Contingency Management for Drug Use Disorders: Meta-Analysis and Application of Tolin's Criteria.

Several professional organizations and federal agencies recommend contingency management (CM) as an empirically supported treatment for drug use disorder. However, the release of the "Tolin criteria" warrants an updated recommendation. Using this methodology, five meta-analyses (84 studies, 11,000 participants) were reviewed. Two meta-analyses were rated moderate quality, and three were rated low or critically low quality. Comparator conditions included active treatment, placebo, treatment as usual, and no treatment. The primary outcome was abstinence. Considering only the moderate quality meta-analyses, the effect of CM versus control on posttreatment abstinence was d = 0.54 [0.43, 0.64] and follow-up abstinence was d=0.08 [0.00, 0.16]. A "strong" recommendation was provided for CM as an empirically supported treatment for drug use disorder.

Predictors of Suicidal Ideation and Continued Substance Use Problems Among Patients Receiving Methadone Maintenance Treatment Who Have Co-Occurring Cocaine Use Disorder.

BACKGROUND: Persons with polysubstance use problems are at high suicide risk, which may complicate substance use treatment. The purpose of this study was to a) examine cross-sectional and longitudinal risk factors for suicidality among persons in methadone maintenance treatment who present with co-occurring cocaine use disorder and b) evaluate whether suicidality impacts substance use outcomes independently and differentially depending on treatment type (i.e. standard methadone care [SC] vs. contingency management plus standard care [CM + SC]). METHODS: Data come from five randomized controlled trials of CM conducted within methadone clinics (N = 562). Participants were categorized (mutually exclusive) as no history of suicidality (56.4%, n=317), past suicidal ideation (SI; 11%, n=62), recent SI (3.6%, n=20), or lifetime suicide attempt (29%, n=163). RESULTS: Suicidality groups differed by sex and baseline employment, income, trauma history, and psychosocial functioning. Suicide attempt history was positively associated with years of polysubstance use, prior drug treatments, and unintentional overdose history. Baseline psychological problem severity and emotional abuse history were associated with SI likelihood 12 weeks later. Past SI was associated with longer durations of abstinence than no suicidality. Unexpectedly, those with recent SI reported lower drug use severity at 12 week if they received SC compared to CM + SC. Effects were small to medium. CONCLUSIONS: Despite greater polysubstance use history, patients with suicide attempts did not show worse substance use outcomes than persons without suicidality. Patients with past SI fared better than those without suicidality on abstinence over 12 wk. Methadone clinics could be key points of entrance and continued services for suicide prevention.

Transit and treatment: Aligning systems to address substance use in Connecticut.

OBJECTIVE: Test hypotheses that proximity to new transit improves substance use disorder treatment provider cost efficiency (i.e., economies of scale and scope). DATA SOURCES AND STUDY SETTING: Connecticut substance uses disorder treatment providers/programs. A 2015 rapid transit line opening with 10 stations, near some providers/programs. Providers' annual operating costs from publicly available federal tax forms (2013-2018). Annual client counts, service-type (including substance use disorder and/or mental health, among others), and location data, for 50 providers and their programs, from Department of Mental Health and Addiction Services, with an unbalanced panel of 285 provider-years. STUDY DESIGN: Economies of scale occur when the percent change in operating costs is less than the percentage change in clients. Economies of scope occur when operating costs fall as providers treat clients with multiple service needs. With our quasi-experimental, multivariate regressions approach, we test hypotheses that proximity to a new transit line enhances economies of scale and scope (i.e., lowers unit operating costs). DATA COLLECTION/EXTRACTION METHODS: Annual provider-level operating costs merged with new transit station locations and Department of Mental Health and Addiction Services program/provider-level secondary data (locations, client counts/completions/dates, service types, and average demographics). PRINCIPAL FINDINGS: For providers with programs within 1-mile of new transit (compared with a "control" sample beyond 1-mile of new transit), (i) a 10% increase in clients leads to a 0.12% lower operating costs per client; (ii) a 10% increase in clients completing treatment results in a 1.5% decrease in operating costs per client; (iii) a 10% increase in clients receiving treatment for multiple services causes a 0.81% lower operating costs per client; (iv) offering multiple services leads to 6.3% lower operating costs. CONCLUSIONS: New transit proximity causes operating cost savings for substance use disorder/mental health treatment providers. System alignment may benefit transit and health care sectors.

