supporters along the way. Just the last two steps. Sorry, I have all this detailed in my slides if you want to look at them later. After the monthly coaching calls, we then do ongoing fidelity monitoring. And to meet the requirements of CMS as they were written into our protocol, we do two fidelity monitoring sessions in the first six months, and one fidelity monitoring session every six months after that. It looks exactly like the, well, different questions, but very much like the readiness assessment. They do a self-study, we schedule an interview, talk to them about what's going on, and make sure that we're not seeing any protocol drift. So all of that's detailed. By the way, the link to our online course is there in the slides. All of that's detailed pretty thoroughly in my slides. But I wanted to spend most of the time talking about the importance of the incentive manager, but then giving you a little bit of data associated with that as well. So the incentive manager, they do a really amazing job in helping us find incentives that are relevant and appropriate for the client base that we have. So we started with, I think, 12 different gift cards that were available to people when they enrolled in the program. But one client was like, I don't want any of that. I play games. Can I get games? So the incentive manager company looked, and they found that GameStop was an appropriate place for that. The CMS required that we only use gift cards that are limited for things that could be considered bad. I struggle with that a little bit because it seems a little moralistic. I really think that we should probably be able to use cash, but we can't. And we can't use gift cards that allow them to buy alcohol, tobacco, firearms, or ammunition, gambling products like lottery tickets, cannabis, and there might be one more in there. And so finding those gift cards is a real challenge because none of the big box stores like Target offer those restricted gift cards. The only one that does is Walmart, which is why you see it on our list. But we're continually trying to find ways of giving people things that they need with and will incentivize them while meeting those limits. Gas cards, for instance, are a really big one. That would be an amazing incentive, right? I can't afford gas, especially in California. Prices are really good here, by the way, compared to ours. Chevron had a restricted gift card that only can be used for gas. The problem with gas stations is they all have a mini mart attached to them, and you can buy beer there and lottery tickets there, and you can use their gift cards to do those things. So it's a continual search, but this is our current list. I think there's one or two more, and we're working with a big grocery store headquarters, corporate headquarters, who we think is going to offer us a restricted gift card as well. So what did we find? This is our evaluation team, by the way. I'd like to thank you, them, very much for sharing this information with me and with you all. First of all, when we started this protocol, providers were not particularly thrilled. So we, the evaluation team went out and surveyed them and said, what are your concerns? Well, people are going to adulterate the results. They're going to lie about what's going on. They're going to be mad if they're using a drug that they don't get the incentives for, et cetera, et cetera, et cetera. So they came up with a list of these ten things, nine things or so, that everyone was concerned about. The red lines are when they said that that was true often or all the time. The gray lines are when they said that happens sometimes. And the green lines are all, yeah, we didn't see that. And so the things that they were concerned about are not materializing. And I would say that's largely because of the coaching calls, because we're able to talk through those concerns and talk about ways of handling the clients who are coming through their service and help them figure out how to strategize with them in the best possible way to keep them clinically engaged. We were thrilled with these numbers, by the way. We thought they were going to be at least halfway with the red and we got very low rates in that. This is a really old slide. It's the first 11 months. We're at just over 18 months now in recruitment and we just enrolled, we just passed 4,800 people enrolled in the program. By the way, the VA program that both Rick and Larissa mentioned in a paper that they released last year, between 2011 and 2023 nationwide, they've enrolled just over 6,000 patients. We're at 4,800 in 18 months. And I think the difference in the systems actually helped with this as well. But it also demonstrates a powerful need, at least in California, for this particular service in this particular way. We did a number of, we're looking at the data in a number of different ways and first of all, how are people using it? And if you look at these data, we categorized excellent responses. They completed 24 weeks or more. They completed the whole 24-week program. Positive response, they finished the first 12 weeks but then didn't finish the 24 weeks. A partial response, more than 30 days but less than 12 weeks and no response less than 30 days. And we had about 60, what is it, 63% of people that were either positive or excellent responders to the protocol overall. We think that's a pretty good response rate. When we looked at the urine drug tests, it's hard to figure out how to do this in a real clinically meaningful way rather than in a pure research way, right? In a pure research way, every missed opportunity to test is always considered a positive. So first of all, we just looked at, of the tests that we administered, how many were negative for meth, for stimulants of any kind. Ninety-six percent of tests administered were negative. Pretty high number. What if we calculate in the about a third of people that didn't show up for one of their sessions? That, if we consider, again, gross overestimate in this case, I think that every one of those tests was positive. What we see is that number drops down to 74%. So the true number is undoubtedly between 74% and 96% and we're trying to figure out ways with very smart people like Rick and others to use those engagement numbers to track those as well and to see if those who are better engaged are actually getting better results along the way and we hope to refine that to be more clinically meaningful as we move forward. But I'll tell you, if I have a specialty in treatment, it's treating methamphetamine users and I never in any program I've ever run got results like 74% negative for methamphetamine during the course of my treatment. And so I'm really happy with these results and I think they're pointing us in the right direction. Well, what did the clients think? They asked clients in a survey, did the recovery incentives program help you stop? Again, this is no data, right? You don't need a statistics program in order to say that's the difference. Ninety-three percent of people said this helped me stop using the stimulants that I was using. As a result of the program, has your health improved? Ninety-four percent said yes. How much better are you taking care of your responsibilities? Ninety-seven percent said much better. Are you a better member of the community? Ninety-seven percent said yes. Now, survey responders are different than all responders, right? We know that. And so these data are very preliminary, but I think they point in the right direction. We're continuing to follow up with surveys, but we're also doing a series of qualitative interviews with both providers and with clients to get a little deeper into what people experience with this. I didn't state that right now, in the original sample, we had 