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The National Commission on Correctional Health Care (NCCHC) and 166 national organizations recently signed a letter to Senate leadership advocating for increased access to buprenorphine, an FDA-approved medication for opioid use disorder (OUD). They urged US Senate to pass the bipartisan 

Mainstreaming Addiction Treatment (MAT) Act

“In the midst of a deadly and accelerating overdose crisis, the MAT Act is a common-sense solution that will prevent overdoses, increase access to treatment, and reduce stigma,” the letter reads.

, along with methadone and extended-release naltrexone, is 1 of 3 medications currently approved by the US Food and Drug Administration (FDA) to treat OUD and is considered the “gold standard” treatment. It also keeps individuals with OUD from returning to illicit drug use—and to jail.

 severely hinders access to buprenorphine by preventing health care providers from prescribing it. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), only about 1 in 10 people with OUD receive medications for the condition because of the X-waiver. Furthermore, the Department of Health and Human Services claims that fully 40% of US counties do not have any health care providers who can prescribe buprenorphine.

If passed, the MAT Act will eliminate the X-waiver and make buprenorphine more available and accessible for Americans with OUD.

The letter was sent to Majority Leader Chuck Schumer, Minority Leader Mitch McConnell, Chair Patty Murray, and Ranking Member Richard Burr on August 31, Overdose Awareness Day. The letter can be found 

1. NCCHC Supports Access to MOUD. National Commission on Correctional Health Care. September 9, 2022. Accessed September 21, 2022. 

https://www.ncchc.org/ncchc-supports-access-to-moud/

2. The Mainstreaming Addiction Treatment Act (“MAT Act”, S. 445 / H.R. 1384). August 31, 2022. Accessed September 21, 2022. 

https://static1.squarespace.com/static/5eb15fa07d53aa0e85b448d7/t/6317704dfeb1183bfc5ada54/1662480461791/MAT+Act+(S+445)+-+167+Organizations+Submit+Letter+to+Senate+Leadership+Urging+Passage+with+Sept.+CR+(Aug22).pdf

The NCCHC and 166 national organizations recently signed a letter to Senate leadership advocating for increased access to buprenorphine. 

Advocating for Medication for Opioid Use Disorder

Tales From the Clinic: The Art of Psychiatry

, we visit the addiction clinic to discuss accidental overdose deaths. Although death by suicide is known to greatly impact psychiatrists, the impact of overdose deaths on physicians is not well studied. Despite the best efforts exerted in treatment, patients on medications for opioid use disorder may die of accidental overdoses on opioids, having misestimated their current opioid tolerance, or overdose on other substances such as sedatives/hypnotics and stimulants. This article is dedicated to 3 patients lost in this past year—AK, EG, and AW—with heartfelt wishes to their families.

“Ms Verona” was a 45-year-old female enrolled in an addictions treatment program and a mother of 7 children who struggled greatly with 

 and anxiety. She was motivated to stop her opioid use, as it was taking a toll on her health and her family. Ms Verona’s children would sense their mother’s lack of engagement with them, as she was constantly preoccupied with how to mitigate the inevitable opioid withdrawal symptoms. She was a good candidate for buprenorphine therapy, as she met criteria for severe opioid use disorder, and she preferred partial agonist therapy as opposed to naltrexone and methadone. Ms Verona was inducted onto buprenorphine, and her dose subsequently increased to 16 mg total daily in order to adequately address opioid cravings.

As treatment progressed, Ms Verona displayed a chronic tendency to arrive more than an hour late to appointments. Despite her tardiness, she would plead to still be seen, often citing traffic or lack of childcare arrangements. The psychiatrist, Dr Smith, would attempt to be flexible, given the understanding of treatment barriers stemming from social determinants of health, as well as recognizing the time-sensitive nature of 

 refills; however, these accommodations were placing Dr Smith and the treatment team under time constraints in a busy clinic. Such accommodation would either cause the psychiatrist to be late for other appointments, or it would lead to the appointment with Ms Verona feeling rushed. After the patient was accommodated for lateness over a few visits, Dr Smith became aware of his growing countertransference toward Ms Verona.