Effective, but underused: lessons learned implementing contingency management in real-world practice settings in the United States.

Despite being one of the most effective adjunctive behavioral interventions in combination with medication for opioid use disorder, contingency management (CM) is one of the least available interventions in opioid treatment programs. This paradoxical state of affairs is perhaps the greatest example of the research-to-practice gap in the behavioral health field. Implementation science, a discipline that aims to identify replicable methods that can be used across settings and populations to bridge the gap between research and practice, can potentially help. Based on our team's experience implementing CM in opioid treatment programs, we detail five key lessons for researchers, clinicians, policy makers, and others seeking to implement and sustain CM in real-world settings. First, multiple barriers to CM implementation exist at both the counselor- and organization-levels, requiring multi-level solutions. Second, one-shot CM training alone is not sufficient for successful implementation: ongoing support is essential to achieve levels of intervention fidelity that will benefit patients. Third, assessing an organization's capacity for implementation prior to support provision can prevent costly mistakes. Fourth, implementors should plan for high staff turnover rates and expect the unexpected by developing detailed contingency plans. Finally, implementors should remember that the goal is to implement evidence-based CM and not simply incentives. We encourage colleagues to consider these lessons to increase the likelihood that CM can be implemented and sustained in a manner that improves the quality of care in opioid treatment programs.

Percentage of negative urine drug screens as a clinically meaningful endpoint for RCTs evaluating treatment for cocaine use.

BACKGROUND: This study examined a threshold based on the percentage of cocaine-negative (CN) urine drug screens (UDS) collected during treatment as a potential meaningful endpoint for clinical trials. We hypothesized that individuals providing at least 75% CN UDS would have better long-term outcomes than those providing less than 75% CN UDS. METHODS: Two separate pooled datasets of randomized clinical trials conducted at different institutions were used for analyses: one composed of eight trials (N = 760) and the other composed of three trials (N = 416), all evaluating behavioral and/or pharmacological treatments for cocaine use. UDS were collected at least once per week (up to three times per week) during the 8- or 12-week treatment period across all trials, with substance use and psychosocial functioning measured up to 12 months following treatment. Chi-squares and ANOVAs compared within-treatment and follow-up outcomes between the groups. RESULTS: Compared to those who did not achieve the threshold, participants who achieved the 75%-CN threshold were retained in treatment longer and had a longer period of continuous abstinence, and were more likely to report problem-free functioning. Additionally, participants who achieved the 75%-CN threshold were more likely to report sustained abstinence and better psychosocial functioning throughout a follow-up period up to 12 months than those who did not achieve the threshold. CONCLUSIONS: A threshold of 75%-CN UDS is associated with short- and long-term clinical benefits. Future clinical trials may consider this a meaningful threshold for defining treatment responders.

Implementing an evidence-based prize contingency management protocol for stimulant use.

INTRODUCTION: Contingency management (CM) is an efficacious treatment for stimulant use disorders. Support materials for the clinical delivery of prize-based CM are widely accessible, but few resources are available to support design and preparation for CM implementation. This guide aims to fill that gap. METHOD/RESULTS: The article outlines a suggested prize CM protocol and discusses the best practices most aligned with the evidence base and acceptable-if-necessary modifications. This guide also highlights modifications that are not evidence-based and not recommended. In addition, I discuss practical and clinical aspects of preparing for CM implementation. CONCLUSIONS: Deviations from evidence-based practices are common, and poorly designed CM is unlikely to impact patient outcomes. This article provides planning stage guidance to support programs' adoption of evidence-based prize CM for the treatment of stimulant use disorders.