23 counties volunteer to participate across California in order to participate, this was done through California's drug carve-out, drug Medi-Cal, and so you had to be a county that was participating in drug Medi-Cal. Twenty-three counties participated, and their version of a pilot, California, 166 sites, go. So it's hardly a pilot at all, but right now, over in the first 18 months, we have 19 counties participating and we just passed 100 sites that have been enrolled across the state. Those who have been delayed, it's primarily either getting CLIA waivers for their sites so they can do point of care urine drug testing and or staffing issues, largely. They're having trouble finding the staff in order to be able to support the program effectively. We anticipate getting those all on board in the next several months. I have about three more minutes, is that right? So just a couple, one of the things that happened in the survey is people filled out those blank forms that everyone, those blank questions that everyone leaves, those open-ended things at the end of a survey at a really high rate, and both the providers and the clients, and so they were able to take those open responses and do qualitative analysis of them, and they come up with a few themes that I think are really relevant to the work that we're doing. Incentives help to stimulate day-to-day recovery and the things that they need. I was starving. The recovery incentive gift card gave me something to eat. I used them to supplement basic needs. It helped me reduce stress, and I don't have to steal stuff. Last year at the holidays, and I think about this as the holidays are approaching again, one woman said, since my children were born, this is the first time ever I haven't had to steal their Christmas gifts. That's huge, right? One example, but it's an example that comes up over and over again. Incentives work, even for people who struggled with it, with treatment before. I've been in drug treatment since I was 16. I'm now 43, and I never passed a drug test until I joined this program. It helps them have a healthier outlook on life. The clients, who I didn't include here, just raved about the program, and most notably, they said that it helped them to build a stronger sense of confidence. They really saw themselves as being able to make the choice between their craving, recognizing they'd lose the incentive, and choose the incentive as well. And as they were able to do that over and over again, they had this increasing sense of confidence along the way. So we're really happy with where we are. We're enormous and huge, and California is California. It's not like anywhere else. So I'm really looking forward to Larissa introducing my colleague, Sarah, so you can hear about other kinds of implementation that have been done. Thank you for your time. Thanks so much, Dr. Freese. Our final speaker is Dr. Sarah Parent. She's an assistant professor with the PRISM Collaborative, that's Promoting Research Initiative in Substance Use and Mental Health, in the Community and Behavioral Health Department at Washington State University. She managed a multi-site clinical trial examining contingency management adaptations for people with co-occurring serious mental illness and severe alcohol use disorder, through which she personally conducted almost 1,000 CM visits. She has led statewide training and technical assistance efforts to implement CM for Stimulant Use Disorder in Washington and Montana, supports CM trainings in partnership with tribal communities, and is a consultant for the California Recovery Incentives Program. She has co-developed extensive CM training and implementation resources, including electronic tools for facilitating CM delivery and fidelity. She serves on two SAMHSA-led expert panels focusing on CM training and development of a technical assistance publication. Welcome, Dr. Parent. Thank you, Dr. Mooney, and I have the same problem here. I need to be able to see my slides. Let's see. Excellent. Thank you, thank you. I don't know if anybody needs to stand up and stretch their legs. I know two hours is a long time for a symposium, but it looks like there's a lot of interest in this topic. I think we're all really looking for ways to help people we serve who use stimulants. So, hopefully, you're going to be able to take away something useful today. So, in my part of this talk, I want to talk, it's going to be kind of similar to Tom's in that I'm going to describe the statewide CM implementation projects, the training and technical assistance that we developed for them, and some lessons learned around what turned out to be implementation barriers and facilitators. Here, for those of you who have the slides later, a list of acronyms just to kind of define the alphabet soup. Okay. So, Rick kind of set the stage for back in 2020, you know, he's at such the ground floor as 2019 when he learned that the Office of Inspector General was going to modify in their final rule the use of incentives in healthcare. And so, it provided some clarity, or I'll use, I'll air quote clarity because many of you probably know it's still about clear as mud, how we can use incentives in healthcare and not violate anything like the anti-kickback statutes. But, there was enough in that final rule to encourage some states to go ahead and give it a try. And so, around 2020 and 2021 is when both the states of Montana and Washington reached out to our team and said, you all do this in research, can you help us figure out, just train us, we want to go do it in the real world. And I should actually also mention, since we're, I'm in a room full of likely a lot of addiction psychiatrists, that the first team that we trained before we even got to these statewide rollouts was an addiction psychiatrist in town during the height of the pandemic said, you know, I, we're seeing a lot of people use stimulants, we really want to help them, we know you do this research project across the street, can you just show us how to do it, we want to do it. And so, thanks to her advocacy, she still has a program up and running doing contingency management in her recovery clinic. Okay, so we also do the training and technical assistance in similar phases to what they do in California. In fact, so these programs, like I said, started in 2021, so we did a lot of just learning on the job then, and so you can think of this talk as sort of a prequel to California. So, we said, hey, don't make some of the mistakes we did, we'll help you, you know, kind of circumvent some of the pitfalls that we found during our training and technical assistance approach. So, we did start with a planning phase with the state funders, working on that model development, if we don't, if we can't use the word protocol, can we use the word model, maybe the word policies and procedures, and the sites, the states themselves worked on some site selection at that time. I'm going to talk about how, as a training and technical assistance team, we're starting to get more involved in that phase, because it really helps make sure that we're getting a good fit, and more likely for these sites to be able to actually adopt a contingency management program. And then we do the training and technical assistance, very similar with overview and implementation training, and then that ongoing coaching, implementation support in the form of coaching and some implementation tools. So, I'll get into some details about these. You know, not a coincidence that both the states of Montana and Washington with our, in partnership with our team developed a very similar CM protocols, and that is because really, when you look at the evidence base, there are some real sort of key features that seem to be a driver in creating a program that is