Incentivizing Treatment for Stimulant Use Disorder

We talk with Tammera Nauts from the Montana Primary Care Association about how Montana is one of only three states to implement a contingency management program for stimulant use disorder. Called Treatment of Users of Stimulants, or TRUST, this revolutionary program provides a scaling reward to those seeking treatment for the use of stimulants like methamphetamines. 

Those who wish to learn more about or implement this program within their facilities can learn more at https://www.mtpca.org/ or by contacting Tammera Nauts at tnauts@mtpca.org.

Transcript

Tammera Nauts  0:00  

We've had several successes we've had several people fall out, we've had several people not succeed, we've had several people bumped up to a higher level of care. I mean, you name it, we have seen it.

Beth Brown  0:10  

Welcome to Breaking Barriers in Rural Health, a limited series podcast from Mountain Pacific. We are sharing what is working in rural mental health and health care and discussing ways to replicate these successes. We're also shining sunlight where it's needed by identifying breakdowns and gaps in care. Ultimately, we aim to improve the health and wellbeing of our health care communities, and anyone listening in to this podcast. Now here's the latest episode in Breaking Barriers in Rural Health.

Amber Rogers  0:51  

Welcome, everyone. Hi, I'm your host today Amber Rogers with Mountain Pacific Quality Health. This is Breaking Barriers in Rural Health. Today, we are talking with Tammera Nauts. She is the Director of IBH integrated behavioral health for special projects with the Montana Primary Care Association. And today we're going to talk about methamphetamine. Interestingly enough, nationally meth use is 0.69%. But in Montana, that rate is about 1%. So it's quite a bit higher for Montana than it is for many other states. And of course, that has some pretty serious impacts socially, not only on hospitalization rates, emergency department use, but also increases in crime. And then we're very concerned, too, about the number of kids that are separated from their parents related to their parents use of methamphetamine. So today, we're going to talk about some new treatment options for that disorder. So welcome, Tammera, you've been on our podcast before, but why don't you do a quick introduction for our audience that hasn't met you yet? 

Tammera Nauts  2:10  

Well, that's great. Thanks, Amber. Thanks for having me. This is really fun. So I am with the Montana Primary Care Association. I'm a dually licensed clinician LCSW LAC, and I've been in the the world of co-occurring treatment since 1986, so over 30 years. So I've seen a lot of changes. I've seen a lot of cycles. And here we are again, with methamphetamine as a big issue in addition to our continued opioid epidemic that we're working with. So, glad to be here and talk about the new things here in Montana. 

Amber Rogers  2:44  

Great, great. So, we've talked a lot about medications for opioid use disorder in the past, but those medications really haven't been effective or available for methamphetamines. So what's this new treatment that is all the rage called contingency management? 

Tammera Nauts  3:06  

Okay. Yes, I think for those of you who may have listened to our first podcast that we did together, you heard me talk about medications for opioid use disorder and the work we're doing in the emergency department. And if not, I'll just remind everyone that there has not been a lot of, I guess, research effort put forth into looking at pharmaceuticals for stimulant use disorder. However, there has been some evidence and I mean, miniscule evidence that the combination of Wellbutrin and naltrexone may help with methamphetamine. It's not FDA approved, because they don't have enough data to support off-label use. In other words, you'd have to treat a minimum of nine patients with that medication in order to get one relatively good outcome. So, the numbers are not good. And that's unfortunate. We have medications that can help promote recovery and abstinence for opioids for alcohol for tobacco. So, stimulants is kind of the last frontier and we're really hoping that something can be developed soon by our pharmaceutical organizations. So, there is contingency management, though. So, when you think about behavioral health and the treatment of substance use disorders, it's a combination of genetics, it is a brain disease, or brain chemistry gets altered, much like brain chemistry is altered with depression or anxiety sorts of disorders. So, it requires abstinence, hopefully people can achieve that, and a change of behavior. And when you think about cognitive behavioral therapy, or for those of you who are familiar with it, you know that thoughts affect emotions, that affects behavior that affect thought that affect emotion that affect behavior. So, a part of treatment is really intervening somewhere within that cycle, so that a change can happen. So, when you look at contingency management, that's a part of what contingency management does is that it interrupts the unhealthy or ineffective cycle of thought, behavior, emotion, thought, emotion, behavior, etc. But it does so in a little different fashion, it does so with a reward or an incentive for desired behavior. So, I'm not saying that humans are like dogs, but I want to compare contingency management to dog training that you give your dog a reward when they do what it is that you like them or would like them to do, like sit or lay, or stay or off, right? They get a reward or an incentive. Contingency management has been around for a very long time. And it's used in a variety of ways with a variety of disorders and a variety of behaviors that want or that need to be changed. Montana receives state opioid response dollars from SAMSHA. Many agencies, individuals, are able to use those funds to help with treatment, and help with education, training, etc. So, my role with MPC as the special projects coordinator, or director is to put these things in place in partnership with the state. So, three years ago, SAMSHA added stimulant use disorder to the SOR funding stream, because we were seeing that as people were refraining from using opioids, the methamphetamine or alcohol use would go up, right? So, we were seeing methamphetamine on the rise again.