 (ADHD) may have been affecting her presentation. Ms Verona was noticeably circumstantial during sessions and required frequent redirection. She also described a childhood history with symptoms of difficulty concentrating. It was also explored whether her lateness was a manifestation of her inability to focus, organize, and prioritize. She often talked about having gotten Adderall “but not recently, doctor; I know you would not let me.” Dr Smith worked with Ms Verona in problem-solving therapy to help reduce treatment-interfering behaviors and promote punctuality. Ms Verona was also started on bupropion to target ongoing depressive symptoms and simultaneously provide a nonnarcotic option to treat attention-deficit symptoms. There was a concern for her using stimulants or other substances between appointments. Despite these treatment approaches, tardiness to her appointments continued and she appeared even sedated at times, despite negative urine drug screens.

One day, Ms Verona was more than an hour late. She was informed that she could not be seen and had to be rescheduled. She was visibly upset and opted, likely due to splitting defense mechanism, to reschedule to see a different provider in the clinic when this boundary was set. After this, Ms Verona ended up seeing a different psychiatrist for the next 6 months.

One day, Ms Verona’s former psychiatrist met with one of his active patients, Mr Kim, and the following dialog ensued:

Mr Kim: “One of my friends passed away, and I’m attending the funeral. I think you actually used to treat her before.”

Dr Smith: (Somewhat surprised) “I’m sorry to hear about the loss of your friend.”

Mr Kim: “Yea, it was sad… she (Ms Verona) said she used to see you. She was still on buprenorphine, but the suspicion was that she was taking alprazolam the whole time she was in treatment and did not tell anybody, and it is a suspected unintentional overdose. I used to see her all the time, and she would be nodding off. You didn’t hear about this?”

How Do Physicians Cope With Patient Suicide or Overdose?

Dealing with the loss of a patient due to suicide or 

 has a significant impact on the treating physician and is not often talked about. There are a variety of factors that determine how a psychiatrist will be impacted in such a situation. Younger clinicians and trainees are often affected more adversely, as they have not been exposed to the scenario and may feel more vulnerable in terms of their experience and knowledge base.

 According to literature, about 25% to 60% of psychiatrists will report having a patient who died by suicide during their career.

 The number of physicians who lose patients to overdose is not known. However, the rate of overdoses involving opioids jumped by 200% from 2000 to 2014, and between 2013 to 2019, the synthetic opioid-involved death rate increased 1040%.

 The sheer magnitude of these numbers suggest that most physicians dealing with addiction must have been exposed to patient death by overdose.

With these figures in mind, as well as the significant amount of perceived stigma and guilt surrounding disclosure of these outcomes, and with the fear of lawsuits that may occur in these situations, the overall emotional toll it can have on a clinician can be quite intense. The psychiatrist in this scenario was flooded with feelings of guilt related to potential responsibility for the outcome. In addition, there is a possibility of additional emotions of anger toward the patient who was already deceased. We hear team members often saying, “Oh, but they were doing so well,” or “So sad—they stayed off heroin but could not keep off meth.”

When one is processing the suicide of a patient, one should be mindful to not isolate oneself. Efforts should be conducted to reach out to colleagues, as it is likely they would have dealt with similar experiences in the past and can normalize and validate the experience. Discussion of experiences and coping mechanisms may have therapeutic effects for physicians going through such experiences. Clinicians, as part of an organization or group practice, can utilize case conferences—a pragmatic, systematic, and therapeutic approach to exploring the case outcome in more detail. Risk management reviews or meetings could help with apprehension about any impending or perceived lawsuits. This is especially important for clinicians in private practice, who may be more isolated given their work environment structure. The message we need to hear is that a patient loss does not undo or discard the multitude of meaningful life-changing and life-preserving work done with both living and deceased patients. Support and validation go a long way in reminding us why we do what we do.

How Can We Promote Honesty About Recurrence of Substance Use?

 (SUDs), it may be helpful to try to acknowledge and normalize the fear of disclosure of relapses, as well as to emphasize the importance of honesty in recovery from the very beginning of treatment. Although feelings of guilt and internal shame are common, they are not easy to talk about for patients. Whereas the patient may perceive recurrence of use as “starting from scratch,” the clinician can reframe a recurrence of use as a learning point and a way to troubleshoot the circumstances surrounding the use. Being too harsh or strict with the patient may backfire, lead to sustain-talk, erode the therapeutic alliance, and provoke even more feelings of guilt or shame. Relapses sometimes occur because being off substances uncovers a cooccurring mental illness, or because of stress in real life, to which patients with SUDs are more susceptible.

