Discrete Choice Experiment on Financial Incentives for Engaging Young Adults in Vaping Cessation Programs.

INTRODUCTION: Contingency management involves rewarding individuals based on objective evidence of behavioral changes. This study explores preferences for financial incentives in vaping cessation programs. METHODS: A discrete choice experiment (DCE) was conducted among young adult current e-cigarette users aged 19-29. DCE attributes (and levels) included reward amount ($100, $300), reward schedule (consistent value, escalating value), reward procedure (gain-framed, loss-framed), vaping education modules (yes, no), text messaging support (yes, no), and cost ($30, $100). Participants were randomized into one of the four blocks, each containing four choice sets. Each choice set presented two hypothetical vaping cessation programs. Choice data (n × choice sets × alternative programs = 154 × 4 × 2 = 1,232 observations) were analyzed using generalized estimation equation models. RESULTS: Participants showed a preference for vaping cessation programs offering a higher reward amount (odds ratio [OR] = 11.5; 95% CI,7.0-19.2), gain-framed rewards for sustained abstinence (OR = 1.4; 95% CI,1.0-1.8), text messaging support (OR = 1.9; 95% CI,1.4-2.5), and a lower program cost (OR = 2.6; 95% CI,1.8-3.8). Interaction tests showed significant effects of the rewards procedure among daily e-cigarette users (adjusted OR [AOR] = 2.1; 95% CI,1.3-3.5), but not some-day users; and among those with no quit attempts in the past six months (AOR = 2.7; 95% CI,1.5-4.7), but not those with previous quit attempts. Female participants preferred text messaging support (AOR = 3.6; 95% CI,2.3-5.4), whereas male participants did not show this preference. CONCLUSION: A multifaceted vaping cessation intervention augmented with financial incentives might improve participation and engagement among young adults. Future studies should investigate how these attributes can enhance program reach and vaping abstinence outcomes in real-world settings.

Prize-based Incentives for Smoking Cessation Among People with HIV: A Sequential Multiple Assignment Randomized Trial (SMART).

INTRODUCTION: Contingency management (CM) is an incentive-based approach that has demonstrated efficacy for smoking cessation in various populations. There is an unmet need for feasible and effective smoking cessation interventions in people with HIV (PWH). The study purpose is to assess efficacy of prize-based CM for smoking cessation in PWH using a Sequential Multiple Assignment Randomization Trial (SMART) design selected to tailor intervention intensity based on early treatment response. METHODS: During phase 1, 129 participants were randomly assigned to high-magnitude prize CM (HM-CM) or standard of care (SoC) for 4 weeks. Participants who did not reduce smoking were randomized in Phase 2 to continued counseling with HM-CM plus monitoring support or only continued monitoring support for 8 weeks. Participants who reduced smoking were randomized to booster monitoring with low-magnitude CM or no additional care. Outcomes were biochemically-verified smoking reduction and 7-day abstinence prevalence at post-treatment, 6-month and 12-month follow-up. RESULTS: Phase 1 responders (based on biochemical indicators of smoking reduction) were significantly less likely to return to smoking (during treatment and at 6- and 12-months) if they received low-magnitude incentives. Notably, initial exposure to CM vs. SoC did not increase rate of phase 1 response, and high-magnitude incentives later in treatment did not lead to greater smoking cessation for early treatment non-responders. CONCLUSION: Weekly CM sessions in the first four weeks of smoking cessation intervention did not perform significantly better than SoC. However, brief booster CM sessions aimed at maintaining early smoking cessation hold clinical promise and warrant further investigation. IMPLICATIONS: This represents the first trial to examine the use of contingency management for smoking cessation among people with HIV within the context of a Sequential Multiple Assignment, Randomized Trial (SMART) design.

Assessment of reduction in stimulus generalization of ethanol-seeking during recovery: A rapid procedure.