going to be able to replicate some of that success that we see in research models. So, both states chose to reinforce stimulant negative urine drug tests. There's a little bit of a difference in how they selected sites. So, in Montana, it was part of a suite of behavioral treatments that Dr. Rossin helped bring to them, and they used kind of an RFP process. In Washington, they already had a network, a couple of networks of providers that mostly were around, formed around opioid use disorder medication provision, and so we just kind of laid contingency management into that network, and then I'll talk later about whether or not those sites that were well-suited to initiate MOUD could also do a CM program. Total reinforcers, we talked about that magic 599 number, so we ended up at about that, or sorry, it's not a magic number, it's just a not taxable threshold. So, we ended up at that, near that threshold in both states through braiding both federal and state funding. Twice weekly visits for 12 weeks, so basically like the first half of the California model, and then both of these states do have approved Medicaid waivers and will be launching programs soon. So, in the site selection, at this point, the states were kind of in charge of it, and so, you know, I described they went about it slightly differently, so those blue bars are the Montana sites, and then orange is Washington, and so basically the take-home here is that Montana had a slightly more focused, narrower type of site that engaged this sort of pilot or first CM program rollout. In Washington, we had a wide, wide variety of sites, and so we'll talk again about FIT in a little bit. And then the education and training phase, I don't want to spend too much time here because it's going to sound similar to California's, but that CM overview, we really want to focus on some CM basics. So, generally, how does CM work based on those behavioral principles? Does CM work, so what is the research evidence? And then a little bit of what CM looks like, so maybe some demonstration videos. Over time, we've actually started dumping more and more into our CM overview and kind of realizing that there are some things that people really benefit from learning early on, and that a wider variety of learners might benefit from some of this additional content, and so we put in myth-busting, we really focused on the positive spirit of contingency management. We talked about using urine tests in a different way, so we like to call that flipping the script on urine testing, and I literally have an animation about how we're kind of looking at urine testing differently in contingency management. And then those regulatory considerations, enrollment, engagement, and so this overview is getting a little long, but we, oops, wrong direction, but it is available similar to California as an asynchronous, self-paced learning done through 10 different modules, and really what I think the most important part about this phase of learning is that people get it and get excited about it, and that's why it's really, overviews are really good for a wide, wide range. Anybody who may find themselves in a position to refer to a CM program and want to support or champion a program at your site could benefit from these sorts of general CM education. But if you're actually going to be rolling out CM, then you also need implementation training for the folks that are actually going to be delivering the service, and so that's where we get into the nitty-gritty around the exact model. You know, a CM overview can be kind of generic. Once somebody needs to adopt a program, they need to understand the exact model, that escalation, reset, and recovery. If there's, they're using an electronic reward tracker, they need to know how to use it. How to choose effective rewards for your community. This is the part that sometimes can be really adapted to the community that you serve. You understand how staffing, again, enrollment and engagement, and then at this phase is when site-specific implementation challenges come up, and so we want to be able to address that. We also, again, we, you know, we lay out what we think people could benefit from learning, and then people give us feedback about what they still need to know. And so the first request I got after, you know, pouring lots of effort into developing a training and a manual is at the end of all that, they said, okay, but can you give us a template for our policies and procedures? And I thought, well, can't you just make one from all the stuff I just said? But really, that, this has actually been one of the things that people have really appreciated and sites have really appreciated, so we give them a template of here are all the areas that you're going to need to spell out your protocol and exactly how you're going to get it done, similar to the readiness process. And then also adopting some readiness and workflow development tools, practicing introducing contingency management, really strict sort of management of those rewards or incentives. If you're going to have a pile of gift cards in your office, you want to know how to keep them secure and have a paper trail about where they're going. And so this is done through live virtual training so that there's a lot of interactive question and answer, small group opportunities. So another thing we learned along the way, though, is there's a few things that are worth actually not waiting until implementation training to do, but actually to pull it out and get it front loaded into the site selection process. So we found in Washington that people, that sites said, okay, sure, we'll show up to the CM training. You know, CM is supposed to be really effective, let's do that. And they didn't really know what the model was going to be, and it turned out logistically to not be the right fit. And so the more we communicate that model up front, the more sites can kind of make an informed decision about whether or not it's something they can integrate. And then also being clear about the staffing and who is appropriate to do it really helps people send the right people to training, right? So these things we're starting to front load. We also provide a lot of implementation tools. I mentioned a CM manual. We in the states of Washington and Montana right now aren't partnering with a company such as Q2I that does the incentive management. But I really want to underline what Dr. Freese said, that there's a lot of math involved, especially when you use escalation, reset, and recovery. And it is not recommended to do that on paper. So I would strongly recommend some electronic tool. We developed a couple of electronic tools just in-house in our training team, and it really decreases the tendency to make errors when making those calculations. We also have templates such as, like I said, policies and procedures, a CM agreement, which is basically like a consent, and a visit checklist, and we use a readiness assessment and knowledge checks. So the other implementation support phase part that I find the most fun, as Tom mentioned, I do that for the California Recovery Incentives Program, as well as in Washington and Montana. And I think this is really what helps these programs be successful. Dr. Freese mentioned a few things that happen in these calls, and I'd say while each state has a little bit of a different flavor around how we conduct the coaching calls, it's pretty consistent what we're trying to do in those calls. And so if people begin before they've actually implemented their program, then it is a good opportunity to overcome implementation barriers through kind of group problem solving. And then once they've begun their CM program, then we shift to addressing clinical challenges and talk through actual