Amber Rogers  6:38  

So, can you just go back, just because of acronyms? Everybody may not be familiar with SOR. So that is? 

Tammera Nauts  6:46  

Of course, thank you. That is state opioid response dollars. So, at that time, when stimulant use disorders were added to the allowable expenditures under SOR funds, we have a lot of discussion with the state about what is best practice. And right now best practice for stimulant use disorder is contingency management. So, we contacted Dr. Richard Rawson, who originally put together what was called the Matrix program for alcohol use disorders over 20 years ago. He and his partner, Al Hasson out of University of California UCLA, put together, it's a manualized program. It's called TRUST, it's treatment for the users of stimulants. And as a part of that TRUST manualized program, contingency management is included in that. So, you're looking at the treatment of stimulants, you're looking at behavioral changes, you're looking at contingency management, exercise, mindfulness practice, etc. And Montana being Montana, even further discussed how we could have a very robust contingency management program or process. So, Dr. Rawson connected us with Washington State University team, Dr. Michael McDonell, and Dr. Sarah Parent, who actually had done work here in Montana prior to our contacting them with the tribal nations in utilizing contingency management. So, they are the leaders in the nation for implementing contingency management for stimulant use disorders and other disorders. And not just with our tribal nations, but with everyone. And so we have been working very closely with them and Dr. Rawson in implementing the contingency management and TRUST program here in Montana. So, the first year, we started with 11 sites, pilot, just pilot sites that included rural hospitals, federally qualified health care centers, SUD agencies, etc. And, you know, have really learned a lot of lessons and have had had some successes. Now, since that time, we are expanding the program and anyone who would like to participate in contingency management, training and programming can do so. 

Amber Rogers  9:01  

So when you're talking about a reward system, what kind of reward? Is it like cash? Do people have to do certain things to receive a reward? How does the practical nature of that work?

Tammera Nauts  9:16  

So, one of the things that was just a little bit tricky with this is the Office of the Inspector General, at the national level, had some concerns about diversion. So, diversion in the terms of incentives missing, right? So, incentives that are used right now are things are gift cards, primarily, you can't give cash you can't write a check, but you can give gift cards that can be used for purchasing anything but alcohol, tobacco or firearms. So, our pilot sites, they used a myriad of resources, right? Like, you could certainly have a gift gift card to a box store like Target or Costco or Sam's, but not every community In Montana has access to that. And so a lot of communities partnered with their community businesses to do gift cards. So, that I mean that served two purposes. I mean, local economy supporting local economy, and then really educating the community about this program. Incentives, our first two years that we were doing this program could not exceed $315. Because that's what the research shown. Since that time, contingency management has been growing. And so more research and development has been done. And so what we're doing right now is a 599 cap, per year. What's really great about this project too, and I think Montana has a great reason to be proud, is that we were one of three in the nation that were doing contingency management pilot projects for stimulant use disorders. The other was Virginia and then now California is kind of hopping on board. 

Amber Rogers  10:57  

Wow, so pretty cutting edge, then, huh? 