By definition, addiction is a relapsing and remitting illness. Similarly, depression is also a relapsing and remitting illness, but no one benefits from being kicked out of treatment for having a recurrent depressive episode. Thus, patients should not be terminated from treatment for recurrence of use as if often done—they should actually receive more intense care when in a greater time of need. Although recurrence of use might have clinical significance on modifying treatment plans, patients should be informed that using is only a setback if they do not seek further treatment to address it. Patients may be relieved if asked about any internalized and unfounded fear they may have about being terminated from treatment if they divulge recurrence of use.

If a patient states that they are feeling punished for having more frequent visits during recurrence of use, it may help to first empathize with concerns and then reframe the change in treatment plans as a goal toward well-being as opposed to punishment. Utilization of motivational interviewing may be helpful if the patient is still ambivalent about recovery. It is crucial for a provider to have a nonjudgmental approach toward relapses, both past and present. Subconscious criticism, even in the form of subtle body language, can promote denial or reliance on more primitive defense mechanisms in a patient and lead to poorer treatment outcomes, especially if the patient has a harsh superego or difficulty with trusting others.

Previous recurrence of use may lead some patients to think they are a lost cause and lack the willpower and discipline that might be needed for recovery. Internalizing this belief is characteristic of patients with complicated SUD histories. It is important to modify a patient's internal process and remind them that it is not solely willpower or motivation that determines the ability to improve, but also coping and relapse prevention skills, which can be taught through any type of therapy, but especially cognitive-behavioral therapy.

How Do You Find a Balance of Boundaries With the Patient?

Finding the right balance in setting boundaries can be a challenge in a busy schedule, and it requires being mindful of the patient’s perspective while simultaneously acknowledging a patient’s subconscious need for structure to meet treatment goals.

It was important in Ms Verona’s case to validate her struggle with circumstances in her life. After all, the social determinants of health (ie, social, behavioral, and environmental factors) are a predominant influence on treatment outcomes.

 In addition, it is important to acknowledge the role of untreated ADHD (like in Ms Verona’s case) in reducing recovery success.

 At the same time, the medical ethics concept of justice should also be considered. Although justice in this situation may apply to acknowledging Ms Verona’s barriers to care, it may also expose the caveats of this approach since other waiting patients were affected by the patient’s tardiness. A provider is tasked with collectively benefiting all of their patients, treating all with equity and making accommodations where necessary, and without putting 1 patient at risk at expense of another.

In this case, did the boundary-setting change the course of Ms Verona’s clinical treatment? Yes. Would it have been better without it? Not necessarily. Part of the treatment frame is for both physician and patient to be accessible, at a mutually convenient time. Reneging on appropriate boundaries may distort or enable certain expectations of the patient, which can undermine the patient’s perceived responsibility in treatment, reduce the patient’s ability to problem-solve, and lead to the approach that the physician drives the treatment, instead of the dyad making a shared and mutual responsibility. The physician can communicate these messages with empathy and genuine concern in the hopes that the patient will adopt that responsibility. In the case of mitigating overdoses—a poorly understood field—it is essential to know if the patient is using secondary substances outside the opioid being the target of treatment. Secondary substance use significantly increases risk of overdose.

From a larger perspective, a physician’s taking of the alternate approach can contribute to burnout and distress, and potentially adversely affecting outcomes for the other patients. Thus, boundaries can be a mechanism of protection for both the patient and the physician.

Triple Threat of Death: Suicide, Unintentional Overdoses, and COVID-19

Although there is growing literature about how patient 

 can impact physicians, there is a lack of data particularly on how substance overdose may impact a physician’s mental well-being. The lack of data on overdoses and how to cope with them is further compounded by the problem that busy schedules or shift work may inadvertently reduce the physician’s ability to access resources for support while the physician also thinks that “I must carry on.”

In addition, it would be important to differentiate how suicide and overdose are not necessarily the same. Overdoses are not always done with the intention of taking one’s life. In fact, most overdoses are accidental, but ultimately occur due to overestimated tolerance, unknown ingestion, or increasing amounts taken during stressful/inciting events. In 2014, only 12% of drug overdoses were intentional according to the Centers for Disease Control and Prevention (CDC).