individual cases. And then, you know, you may build it, but they still may not come right away. And so I probably have said enrollment engagement like four times already, but it turns out that this is a really important area to focus on, because there is some evidence that people who use stimulants don't always present to treatment, or they don't always stick with treatment, or they've tried it three times already and it was not their thing. And so to be able to communicate that there's something new out there that people who use stimulants and are looking for ways to cut down or stop, there's something new that might help them. And being able to communicate that message in a way that doesn't violate federal regulations is really important. Coaching calls themselves do mitigate protocol drift, just because we continue to talk about delivering it in an evidence-based way. And so people will share their sort of very innovative problem solving, and then we discuss whether or not that has the potential to negatively impact the efficacy, because now all of a sudden you've changed some of the parts that were driving what makes CM work. In some of the smaller CM or coaching calls, we have some small cohorts in our Washington rollout, and so in that way we actually do some goal setting because we see the same group each month. And so they goal set with each other and support each other. And then my favorite part is the sharing stories and generating enthusiasm part. So this is especially great when you can form cohorts where some of the participants in the coaching call have been doing it for a while and some are new. And so the sort of more experienced CM providers can share those stories and really kind of encourage and build enthusiasm and even confidence in the people who haven't yet done contingency management because they might still be unsure about whether it's going to be something they enjoy doing or whether it will work. And so these are facilitated peer-to-peer learning opportunities. Okay, so I also want to share some of the preliminary outcomes that we've seen. We have trained such a wide variety of professional helpers that I couldn't even put it in a chart because there's so many different credentials and job titles, so I made a word cloud and it's just kind of fun to see how many different types of people we've been able to train in contingency management. The take-home message here is that as long as you have that positive regard and sort of willingness to be enthusiastic and encouraging in all of your clinical interactions, you can do contingency management and having adequate training in the protocol. So here are those site types that I kind of flashed up on the screen before. This time I've lumped Washington and Montana together to show in that dark orange we see that those are the types of sites that we trained and then in the light orange which sites are actually currently active. And so my take-home here is that there is actually a lot to be said for logistical fit. And so while we had some really creative sites in Washington State that we trained, we trained some hospitals, we trained four jails, even a fire department because these were some really innovative MOUD sites, but these are not sites that see people twice a week for 12 weeks. And so as much as we tried to brainstorm if there was some way that they could do that, ultimately it wasn't the right fit. And so we really want to be able to front load a little bit more kind of selection process. We also wanted to look at how sites adopted it through a lens of a rural urban lens. You know, the states of Montana and Washington are largely rural communities, rural and small town communities. And so, you know, what do we think? Is CM going to work there? And so if you look at this chart, we're talking on the left is the sites that we initially trained in the middle, those sites implemented at some time and then we've had some drop off over time because we're kind of on our third year in both of these states. And so all the way to the right are the still active. So if you trace the blue through, we've got the vast majority of the rural and small town sites adopted CM and are still up and running. With our urban sites, the majority actually didn't implement the CM program. Now some of those, we've got some overlap, some of those were those jails and hospitals and really innovative sites. But all this to say that, you know, sometimes some people have a hunch, you know, are people in small towns and rural communities going to accept something like contingency management? And I would say that we've largely seen that the answer is yes. And that we have had very little skepticism among the people that we were training in those environments, which is really great. Okay. So we also have some data, some outcomes data, that's kind of the beautiful thing about contingency management. It is sort of a measurements-based care in a way in that because we're reinforcing negative urine drug screens, now we automatically have data about twice a week for 12 weeks whether somebody was or wasn't using stimulants and we also have data on their attendance and their enrollment and dropout rate. And so just by using our electronic incentive managers, we can collect this data. So yeah, not a research study, which means we've got some real heterogeneous stuff going on out there. But to gather these numbers, at the time, this is going to be a year snapshot. We've had the data collection tool up and running in Montana for a year. So it represents seven of the 11 trained sites using this tool. They enrolled a total of 261. Yeah, not quite as many people in Montana as California. But at the time that I grabbed this data, 66 people were active. 104 of those 261 completed the 12-week program. We did see 91 disenroll, but 23 re-enroll. And so I always focus on that data because disenrollment is not the end of the story in contingency management programs. It sometimes takes people a second or third time to engage the program and eventually get some traction with it. So looking at, I'm just going to move on to the next slide. I've got some pie graphs to look at the actual urine drug test data. Very similar in that when you look at just the urine drug screens that were conducted, so those are folks that showed up for the visit, 97% of them were negative, which is kind of mind-blowing. That goes along with where we're making this up, that can't be true. Now of course not everybody made it in for every visit. So if I go ahead and expand the pie chart to show what happened at each visit, of course we have some excused and unexcused absences, but we still have 81% of every visit available to somebody resulted in a stimulant negative urine test in Montana. In Washington, we have a four-month snapshot. It just took us a little longer to get the data collection tool up and running there. There's a lot of data sharing challenges involved in collecting PHI. And again, we had a smaller number of sites able to adopt it in Washington, so nine out of the 24 sites trained. We have 106 people enrolled in that four-month period. And again, 40 were currently active, 40 had completed the 12-week program, and again, we see some disenrollment, but many of those re-enroll. And then looking at the data there, we definitely have a little bit of a different picture. So again, of the people showing up and submitting the urine drug test, we have 76% of those tests were negative for stimulants. And then if we kind of expand to say, well, tell me more about whether people came in for the visits, we do have a larger proportion of both excused and unexcused absences in Washington. I have some theories around there, but before I even go into that, to me, seeing positive urine drugstream