Previously, we developed a procedure which showed that longer histories of reinforced alternative behavior decrease the risk of relapse caused by a range of stimuli which had previously occasioned drinking. The decrease in relapse risk was likely due to a decrease in attention to the stimuli over the course of repeated engagement in the alternative behavior. However, this previous procedure was time consuming and did not mirror the procedure we used to observe changes in relapse risk. This study aimed at replicating the previous relationship between the duration of engaging in an alternative behavior and shift in stimulus generalization for drinking using a procedure that allows longitudinal analysis over time and is consistent with other procedures we have developed. Rats were trained to respond for ethanol in the presence of one stimulus (16 kHz tone; food Fixed Ratio (FR)150 and ethanol FR5), and for food in the under another stimulus (8 kHz tone; food and ethanol FR5). Then, recovery-like sessions with food predominant responding occurred in the presence of only the low-cost food stimulus. During these sessions, rats were exposed to non-reinforced graded stimuli alternation from 8 to 16 kHz alternating with the reinforced low-cost food stimulus. The number of responses on each (food and ethanol) lever before completing 5 responses on either lever was the main measure. Consistent with the earlier procedure, the current procedure showed that graded variation of tone from 8 to 16 kHz produced a graded increase in responding for ethanol compared to responding for food. In addition, longer periods of engaging in recovery-like responding shift the generalization function downwards. This procedure confirms the earlier pattern of stimulus generalization over longer periods of behavior consistent with recovery. This strengthens our hypothesis that shifts in attention to alcohol-related stimuli are important to the development of relapse resistance during recovery.

Social validity of digital social incentives in the treatment of substance use disorders.

Substance use disorders (SUDs) affect millions and have substantial negative consequences for individuals and society. Social incentives that leverage social networks for reinforcement or feedback have been used to improve health behaviors such as physical activity. This study investigated the feasibility, acceptability, and usability of a novel digital social incentive system embedded into a web- and smartphone-based platform for SUD recovery. The system leveraged a preexisting care team to deliver social incentives following notifications on recovery-related goal completion and abstinence to members undergoing SUD treatment. In total, 243 notifications were sent to care-team members, resulting in 117 social incentives, nearly all of which (99.15%) were coded as positive. Treatment members and care-team members provided favorable endorsements on acceptability and usability measures. Some areas of improvement were identified, such as increasing personalization and transparency. This digital social incentive system was feasible, acceptable, and usable as an adjunct treatment component for SUD recovery.

Contingency Management for Cannabis Use Disorder Treatment.

INTRODUCTION: Although recreational cannabis use and abuse are expressive worldwide, the comparison of worldwide used psychotherapies, such as cognitive behavior therapy, with contingency management in the treatment of cannabis use disorder remains inconclusive. METHODS: We screened all articles published on MEDLINE (via PubMed) published until October 2023 and conducted a systematic review with meta-analysis. RESULTS: Sixteen studies were included, and contingency management intervention likely promotes abstinence outcomes and more negative urinalyses for adults or adolescents with cannabis use disorder. DISCUSSION: This review provides moderate- to high-quality evidence that contingency management can be used to treat cannabis use disorder. However, further trials need to be developed to analyze the quantity of substance use, personal achievements, and operational improvements after treatment.

Voucher-based contingency management to promote treatment engagement in comorbid alcohol use disorder and alcohol-related liver disease: A pilot theory-informed qualitative study with service users.

BACKGROUND: Effective interventions for the management of alcohol-related liver disease (ARLD) remain a gap in clinical practice, and patients' engagement with alcohol services is suboptimal. Based upon the principles of operant conditioning, contingency management (CM) is a psychosocial intervention th at involves gradual, increasing incentives upon completion of treatment-related goals such as treatment attendance. METHODS: A pilot feasibility trial was conducted with 30 adult patients recruited from an inpatient clinical setting. Consecutive sampling was used to recruit patients presenting comorbid alcohol use disorder (AUD) and ARLD. Participants were randomized to integrated liver care (ILC), receiving hepatology and AUD care, or ILC with a voucher-based CM intervention (intervention arm). A longitudinal qualitative approach was adopted to explore anticipated (Stage 1) and experienced acceptability (Stage 2). The Theoretical Framework of Acceptability (TFA) guided semi-structured in-depth interviews and deductive analysis. RESULTS: Thirty participants were enrolled in the pilot trial, and interviews were conducted with 24 participants at Stage 1 and seven at Stage 2. Over half of the cohort (54.2%, n = 13) presented decompensated liver disease, and an average of 179 units of alcohol were consumed per week. Overall positive views toward voucher-based CM were noted, and explanatory data emerged across five TFA domains (intervention coherence, ethicality, self-efficacy, perceived effectiveness, and affective attitude). The core aspects of the voucher-based CM intervention matched participants' preferences and needs. Participants regarded CM as having a symbolic value and strengthening the therapeutic alliance with healthcare providers. CONCLUSION: The data support the scope of voucher-based CM intervention to promote engagement with treatment services, and its potential to address the gaps in the care continuum in ARLD. The findings are of practical significance for developing person-centered, tailored interventions for this clinical population. The outcomes of this investigation can inform decision-making among stakeholders and healthcare providers and improve health outcomes for this clinical population.

