A review of the literature on contingency management in the treatment of substance use disorders, 2009-2014.

Purpose

Little qualitative research has examined factors associated with care in substance abuse treatment agencies in Southeastern rural communities. This study explored client- and agency stakeholder-perceived barriers and facilitators to substance use treatment delivery in southeastern rural communities.



Methods

Group and individual interviews were conducted with 40 key stakeholders and 40 clients at 9 substance abuse agencies serving rural communities in a southeastern state. Qualitative thematic analysis was used to identify perceived barriers and facilitators to substance abuse services in rural communities.



Findings

Four primary themes emerged from the client and stakeholder interviews as both barriers and facilitators: availability of services for individuals with substance use disorders; access to the current technology for client services and agency functioning; cost of services; and stigma.



Conclusions

This study identifies novel barriers and facilitators to substance use care in the rural South and highlights essential areas for consideration when developing and implementing substance use care in this geographic region. These findings can be used as guidelines to provide better care to individuals with substance use disorders living in rural communities.

Barriers and Facilitators to Substance Use Treatment in the Rural South: A Qualitative Study

The burden of substance use and especially the unmatched rates of overdoses in rural Central Appalachia highlight the need for innovative approaches to curb the initiation to drug misuse and to address current substance use disorders. Effective substance use interventions involve a thorough understanding of the region. In Central Appalachia, many of the barriers to treatment are shared with other rural and impoverished areas, including a lack of access to health care and lack of health care providers with specialized training. Parts of Appalachia also present their own considerations, including the challenges of fostering trust and encouraging treatment-seeking in communities with dense, long-term, place-based social and family networks. Current policies and interventions for substance use have been largely inadequate in the region, as evidenced by continued increases in substance use and substance-related deaths, especially related to nonmedical prescription drug use and increasing heroin use. The authors discuss ways in which rural life, poverty, identity, and values in Appalachia have influenced substance use and treatment and propose strategies and interventions to improve outcomes.

/pdf/substance-use-in-rural-central-appalachia-current-status-and-4t1jihnsl4.pdf

Substance Use in Rural Central Appalachia: Current Status and Treatment Considerations

Aims

Contingency management (CM) uses tangible incentives to systematically reinforce abstinence and is among the most efficacious psychosocial substance abuse treatments. This study assessed the feasibility and initial efficacy of a portable CM procedure designed to address technical limitations for detecting drinking that have prevented using CM for alcohol problems.



Design

Participants received a cellphone, breathalyzer and training on video-recording alcohol breath tests (BrACs) and texting results. For 4 weeks, staff texted participants one to three times daily indicating that a breath alcohol concentration test (BrAC) was due within the hour. Participants were randomized to (1) modest compensation for submitting dated time-stamped BrAC videos regardless of results or (2) the same plus CM with escalating vouchers for on-time alcohol-negative tests (n-BrAC; <02 g/dl). ‘Thank-you’ texts were sent, with CM patients also informed of results-based earnings.



Setting

Participants' natural environment.



Participants

Adults (n = 30; ≥ 21 years) who drank frequently but were not physiologically dependent.



Measurements

Drinking and related problems were assessed at intake and week 4. BrACs and self-reports of drinking were collected throughout. The primary outcome was the percentage of n-BrACs. Other outcomes were the longest duration of consecutive n-BrACs (longest duration of abstinence) and self-reports of drinking.



Findings

On average, 88.6% (10.4%) of BrACs were submitted on time, without group differences (P = 0.18). The percentage of n-BrACs and LDA were greater with CM, and there was an interaction effect on drinking frequency and negative consequences, with decreases over time with CM (P = 0.00; effect sizes d = 0.52–0.62).



Conclusion

Cellphone technology may be useful for extending contingency management to treatment for alcohol problems.

/pdf/a-randomized-study-of-cellphone-technology-to-reinforce-5y32v1jqoz.pdf

A randomized study of cellphone technology to reinforce alcohol abstinence in the natural environment

Motivation is an integral factor in substance use treatment and long-term recovery. However, it is unclear what role intrinsic and extrinsic motivation play across different treatment modalities. A meta-analysis (N = 84) was performed to estimate the pooled effect size of Motivational Interviewing (MI; primarily targeting intrinsic motivation) and contingency management (CM; primarily targeting extrinsic motivation) at different follow-up periods. Collapsed across all substance types, CM had a significant effect at 3-month follow-up, only. In contrast, MI had a significant effect at 6-month follow-up, only. CM had small and medium effects on multiple substances at 3-month follow-up (i.e., tobacco, marijuana, stimulants, polysubstances), but not at 6-month follow-up. MI had 1 significant medium effect at 3-month follow-up (i.e., marijuana), but several significant small effects at 6-month follow-up (i.e., alcohol, tobacco, polysubstances). This meta-analysis suggests that both CM and MI promote reductions in a range of substances, even several months after the intervention concludes. Further, these results provide some evidence that extrinsically focused CM may produce medium follow-up effects in the short run, but intrinsically focused MI may produce small but durable follow-up effects. However, this interpretation is complicated by the differences between the MI and CM studies that preclude statistical tests comparing effect sizes, and few studies assessed motivation itself. Future researchers should investigate how motivational dynamics impact lasting outcomes in substance use treatment. (PsycINFO Database Record

Follow-up treatment effects of contingency management and motivational interviewing on substance use: A meta-analysis.