data in a CM program is actually really encouraging, because what that means to me is that this program was able to continue to serve and engage people who were actively using stimulants, therefore not receiving a tangible reinforcer, and they still kept coming back. So they're doing something to engage folks. And the idea that eventually, if they can, you know, string together about three days of stimulant abstinence, that they're going to be able to earn that first incentive. And so to me, I like being able to see that some people who test positive for stimulants still engage a CM program. So again, this is not research. We can't control for all of the things out there. So some of my theories around the difference between the Montana and Washington data, I think we had some more court-involved people in some of the Montana sites. I think we might have had higher stimulant use severity in some of the Washington sites. And then one thing is that, again, so in both of these protocols in Washington and Montana, there were some things that were set in stone. You have to do it this way, because that's what the state says. And there are other things that each site was allowed to create a policy for themselves. And so the attendance policy varied site to site. Some people said if you don't show up for two visits in a row, then you're discontinued for the program. Some said, I'm never going to discontinue, I'll just, even if you only came to the first one, never came back, I'm going to mark absences for all the other 23 visits. And so that's going to give you some different data. And so that's one of the reasons, I think, why we saw more absence data in Washington, because we had some sites adopt that, I'm just going to mark absent for every single one. Nobody was ever dis-enrolled. Okay, so what did we learn from trying to fit these contingency management protocols in different real-life settings? So some of the implementation barriers, I think, that were themes really can be divided into some that are speed bumps, so really just kind of slow down implementation, but they're not insurmountable. And some were roadblocks that ultimately they were not able to adopt. So I think philosophical fit, which is really tied to buy-in, I think is a modifiable factor. And then staffing and bandwidth, sometimes you just have to be patient while people kind of find the right time to be able to adopt something new in their site. But some of the logistical fits, if you can't fund a CM program, you can't do a CM program, and then sometimes some sites had just really strict policies around, for instance, doing point-of-care urine tests. And so that ultimately precluded their ability to do contingency management. So the logistical fit, now we're front-loading a little bit in Washington as we're helping gather the sites that are going to be part of the Medicaid waiver. We want them to know right off the bat, what is this program going to look like, so you can decide whether it fits. And so right off the bat, they're being asked, do you serve people who use stimulants? Are you an outpatient facility? Those hospitals and jails weren't quite the right setting. Do you currently use point-of-care tests? Are you willing or able to? Does your organization allow for gift cards? And can you accommodate twice-weekly visits for 12 weeks? Simple stuff, but if you didn't know that going into it, you wouldn't even realize that it wasn't the right fit. That philosophical fit, though, how do you get buy-in for sites that say, I don't know what I know about contingency management so far and all that urine testing, I don't think that's going to work for me. So in this case, I actually think that there's some implementation science that kind of informs this and this is also what we saw in the real world, which is that access to good CM education, so going through all that overview and sometimes implementation training already helped people know, yes, there is a sort of solid mechanism of action behind contingency management in terms of the behavioral principles and that it's not just a transactional paying people not to use, right, that there's actually a therapeutic foundation there. And then going over the research evidence helps people know it's not, it doesn't just theoretically work, it actually works. And then things like coaching calls can give people the opportunity to get questions and concerns addressed and hear that patient and provider testimony. Some of those quotes that Dr. Fries shared really can be powerful in seeing that it actually reaches real people and makes real change. And then I would say the other most important opportunity to kind of become won over to CM is if you can just decide that you'll give it a try, then through doing contingency management, often people go from skeptics to champions, and I will count myself among them. When I first got, worked on that study that Dr. Mooney mentioned was my introduction to contingency management, I was a CM skeptic. I was like, there's no way this is going to work, but okay, I need a job, so I'll do that. And in the room with the, in this case, study participants, I realized this really simple brief interaction was doing so much more than I could have imagined that it does. And even something like talking about what gift card, what somebody's going to spend their gift cards on, is this glimpse into who they are as a person, what they value, what they're getting out of their recovery. And I would say what a theme that comes up over and over again that Dr. Fries touched on is people will tell you that they're spending those gift cards on gifts for other people. And that, it happens over and over again, it never gets old to me, it kind of warms my heart, it represents repaired relationships, it's so much more than just a tangible exchange or a transaction. So you don't really, really see that until you're in the room doing it. Okay, and so what are implementation facilitators? I really think these states that have state support is really, it takes away the funding and the model development heavy lift that it can be for each individual site to have to figure that out themselves. Obviously sustainable funding, access to ongoing high quality training and technical assistance, and then a CM champion to be really enthusiastic, confident that you can do it and that it will help people. And so hopefully today we might have grown a few CM champions out there in the audience, I hope so. Okay, with that, back to Dr. Mooney. Thank you so much to our excellent speakers. Really interesting session. Before I open it up to discussion, Q&A, we really want to hear from you, I will just share really briefly a couple of anecdotes about our Greater Los Angeles VA Contingency Management Program, pulling together some of what you've heard today. The GLA VA is a huge VA with three main sites, the three substance use disorder sites have replicated programs, an opioid treatment program, an intensive outpatient program, general outpatient care, we even have a domiciliary residential facility. And over the years that I've been at the VA since 2015, I would say that CM, though it's supported nationally at the VA, and we can get the vouchers, the gift cards funded through the VA, delivered to our sites, and there's an incredible training, technical assistance program, coaching calls, lots of resources. Whether or not any of our clinics has CM at a given time is really dependent on staffing and resources. And though, again, financially it's supported by the VA, it takes clinic champions who have some bandwidth and who feel passionate about it to implement it. And so I have seen the program sort of come and go over the years, COVID pandemic, for example, with, you know, depending on resources, we