Participant experiences with a text message and contingency management intervention for alcohol use during pregnancy and lactation in Cape Town, South Africa.

Background: The Western Cape region of South Africa has one of the highest global rates of Fetal Alcohol Spectrum Disorder (FASD), underscoring the urgent need for effective interventions. This qualitative study explores pregnant and lactating participants' perceptions and experiences of a text message and contingency management (CM) intervention. Methods: The study involved post-intervention interviews with 10 pregnant participants and 10 post-partum lactating participants. Coding and a thematic analysis approach were applied to the collected data using NVivo 12. Results: Four main themes emerged from the analysis: (1) program experiences; (2) intervention components; (3) health behavior change; and (4) recommendations for program improvements. The participants valued financial incentives and health-promoting text messages, noting reduced alcohol consumption. Conclusion: The findings highlighted the potential benefits of the intervention in improving individuals' health behaviors. However, logistical barriers and the need for expanded support services were identified, emphasizing the importance of refining intervention strategies in resource-limited settings.

An Assertive Community Intervention to Engage Youth with Opioid Use Disorder and Their Families.

Medications for opioid use disorder (MOUD) are the most effective treatment for OUD. Many patients struggle with adherence, but young adults face unique developmental barriers and experience higher relapse rates. The Youth Opioid Recovery Support (YORS) intervention is a developmentally informed behavioral approach to increase medication adherence through assertive outreach, family involvement, low-barrier access to extended-release MOUD, and contingency management. Early studies have shown promising results, and a randomized controlled trial is underway. Here we describe the implementation of YORS using case examples, offer guidance on adapting YORS to real-world clinical settings, and explore future directions for research and practice.

California's Recovery Incentives Program: Implementation strategies.

INTRODUCTION: Due to the increasing role of psychostimulants in the US drug poisoning crisis, there is an increasing need to effectively implement evidence-based treatment for individuals with stimulant use disorder (StimUD). Contingency management is a behavioral strategy with robust evidence of support for the treatment of StimUD. In 2023, California initiated a large-scale effort to implement CM as a treatment for individuals with a stimulant use disorder (cocaine, methamphetamine, amphetamine) called the Recovery Incentives Program: California's Contingency Management Benefit. METHODS: The Recovery Incentives Program is being systematically implemented using the Becker et al. Science to Service Lab (SSL) implementation approach with several augmentations for this project. The SSL features three core components: didactic training, performance feedback, and external facilitation. We have augmented this approach with a readiness assessment process for sites prior to CM service launch, and an ongoing fidelity monitoring and feedback component post-launch. RESULTS: The present paper is a preliminary report describing the use of this augmented SSL strategy for CM implementation in a large-scale implementation effort. Data are presented to describe the implementation activities during the first ten months of the Recovery Incentives Program. CONCLUSION: The California Recovery Incentives Program has been systematically implemented and appears to be receiving a positive response from treatment program staff and enrolled members. Future papers and evaluation reports will continue to document member response to the Program and report on the ongoing training and implementation process.

Implementing contingency management into rural recovery housing: recommendations of a professional advisory expert panel.

