We Must Do Better on Implementing Evidence-Based Treatments for Substance Use Disorders

In this issue of the Journal, Coughlin et al. report examining longer-term health outcomes associated with contingency management (CM) treatment for stimulant use disorder (StUD) (1). CM is an efficacious behavior-change intervention for substance use disorders (SUDs) and other behavioral health conditions wherein patients receive material incentives (e.g., vouchers exchangeable for retail items) contingent on objectively verified behavior change (2). When used to treat SUDs as in Couglin et al. and other studies discussed below, the contingency typically involves patients receiving modest financial incentives contingent on biochemically verified abstinence from recent substance use.

We want to first commend Coughlin and colleagues on this interesting, innovative, and potentially impactful study indicating that CM treatment for StUD is associated with reductions in all-cause mortality in the year following treatment entry. Kudos also to the U.S. Veterans Health Association (VHA) for a) implementing CM when other U.S. healthcare systems failed to do so despite extensive evidence supporting its efficacy and the absence of any evidence-based alternative treatment and b) their investment in creating an electronic health record system that can support innovative research like the Coughlin et al. study (1, 3). This well-deserved praise for the VHA notwithstanding, we were a tad surprised to see how few of the many VHA patients who met diagnostic criteria for StUD in the present study received CM treatment. We hope the present study and its promising results drive greater utilization of CM for StUD within and beyond the VHA system.

Second, while we must await future prospective studies to know with confidence whether there is a causal relationship between CM treatment and reductions in all-cause mortality as reported by Coughlin and colleagues, it is certainly plausible given current knowledge. That is, CM has been demonstrated to reduce stimulant use for a year or more beyond treatment termination (4, 5) and thus has potential to increase longevity directly by decreasing drug-related deaths or indirectly by enhancing patient engagement with the healthcare system. As the patient characteristics in the present study well illustrate, co-morbidities are the norm when treating StUD and other substance use disorders (SUDs). Engaging patients in effective SUD treatment provides important opportunities to treat these other conditions. In the Coughlin et al. study, CM treatment was associated with a greater likelihood of receiving inpatient psychiatric treatment which very plausibly may have been a difference maker in terms of CM-treated patients surviving the next year. There is no question that chronic stimulant use is often highly destabilizing. Even short-term abstinence can provide opportunities for patients to attend to other serious health problems including other psychiatric conditions that are often either simply ignored during active drug use or at a minimum are difficult to properly diagnose and treat.

Third, while prospective controlled trials provide the most compelling data and should be pursued in following up the present results, there is a roll for additional observational research that might be helpful. For example, one might look for evidence of dose-response relationships between duration of CM treatment or continuous stimulant abstinence achieved and outcomes. Another possibility is to examine whether the decreases in use of CM treatment for StUD since the COVID-related disruptions that the authors mentioned are associated with increases in all-cause mortality rates, decreases in hospitalization rates for psychiatric conditions, or other relevant outcomes. In brief, this study has produced very interesting findings, and we encourage the authors and other researchers to be resourceful and multi-faceted in fleshing them out.

Fourth, as noted by Coughlin and colleagues, the examination of CM and all-cause mortality is timely considering the growing role of stimulants in overdose deaths. In what has come to be known as the fourth wave of the overdose crisis, individuals for whom stimulants are their preferred drug are among those with the highest risk for overdose due to potentially unintentional exposure to fentanyl through an adulterated drug supply, limited-to-no tolerance to fentanyl, and lower likelihood of being prepared to use practices to reduce the risk of an opioid overdose (e.g., fentanyl test strips, carrying naloxone) (6). In these situations, the toxicology report from the fatal overdose may indicate both stimulant and fentanyl involvement, yet there was never an intention to use fentanyl. Relatedly, with the focus on all-cause mortality, we believe it is important to highlight the often underrecognized adverse health effects of chronic stimulant use beyond a fatal overdose that increase risk for premature death. Compared to a fatal overdose where effects are acute and immediate, many of the health effects from chronic stimulant use are delayed (e.g., heart disease), and the role of stimulant use often missed or not discussed as a contributor to the premature death. Examining all-cause mortality is an important approach to illuminating these longer-term health effects associated with chronic stimulant use.

Fifth, we want to underscore the fundamental importance of providing evidence-based treatment for SUDs. Despite considerable recent progress in recognizing SUDs as medical disorders that warrant evidence-based treatment just like any other medical disorder and evidence that treating them is often cost-effective, it remains the case that most individuals with SUDs in the U.S. are not receiving treatment. For example, among individuals aged 12 years and older who met criteria for having a past year substance use disorder in the 2023 U.S. National Survey on Drug Use, only 23.6% received substance use treatment in the past year (7). SUDs are without question a major contributor to chronic disease and premature death (2). SUDs are also an important contributor to the shockingly poor relative status of U.S. population health compared to other developed nations despite spending orders of magnitude more on healthcare (2, 8). The seminal randomized clinical trials supporting the efficacy of CM for treating StUD were reported in the 1990s (9, 10). If we are to improve U.S. population health including longevity, we must do better than taking 3+ decades to implement new evidence-based SUD treatments into routine clinical care.

Lastly, we would be remiss if we did not take this opportunity to draw attention to perinatal smoking as another relatively treatment-recalcitrant condition for which there is an abundance of empirical evidence at the level of randomized clinical trials and meta-analyses supporting the efficacy and cost-effectiveness of CM (11–13). CM produces late-pregnancy smoking abstinence rates that are orders-of-magnitude better than current best-practices for treating this problem and cost-effective (14, 15). Yet, to our knowledge, CM is not being used anywhere in the U.S. including the VHA system. This is a serious concern, as smoking during pregnancy is the leading cause of poor pregnancy outcomes in the U.S. and other developed countries, increasing risk for small-for-gestational age deliveries, sudden unexpected infant death, and other serious adverse infant and maternal outcomes. The evidence supporting CM’s effectiveness was sufficiently compelling for the United Kingdom to move forward in 2024 with national implementation of CM treatment for perinatal smoking cessation (16). Yet, despite the passage of 2+ decades since publication of the seminal CM trials on perinatal smoking (16, 17), trials that were conducted here in the U.S., we know of no U.S. state or national efforts to implement CM treatment for perinatal smoking. Again, we need to do considerably better with timely implementation of evidence-based treatments for SUDs if we are going to reduce their terrible adverse health effects and improve the unsettling status of U.S. population health (8).