either have it or we don't, and we don't necessarily have it at all three main sites. And one of our sites, the champion was a nurse who felt really strongly about it, got the trainings, got the, you know, went on the calls and started to just implement the program. And at another site, it was an addiction psychiatrist and an addiction medicine physician who really started changing the culture and trying to figure out a way to have it fit into the workflow so that it was, you know, compatible with just limited staffing resources. And the program that we have is what we call now a virtual fishbowl, an Excel sheet that basically on the computer, you know, can shuffle up to 500 prizes. About half of them are just motivational statements, you know, good job, about 40%-ish are $3 gift cards that they can, veterans can exchange at the canteen for goods, all sorts of goods. A larger, you know, the next percentage is about $20 gift cards and there's one $100 gift card out of the 500 that once in a while somebody wins. So over the course of a 12-week program and they do twice weekly urine testing for stimulant use disorder, that's, the VA actually supports applications beyond stimulant use disorder, but we have it for stimulant use disorder. The veterans love this program and it's embedded in the OTP or in their MOUD care or any other services they're receiving. They love it, they come back, they enjoy it. It takes about 10 to 12 minutes or so per session for, in most cases, it's our nurses actually doing the sessions with the patients. So you know, there is some time involved even once it's up and running, but it is very therapeutic and effective and, you know, some of the veterans earn several hundred dollars over the course of the program. My brief anecdote about our experience at the VA and please, we would love to hear your questions. We'll start here with Dr. Weiss. Hi. Roger Weiss from McLean Hospital, Harvard Medical School. This is great. I was at a scientific conference a couple years ago on CM and asked a question about actually implementing these things. And the response was, what a quaint question. And this is actually the first one I've been to where people really talked about how to do this in real clinical practice. So a few things. It seems as though you need to start with the funding agency. And when you say, where is the money coming from, it's got to come from whoever is funding it who thinks this is a good idea. There's been a lot of emphasis on the cost of the actual rewards. But there's also a cost of staffing. Because when it's run in research programs, there is an administrative staff member. There's a lot of extra work to be done here. And you've made that really clear in terms of all the training that needs to be done and the fidelity monitoring and all of this. That's got to be worked out with the funding agency as well. So those are my statements. Two questions. One, do you have experience or thoughts about non-abstinence rewards? That's the first one. And the second one is comparison of fishbowl versus vouchers. Because I've heard some people who were using the fishbowl that patients who, through bad luck, got a good job like two or three times in a row became very upset with the idea that they didn't get a reward. So those are my two questions. I can, I, is this on? Can you hear me? I'll start with the last question just because I have actually done both voucher and what I call prize draw versions of CM. Prize draw is kind of fun. There's a little bit, because of that element of chance, it's, you know, we all can get excited together. But the protocol that we developed for that study that just wrapped up, and so data will be published, you know, in the coming year, was they had a minimum of five prize draws. And I used to be able to say I've never seen anybody get all five good jobs. And then it finally happened one time. And I was like, I'm so sorry. That used to be a true statement. But it is true. You can get, even one small, one dollar store item can be underwhelming over time. And so the element of fun in that chance also has to be counterbalanced with the element of disappointment. So the voucher protocol is straightforward. And you know, if you hold up your end of the bargain, which I worked hard to be stimulant negative these last three days, I really want to be able to, you know, know I'm going to earn something. And so I, you know, I think both work. But in practice, I can see the pros and cons of prize draw model. With a funding question, I think you're right. We need to start with the funding. In California, we were really lucky. It's funded through, as a billable Medi-Cal service. And so the state puts the money forward as startup funds through California general fund dollars. But the rest of it is billable according to standard Medicaid rules at a negotiated rate per 15 minutes. And there was another question. Ah, yeah, there is some research on non-absence rewards. Attendance probably being the most common in that. The issue is the research is much less robust at this point. So we need more real research in that arena. The other thing is how do you measure it? Like exactly what is attendance? Is it showing up, I get my gift card immediately and then I get to leave? Is that attendance? Do I have to stay there through the whole time and then am I being coerced to participate in treatment? I think there's subtlety and nuance when you don't have a biological measure that makes it much more challenging. But there is some evidence that shows that it works. Yeah, the one thing, Roger, about the issue of the second one, what was the second one? I completely lost my, no, the issue of the schedule, the prize versus voucher. No direct studies comparing them. But if you go to the operant conditioning literature on how would you establish a new response, they would recommend continuous reinforcement, which is the voucher model, as the best way to establish a new response. Then there would be some other aspects of it. And also it's simpler. It's simpler to deliver than the prize-based. But there haven't been any direct comparisons of the two models. Thank you, next question. Thank you so much for this really excellent symposium. On the one hand, you really emphasize like some of these stories how the program seems to sell itself. These responses from individuals are really compelling. And yet you've also shown data that some of the programs have folded up shop. So what do we know about the characteristics of the programs or the situations where they weren't able to sustain? Something about how they recruited, their staffing, some of the logistics, or some of the philosophies and details in how they implemented it? Thanks. Yeah, I can speak to, you know, yeah, why did some programs close up shop? I think staffing is probably the biggest. I mean, we all know there's a huge amount of turnover in this field. And so if you lose your champion or even just lose your delivery staff, the people who are doing it, to be able to have access to training, the California program is doing such amazing work in providing this training on an ongoing basis because not only are they adding new sites, but there's turnover at the established sites. But that's not always, that level of training and technical assistance isn't always funded. So you may not be able to train the next staff. And then secondly, I would say that in these rural small town areas, in one case, we had two service sites doing contingency management in the same small town. One was a hospital, the other was a specialty SUD clinic. And they're like, you know what, the hospital setting was not, was a difficult logistic fit to begin with, and they can just go across town. Now, in LA, you could have a million sites