Contingency Management and Pre-Exposure Prophylaxis Adherence Support Services (CoMPASS): A hybrid type 1 effectiveness-implementation study to promote HIV risk reduction among people who inject drugs.

BACKGROUND: HIV disproportionally affects persons who inject drugs (PWID), but engagement with HIV pre-exposure prophylaxis (PrEP) is low. We describe the rationale and study design for a new study, "Contingency Management and Pre-Exposure Prophylaxis (PrEP) Adherence Support Services (CoMPASS)," a hybrid type 1 effectiveness-implementation trial to promote HIV risk reduction among PWID. METHODS: In four community-based programs in the northeastern United States, PrEP-eligible PWID (target n = 526) are randomized to treatment as usual or Contingency Management (CM) and, as indicated, stepped up to PrEP Adherence Support Services (CoMPASS) over 24 weeks. During CM sessions, participants receive timely tangible rewards for verifiable activities demonstrating 1) PrEP initiation and adherence, and 2) engagement with medications for opioid use disorder (MOUD) and other OUD-related care. Participants who do not have high levels of biomarker-confirmed PrEP adherence at week 12 will be stepped up to receive PrEP Adherence Support Services (PASS) consisting of strengths-based case management over 12 weeks. Interventions are delivered by trained PrEP navigators, staff embedded within the respective sites. The primary outcome is sustained PrEP adherence by dried blood spot testing at 24 weeks. To inform future implementation, we are conducting implementation-focused process evaluations throughout the clinical trial. CONCLUSIONS: Results from this protocol are anticipated to yield novel findings regarding the impact and scalability of CoMPASS to promote HIV prevention among PWID in partnership with community-based organizations. http://ClinicalTrials.gov identifier: NCT04738825.

Testing the incremental effectiveness of pay-for-performance to improve implementation of a motivational interviewing brief intervention for substance use disorders in HIV settings: Results of a cluster-randomized type 3 hybrid trial.

Background: Substance use disorders (SUDs) have a serious adverse impact on people living with HIV. Previously, using a 39-site dual-randomized type 2 hybrid trial design, findings from the Substance Abuse Treatment to HIV Care Project supported the Implementation and Sustainment Facilitation (ISF) strategy to improve implementation and effectiveness of a motivational interviewing brief intervention (MIBI) for SUD within HIV service settings across the United States (US). Building on this trial, this cluster-randomized type 3 hybrid trial aimed to test the incremental effectiveness of a pay-for-performance (P4P), a form of the "alter incentive/allowance structures" strategy. Methods: Twenty-six HIV service organizations, their staff participants (N=87), and their client participants (N=341) were cluster-randomized to one of two implementation conditions. The control condition included staff-focused training, feedback, and consultation (TFC) and team-focused implementation and sustainment (ISF). The experimental condition included TFC+ISF as well as P4P (TFC+ISF+P4P). P4P used financial incentives to reward MIBI implementation (US$10 per MIBI delivered) and MIBI implementation at or above a pre-defined level of quality (US$10 per demonstration). In addition to these outcomes, past 4-week changes/reductions in client participant's days of primary substance use and anxiety symptoms were examined. Results: The addition of P4P had a large and significant effect on the number of MIBIs implemented (d=1.30, p<.05) and reduction in anxiety (d=-1.54), but there was no impact on days of substance use. P4P had large effects on MIBI quality (d=1.24) and MIBI implementation effectiveness (d=1.28), but these were not significant (p<.10). Conclusions: P4P is a form of the "alter incentive/allowance structures" strategy Its function is to reward the implementation of a clinical innovation. Rewarding implementation is consistent with the theory of implementation effectiveness, which suggests implementation climate (i.e., the extent to which implementation is expected, supported, and rewarded) is a key antecedent of implementation effectiveness (i.e., the consistency and quality of implementation). We found that P4P had a significant, positive impact on MIBI implementation in HIV service settings, but client-level outcomes were mixed. Future research should examine the cost-effectiveness of this strategy, as well as to examine the effectiveness of P4P to improve the implementation of other evidence-based innovations. Trial registration: ClinicalTrials.gov: NCT04687917. Registered 12/18/2020.

