AN ACUTE CARE CONTINGENCY MANAGEMENT PROGRAM FOR THE TREATMENT OF STIMULANT USE DISORDER: A CASE REPORT

Abstract

Background:

Illicit stimulants such as crystal methamphetamine and cocaine are a rising cause of morbidity and mortality in North America. Unfortunately, there are few evidence-based approaches for the management of stimulant use disorder. Contingency management programs are currently the best evidenced treatment strategy, designed to reward behavior change and offer competing reinforcers toward the goal of reducing substance use, but these programs are often difficult to access. Given that it is well understood that hospitalization presents a valuable opportunity for the initiation of treatment for a variety of substance use disorders, the adaptation of contingency management programs to an acute medicine inpatient setting is a potentially viable option to improve care, and to increase access to effective treatment for stimulant use disorders.

Case Summary:

We present a case outlining the clinical care of a complex medical patient admitted with osteomyelitis, whose course in hospital changed significantly upon enrollment in a pilot contingency management program in an urban hospital in Canada.

Discussion:

This case illustrates how effective treatment programs can be adapted as needed for use in novel settings, especially where current options are inaccessible, inadequate, or ineffective.

INTRODUCTION

Stimulant use disorder is a rising cause of morbidity and mortality in North America, contributing to record levels of hospitalizations and overdose deaths (Winkelman et al., 2018; Kariisa et al., 2019). Acute admission to hospital represents an opportunity to help engage patients with substance use disorders in treatment, and the positive impacts of inpatient interventions on substance-related outcomes are well demonstrated (Liebschutz et al., 2014; Eisenberg et al., 2016). To our knowledge, no successful programs have ever been described for the treatment of stimulant use disorder in hospital.

Psychosocial interventions are the gold standard for the treatment of stimulant use disorder, with contingency management (CM) programs being the best evidenced strategy (Prendergast et al., 2006). These programs make use of a reward-based system as positive reinforcement for decreased substance use, with the 2 most common strategies being the provision of ‘vouchers’ with increasing monetary value in exchange for negative urine or breath samples, or using a ‘fish bowl’ random draw for rewards of various values in exchange for the same negative biologic samples. Compared to other psychosocial interventions, CM has been shown to promote decreased use of stimulants and increased retention in treatment, outperforming cognitive behavioral therapy, non-contingent rewards, 12-step programs, and combination treatments (De Crescenzo et al., 2018).

CM programs have previously been adopted in outpatient and residential treatment settings, but have not been described in an acute medical ward. Given the unique opportunity that hospitalization presents for the initiation of treatment, inpatient CM interventions may be of value in decreasing stimulant use, increasing retention in hospital, and improving health outcomes. This case describes the impact of an inpatient CM program on the clinical course of a complex medical patient with severe cocaine use disorder.

CASE DESCRIPTION

A 38-year-old male was admitted to hospital with infected sacral decubitus ulcers secondary to T9–10 paraplegia from a remote motor vehicle accident. His medical history was significant for a neurogenic bladder, and for hardware in place following an old femur fracture. He lived independently in subsidized housing and received his income through the governmental disability assistance program. He had been hospitalized on 7 occasions over the past year for similar issues, with three discharges against medical advice (AMA) related to substance use.

He had a long history of use of various substances, with smoked crack cocaine and heroin as his primary substances of use. He stated no history of methamphetamine use, and no past injection drug use. He smoked marijuana on a daily basis, and was a previous cigarette smoker. In the past year he had been maintained on methadone as opioid agonist therapy, however he had recently switched over to buprenorphine/naloxone treatment which effectively reduced his opioid use. He had previously attended inpatient treatment programs for stimulant use disorder though could not recall the details of these stays, but had never participated in a CM program.

During his hospitalization, a CT scan of his pelvis revealed ischial osteomyelitis, and he was initiated on a 6-week course of antibiotics. His stay in hospital was protracted, with complications including recurring infection of his wounds, and seeding of his femur hardware. Plastic surgery and orthopedic surgery were both consulted but determined the patient to be high risk for surgical complications, in part due to his ongoing substance use.