 Although the percentage of intentional overdoses is the minority, another thing to consider is whether clinician perception of guilt is more intense if the overdose is intentional. A physician can be vulnerable to guilt for not effectively being able to treat a patient’s addiction or form a close enough relationship to know of their usage—even if the patient knowingly did not disclose use. Then there is the question of whether some severe addictive disorders could be considered like a “terminal illness,” where a clinician may feel that no matter how many treatment approaches have been tried, it is a matter of “not if, but when” in regards to either overdose or a chronic decompensation toward death.

Although we have seen that doctors who hear about their patients overdosing may actually reduce the amount of their opioid prescribing,

 mental health clinicians may be affected in a somewhat different capacity, as their role is also tied inevitably into also treating comorbid depression, anxiety, and suicidal ideation. The COVID-19 pandemic has further exacerbated this problem, as the estimated prevalence of suicidal ideation today is higher in comparison to the prevalence prepandemic.

If a clinician’s natural tendency to do more and become more hypervigilant following the loss of a patient, it is noteworthy to mention that most physicians suffer from burnout at one point in their life. A cross-sectional study was able to demonstrate that increases in suicidal ideation endorsement were significantly correlated with physician burnout rates.

 Considering that overdoses can be as lethal as suicides, it would be a fair but unproven assumption that it would also similarly contribute to physician burnout.

We believe further research is necessary to understand the many ways in which patient overdoses are affecting physicians, as well as developing more efficient strategies and support for dealing with the aftermath. 

is an associate professor and addiction-boarded faculty at Harris Health System in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. He is Director of Harris Health Substance Addiction Treatment Program and Associate Program Director for Baylor College of Medicine Addiction Fellowship Program. 

is currently a resident in psychiatry at Baylor College of Medicine. 

 is an associate professor in the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, as well as the Ben Taub Adult Outpatient Services director and the medical director of the Stabilization, Treatment & Rehabilitation (STAR) Program for Psychosis, also at Baylor College of Medicine. She also serves on the 

1. Ruskin R, Sakinofsky I, Bagby RM, et al. 

Impact of patient suicide on psychiatrists and psychiatric trainees.

2. Plakun EM, Tillman JG. The impact of patient suicide on clinicians. 

https://www.psychiatrictimes.com/view/impact-patient-suicide-clinicians

3. Rudd RA, Aleshire N, Zibbell JE, Gladden M. Increases in drug and opioid overdose deaths - United States, 2000–2014. Centers for Disease Control and Prevention. Accessed September 12, 2022. 

https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm

Trends and Geographic Patterns in Drug and Synthetic Opioid Overdose Deaths - United States, 2013-2019.

Relapse prevention and the five rules of recovery.

6. Williams N, Bossert N, Chen Y, et al. 

Influence of social determinants of health and substance use characteristics on persons who use drugs pursuit of care for hepatitis C virus infection.

Adult attention-deficit hyperactivity disorders and its correlates in patients with opioid dependence: an exploratory study.

8. Austin AE, Proescholdbell SK, Creppage KE, Asbun A. 

Characteristics of self-inflicted drug overdose deaths in North Carolina.

Opioid prescribing decreases after learning of a patient's fatal overdose.

Suicide, self-harm and suicidal ideation during COVID-19: a systematic review.

11. Menon NK, Shanafelt TD, Sinsky CA, et al. 

Association of physician burnout with suicidal ideation and medical errors.

My Patient Overdosed and Now I Feel Guilty… 

Contingency management (CM) is an effective behavior change technique commonly used to treat substance use disorders (SUDs). CM is one of the most effective behavioral interventions for initiating and maintaining abstinence from most types of commonly used drugs and alcohol.

CM-based treatments for SUD originate in basic behavioral science, namely the operant conditioning literature. Operant conditioning is a type of learning in which behavior is modified or maintained through the consequences it produces. In the context of SUD treatment, CM typically modifies substance use by delivering tangible, positive reinforcers (eg, prizes, vouchers, or monetary reinforcement) in exchange for evidence of the performance of the targeted behavior, such as the submission of a drug-negative urine sample.

Several meta-analyses have found CM to be among the most effective interventions for SUDs, in addition to being effective at promoting treatment retention and medication adherence.

 Moreover, clinical trials have consistently shown that CM is also a cost-effective technique.

 Indeed, studies conducted over the past 30 years have found that CM can be used to promote abstinence from substances including cocaine,

 Further, the aforementioned meta-analyses have also found CM to be effective among highly diverse populations, including pregnant women, adolescents, veterans of war, individuals with serious mental illness, unhoused individuals, those from racial and ethnic minority backgrounds, LGBTQ+ community members, and individuals with HIV and hepatitis. Notably, CM’s consistent effects during treatment across diverse trials may be indicative of CM’s ability to improve long-term treatment outcomes, in light of evidence indicating that longer abstinence during treatment is associated with better long-term treatment outcomes.