Background: Rural areas in the United States have been severely impacted by recent rises in substance use related mortality and psychosocial consequences. There is a dearth of treatment resources to address substance use disorder (SUD). Rural recovery houses (RRH) are important services that provide individuals with SUD with an environment where they can engage in recovery-oriented activities, but dropout rates are unacceptably high, and evidence-based interventions such as contingency management (CM) may reduce dropout and improve outcomes for RRH residents. In this paper, we describe the results of a national convening of experts that addressed important issues concerning the implementation of CM within the context of RRHs.Methods: Twelve experts (five female) in the areas of CM, RRH and rural health participated in a one-day facilitated meeting that used nominal group technique to identify expert consensus in three areas as they pertain to RRH: (a) facilitators and barriers to CM implementation, (b) elements necessary for successful program building based on group feedback, and (c) recommendations for future implementation of CM.Results: Several RRH- and system-level barriers and facilitators to implementing CM were identified by the panel, and these were categorized based on the level of importance for and ease of implementation. CM funding, staff and resident buy-in, set policies, education on CM, and consistent fidelity to CM procedures and tracking were identified as important requirements for implementing CM in RRH.Conclusions: We provide recommendations for the implementation of CM in RRH that may be useful in this context, as well as more broadly.

Evolution of the substance use landscape: Implications for contingency management.

Contingency management (CM), which involves the delivery of incentives upon meeting behavioral goals, has the potential to improve substance use treatment outcomes. The intervention allows for flexibility through numerous modifiable components including changes to incentive magnitude and schedule, target behavior, and intervention structure. Unfortunately, numerous changes in the substance use landscape have occurred in the past 10 to 15 years: Substances are more potent, overdose risk has increased, new substances and methods of use have been introduced, and substance classes are increasingly being intentionally and unintentionally mixed. These developments potentially undermine CM outcomes. We explored recent substance use changes due to legislative, regulatory, social, and economic factors for four substance classes: stimulants, opioids, tobacco, and cannabis. We discuss potential adjustments to the modifiable components of CM for future research in response to these changes. By continually adapting to the shifting substance use landscape, CM can maintain optimal efficacy.

Implementation outcomes from a pilot study of training probation officers to deliver contingency management for emerging adults with substance use disorders.

INTRODUCTION: Emerging adults (EAs) in the criminal legal system are at high risk for substance use and related negative outcomes. EAs also have low levels of engagement in treatment services, a pattern exacerbated for those living in rural communities. This pilot study investigated implementation outcomes of task-shifting an evidence-based substance use intervention, via a developmentally targeted program, provided by probation officers (POs) to selected EA clients. METHODS: Ten POs recruited from two counties in Oregon who provide services to rural clients were trained and supported in delivering contingency management for EAs (CM-EA) to 17 EAs on their current caseloads. The pilot took place entirely during the COVID-19 pandemic. POs submitted session audiotapes and checklists from meetings with participating EA clients and participated in focus groups. EA clients completed baseline interviews and agreed to have their adult criminal records collected. Ten semi-structured interviews were completed with probation/parole administration and staff from four rural counties across three states highly impacted by the opioid epidemic about the barriers and facilitators for delivering a program like CM-EA in their offices. RESULTS: Based on self-reports and observational coding, POs demonstrated fidelity and adoption as they delivered all CM-EA components and engaged in CM-EA quality assurance protocols. Penetration was demonstrated by the selection of EAs reflecting the demographics of their local offices (i.e., White, non-Hispanic, balanced across sex), struggling with polysubstance use, and primarily holding felony convictions. Emerging themes from focus groups and interviews revealed feasibility, acceptability, and appropriateness of CM-EA, including use with clients not currently in the research program and reported intentions to continue CM-EA use. Barriers for future use include those found for the delivery of other programs in rural areas such as resource limitations. CONCLUSIONS: There is initial support for the implementation outcomes related to task-shifting a program like CM-EA to POs, particularly those serving rural clients, to increase access to evidence-based substance use services for EAs. Future research with larger samples and multiple follow-ups will allow for effectiveness testing and further program refinement for this high-priority population.

Leveraging Parents and Peer Recovery Supports to Increase Recovery Capital in Emerging Adults With Polysubstance Use: Protocol for a Feasibility, Acceptability, and Appropriateness Study of Launch.

