This review of contingency management (CM; the behavior-modification method of providing reinforcement in exchange for objective evidence of a desired behavior) for the treatment of substance-use disorders (SUDs) begins by describing the origins of CM and how it has come to be most commonly used during the treatment of SUDs. Our core objective is to review, describe, and discuss three ongoing critical advancements in CM. We review key emerging areas wherein CM will likely have an impact. In total, we qualitatively reviewed 31 studies in a systematic fashion after searching PubMed and Google Scholar. We then describe and highlight CM investigations across three broad themes: adapting CM for underserved populations, CM with experimental technologies, and optimizing CM for personalized interventions. Technological innovations that allow for mobile delivery of reinforcers in exchange for objective evidence of a desired behavior will likely expand the possible applications of CM throughout the SUD-treatment domain and into therapeutically related areas (eg, serious mental illness). When this mobile technology is coupled with new, easy-to-utilize biomarkers, the adaptation for individual goal setting and delivery of CM-based SUD treatment in hard-to-reach places (eg, rural locations) can have a sustained impact on communities most affected by these disorders. In conclusion, there is still much to be done, not only technologically but also in convincing policy makers to adopt this well-established, cost-effective, and evidence-based method of behavior modification.
Background and Aims
Many evidence‐based treatments (EBTs) for substance use disorder (SUD) exist, yet few are tailored to Indigenous patients. This trial tested the efficacy of a culturally tailored EBT that combined Motivational Interviewing and the Community Reinforcement Approach (MICRA) versus treatment as usual (TAU).
Design
A mixed efficacy/effectiveness randomized controlled trial of MICRA (n = 38) and TAU (n = 41) using a parallel design with follow‐up assessments at 4‐, 8‐, and 12‐ months post baseline.
Setting
United States, reservation‐based outpatient, addiction specialty care treatment program.
Participants
79 (68% male) American Indian and Alaska Native (AI/AN) Tribal members meeting criteria for SUD and seeking SUD treatment.
Interventions
MICRA (individual therapy sessions beginning with MI for 2–3 sessions) compared with TAU (individual and group counseling sessions in a didactic style with Twelve‐Step philosophy and elements of relapse prevention).
Measures
Demographics, percent days abstinent (PDA; the primary outcome at 12months assessed by Form 90D), Inventory of Drug Use Consequences, Alcohol and Drug Use Self‐Efficacy Scale, Native American Spirituality Scale, and SCID‐DSM‐IV‐TR.
Findings
There was no evidence for the benefit of MICRA over TAU (MICRA PDA = 72.63%, TAU = 73.62%, treatment effect: B = −4.04 (SE = 5.47); 95% CI = −14.941, 6.866; BF = 3.44) in the primary outcome. Both groups showed improvements in PDA, SUD severity, and negative consequences from baseline to the 12‐month follow‐up. Neither self‐efficacy nor spirituality were significant mediators of MICRA.
Conclusions
There were no treatment group differences between culturally tailored evidence‐based treatments for substance use disorder and treatment as usual in this randomized controlled trial with American Indian and Alaska Native participants. Nonetheless, participants improved over time on several substance‐related outcomes.
A CM intervention for alcohol use disorders should be in alignment with existing cultural and community practices such as alcohol abstinence, is more likely to be successful when Elders and community leaders are champions of the intervention, the intervention is compatible with counseling or treatment methodologies, and the intervention provides rewards that are both culturally specific and practical.
Background
Opioid misuse is a large public health problem in the United States. Residents of rural areas and American Indian (AI) reservation/trust lands represent traditionally underserved populations with regard to substance-use-disorder therapy.
Purpose
Assess differences in the number of opioid agonist therapy (OAT) facilities and physicians with Drug Addiction Treatment Act (DATA) waivers for rural versus urban, and AI reservation/trust land versus non-AI reservation/trust land areas in Washington State.
Methods
The unit of analysis was the zip code. The dependent variables were the number of OAT facilities and DATA-waivered physicians in a region per 10,000 residents aged 18–64 in a zip code. A region was defined as a zip code and its contiguous zip codes. The independent variables were binary measures of whether a zip code was classified as rural versus urban, or AI reservation/trust land versus non-AI reservation/trust land. Zero-inflated negative binomial regressions with robust standard errors were estimated.
Results
The number of OAT clinics in a region per 10,000 zip-code residents was significantly lower in rural versus urban areas (P = .002). This did not differ significantly between AI reservation/trust land and non-AI reservation/trust land areas (P = .79). DATA-waivered physicians in a region per 10,000 zip-code residents was not significantly different between rural and urban (P = .08), or AI reservation/trust land versus non-AI reservation/trust land areas (P = .21).
Conclusions
It appears that the potential for Washington State residents of rural and AI reservation areas to receive OAT is similar to that of residents outside of those areas; however, difficulties in accessing therapy may remain, highlighting the importance of expanding health care insurance and providing support for DATA-waivered physicians.
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