Tammera Nauts  11:00  

It is very cutting edge. And the incentive, what we're incentivizing right now, is a stimulant-free urine drug screen. This, along with our opioid use disorder treatment protocols, has really introduced the concept of harm reduction. So, for example, someone has, is not using a stimulant. But maybe they're screening positive for alcohol, maybe they're still drinking. However, what's happening in their lives is their baseline functioning is improving. And so we would consider that like partial abstinence on the way to recovery, so to speak, on the way to full abstinence. I think we're learning a little more tolerance for partial abstinence or harm reduction approach, because the success rates are so incredibly high when you go that route instead of demanding right now, abstinence, right? Because we're human beings, and that's totally against human nature. It's not possible. Think about anytime we have tried a new food plan or a new exercise regime, we don't do it perfectly coming out of the gate. And we slip and fall many, many times as we do with tobacco cessation, etc. 

Amber Rogers  12:09  

So, they receive a reward of a gift card, if they have a negative urine for methamphetamines. But if they have alcohol, what about if they have marijuana or other substances? Do they still receive?

Tammera Nauts  12:26  

They still receive because the target is stimulants. But if there were other substances present in that screen that is grist for the treatment mill, right? So, they just continue on their treatment plan with their clinician and their team and work their way toward full abstinence. right? So, we know it's a process. So, the other thing that Montana did is with, you know, we're in touch with and working closely with the national leadership in contingency management, who is working with the Office of the Inspector General and SAMSHA, to make sure that everybody's on the same page in terms of guardrails and what is allowable and what is not. And so Montana has done a very good job and been very careful in operating within those guardrails for stimulant use disorders, so that we're not doing things incorrectly, so that we're managing things well, and being good stewards of the grant funding that comes through. And lastly, adhering to research and data, you know, showing what actually is working. So, we've had, gosh, I don't know her exact numbers, we're actually in the process right now of tallying numbers overall, for the last about two and a half, three years, we've had several successes, we've had several people fall out, we've had several people not succeed, we've had several people bumped up to a higher level of care. I mean, you name it, we have seen it. One of the things that we have had some difficulty with is client recruitment. You know, kind of getting the word out and helping people understand this is available, and this is how it works, and, you know, it's pretty awesome. We're doing better at that. So, remembering we've had to remind ourselves several times that the definition of a pilot project is we're trying things out, and we're seeing what works and what doesn't, and we get to adjust along the way. So, we've learned a lot of lessons. We just have had a joint authored paper be published in quite a few journals on our lessons learned here in the state of Montana. So we're pretty excited. We just had another training in June where anyone and everyone was welcome to get trained up on this. We'll continue with training throughout the years to come. And then possibly, another piece of the most exciting news is with the governor's HEART fund, and HEART, I guess that's the HEART fund project or the HEART Project. There is hope that those who are offering this specific contingency management program that have been trained in this program will be able to access HEART funds in order to cover incentives for patients. So, that is, that's very exciting. We're waiting, I think that is almost decided and resolved. We're working very closely and just waiting for, for the final "Okay," so that's, that's pretty awesome. The other thing I wanted to say about the incentives is that the incentives are given in a graduated amount, right? So you're not just taking $600 and dividing it by, let's say, 12 visits. They're in a graduated amount, right. So you first maybe get $5, and then $6.50, and then eight, and then 12, and then 15, etc. So, it's graduated, which in itself is an incentive to continue with the program, you know, because your your incentive amount grows.

So can you give us a spoiler alert on your your paper, your published paper about a lesson learned?

I think a couple of of lessons that we've learned with our 20/20 vision in hindsight, is with all of the sides, making sure that administration is fully trained and understands the program and the impacts thereof. There are a few where there wasn't quite that understanding achieved, and/or administrative staff changed, and were not brought up to speed. So, that's a piece. I mean, as we all know, in any workplace, it's so important to have that top down support. So, that was a lesson that we learned. Another lesson that we learned was about client recruitment. As I mentioned before, in the beginning, the OIG was stringent about what you could or could not say about this program in a brochure. So, of course, you're not going to say we're going to, we're going to pay you to stay clean or sober or abstinent. And so there was, there was a lot of discussion and exploration research about what we could say. So, probably a lesson learned would be how to recruit clients and what we can say. And of course, early on, we didn't know what we didn't know. And neither did the OIG, right? So, since then, we've come a long way, and now we know what we can say. And so that, that definitely was a lesson learned. 