The influence of reinforcer magnitude and reinforcer delay on smoking abstinence was studied using an analog model of contingency management. Participants (N = 103, 74% men) visited our laboratory 3 times daily for 5 days and received money for providing a breath sample that indicated smoking abstinence (carbon monoxide level ≤6 parts per million). Using a factorial design, we assigned participants randomly to 1 of 4 groups that could earn a total of either $207.50 (high-magnitude condition) or $70.00 (low-magnitude condition), and received earnings either at each visit (no-delay condition) or in a single lump sum 1 week following the study (delay condition). High-magnitude reinforcement, regardless of delay, was associated with higher rates of abstinence than was low-magnitude reinforcement. High magnitude of reinforcement provided immediately but in incremental amounts was associated with longer intervals to relapse during treatment in comparison with high-magnitude reinforcement provided in a single lump sum after a delay. Low rates of responding in the low-magnitude conditions made interpretation of the impact of delay in those conditions difficult. These findings further demonstrate that high magnitude of reinforcement results in better outcomes than does low magnitude of reinforcement, and that a delay to reinforcement can be detrimental-even when a high magnitude of reinforcement is provided.

Investigating reinforcer magnitude and reinforcer delay: a contingency management analog study.

Background and Objectives
This investigation compared cotinine (primary metabolite of nicotine) at study intake to self-report metrics (eg, Fagerstrom Test of Nicotine Dependence [FTND]) and assessed their relative ability to predict smoking outcomes.

Methods
We used data from an analog model of contingency management for cigarette smoking. Non-treatment seeking participants (N = 103) could earn money in exchange for provision of a negative carbon monoxide (CO) sample indicating smoking abstinence, but were otherwise not motivated to quit. We used intake cotinine, FTND, percent of friends who smoke, and years smoked to predict longitudinal CO and attendance, time-to-first positive CO submission, and additional cross-sectional outcomes.

Results
Intake cotinine was consistently predictive (p < .05) of all outcomes (eg, longitudinal CO and attendance, 100% abstinence, time-to-first positive CO sample), while years smoked was the only self-report metric that demonstrated any predictive ability.

Conclusions and Scientific Significance
Cotinine could be more informative for tailoring behavioral treatments compared to self-report measures. (Am J Addict 2014;23:15–20)

Biochemical marker of use is a better predictor of outcomes than self-report metrics in a contingency management smoking cessation analog study.

There are many factors that contribute to a college athlete's risk for injury.  Previous studies have shown that life stress can be a predictor for injury.  The current study investigated if academic stress plays a role in athletic injury rate.  Data collected from the university athletic trainer between 2012 and 2015 on athletic injuries was analyzed.  Results indicate that season start and end dates play a role in when injuries occur.  No evidence was found for academic events such as mid-terms and finals influencing the rate of injury. These findings suggest that the rate of injury for a given sport may be classified as being predominantly early-season, predominantly late-season, or predominately mid-season. Further research is needed to determine the individual factors for each sport that may explain the changes in rate of injury.

/pdf/relationship-of-athletic-injuries-to-the-sport-s-season-2g4h57j72v.pdf

Relationship of Athletic Injuries to the Sport's Season (Poster)

Purpose

The purpose of the investigation was to examine variations in evidence-based practice (EBP) utilization between rural and urban mental health and substance abuse prevention provider agencies in Washington State.



Methods

We conducted a secondary analysis of the 2007 EBP Survey, which was administered to 250 of Washington State Department of Social and Health Services’ contracted mental health and substance abuse treatment agencies. The survey solicited input from solo and group practices across the state on EBP implementation, successes, and challenges.



Findings

Most mental health and substance abuse treatment agencies used more than 1 EBP, although rural substance abuse agencies were less likely to do so than urban agencies. Rural substance abuse agencies were more likely to be solo than group practices. Urban agencies reporting significantly more collaboration with universities for EBP training, although training by internal staff was the most commonly reported training mechanism regardless of agency focus or location. Over half of agencies reported conducting no systematic assessment of EBPs, and of those who did report systematic assessment, most used outcome monitoring more than program evaluation or benchmarking. Urban and rural mental health and substance abuse prevention providers reported shortages of appropriately trained workforce and financing issues available to pay for EBPs as the greatest barriers to utilization.



Conclusions

Challenges to EBP utilization and fidelity should be monitored as EBPs contribute to the delivery of high-quality care. Collaborations between universities and rural agencies may support an agency's abilities to adopt EBPs, train staff, and systematically assess impact.

Urban and rural utilization of evidence-based practices for substance use and mental health disorders.

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Investigating reinforcer magnitude and reinforcer delay: a contingency management analog study.

Biochemical marker of use is a better predictor of outcomes than self-report metrics in a contingency management smoking cessation analog study.

Relationship of Athletic Injuries to the Sport's Season (Poster)

Urban and rural utilization of evidence-based practices for substance use and mental health disorders.