up and running and you'd probably need one more. 42 today. Yeah. 42 in LA alone and 75 slated to begin in LA County because it's so huge. Whereas in rural counties, we may only have one or two. We've had the good fortune of having no programs stop once we started them with over 100 programs enrolling. But part of that is because we do the ongoing training, it can handle the staff turnover. The other thing is those programs, one of the biggest barriers we have to those programs who have not yet implemented is that staffing issue. And so I think we need to really look at that and along the lines with the funding as well, we need to make sure that we have a plan for staffing and a plan for retraining before we implement a protocol like this. Thank you. Next question. Jim Halicus, now here in Naples in practice, formerly in academics. More than 30 years ago, first of all, an anecdote. More than 30 years ago, I was doing a site visit in Alameda County Mental Health Center in Oakland. And they had a program, a contingency program that was remarkable. Positive reinforcement of using Target, the store, Target coupons for crack negative urines in pregnant women. And it was very impressive. At the same time, NIDA was doing punishment-based grants. If you had a positive urine in a methadone program, they reduced your methadone dose. It was ridiculous. Now my questions. What do you, as psychiatrists, we give psychiatric medications and they often foul up urine drug screens. So what do you do about false positives? And then the second question is, is there anybody setting up any kinds of CM programs in alcohol or opiates? I'll take the first question. We had hours and hours of discussion about what do we do about those medicines that may cross-react with the urine drug tests. First of all, we had the approved urine drug tests in the program. We took the entire catalog that were available in California and sent them to a nationally renowned toxicologist whose expertise is in identification of drugs and said, we wanna test that's sensitive enough that it's gonna catch use if it happens and specific enough that it's gonna catch that use once if a second use doesn't happen, if we're testing twice a week. We took a pool of about 30 some tests and narrowed it down to four. Since then, we've added two more, the exact same test, but they've added a CLIA wave fentanyl test to those tests as well. And so we've added those as well. So a test is not a test is not a test. And we need to be really careful about what it is that we're calling that. The other thing that we recognized is that if they're taking ADHD medicines for legitimate reasons for ADHD, there's no way for our point of care tests to determine those. And we just tell people that. Some people have gone back to their treating physician and said, is there another medicine I can use? Couple of cases they've said no. Yes, most cases they've said no. And then we give them a list. I think it has 20 some medicines that are known to cross react. And they sign a consent that says, if you test positive, it's positive. So you might wanna avoid these if you can. And if you take one of these and you test positive, that's gonna be considered positive test on that day. We've had a couple of people argue with some of the tests, but ultimately we remind them of what they agreed to and they recognize that that's true. Yeah, there's a limitation there. I can definitely speak to alcohol because that's one of my team's also kind of little niche areas of contingency management research. Thanks to the biomarker ethylglucuronide, ETG, we now, there's a urine marker for alcohol use has about the same detection window as the stimulant test. And so the protocol for alcohol CM can be almost the same thing, twice weekly urine tests. Before that, there are app-based programs that use breathalyzers and you have to do that several times a day and your face is on screen. It's possible to do it that way. But the study that we're just wrapping up right now did twice weekly urine tests looking at ETG. And do I get to spoil the results? Maybe not. Look for them coming soon. But yeah, definitely people respond to that, to CM for alcohol. Now I know there are medications for alcohol use disorder as there are for opioid use disorder. And so I think the general consensus among those of us who do CM training is medications first for opioid use disorder. They're life saving and we don't want anything to sort of get in the way of people's access to MOUD. But layering CM on, especially for the co-use of stimulants among people who already have a tool to address their opioid use, it seems to be a really powerful combination. So, I don't know, Rick, do you or anyone else want to speak to that? Yeah, the only thing is the CM for with OUD has been to reinforce medication taking. So, it's not for the drug use itself, it's for increasing MOUD use. And in the Bolivar study that Rick referenced, in 18 of 22 studies, they showed a positive effect for stimulants in people who were taking medicines for opioid use disorder. And that literature is fairly robust. It's not as robust for use directly in opioid use. Thank you. Next question. My original questions are actually heated. So, now I'm very curious about. So, I understand now the contingency management can be applied to and expanded to other substance use disorders. But in that case, do you believe that contingency management is kind of more effective in managing stimulants compared to other substances? Or do you think that maybe it's the same? And the second question is, if they are all effective, but how effective it would be? For example, in OUD management, which one would be better? Contingency management is better or just medication assisted management is better? If you have any idea. Yeah, MOUD is the treatment of choice for people with opioid use disorder. No second discussion. The buprenorphine and methadone and naltrexone are certainly, that's the primary treatment. There's just more data with stimulants than with any other drug category because we have no medications at the current time that are approved. So, all of the vast amount of research has been on stimulants. Sure, it'll work with alcohol. You can increase medication taking. I'm sure you could, there's been some work with cannabis a little bit. But it's a very simple principle. It'll work. I mean, if you reinforce it, it will happen. And, but stimulants are where it has its most valuable application at the present. And where medicines are the front line for opioid use disorder. If you're only going to do one thing with a stimulant user, CM should be our front line offering with other things supporting that. Thank you. Next question. Hi, Mark Fishman, Maryland. The scale of the California implementation is remarkable. And, yeah, mind blowing. So, I wanted to follow up on Roger's question and drill down a little bit on this funding question. You mentioned that there's a fee for service reimbursement under Medicaid, which certainly seems more sustainable over time than pilot grants that need to be renewed and the like. But I'd like to ask about that. So, what about the actual CM amounts? Is that just a billable pass through as they come? Yeah, I'm not a billing expert in any way. And particularly Medicaid billing is highly confusing to me. But as I understand. And then some. Yeah. As I understand it. By the way, as the first in the nation doing this, we're the only Medicaid program at this point that is actually providing services. And the scale is astronomical. We get calls from all over the country, including from CMS, asking us questions about what we're doing on an ongoing basis. So, it's a lot of pressure, but we've learned a whole lot. And that billable rate, I think, is really