Research results suggest that CM must have 3 key ingredients to optimize utility (

). The first is the frequency with which the reinforcer is delivered. Studies suggest that reinforcers should be provided at least twice weekly to enhance the efficacy of CM for SUD management.

 The second ingredient is the immediacy of the reinforcer, or the exchange delay (ie, the shorter the period between the performance of the targeted behavior and delivery of the reinforcer, the greater likelihood of behavioral change).

 The third ingredient is the magnitude of the reinforcer. Although higher-magnitude reinforcers increase the chances of behavior change, they also increase the cost of the CM intervention.

 In at least 1 study, however, it is notable that the average reinforcer actually costs around 40% of the maximum amount.

Although more than 30 years of research evidence collected throughout the world supports the effectiveness of CM, widescale implementation of CM in clinical care has been limited, particularly due to funding and regulatory issues. While reinforcers are commonly used in health care to increase a targeted behavior (eg, gift cards for completing a health assessment), the recommended frequency (twice weekly) and magnitude of CM reinforcers is unique. Historically, funding for CM programs has relied on grants, donations, and funding from federal sources. Currently, the Substance Use and Mental Health Services Administration (SAMHSA) allows grantees to spend up to $75 per patient for CM incentives, although there is limited evidence for the efficacy of this amount.

In addition to funding, the prohibition against the use of reinforcers with Medicaid and Medicare patients through antikickback regulations, has produced a regulatory roadblock. Until recently, it was unclear if CM violated these prohibitions; however, in 2019, the Office of the Inspector General published a document providing guidance on how CM can be used within specific parameters. This has led to increased interest in CM, with state-level implementation underway in Montana, Washington, and California. California received a Medicaid demonstration waiver for the state’s CM pilot, planned to cost more than $50 million, that will include as many as 200 sites. Importantly, these implementations of CM include models that are based on research evidence with funding for reinforcers varying from $325 to $599. These policy changes represent a pivotal modification that may provide a path for nationwide dissemination and implementation of one of the most effective, yet underutilized, interventions for SUDs.

One important challenge for CM implementation includes philosophical and/or moral concerns about “paying substance users” to stop using drugs; another is the belief that the effect may not persist after CM is concluded.

 Implementation research has shown that provider resistance can be allayed with education and training and, more importantly, from observing increased patient engagement and other positive treatment outcomes.

 In fact, after being exposed to CM in the workplace, previously skeptical clinicians noticed that CM had not only improved response to treatment, but also helped improve therapeutic alliances with patients and increased practitioners’ job satisfaction.

 In other words, training and exposing practitioners to CM in the workplace is effective in overturning philosophical and moral concerns.

A burgeoning science is focused on CM implementation, and lessons learned from the Veterans Administration CM program and other state-level implementations can provide guidance to clinicians hoping to implement CM.

 Clinicians must secure funding for an adequate dose (eg, reinforcer monetary value) of CM. Programs must identify the clinical staff members who will implement the program. We have found that nurses, care managers, substance use disorder counselors, and peer support specialists are well positioned to conduct CM, depending on the clinical setting required to effectively deliver CM.

 CM can be integrated into other treatment modalities or delivered separately by nonlicensed staff, as long as the CM provider has been adequately trained in the use of CM, with emphasis on administering urine tests, tracking reinforcer distribution, and maintaining a positive, nonjudgmental tone with patients. Coaching sessions and fidelity monitoring are also important elements to ensure the success of a CM program.

Although evidence indicates that CM is associated with increased attendance, use of reinforcers to increase revenue from billable encounters is prohibited and should be avoided.

Another tip includes using an electronic CM platform system to calculate and monitor reinforcer magnitude and distribution. CM often incorporates a reinforcement schedule that includes escalating reinforcement magnitude as increased durations of abstinence are achieved, as well as loss and recovery of the escalation bonus if and when a return to use and a return to sustained abstinence occur (known as “reset” and “recovery”).