Amber Rogers  17:22  

It gives a person a lot of hope that there's these new treatment options for folks, because it is really sad what it's doing to many, many young families in particular, 

Tammera Nauts  17:33  

Yeah. 

Amber Rogers  17:34  

That has downstream effects for not only this generation, but the next generation as well.

Tammera Nauts  17:40  

Yeah, and I think, you know, I would be neglectful if I did not bring up the issue of stigma, with the resultant discrimination that happens within this field of work, and with people with substance use disorders. I've said it before, and I'll say the 1000 more times that we need to remember, a substance use disorder is a real disorder. It is a chronic illness that requires lifelong management, not unlike someone with diabetes, or asthma or high blood pressure. And I think part of our issue that we have experienced in this nation is it's almost like the chicken in the egg, it's like we we've kind of created our own mess. Oftentimes, people are a little bit resistant to seeking help, because of the stigma and discrimination that they experience from providers. And when I say, when I say providers, I mean, the full gambit, or the full continuum of health care providers that would serve a client from case managers, medical, behavioral health. I mean, you name it, anybody that could be involved with a client's care, definitely has internal biases, you know, that are then acted out. Even those of us in the substance use disorder treatment field. I mean, we bring our biases, we're humans, everyone has biases. And it's, it's normal, it's okay. But our responsibility is to check those at the door, when we walk into our workplaces. Really focus on that client or that patient and do patient-centered care. What is it that patient needs? Exercise compassion, because I guarantee you that when, when we're all adolescents, we don't go to bed hoping and wishing that when we wake up as adults that we will be addicted to a substance. 

Amber Rogers  19:25  

No, we do not. That is awesome. I'm so glad that there's some additional resources for folks in our state. And it's interesting to know that we're actually on the cutting edge to be one of three states that is actually implementing this program is pretty remarkable for a very large but very small population state.

Tammera Nauts  19:46  

Yeah. And I think, you know, lots of kudos out too, to the WSU staff and Dr. Rawson and Al Hasson out of UCLA and, you know, it just, it just takes such team effort and I think a part of what has happened with these pilot projects, both here and in, gosh, it's either North Carolina or West Virginia, I'm sorry. But it has really kind of motivated and pushed along the work at the national level with OIG and SAMSHA, that needs to be done in order that this program can be fully implemented with very clear guidelines, so that we can have more success with more patients, with more clients. So that's good.

Amber Rogers  20:27  

And so just to wrap things up, if other clinicians or programs are interested in implementing this in their facilities, how do they get ahold of you? And what are the next steps? 

Tammera Nauts  20:40  

Okay, so anyone who is interested, time is of the essence. So shoot me an email, which is in the show notes of this podcast. We have a an overview training scheduled, I believe, for two to three hours on September 20, that anyone and everyone is welcome to come to. Just reach out, let me know, and I'll get you all the information. Then we do have a few late comers, so to speak. They actually missed the training in June, and so we have arrangements to begin training again via Zoom after that September 20th date, for anyone who's interested. We also provide ongoing coaching once a month, and are available for questions really, at any time. So yeah, it, right now is a great time to start and get on board and do this because we've got all of our, I guess, mistakes figured out. You know, from all those lessons learned. So we've got all of that stuff figured out. And we are, we are more ready now than ever to help people get on board. 

Amber Rogers  21:44  

And I will also give a shout out to your website that is also a place where all of your trainings are listed. And so that's at MontanaPrimaryCareAssociation.org. 

Tammera Nauts  21:56  

Yes. Yes, thank you. 

Amber Rogers  21:58  

So check that out as well. 

Tammera Nauts  22:00  

Thanks, 

Amber Rogers  22:00  

Okay. Thank you, Tamra. 

Tammera Nauts  22:02  

Thanks, Amber. This was great. Thank you.

Beth Brown  22:04  

Thank you for listening. Be sure to subscribe to Breaking Barriers in Rural Health and learn more about Mountain Pacific at www.mpqhf.org.