critical. And in California, it's negotiated between the state and the county according to the way that they negotiate other Medicaid billable services. They get paid per 15-minute increment, can bill for multiple increments as needed. And the business model works? The incentive itself is a component of the overall service. But the state has a relationship directly with the incentive manager. And that contract is paid by the state. And then as they negotiate the billables with the counties, that gets taken care of in the wash with the county match doing their piece. And then the rest of the Medicaid billing system covering the rest. So, it's a complicated issue that involves some state money. But really, it's largely between the federal and non-federal match and the, as it's negotiated between the states and the county. And these hundred individual programs find that the business model works. That they can staff, they can train. We have 100 programs that have launched in none of them have dropped out. I got to see the spreadsheet. This is great. Yeah. And I will just briefly say that Washington and Montana are doing the opposite. And that they're trying to figure out how the Medicaid reimbursement will cover the incentive, but aren't necessarily going to choose to make the encounter a billable encounter. And so, yeah. Well, on the one hand, funding the incentives is the biggest challenge. Because you can't use these federal dollars. But the other is not trivial. People don't want to work for free. So, yeah. Yeah. Yeah. Saraswati Thukar, Queen's University, Canada. Can you point to any differences between implementation of CM program in ambulatory versus residential rehabilitation treatment setting? Well, I think the only way you would use it in a residential treatment program, as we're thinking of it now, would be in the continuing care post-discharge. In the center itself. I mean, there used to be things that we used incentives in residential settings, token economies, and things like that, that you could use. But for the treatment of stimulant use disorder, it certainly has its greatest value in an outpatient setting following an inpatient treatment episode. We've had some discussion about using it in residential settings. And nobody I know is doing that on a large scale. Thank you. Next question. Hi. I'm Shoop Barman. I'm an addiction psychiatrist from Wisconsin. Thanks to the AAAP for selecting contingency management as a symposium. Because, let's face it. For stimulant use disorder treatment, for lack of a better word, we suck. So, thank you. But my comment and question is I understand that most of the evidence base for CM is in stimulant use disorders, largely because of lack of adequate pharmacotherapy options. And, but at the same time, I mean, I was encouraged that you're doing some studies on alcohol use disorders. Because there is no reason why it would not be effective for other substance use disorders. I can share anecdotally that I was using a CM CBT based app in my clinical practice for a period of three and a half years. And in a little over 200 separate individuals in a real world practice, most of my patients were actually primarily alcohol use disorders. And the best thing for any CM tool or anything in addiction treatment whatsoever is retention, retention, retention. And the program I'm talking about, some of you have probably know about it, Reset and Reset-O. They help tremendously in engaging our patients. And I must say that the outcomes for patients with alcohol use disorder was actually better than stimulant use disorder. So, I'm excited to hear about some of the other studies being, going on. But I'm clearly interested in knowing about what else is out there. I think we have reasonable evidence that it works across substances. And Sarah's work in the project that she talked about demonstrates that it works with a variety of substances including alcohol. In California, we made the decision to say what is the biggest research block that we have. And again, because we're under such scrutiny being the first out of the gate, we wanted to give it the best possibility of working with an eye toward rolling out this pilot to its completion and learning what we can so that then we can figure out hopefully as it becomes a regular, not an 1115 waived service, but a regular service, we can figure out how to apply that creatively to other substances and to other non-substance kinds of indicators as it makes sense. So, there is an eye to that in the future in California. But right now, we're sticking with the thing that has the best research. I have also a really boring answer for that is that right now there are no CLIA waived ETG point of care tests. And so, they're all considered for forensic use only. So, if anybody is friends with a point of care urine test manufacturer, try to get a CLIA waived one on the market. Yeah. Send outs might, that you can't get instant results and so you can't, it's harder to do immediately. Yeah. Yeah. And I would say, I would question whether that was instant enough to be really faithful to the model of contingency management. It could work. Yeah. Great to hear that it worked. I will also put in a plug that we all are, the next alcohol study that just launched within our team is a remote study. And what I like about that is that there's so much stigma around seeking treatment for alcohol use disorder, I mean for all substance use disorder, but particularly alcohol use disorder. And so, we're finding that people being able to do it in the privacy of their own home and sort of not have to like go out there and make it obvious that they're seeking treatment for alcohol use disorder has seemed to be very powerful. So, I wonder if that was at play for your results as well. Thank you. We are butting up against lunch. I have time for one final quick question and then any others please feel free to come up to us after. One more. Yeah. Christian Batra, I'm private practice psychiatrist at Tampa and USF teaching also. This is a great conversation about CM and very useful treatment activity. My question is about the fact that we know cannabis use in adolescent phase is like induction for future addiction. And it's so prevalent with legalization also. There's a huge public health concern and we as addiction psychiatrists recognize that problem. So, these presentations, I was a few minutes late but didn't hear about the age group. I assume that these are done, they have been done on adult patients or maybe young adults. But what's the opinion? Is there any interest of studies being done for teenagers and cannabis use? I know there's a complication about the UDS you have to wait for three more weeks to clear. California, I mean cannabis is on the list in California for things that we want to look at in the future. There are no age restrictions on participation in the program. We have several adolescent programs that are participating in the service and you just have to meet the basic diagnostic criteria and show medical necessity and age is irrelevant to the service. And what have you seen, the outcome, results, how encouraging is this? I'm looking forward to seeing that evaluation data as well. We're not there yet.

contingency management

stimulant use disorder

evidence-based treatment

Richard Rawson

stimulant-related overdoses

opioids

fentanyl

funding restrictions

Thomas Freese

California implementation

voucher system

Sarah Parent

community settings

training and support

substance use disorders

Dr. Larissa Mooney

Veterans Affairs

Medicaid Reimbursement

California

Washington

Montana

Dr. Richard Rawson

Positive Reinforcement

Dr. Thomas Freese

State-funded Initiatives

Client Engagement

Alcohol Use Disorder

Opioid Use Disorder