 Although adding these features to a CM program increases the complexity, the therapeutic benefit is well documented and can be executed consistently by using an electronic CM platform. Notably, in various stages of development are a number of phone apps (with accompanying web-based management portals) that could help clinicians, staff, and patients deliver and receive reinforcers more readily; such a system would reduce staff burden for tracking and calculating reinforcer values.

Lastly, CM can represent a paradigm shift for many systems and clinicians who have been required to deliver punitive consequences when substance use occurs. When objective evidence of use is recorded, clinicians focus on strength-based feedback, such as praise for attendance, and encouragement that the next opportunity for reinforcement will occur again in just a few days. They can further engage the patient by discussing what reinforcer they are excited to work toward, orienting the patient toward the reinforcement inherent in CM.

Obtaining initial training and ongoing technical support from CM experts is key to successful implementation and compliance with Office of Inspector General regulations. Several teams have developed extensive training materials that provide best-practice guidance on CM implementation, including didactic trainings, ongoing coaching, and technical support. Driven by the escalating prevalence of methamphetamine use and recent changes in federal policy, the rapid dissemination of CM can bring this feasible, strength-based approach to millions of people affected by stimulant use disorders throughout the United States—if the unique challenges that the method presents can be overcome.

One of the biggest barriers to effectively utilizing CM in real-world treatment situations has been the lack of adequate public policies to finance CM interventions. Convincing policy makers why CM should be more broadly integrated into drug and alcohol use disorder treatment has proven difficult. Nonetheless, CM interventions are being applied in a variety of clinical practices throughout the United States and the United Kingdom.

 For example, CM is being increasingly used as the SUD treatment of choice within the Veterans Administration system in the United States.

 Since 2011, the Veterans Administration has successfully integrated CM into 70 of its intensive outpatient substance abuse treatment clinics for veterans.

 At the same time, the National Health Service in the United Kingdom has also implemented CM into its SUD treatment guidelines, and CM is currently being offered at several treatment facilities.

Investigations of CM dissemination are currently underway, including studies designed to better understand systemic and clinician variables that impede or facilitate CM implementation.

 One of the most important pieces of evidence that has emerged in the CM literature, especially in light of the political challenges, is that CM is a cost-effective treatment option.

 This should lead to greater adoption across the US health care system, which is in desperate search of economically viable alternatives in the face of scarce and diminishing resources.

A final crucial aspect of CM that makes it amenable to several different adaptations and optimizations is that CM produces virtually no adverse events and can be combined with virtually any other form of treatment.

 This makes CM both effective and amenable to ongoing experimentation and optimization efforts across a diverse array of settings and populations that will only be leveraged further by ongoing technological, psychosocial, and pharmacological developments.

is director of the Program of Excellence in Addictions Research; assistant dean, research; and a professor at the Washington State University (WSU) Elson S. Floyd College of Medicine. He is also associate director of research for analytics and discovery at the Providence Medical Research Center and head and principal investigator of the Analytics and Psychopharmacology Laboratory.

is an assistant research professor at WSU Elson S. Floyd College of Medicine.

 is a professor in the Department of Community and Behavioral Health at WSU Elson S. Floyd College of Medicine.

is a professor and vice dean for research at WSU Elson S. Floyd College of Medicine.

Contingency management. Incentives for sobriety. 

2. Prendergast M, Podus D, Finney J, et al. 

Contingency management for treatment of substance use disorders: a meta-analysis.

3. Dutra L, Stathopoulou G, Basden SL, et al. 

A meta-analytic review of psychosocial interventions for substance use disorders.

4. Plebani Lussier J, Heil SH, Mongeon JA, et al. 

A meta-analysis of voucher-based reinforcement therapy for substance use disorders.

5. Peirce JM, Petry NM, Stitzer ML, et al. 

Effects of lower-cost incentives on stimulant abstinence in methadone maintenance treatment: a National Drug Abuse Treatment Clinical Trials Network study.

6. Murphy SM, McDonell MG, McPherson S, et al. 

An economic evaluation of a contingency-management intervention for stimulant use among community mental health patients with serious mental illness.

The cost-effectiveness of prize-based and voucher-based contingency management in a population of cocaine- or opioid-dependent outpatients.

Clinic variation in the cost-effectiveness of contingency management.

9. Higgins ST, Budney AJ, Bickel WK, et al. 

Incentives improve outcome in outpatient behavioral treatment of cocaine dependence.

Contingency management: an evidence-based component of methamphetamine use disorder treatments.

