Contingency management for substance use disorders in the U.S. Veterans Health Administration: 2018-2022

Lara N Coughlin; Lan Zhang; Madeline C Frost; Gabriela Khazanov; James R McKay; Dominick DePhilippis; Lewei Allison Lin

doi:10.1016/j.josat.2024.209400

Contingency management for substance use disorders in the U.S. Veterans Health Administration: 2018-2022

J Subst Use Addict Treat. 2024 May 10:209400. doi: 10.1016/j.josat.2024.209400. Online ahead of print.

Authors

Lara N Coughlin¹, Lan Zhang², Madeline C Frost³, Gabriela Khazanov⁴, James R McKay⁴, Dominick DePhilippis⁵, Lewei Allison Lin⁶

Affiliations

¹ Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States of America. Electronic address: laraco@med.umich.edu.
² Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States of America.
³ Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, United States of America; Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America.
⁴ Center for Excellence in Substance Addiction Treatment and Education (CESATE), Corporal Michael J Crescenz VA Medical Center, United States of America; Department of Psychiatry, University of Pennsylvania, United States of America.
⁵ Department of Psychiatry, University of Pennsylvania, United States of America; Office of Mental Health and Suicide Prevention, Veterans Affairs, United States of America.
⁶ Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States of America; VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America.

PMID: 38735480
DOI: 10.1016/j.josat.2024.209400

Abstract

Introduction: Contingency management (CM) is one of the most effective interventions for substance use disorders (SUDs), including stimulant use disorder. In the United States, the Veterans Health Administration (VHA) led the largest-scale rollout of CM in the US to date, but little is known about characteristics of patients treated and CM clinical practices.

Methods: In this retrospective cohort study, we used VHA electronic health records data to descriptively examine CM treatment course (e.g., number of visits, time between visits, duration of treatment episode) and characteristics of patients receiving CM for SUDs from 2018 to 2022.

Results: From January 2018 to September 2022, 2844 patients received CM at 90 VA Health Systems (including 98 VA Medical Center, 7 community-based outpatient clinics, and 15 other sites). The median number of CM visits was 8 (mean = 10.17, SD = 8.12) visits over the course of 1.5 months (median = 45 days, mean = 57.46 days, SD = 62.65). The target substance was stimulants in 86.42 % of visits. Average age of patients was 52.29 years (SD = 12.10), with 55.06 % of patients experiencing homelessness or housing instability, and 97.50 % of patients diagnosed with more than one SUD. Compared to the year prior to the COVID-19 pandemic (03/2019-02/2020; mean = 957.33, SD = 157.71 visits/month), CM visits declined by 83.20 % in the year following the pandemic (03/2020-02/2021; mean = 160.83, SD = 164.14), and have yet to return to pre-pandemic levels.

Conclusions: The CM rollout has been markedly successful in the VHA, with adoption across multiple VHA sites within a complex patient population, indicating the potential for effective, more widespread CM implementation. At the same time, there was a considerable reduction in CM care during the COVID-19 pandemic and CM has not yet returned to pre-pandemic levels. Moreover, only a small minority of VA patients with stimulant use disorder have received CM. Given increasing rates of overdose, including stimulant-involved overdose, it is important to increase CM provision in VHA and non-VHA settings.