BACKGROUND: Emerging adults (aged 18-26 years) are the most at-risk yet underserved age group among people with substance use disorder, especially rural emerging adults, and polysubstance use is common. Recovery capital is lower among emerging adults than older adults, and evidence-based treatments are typically unavailable or not developmentally tailored, especially in rural areas. Both supportive parents (or parental figures) and peer recovery support services (PRSS) can be leveraged to better support these emerging adults. Previous research indicates parents can be engaged to deliver contingency management (CM), an extensively researched evidence-based intervention for substance use. OBJECTIVE: This protocol describes a funded pilot of Launch, a novel, scalable service package that pairs web-based coaching for parents to deliver CM for emerging adults (CM-EA) at home and in-person PRSS with educational and vocational goal setting. Specifically, this protocol describes feasibility, acceptability, and appropriateness testing (implementation-related outcomes) and steps taken to prepare for a future large-scale trial of Launch. METHODS: Upon the recruitment of 48 emerging adult and parent pairs from sites serving primarily rural clients, participants will be randomized into 1 of 3 conditions for this randomized controlled trial: virtual parent coaching to deliver CM-EA, in-person PRSS for emerging adults, or both sets of services. Emerging adult eligibility includes polysubstance use, a substance use disorder, and availability of a consenting parent. Emerging adults will be interviewed at baseline and 6 months about substance use, quality of life, recovery capital, parental relationship, and Launch implementation-related outcomes (6-month follow-up only). Parents, peer workers delivering PRSS, and parent CM-EA coaches will be interviewed about implementation-related outcomes at the end of the study period. Peer workers and CM-EA coaches will be asked to complete checklists of services delivered after each session. Finally, payers and providers will be interviewed for additional insights into Launch implementation and to identify key outcomes of Launch. Data analysis for emerging adult outcomes will be primarily descriptive, but parent CM-EA training adherence will be assessed using nested mixed-effects regression models of repeated measures. RESULTS: Launch is currently ongoing, with funding received in August 2023, and is expected to end in September 2025, with data analysis and results in December 2026. Participants are expected to begin enrolling in June 2024. CONCLUSIONS: While this pilot is limited by the small sample size and restriction to emerging adults with an involved parent, this is mitigated by the study's strengths and is appropriate for the pilot stage. Launch uses an innovative combination of existing strategies to generate better outcomes for emerging adults while remaining scalable. This pilot will provide insights into the feasibility and acceptability of Launch from the perspectives of service recipients, providers, and payers to inform a larger-scale effectiveness trial. TRIAL REGISTRATION: ClinicalTrials.gov NCT06414993; https://clinicaltrials.gov/study/NCT06414993. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/60671.

Use of Transdermal Alcohol Sensors in Conjunction With Contingency Management to Reduce Alcohol Consumption in People With Alcohol Dependence Attending Alcohol Treatment Services: Protocol for a Pilot Feasibility Randomized Controlled Trial.

BACKGROUND: Wearable technology for objective, continuous, and reliable alcohol monitoring has been developed. These are known as transdermal alcohol sensors (TASs). They can be worn on the wrist or ankle with the sensor pressed against the skin and can measure sweat vapors being emitted from the skin, to record transdermal alcohol concentration (TAC). Previous studies have investigated the accuracy and acceptability of the available TAS brands, but there has been little research into their use in people with alcohol use disorders (AUD). OBJECTIVE: This feasibility randomized controlled trial aims to explore the feasibility, strengths, and limitations of using a TAS to monitor alcohol consumption in individuals in treatment for AUD with or without contingency management (CM) to promote abstinence or low-level alcohol consumption. METHODS: The target sample size is 30 (15 randomized to each group). Participants will be recruited through poster adverts at alcohol services. Both groups (control and CM) will wear the TAS (BACtrack Skyn) for 2 weeks in the context of their usual treatment, meeting with the researcher every other weekday. In the last meeting, the participants will complete a postwear survey on their experience of wearing the TAS. The CM group will also receive small financial incentives for low or no alcohol consumption, as measured by the TAS. On days where the TAC peak is below a set threshold (<115.660 g/L), CM group participants will be rewarded with a £5 (US $6.38) voucher. There are financial bonuses if this target is achieved on consecutive days. The researcher will monitor TAC for each day of the study at each research visit and allocate financial incentives to participants according to a set reinforcement schedule. RESULTS: The first participant was enrolled in June 2023, and the last in December 2023. Data analysis is underway and is estimated to be completed by June 2024. A total of 32 participants were enrolled. CONCLUSIONS: Most TAS brands have had limited application in clinical settings, and most studies have included healthy adults rather than people with AUD. TAS has the potential to enhance treatment outcomes in clinical alcohol treatment. The accuracy, acceptability, and feasibility of TAS for people with AUD in clinical settings need to be investigated. This is the first study to use TAS in specialized alcohol services with diagnosed AUD individuals currently receiving treatment from a south London alcohol service. TRIAL REGISTRATION: ISRCTN Registry ISRCTN46845361; https://www.isrctn.com/ISRCTN46845361. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/57653.