Virtual Training Is More Cost-Effective Than In-Person Training for Preparing Staff to Implement Contingency Management.

Behavior therapy implementation relies in part on training to foster counselor skills in preparation for delivery with fidelity. Amidst Covid-19, the professional education arena witnessed a rapid shift from in-person to virtual training, yet these modalities' relative utility and expense is unknown. In the context of a cluster-randomized hybrid type 3 trial of contingency management (CM) implementation in opioid treatment programs (OTPs), a multi-cohort design presented rare opportunity to compare cost-effectiveness of virtual vs. in-person training. An initial counselor cohort (n = 26) from eight OTPs attended in-person training, and a subsequent cohort (n = 31) from ten OTPs attended virtual training. Common training elements were the facilitator, learning objectives, and educational strategies/activities. All clinicians submitted a post-training role-play, independently scored with a validated fidelity instrument for which performances were compared against benchmarks representing initial readiness and advanced proficiency. To examine the utility and expense of in-person and virtual trainings, cohort-specific rates for benchmark attainment were computed, and per-clinician expenses were estimated. Adjusted between-cohort differences were estimated via ordinary least squares, and an incremental cost effectiveness ratio (ICER) was calculated. Readiness and proficiency benchmarks were attained at rates 12-14% higher among clinicians attending virtual training, for which aggregated costs indicated a $399 per-clinician savings relative to in-person training. Accordingly, the ICER identified virtual training as the dominant strategy, reflecting greater cost-effectiveness across willingness-to-pay values. Study findings document greater utility, lesser expense, and cost-effectiveness of virtual training, which may inform post-pandemic dissemination of CM and other therapies.

Characterizing nicotine withdrawal in smokers experiencing homelessness.

OBJECTIVE: The rate of cigarette smoking among persons experiencing homelessness is five times the national prevalence, and these smokers experience difficulty quitting. Nicotine withdrawal may be a barrier to initiating and sustaining successful smoking cessation, but its time course is poorly characterized in this population. We hypothesize that withdrawal symptoms will be elevated and related to treatment outcomes. METHODS: This secondary data analysis characterized nicotine withdrawal symptoms, as measured by the Minnesota Nicotine Withdrawal Severity Index, during a quit attempt in treatment-seeking smokers experiencing homelessness who enrolled in a randomized smoking cessation trial. Participants (N = 70) reported MNWS symptoms three times prior to the scheduled quit date and twice weekly for 4 weeks post-quit date. We also examined the relation of pre-quit symptoms to treatment outcomes (quit day smoking status, patch adherence, duration of abstinence, and percent negative CO samples submitted). RESULTS: Endorsement of withdrawal symptoms was highest prior to the quit date and decreased over time with increases at weeks 3 to 4; a sizable percentage (20% to 35%) of participants endorsed symptoms throughout the 4 week post-quit period. Severity for most symptoms was at its lowest 2-3 weeks post-quit date, then increased in weeks 3 and 4. Anticipatory withdrawal was inversely related to nicotine patch adherence (p = .01), but not the abstinence-based treatment outcomes (ps > 0.05). CONCLUSIONS: Continued withdrawal symptom endorsement throughout treatment and increases in severity noted 3 to 4 weeks post-quit date suggest possible targets for intervention as part of smoking cessation counseling for smokers experiencing homelessness. Anticipatory withdrawal symptoms (prior to the quit date) were common and predictive of poor adherence to cessation aids.

