April 7, 2022

Substance Use Disorder Program Offers New Approach to Stimulant Addiction Treatment

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Low-barrier, street-level clinic uses contingency management model that utilizes incentives to promote cessation or reduction of stimulant use.

Substance use and overdose deaths have been front-page news in recent years as the healthcare community works to effectively treat addiction and improve access to services for patients.

Although many programs have focused on opioid and alcohol addiction, the use of stimulants has been on the rise in recent years, as are the number of overdose deaths from stimulants. BMC’s Stimulant Treatment and Recovery Team (START) Program, which opened its doors in June 2021, aims to fill that need.

Filling a dire need for addiction treatment 

According to Marielle Baldwin, MD, MPH, medical director of START, the idea for the program began with Colleen LaBelle, MSN, RN-BC, director of BMC’s Grayken Center for Addiction Training and Treatment Assistance, and Justin Alves, RN, MSN, ACRN, CARN, CNE. Alves had started seeing a lot of stimulant use disorder in his patients with HIV, and he and LaBelle recognized a dire need for this program. The two-year pilot program is funded by the Bureau of Substance Addiction Services (BSAS) as a state opioid response (SOR) grant that uses an evidence-based approach to addiction treatment — contingency management. It utilizes positive incentives to promote cessation or reduction of stimulant use and engagement in treatment. “Unlike with opioid and alcohol treatment, there are no FDA-approved medications for stimulant use, but there is a plethora of evidence to support certain behavioral interventions, including contingency management,” says Baldwin.

Earning points for cash and prizes

Under this model, patients earn cash or chances to win prizes as incentives for people to abstain from or reduce the use of stimulants. Participants gain points by engaging in certain activities, such as meeting with START providers or attending groups, engaging in physical activity, and having stimulant-free weekly urine toxicology screenings. Points are tallied weekly.

Although paying people who use drugs to stop using is controversial, data suggests it’s effective. However, the Centers for Medicare and Medicaid Services (CMS) currently caps the amount a participant can receive to $75 a year, which Baldwin says may not be enough to be effective. “Studies have shown that contingency management becomes really effective at about $300 to $500 per person per year. Our team has been actively advocating for that change within the system.”

Beyond the allotted $75, START is able to provide an additional incentive utilizing an FDA-approved app created by Pear Therapeutics, which allows patients to complete cognitive-behavioral therapy (CBT) sessions to earn incentives.

The START Program uses harm reduction in approaching patients’ medical, psychosocial, and structural needs without judgment, which is crucial in keeping people engaged and participating. Click To Tweet

Serving a highly diverse group

To date, START has received 300-plus referrals, and now has more than 70 patients actively engaged in the program. They have logged more than 700 individual visits. Baldwin says that because the program is the first of its kind in the state to get off the ground, patients travel from as far away as Western Massachusetts to participate. To be eligible for the program, patients must use stimulants as a primary or secondary substance and want to participate. They do not need to be BMC patients, though Baldwin says many do engage in primary care within START once they begin the program.

“We see a highly minoritized group of patients — a little over 50% of our patients are Black, Latino, or Asian, and a little under 50% identify as LGBTQI,” says Baldwin. “Many of our patients have felt stigmatized for their drug use and minoritized identities over time, and most have experienced significant trauma in their lives. The START Program uses harm reduction in approaching patients’ medical, psychosocial, and structural needs without judgment, which is crucial in keeping people engaged and participating.”  

There are many potential points of contact for patients within the program, depending on the person’s individual needs. START has weekly group meetings, offering both medical groups and behavioral health groups. “Many of our patients have complex medical and psychiatric needs and some come to both groups,” says Baldwin. In addition, patients can opt to have individual nurse visits or meetings with the team’s psychiatrist, who specializes in psychosis, a special concern for patients who use methamphetamines long-term. They also have access to trauma therapy through BMC Family Medicine and the Grayken Center for Addiction’s Rapid ACCESS Program for individual therapy.

A dedicated case manager provides holistic assistance, addressing patients’ social determinants of health such as homelessness, housing stability, hunger, transportation, and job referral and training. And Baldwin and another family medicine doctor provide primary care and addiction care to those who need it. Baldwin says it’s crucial to have access to varied resources for patients with stimulant use disorder, as they often need a lot of support and have complex needs.  

Based in Family Medicine

The START Program is housed within the Family Medicine Clinic at BMC, right in the center of Mass and Cass. The clinic features a group room space for patient visits and a “cool-down” space with a cot, white noise machine, and earplugs. It’s a safe space where patients can come to reduce symptoms of “overamping,” a psychostimulant overdose.

“Patients often walk into clinic after a 3- or 4-day binge, during which time they’ve not slept, eaten, or hydrated at all. Their bodies are on overdrive and at risk of serious medical complications,” says Baldwin. “We use the cooldown space about twice a week for patients who need rest or quiet space. It’s a low-cost and, so far, highly effective intervention and has likely reduced the need for public safety intervention or having to send people to the emergency department. The cool-down space has been invaluable in helping those in post-acute withdrawal.”

Positive feedback from patients and staff

Baldwin says that while it’s too early to have enough data for any kind of outcomes reporting, she has heard positive anecdotal feedback from both patients and staff.

“We’ve had several patients with us since the beginning. Many have returned to use intermittently, but have stuck with the program,” she says. “The most common thing I hear patients say about START, and why they are driving here from so far away, is that it’s the first time their stimulant use is being seen as a primary focus and that our team can validate the stigma they’ve encountered around their drug use and varying identities.”

“While the cornerstone of our program is contingency management, and that’s very helpful, I think that the relationships formed with our staff, who are racially diverse and diverse from a gender-sexual standpoint, has been a critically important part of patient engagement.”

Looking ahead, Baldwin says she hopes this program will continue to expand. “It’s my hope that this program will not be contained to BMC. I hope to see START’s model expanded across the state. We’ve made it work within our small space in Family Medicine, so I think that shows it can really work anywhere. The fact that some patients are driving in from 2-plus hours away speaks to a clear unmet need for evidence-based, low-barrier treatment programs for stimulant use disorder. We need more funding to support these types of programs, and we need to lift the $75 per person cap on contingency management programs to match treatment with evidence.”

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About the Author

Elli Greenlaw

Elli Greenlaw is co-founder of Felix, a healthcare content agency based in Boston. She’s been writing about health and healthcare for more than 20 years.

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