11. Stitzer ML, Rand CS, Bigelow GE, Mead AM. 

Contingent payment procedures for smoking reduction and cessation.

12. McDonell M, Leickly E, McPherson S, et al. 

A randomized controlled trial of ethyl glucuronide-based contingency management for outpatients with co-occurring alcohol use disorders and serious mental illness.

13. Robles E, Stitzer ML, Strain EC, et al. 

Voucher-based reinforcement of opiate abstinence during methadone detoxification

14. Kadden RM, Litt MD, Kabela-Cormier E, Petry NM. 

Abstinence rates following behavioral treatments for marijuana dependence.

Reinforcement of drug abstinence: a behavioral approach to drug abuse treatment.

16. Weisner C, Ray GT, Mertens JR, et al. 

Short-term alcohol and drug treatment outcomes predict long-term outcome.

One year follow up of disulfiram and psychotherapy for cocaine alcohol users: sustained effects of treatment.

18. McPherson SM, Burduli E, Smith CL, et al. 

A review of contingency management for the treatment of substance-use disorders: adaptation for underserved populations, use of experimental technologies, and personalized optimization strategies.

The influence of exchange delays on cigarette versus money choice: a laboratory analog of voucher-based reinforcement therapy.

20. Packer RR, Howell DN, McPherson S, Roll JM. 

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

21. Petry NM, Alessi SM, Barry D, Carroll KM. 

Standard magnitude prize reinforcers can be as efficacious as larger magnitude reinforcers in cocaine-dependent methadone patients.

Contingency management treatments: controversies and challenges.

23. Oluwoye O, Kriegel L, Alcover KC, et al. 

The dissemination and implementation of contingency management for substance use disorders: a systematic review.

24. Kellogg SH, Burns M, Coleman P, et al. 

Something of value: the introduction of contingency management interventions into the New York City Health and Hospital Addiction Treatment Service.

Considerations for implementing contingency management in substance abuse treatment clinics: the Veterans Affairs Initiative as a model.

26. Roll JM, Higgins ST, Steingard S, McGinley M. 

Use of monetary reinforcement to reduce the cigarette smoking of persons with schizophrenia: a feasibility study.

27. Pilling S, Strang J, Gerada C; NICE. 

Psychosocial interventions and opioid detoxification for drug misuse: summary of NICE guidance.

28. Petry NM, DePhilippis D, Rash CJ, et al. 

Nationwide dissemination of contingency management: the Veterans Administration initiative.

29. Petry NM, Roll JM, Rounsaville BJ, et al. 

Serious adverse events in randomized psychosocial treatment studies: safety or arbitrary edicts?

Contingency management is an effective behavior change technique commonly used to treat substance use disorders. 

Contingency Management Is a Powerful Clinical Tool for Treating Substance Use Research Evidence and New Practice Guidelines for Use

Suicide Prevention Week is September 4-10. This week, we at 

 want to highlight how best to support patients, friends, family, and anyone who might be having suicidal thoughts. We sat down with Manish Mishra, MBBS, the Chief Medical Officer of the Texas Healthcare and Diagnostic Center, to discuss.

PT: What does research say the role of alcohol/substances is in suicide?

Research on the link between alcohol and substances in 

 has been driven by the prevalent involvement of alcohol and substance abuse in suicide cases. There is a multitude of factors to be considered when examining the correlation between substance abuse and suicide as independent variables with an anecdotally strong interdependent relationship.

Historical data used to inform research suggests that across general populations, all types of 

 and substance use disorders are associated with increased risk for suicidal behaviors, including ideations, attempts, and fatalities. Substance abuse involving alcohol and illegal or prescription drugs is a much higher risk factor for suicidal mortality.

One of the reasons why alcohol and drug abuse is so strongly associated with suicide has to do with the psychological and psychosocial outcomes of untreated alcohol and drug dependence. Substance abuse and 

 often result in social isolation and marginalization, disruptions and conflicts in personal relationships, and aggravation of psychiatric symptoms such as depression and anxiety, all of which contribute to suicidal behaviors.

Another strong correlation is that alcohol and mind-altering substances are used as means of self-medication to cope with untreated mental health disorders, the symptoms of which are reciprocally exacerbated by substances. This causes a spiral effect of emotional decline and mental impairment that occurs with chronic alcohol and drug use and intoxication.

PT: People with alcohol use disorder are up 120 times more likely to commit suicide than those who are not dependent on alcohol.