Tobacco use patterns and clinical outcomes in the T1D exchange.

AIMS: This study examined associations between tobacco use and diabetes outcomes using the T1D Exchange Registry. METHODS: Adult participants (N = 933) completed standardized questionnaires including self-reported outcomes: past year serious hypoglycemic and diabetic ketoacidosis episodes, diabetes self-care, diabetes distress, and self-monitoring of blood glucose. Chart-extracted outcomes included HbA1c, nephrology and neuropathy diagnoses, and BMI. We examined the relation of tobacco use status (never, former, current) and frequency of use (daily versus less than daily) to these outcomes. RESULTS: The majority had never used tobacco (55%, n = 515); 27% (n = 252) were former users and 18% (n = 166) were current users (with 31% using daily). Tobacco status was associated with HbA1c, BMI, self-care, distress, and blood glucose monitoring frequency. Across most outcomes, current users evidenced worse values relative to never users, and former users were largely similar to never users. Daily use was associated with significantly worse outcomes on HbA1c, diabetes self-care, and distress scores relative to less than daily use. CONCLUSIONS: These cross-sectional comparisons suggest that current tobacco use is associated with worse status on important clinical diabetes indicators. Former users did not evidence these deleterious associations. Findings point to potential diabetes-specific motivators that could inform tobacco cessation interventions.

The impact of marijuana use on cocaine use outcomes among patients in methadone maintenance treatment across five trials of contingency management.

OBJECTIVE: Cocaine use is prevalent among patients in methadone maintenance and a risk factor for poor treatment outcomes. Contingency management (CM) decreases cocaine use in this population, but little is known about its efficacy when marijuana use is present prior to or during treatment. METHOD: Data from five randomized CM trials (N = 557) were used to evaluate whether: (a) marijuana frequency (none, low, or high) prior to or during treatment impacts cocaine use outcomes and (b) marijuana use differentially impacts cocaine outcomes with standard care (SC) + CM versus SC alone. RESULTS: Relative to no marijuana use, low (ß = .28, p < .01) and high marijuana use (ß = .32, p < .05) during treatment were associated with roughly 1 week shorter duration of cocaine abstinence on average. Low marijuana use (ß = .71, p < .05) during treatment was associated with a lower proportion of negative cocaine samples during treatment relative to no marijuana use. Treatment group by marijuana use (before or during treatment) interactions on duration and proportion of cocaine abstinence during treatment were not significant. For longer term outcomes, in SC + CM, marijuana use during treatment did not impact cocaine abstinence 6 months post-baseline. In SC, low (OR = .44, p < .05) and high (OR = .26, p < .001) marijuana use during treatment decreased odds of cocaine abstinence at 6 months post-baseline relative to no use. CONCLUSIONS: Findings highlight the benefits of SC + CM and abstaining from marijuana use during active treatment. At 6 months postbaseline, SC + CM evidenced similar cocaine abstinence regardless of marijuana use levels during treatment, while those with low and high marijuana use showed decreased abstinence rates in SC only. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Contingency management for treatment attendance: A meta-analysis.