Throughout his admission he was followed by the Addiction Medicine Consult Service, an interdisciplinary team of physicians, nurses, and social workers with specific expertise in the treatment of substance use disorders. He was maintained on his buprenorphine/naloxone in hospital, and used no illicit opioids during his stay. His cocaine use, however, was ongoing, and presented a significant barrier to his care. The patient left the hospital for extended periods of time when using cocaine, and had one discharge AMA four months into his hospitalization. These absences were leading to interruptions to his antimicrobial therapy, and contributing to his recurrent infections. In turn, this was resulting in frustration from his healthcare providers, and prolonging his duration of stay.

The hospital at which he was admitted cares for a largely urban patient population with high rates of substance use, and has previously implemented numerous innovative strategies to help improve health outcomes in patients with substance use disorders. Two months into his hospitalization, an inpatient CM program for the treatment of stimulant use disorder was initiated as a part of a research study to address this unmet need (Table 1). Participants in the program meet with staff twice per week to set health-related goals and provide a urine drug test (UDT); they are awarded prizes through a gift card-based fish-bowl reward system for UDTs negative for stimulants and for achieving their health-related goals. They may join the program for up to twelve weeks during their admission, and upon discharge can be connected with a nearby outpatient program.

Table 1.

Contingency Management (CM) Program Process

In-hospital Visit Type	Description of Intervention	Prize Draws*
Initial visit by the Addiction Medicine Consult Team following identification of a possible substance use disorder	Referred to CM Program if meets screening criteria: estimated 2+ week hospital admission, diagnosis of stimulant use disorder, open to exploring changes to stimulant use	N/A
Enrollment in CM program	Eligibility screening: diagnosis of stimulant use disorder, either active or in early remission (<3 months abstinent)	N/A
Follow-up A (Tuesdays)	Urine drug test (UDT), set health-related goal, and self-report any stimulant use	Prize draw(s) for:- Achieving SMART† healthcare goal set in previous week (ex. “get new phone”)- UDT negative for stimulants (cocaine or amphetamines)
Follow-up B (Fridays)	UDT	Prize draw for:- UDT negative for stimulants
Hospital discharge	Referral to outpatient CM program	N/A

^*Fishbowl for draws contains 63 chips: 47x$5, 15x$20, and 1x$100. Prize draw completed immediately after negative UDT and/or goal achieved.

^†SMART goal: S=specific, M=measurable, A=achievable, R=relevant, T=time-bound.

Once enrolled, the patient’s cocaine use rapidly declined and he became increasingly engaged in his care. He met regularly with the program staff and set goals including working to increase his mobility and talking to a prescriber about treatment options for depression. Two periods of return to cocaine use lasting 1 to 3 weeks each did occur while participating in the CM program, both during high stress periods for the patient; one just before a planned surgery, and the other as his discharge approached (Table 2). Between these episodes he was able to achieve multiple weeks at a time without stimulant use, as evidenced by both self-report and UDTs. Alongside the decrease in his cocaine use, he completed a successful course of antibiotics, and underwent surgery for the removal of his infected femur hardware. In the CM program evaluation surveys, he indicated the program helped him complete medical treatment, and he indicated that “it has helped me to have more confidence to say no to my addiction”. His total stay in hospital ended up being 195 days (with a one-day discharge AMA at day 145), and he was eventually discharged home and connected to an outpatient CM program for ongoing management of his stimulant use disorder. Prior to discharge informed consent was obtained for publication of a case report.

Table 2.