Adherence to buprenorphine-XR through hybrid telehealth contingency management procedures: a case series.

Background and objectives: Contingency management (CM) for substance use disorders (SUD) is effective in strengthening recovery behaviors, however can be quite burdensome. When health facilities experience staff shortages, adapting current CM protocols to be less staff and time intensive may be one way to address this challenge. Methods: Case series (N = 3). Results: Three veterans with opioid use disorder (OUD) received CM for treatment adherence through a Veteran Health Administration Outpatient Substance Disorder program. Due to the COVID-19 pandemic, traditional CM procedures resulted in limited accessibility and staff, delayed appointments, and decreased patient satisfaction. In response, the hybrid telehealth contingency management (HTCM) procedure was developed and implemented. Flexibility offered by HTCM allowed for consecutive completion of appointments and maintained adherence to BUP-XR treatment. Conclusions: This is a novel method of CM implementation. HTCM streamlined the process and was successful in increasing accessibility, reducing time-burden on patients and staff, while preserving fidelity to key components of the model. Considerations for future implementation and implications of HTCM are discussed.

An incentive-based text-messaging intervention to reduce maternal alcohol use during pregnancy and lactation in South Africa (MaRISA study): Findings from a single-arm pilot study.

BACKGROUND: South Africa has the highest rate of fetal alcohol spectrum disorders (FASD) globally. As with alcohol use during pregnancy, alcohol consumption while breastfeeding adversely impacts infant development. We pilot tested an incentive-based text-messaging intervention to reduce alcohol use during pregnancy and lactation in South Africa. METHODS: A single-arm pilot trial was conducted over 3 months in healthcare facilities in Cape Town, South Africa. Pregnant and breastfeeding participants tested positive for recent alcohol use by urinalysis. The three-month intervention had two components, contingency management of alcohol abstinence confirmed by urinalysis twice weekly and weekly health-related text messaging from an evidence-based brief intervention. We collected twice weekly urine samples for measurement of ethyl glucuronide (EtG), an alcohol biomarker, and measures of self-reported alcohol and drug use, violence exposure, and mental health at six weeks and three months post-enrollment. RESULTS: Sixty participants were enrolled, of whom 31 were pregnant and 29 lactating. The number of days with four or more drinks in the past month decreased from 9 days at baseline, on average, to 1-3 days (p-value range: 0.144-0.010) at follow-up timepoints. There were statistically significant increases in the proportions of participants with alcohol-negative urine tests (p < 0.001). The percentages of participants breastfeeding while using alcohol decreased from baseline to the end of 3 months in the overall sample and among those enrolled postpartum, though these were not significant (p-value range: 0.255-0.147). Maternal depression scores also decreased among participants enrolled postpartum (p = 0.054). Emotional abuse by the main partner, but neither physical nor sexual abuse, significantly decreased at both follow-ups in the overall sample (p = 0.032) and among participants enrolled while pregnant (p = 0.015). CONCLUSIONS: This study is among the first to pilot test an incentive-based text-messaging intervention for maternal alcohol use and other outcomes such as depression and violence exposure. Further testing is warranted in a well-powered, randomized controlled trial.

Behavioral therapies targeting reward mechanisms in substance use disorders.

Behavioral therapies are considered best practices in the treatment of substance use disorders (SUD) and used as first-line approaches for SUDs without FDA-approved pharmacotherapies. Decades of research on the neuroscience of drug reward and addiction have informed the development of current leading behavioral therapies that, while differing in focus and technique, have in common the overarching goal of shifting reward responding away from drug and toward natural non-drug rewards. This review begins by describing key neurobiological processes of reward in addiction, followed by a description of how various behavioral therapies address specific reward processes. Based on this review, a conceptual 'map' is crafted to pinpoint gaps and areas of overlap, serving as a guide for selecting and integrating behavioral therapies.