BACKGROUND: Treatment providers have applied contingency management (CM) treatment, an intervention that often rewards individuals for drug abstinence (i.e., ABS CM), to treatment engagement as well. However, we know little about the magnitude of treatment effects when providers target attendance behaviors (i.e., ATT CM). METHODS: This study conducted a systematic search to identify studies that included ATT CM, either in isolation or in combination with ABS CM. The study used meta-analysis to estimate the effect size of ATT CM and ABS CM + ATT CM on treatment attendance and drug abstinence. We identified a total of 10 studies including 12 CM treatments (6 ATT CM and 6 ABS CM + ATT CM) with 1841 participants. RESULTS: Results indicated a moderate effect (d = 0.47, 95% confidence interval (CI) [0.25, 0.69]) of ATT CM on attendance relative to non-reward active comparison conditions. Frequency of rewards was significantly associated with larger effect sizes. Results also indicated a small effect (d = 0.22, 95% CI [0.12, 0.33]) of ATT CM on abstinence outcomes relative to nonreward comparisons, p < 0.001. The study found no significant differences in attendance or abstinence between ATT CM and ABS CM + ATT CM (p's > 0.05). CONCLUSION: Overall, the results supported ATT CM for increasing treatment engagement, with smaller effects on abstinence. Effects on abstinence were smaller than those observed in prior meta-analyses focused on ABS CM. No significant differences existed in attendance or abstinence outcomes between ATT CM and ABS + ATT CM. However, future studies are needed to experimentally compare ABS CM + ATT CM to ABS CM, and ATT CM to determine additive effects. Clinics implementing CM should consider the differential effects between ATT CM and ABS CM when selecting target behavior(s).

Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics): A cluster-randomized type 3 hybrid effectiveness-implementation trial.

BACKGROUND: Opioid-related overdoses and harms have been declared a public health emergency in the United States, highlighting an urgent need to implement evidence-based treatments. Contingency management (CM) is one of the most effective behavioral interventions when delivered in combination with medication for opioid use disorder, but its implementation in opioid treatment programs is woefully limited. Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics) was funded by the National Institute on Drug Abuse to identify effective strategies for helping opioid treatment programs improve CM implementation as an adjunct to medication. Specific aims will test the impact of two different strategies on implementation outcomes (primary aim) and patient outcomes (secondary aims), as well as test putative mediators of implementation effectiveness (exploratory aim). METHODS: A 3-cohort, cluster-randomized, type 3 hybrid design is used with the opioid treatment programs as the unit of randomization. Thirty programs are randomized to one of two conditions. The control condition is the Addiction Technology Transfer Center (ATTC) Network implementation strategy, which consists of three core approaches: didactic training, performance feedback, and on-going consultation. The experimental condition is an enhanced ATTC strategy, with the same core ATTC elements plus two additional theory-driven elements. The two additional elements are Pay-for-Performance, which aims to increase implementing staff's extrinsic motivations, and Implementation & Sustainment Facilitation, which targets staff's intrinsic motivations. Data will be collected using a novel, CM Tracker tool to document CM session delivery, session audio recordings, provider surveys, and patient surveys. Implementation outcomes include CM Exposure (number of CM sessions delivered per patient), CM Skill (ratings of CM fidelity), and CM Sustainment (number of patients receiving CM after removal of support). Patient outcomes include self-reported opioid abstinence and opioid-related problems (both assessed at 3- and 6-months post-baseline). DISCUSSION: There is urgent public health need to improve the implementation of CM as an adjunct to medication for opioid use disorder. Consistent with its hybrid type 3 design, Project MIMIC is advancing implementation science by comparing impacts of these two multifaceted strategies on both implementation and patient outcomes, and by examining the extent to which the impacts of those strategies can be explained by putative mediators. TRIAL REGISTRATION: This clinical trial has been registered with clinicaltrials.gov (NCT03931174). Registered April 30, 2019. https://clinicaltrials.gov/ct2/show/NCT03931174?term=project+mimic&draw=2&rank=1.

Changes in secondary outcomes associated with brief interventions for problem gambling in methadone patients.