 Psychoeducation on substance use and suicide for patients and their families seems to be more important than ever. In your experience, what are the best strategies for clinicians to broach this subject?

The abuse of alcohol or drugs is one of the most common risk factors for suicidal behavior. Although this is a difficult way of intervention and requires significant involvement and commitment from both patient and family members, psychoeducation has been proven to be effective in treating mental health disorders and managing the prognosis in the long run. Different strategies are used by clinicians to assess and manage symptoms and avoid remission. Some of the strategies commonly used are as follows:

1) Brief intervention to reduce suicidal behavior

These types of interventions are mostly used with postdischarge patients for follow-up. It can include postcards, letters, or even a phone call. It helps in reducing the patient’s sense of isolation contributing to decreasing future suicidal behaviors.

Brief motivational enhancement techniques to increase patients’ willingness to pursue treatment and overcome obstacles may also be an effective engagement approach. Motivational interviewing is focused on helping people work through their ambivalence about changing their behavior and explores patients’ concerns and beliefs about change.

Most important to motivational interviewing is to engage patients in a discussion that is noncoercive and nonthreatening, and to create an atmosphere that is empathic, nonjudgmental, and supportive of the patients’ concerns. Open-ended questions, affirmations, reflective listening, and summarizing are the cornerstones of this approach.

Early intervention after a suicide attempt is vital because the 3-month period after an initial attempt is when an individual is at the highest risk of additional suicidal behavior. Yet those who attempt suicide have been found to be very difficult to engage in treatment. These interventions can include outpatient or inpatient treatment depending upon the severity. Postcards and phone calls can both be used for the outpatient approach, whereas motivational interviewing has been more effective with inpatient treatment.

This strategy provides for participation in activities that exclude alcohol, tobacco, and other drug use. Constructive and healthy activities offset the attraction to, or otherwise meet the needs usually filled by, alcohol, tobacco, and other drug use, which ultimately reduces suicidal tendencies.

PT: How can mental health clinicians improve the conversation surrounding this issue beyond the office?

Part of preventing suicide is raising awareness around the topic and bringing it into conversations. The topic of suicide is surrounded by secrecy, which is one of the barriers to getting treatment for people who need it. Mental health clinicians can play a part in dispelling the secrecy and stigma around suicide, and increase social empathy by discussing it as often and openly as other mental health issues are commonly verbalized.

As subject matter experts in their fields, mental health professionals have the capacity and agency to shed light on how prevalent suicidal behaviors actually are among general populations, and help to destigmatize suicide and associated mental health disorders. This stigma is a big reason why many people do not seek help for treatable mental health conditions and preventable tragedies.

PT: Global alcohol consumption has increased in recent decades, and is linked with more than 60 types of diseases and injuries.

 Should clinicians be talking to patients about healthy alcohol consumption levels, or even abstinence?

Many people who drink to excess would not categorize themselves as being alcoholics or having an 

. Many would also not consider broaching the subject to a clinician if they think it would be irrelevant, or they do not want to be labeled as someone with an alcohol problem. Clinicians are responsible for informing their patients of the dangers and risks associated with excessive alcohol consumption, including binge drinking and chronic intoxication, as a preventative protocol—not only as a response to an immediate health concern.

Even if someone does not fit all the criteria of an alcohol use disorder, they can still be at risk of developing alcohol dependence, putting their physical and mental health at risk due to alcohol abuse. Addressing alcoholism in a clinical setting and providing recommendations about setting limits or considering abstinence can help people make informed and conscientious decisions about their alcohol consumption.

PT: When devising a safety plan with patients, how do you discuss substance use?

Safety planning is a brief intervention to help individuals survive suicidal crises by having them develop a set of steps to reduce the likelihood of engaging in suicidal behavior. Safety planning is frequently included as an element in cognitive behavioral interventions for suicide prevention and can also be used as a brief standalone intervention, typically paired with a referral for mental health treatment.

The role of the substance abuse treatment program is to provide safety for its clients: recognizing suicidality when it appears, having policies and procedures for addressing suicidal thoughts and behaviors, and ensuring that treatment for the substance use disorder is not lost in the suicidal crisis. A Treatment Improvement Protocol (TIP) developed a protocol, with the acronym GATE for discussing suicidality in patients with substance abuse. It is comprised of the following steps:

Suicide Prevention Week is September 4-10. Are you ready? 

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