Effect of modified income assistance payment schedules on substance use service access: Evidence from an experimental study.

BACKGROUND: Despite being critical to reducing the impacts of poverty internationally, synchronized monthly government income assistance payments are linked to intensified drug use and associated harms, including disrupted access to substance use-related services. This study evaluates whether alternative income assistance distribution schedules improve harm reduction (HR), pharmacotherapy and substance use service utilization. METHODS: This exploratory, parallel group, unblinded, randomized controlled trial analyzed data from adults (n = 192) in Vancouver, Canada receiving income assistance, and reporting active, regular illicit drug use. Participants were randomly assigned on a 1:2:2 basis for six income assistance payment cycles to: (1) existing government schedules (control); (2) a "staggered" single monthly payment; or (3) "split & staggered" twice-monthly payments. Generalized linear mixed models analyzed secondary outcomes of HR, pharmacotherapy and substance use service utilization as well as barriers accessing these services. RESULTS: Forty-five control, 71 staggered, and 76 split & staggered volunteers participated between 2015 and 2019. Multivariable modified per-protocol analyses demonstrate increased access to substance use services (Adjusted Odds Ratio [AOR] 1.64, 95% Confidence Interval [CI] 1.02-2.64) for split & staggered arm participants, and, conversely, increased barriers to HR for participants in the staggered (AOR 2.34, 95% CI 1.24-4.41) and split & staggered (AOR 2.16, 95% CI 1.08-4.35) arms. Results also showed decreased barriers to pharmacotherapy around government payments (AOR 0.23, 95% CI 0.06-0.90), pharmacotherapy around individual payments (AOR 0.12, 95% CI 0.02-0.58), and HR around individual payments (AOR 0.11, 95% CI 0.02-0.63) for staggered arm participants. CONCLUSION: Modifying payments schedules demonstrate improved access to overall substance use services, and reduced barriers to HR and pharmacotherapy around income assistance payments. However, increased overall barriers to HR access were also shown. These complex, predominantly beneficial findings support the exploration of offering alternative payment schedules to support service access.

Research With Women Who Use Drugs: Applying a Trauma-informed Framework.

Women who use drugs (WWUD) experience high rates of trauma. The complex impacts of trauma can act as a barrier to accessing substance use and harm reduction services, and to participation and representation within substance use research. Trauma-informed practice is an evidence-based approach for improved clinical care among WWUD, the principles of which can be applied to substance use research. Many researchers are integrating trauma-informed approaches across research settings, yet these principles are often not referenced specifically within publications, and there is a lack of comprehensive guidance regarding integration of trauma-informed methods across different research designs and methodologies. This commentary describes and discusses the merits of applying the 4 principles of trauma-informed practice - trauma awareness, safety and trustworthiness, choice collaboration and connection, and strengths-based and skills building - to promote safety and inclusion of WWUD in substance use research.

An Acute Care Contingency Management Program for the Treatment of Stimulant Use Disorder: A Case Report.

BACKGROUND: Illicit stimulants such as crystal methamphetamine and cocaine are a rising cause of morbidity and mortality in North America. Unfortunately, there are few evidence-based approaches for the management of stimulant use disorder. Contingency management programs are currently the best evidenced treatment strategy, designed to reward behavior change and offer competing reinforcers toward the goal of reducing substance use, but these programs are often difficult to access. Given that it is well understood that hospitalization presents a valuable opportunity for the initiation of treatment for a variety of substance use disorders, the adaptation of contingency management programs to an acute medicine inpatient setting is a potentially viable option to improve care, and to increase access to effective treatment for stimulant use disorders. CASE SUMMARY: We present a case outlining the clinical care of a complex medical patient admitted with osteomyelitis, whose course in hospital changed significantly upon enrollment in a pilot contingency management program in an urban hospital in Canada. DISCUSSION: This case illustrates how effective treatment programs can be adapted as needed for use in novel settings, especially where current options are inaccessible, inadequate, or ineffective.