BACKGROUND: Patients in methadone maintenance treatment (MMT) with problem gambling (PG) experience worse psychosocial outcomes than their non-PG counterparts. Interventions targeting PG in MMT may enhance psychosocial functioning beyond gambling reduction and abstinence. The present study was a secondary data analysis that examined the trajectories of non-gambling outcomes of three brief PG interventions (i.e., brief psychoeducation, brief advice, motivational enhancement therapy plus cognitive-behavioral therapy [MET + CBT]) among MMT patients. METHODS: Participants (N = 109) were engaged in substance use disorder treatment, met criteria for PG, and had a current or lifetime history of MMT. Latent growth curve models examined outcome trajectories of psychiatric, medical, legal, employment, and social problems, as well as psychological distress and quality of life. Follow-up analyses examined clinically significant change. RESULTS: MET + CBT patients reported lower medical problems at baseline and over time than the brief interventions. There was no evidence of differences between interventions on the other outcomes. Psychiatric problems and psychological distress decreased over time for the entire sample, regardless of the PG intervention. About 24% and 13% of the sample demonstrated clinically significant improvements in psychological distress from baseline to 5 months, and 5 months to 12 months, respectively. Nearly 21% of the sample showed clinically significant improvements in psychiatric problems from 5 months to 12 months. Among all patients, men and those with more severe opioid dependence symptoms demonstrated the greatest psychological improvements. CONCLUSIONS: Many patients in MMT with PG experience improvements in psychological problems, including long-term improvement, regardless of the PG intervention offered.

Long-term efficacy of contingency management treatment based on objective indicators of abstinence from illicit substance use up to 1 year following treatment: A meta-analysis.

OBJECTIVE: Contingency management (CM) is often criticized for limited long-term impact. This meta-analysis focused on objective indices of drug use (i.e., urine toxicology) to examine the effects of CM on illicit substance use up to 1 year following treatment. METHOD: Analyses included randomized trials (k = 23) of CM for stimulant, opioid, or polysubstance use disorders that reported outcomes up to 1 year after the incentive delivery had ended. Using random effects models, odds ratios (OR) were calculated for the likelihood of abstinence. Metaregressions and subgroup analyses explored how parameters of CM treatment, namely escalation, frequency, immediacy, and magnitude of reinforcers, moderated outcomes. RESULTS: The overall likelihood of abstinence at the long-term follow-up among participants who received CM versus a comparison treatment (nearly half of which were community-based comprehensive therapies or protocol-based specific therapies) was OR = 1.22, 95% confidence interval [1.01, 1.44], with low to moderate heterogeneity (I² = 36.68). Among 18 moderators, longer length of active treatment was found to significantly improve long-term abstinence. CONCLUSIONS: CM showed long-term benefit in reducing objective indices of drug use, above and beyond other active, evidence-based treatments (e.g., cognitive-behavioral therapy, 12-step facilitation) and community-based intensive outpatient treatment. These data suggest that policymakers and insurers should support and cover costs for CM, which is the focus of hundreds of studies demonstrating its short-term efficacy and, now, additional data supporting its long-term efficacy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Sustainment of Contingency Management within Opioid Treatment Programs: COVID-Related Barriers and Innovative Workflow Adaptations.

Introduction: Contingency Management (CM) is one of the most effective interventions for persons with opioid use disorder, but one of the least available interventions in community settings, including opioid treatment programs. Project MIMIC is a NIDA-funded cluster randomized trial that is measuring CM implementation and sustainment across 30 opioid treatment programs in the New England region of the United States. The advent of the COVID-19 pandemic occurred in the midst of Project MIMIC's first cohort of eight opioid treatment programs, presenting a natural opportunity to document and analyze novel challenges to CM sustainment. Utilizing both quantitative and qualitative data collection, we aimed to identify both COVID-related barriers to CM sustainment and innovative workflow strategies to mitigate these barriers. Methods: Quantitative analysis was conducted using data collected from a study-specific CM tracker tool on various CM implementation metrics over three distinct, successive time intervals: prior to COVID-19 social distancing orders with active support; during COVID-19 social distancing orders with active support; and during COVID-19 social distancing orders after removal of support. Semi-structured qualitative interviews were conducted with a representative from each of the eight opioid treatment programs. Using a reflexive team approach, transcripts were coded by independent raters to identify both COVID-related barriers to sustainment and innovative workflow adaptations. Results: Quantitative data revealed a substantial decrease in the number of CM encounters following social distancing orders from 31.8 encounters weekly across eight programs to 6.9 encounters weekly across five programs. A further decline to 1.8 weekly encounters across three programs was observed after implementation support was removed. Four COVID-related barriers were identified via thematic analysis: fear of contagion; difficulty engaging patients remotely; challenges re-defining the CM attendance target due to changing regulations; and staff shortages. Potential adjustments discussed to help address one or more of these barriers included an electronic prize generator; use of technology to promote engagement; brief individual remote check-ins; and expansion of training to non-counseling staff. Conclusion: Although CM implementation challenges emerged during the pandemic, associated workflow adaptations also emerged. The feedback solicited in this study will inform multi-level strategies to aid with CM sustainment post-pandemic.