Urine Drug Test Results and Outcomes Achieved Throughout the Duration of the CM Program

Program Day	Cocaine	Amphetamine	Self-reported Stimulant Use (Collected Weekly)	Health-related Goal Achieved	Prize Drawn for Either Negative UDT and/or Goal Achieved
Day 1	+	−	No	Goal set	N/A
Day 3	−	−	N/A	N/A	$5
Day 9	−	+	No	Yes	$20
Day 11	−	−	N/A	N/A	$5
Day 15	−	−	No	Yes	$5 + $5
Day 18	+	−	Yes	N/A	N/A
Day 25	+	−	N/A	Yes	$5
Day 29	+	−	Yes	N/A	N/A
Day 36	+	−	No	Yes	$20
Day 40	+	−	N/A	N/A	N/A
Day 43	+	−	No	No	N/A
Day 46	−	−	N/A	N/A	$20
Day 49	−	−	No	No	$5
Day 53	−	−	N/A	N/A	$5
Day 57	−	−	No	Yes	$20 + $5
Day 60	−	−	N/A	N/A	$20
Day 65	+	−	Yes	Yes	$20
Day 71	+	−	Yes	N/A	N/A
Day 74	+	+	N/A	Yes	$20
Day 78	−	−	No	N/A	$5
Day 81	−	−	N/A	Yes	$5 + $5
Day 84	−	−	No	N/A	$5
					TOTAL = $200

DISCUSSION

People who use substances are at an increased risk of hospitalization for a variety of reasons, but once admitted to hospital they also have higher rates of discharge AMA, which in turn is associated with increased risk of mortality and readmission (Southern et al., 2012; Ti and Ti, 2015; Ronan and Herzig, 2016). In the case of opioid use disorder, initiation of opioid agonist therapy in hospital has been shown to reduce this risk and increase the likelihood of treatment success, but no comparable hospital-based interventions have been described for stimulant use disorder (Chan et al., 2004).

CM programs are the best evidenced treatment for stimulant use disorder, but are often underutilized (Prendergast et al., 2006). For patients admitted to an acute medical bed, inpatient CM programs can potentially achieve the dual goal of reducing substance use during the hospitalization itself, while also helping patients to engage in long-term treatment. In the described case, a patient with a complicated series of infections had an extended stay in hospital, exacerbated by ongoing stimulant use and recurrent AMAs. Upon engagement in the CM program, he was able to achieve abstinence from cocaine, set health-related goals, and build confidence in himself, leading to a profound change in the course of his hospitalization.

While their effectiveness is well established, limited access to CM programs remains a major issue across North America. Recognizing the potential impact of increasing access to such a resource, the Veterans Health Administration system in the U.S. has recently undertaken the first ever large-scale implementation of CM within their healthcare network. Currently, they have rolled out access in 94 stations across the US with response rates comparable to those described in controlled clinical trials (DePhilippis et al., 2018). This implementation has not only helped expand access to badly needed treatment, but also serves as an example for how CM programs could be implemented within other private or public health care systems. Instituting programs such as this one within acute care hospitals is yet another feasible approach to help improve access to the current gold standard in care for patients with stimulant use disorders.

Limitations for these programs include the infrastructure necessary to identify patients that could benefit, a need for interest in reducing use from the patient themselves, a willingness to participate in the program, and adequate medical stability for participation. Resources such as trained staff, financial support for rewards, and links to ongoing outpatient care are also required. When compared to the financial burden of prolonged and/or repeat hospitalizations, the potential cost-effectiveness of such a program is apparent. A key feature of this particular hospital is a substance-use policy that incorporates harm reduction principles and does not require complete abstinence, allowing for open conversations and the pragmatic application of this evidence-based intervention for patients in early remission or with ongoing use.

CM currently represents the most effective known treatment for stimulant use disorder. Inpatient CM programs represent a unique adaptation of this approach to support the acute care of patients with ongoing stimulant use, and to link them to long-term treatment options once discharged. This program serves as an example of how existing strategies for the management of substance use disorders can be adapted for use in non-traditional settings.

Abbreviations:

AMA

Against medical advice

CM

contingency management

UDT

Urine drug test