Alcohol Use and Clinical Outcomes in Adults in the Type 1 Diabetes Exchange.

OBJECTIVES: Alcohol consumption has serious potential consequences for persons with type 1 diabetes. This cross-sectional study examined associations between drinking status and diabetes-related outcomes. METHODS: Participants included 934 adults at Type 1 Diabetes Exchange Registry clinics who responded to an e-mail invitation to complete an electronic survey with items on alcohol consumption; glycated hemoglobin (A1C) and body mass index (BMI) were extracted from medical charts. Participants were an average 38±16 years of age, 61% were women and 90% were non-Hispanic white; A1C was 7.8%±1.5%. The sample was made up of 11% (n=103) never drinkers, 9% (n=89) former drinkers, 61% (n=567) current (past year) nonbinge drinkers and 19% (n=174) current binge drinkers. RESULTS: After controlling for covariates, diabetes distress was lower among never drinkers compared with former and nonbinge drinkers (p<0.009). Never drinkers compared with former drinkers had lower odds of past-year severe hypoglycemia (p=0.001) and lower odds of a neuropathy diagnoses (p=0.006). There were omnibus model trends toward associations between drinking status and diabetes self-care (p=0.10) and between drinking status and BMI (p=0.06). Never drinkers did not differ from other groups on daily frequency of blood glucose self-monitoring, A1C or past-year diabetic ketoacidosis (p>0.05). CONCLUSIONS: These results suggest complex relationships between drinking and diabetes-related distress, and that recent severe hypoglycemia and the presence of neuropathy may motivate some to stop drinking. Prospective studies may improve understanding of these findings.

Sexual orientation and substance use treatment outcomes across five clinical trials of contingency management.

Lesbian, gay, and bisexual (LGB) individuals have elevated rates of substance use disorders and present to treatment with more severe substance use problems. Despite this health disparity, recent reviews highlight the paucity of studies reporting sexual orientation in substance use research (e.g., Flentje, Bacca, & Cochran, 2015). Using data from 5 clinical trials of contingency management (CM), the current study investigated the impact of sexual orientation on 3 substance use outcomes: treatment retention, longest duration of abstinence, and percent negative samples submitted. Participants (N = 912; mean age = 36.6 years; 51.1% female; 45% African American, 42.2% Caucasian) were randomized to standard care in community-based intensive outpatient treatment (IOP) or the same plus CM. Patients identifying as LGB made up 10.6% of the sample. A significant proportion identified as bisexual (8.2% of the total sample). Regardless of sexual orientation, participants receiving CM achieved better treatment outcomes than those receiving IOP alone. There were no statistically significant differences between LGB and heterosexual participants in their response to IOP in general, and CM specifically, across all 3 treatment outcomes (ps > .05). However, equivalence testing revealed that outcomes were not statistically equivalent for LGB and heterosexual participants, with the exception of percentage of negative samples, which was equivalent within the CM group only. Differences in treatment response to CM and standard community-based IOP do not reach the level of statistical significance; however, in most cases, we cannot conclude that treatment response is equivalent for LGB and heterosexual individuals. (PsycINFO Database Record (c) 2020 APA, all rights reserved).