I'm starting the recording and then I'll switch it over. So people are going to start to filter in. And we'll wait a couple of minutes before we start. Sure. When we were in the meeting room prior to this discussion, we were just talking about Jim Sorensen and how he was kind of a pioneer in our field, and he unexpectedly passed away yesterday. I don't know if Dr. Rauschen would like to say a couple words about Jim Sorensen while we're... Yeah, Jim and I, he started at UCSF, I think, in about 1977. I had started at UCLA in 1974. And we were in kind of a weird period where NIDA had started, National Institute on Drug Abuse started in 1974. And we both had some of the early NIDA grants that came out when NIDA first opened. And we were in this kind of weird no man's land between sort of applied evaluation and doing research. And so we were out in real world treatment. I mean, Jim did stuff in the VA and other treatment systems in San Francisco. And I was doing a lot of stuff in Southern California and out in the real world methadone. I remember Barbara Havasey was involved and Sharon Hall. And they all were people who had good research skills and knowledge, but they had an even better understanding of the real world treatment system. And so a lot of what we were doing was research to answer practical questions about the services being provided and the nature of the disorders. And it wasn't really theory driven research. I know and I still monitor what my younger colleagues are doing now. And it all has to be tied to some theoretical framework of some sort. We didn't do that. We just asked questions that we thought were interesting and were important and would provide information that people could use. And Jim decided to edit a book. And Joe Gydish and I and somebody else were edited a book of articles on the transfer of knowledge from science to practice. And it was one of the first collections at the time that we were starting to think about, well, how do we use science to improve practice and not just have a bunch of papers and journals, but actually use it? And he was always really sort of pushing the system to do useful stuff, not just interesting theoretical stuff, but stuff that people could actually use the information to better understand the addiction or better understand what we should be doing for treatment. I miss that kind of research because there's a lot of questions I have now that I'd like to write. Well, if I was still writing grants that I would write grants to ask. But you can't do that anymore. You have to have your research lined up with the priorities of the Institute and it has to sort of tie into a bigger theoretical model. So Jim and I were fortunate that we were able we were at a time where you could do that. He was really good. He always asked great questions and provocative things that we should be looking at and really push the field. So for those of you who are just joining, we're talking about Jim Sorensen, who is a pioneer in the field who worked a lot with Dr. Ross in the past, and it sounds like you were kind of at the forefront with the initial practice of translational medicine. So we're very lucky to have Dr. Ross here today. So I guess we'll get started. There'll probably be a few people who are trickling in. So welcome, everybody, to the Advanced Addiction Psychotherapy curriculum. As most people probably already know, we meet once a month and bring in a speaker who specializes in certain aspects of the psychotherapeutic process to discuss their expertise to help us psychiatrists be better informed about the psychotherapeutic modalities, both in terms of being able to understand the appropriate time to refer. And with some of these things, of course, also we can use them ourselves. So we strongly encourage participation in the session. So feel free to ask questions in the question box any time during the presentation. And, you know, at times we may actually answer them in the middle, but we're going to reserve some time at the end. After the session, you can access the handouts. You can visit. You can view the video again as well and claim credit by logging into your AAAP account and accessing the course. So please complete the evaluation and follow the prompts provided to claim your credit. As additional courses are added, you will be automatically registered for them if you've registered to be so far. Some of the upcoming lectures we have next month will be Melanie Harned talking about dialectical behavioral therapy. And then Chris Belfer will be discussing psychedelic-assisted psychotherapy for addictions in August. So today we are very lucky to have Dr. Richard Rawson, who is a Ph.D., a research professor at the Vermont Center for Behavioral Health and the University of Vermont, and a professor emeritus at the UCLA Department of Psychiatry. He received his Ph.D. in experimental psychology from the University of Vermont in 1974. He conducted numerous clinical trials on pharmacological and psychosocial behavioral addiction treatments for the treatment of individuals with cocaine and methamphetamine use disorder. He's led addiction research and training projects for the United Nations, the World Health Organization, U.S. State Department, exporting science-based knowledge to many parts of the world. He's a member of Motivational Incentive Policy Group, a volunteer group that is working to reduce obstacles to the use of contingency management for the treatment of stimulant use disorder. He's currently providing technical assistance to eight states on the development of treatment services for individuals with stimulant use disorder. He was recently awarded the ASAM Presidential Award for Excellence in Teaching and Leadership in Addiction Medicine, and was made a Distinguished Fellow of the International Society of Addiction Medicine. Dr. Rawson has published three books, 40 book chapters, and over 250 review articles, and has conducted approximately a zillion workshops of paper presentations and training sessions. And he's also famous for being the creator of the Matrix Model, which we're going to talk a little bit about today. So, nonetheless, we're very grateful that you're here today, and I'm going to pass it off to Dr. Rawson. Thank you for coming. Thank you. Happy to talk with you today. I just saw there was a, I got a blurb in my email about Jim Sorensen's passing, and it had something about 250 published articles. He and I had a lot of our career in parallel, and a lot of the topic work we did. Actually, Jim and I worked on projects having to do with stimulant use disorder and treatment for people with stimulant use disorder. We both published papers showing that the treatment response to behavioral treatments was comparable for people with cocaine and methamphetamine use disorders. Not that that's a surprise, but there were folks who were saying when we developed the literature on treatment for cocaine use disorder, oh, well, we don't know if that's going to work for methamphetamine use disorder. And Jim and I both looking at different data sets came to the same conclusion that treatment of stimulant use disorder, at least with behavioral and psychological treatments, looks like you get a pretty comparable response. Now, medications may be a different story, but with behavioral treatments. So I'm going to talk about stimulants, and for the most part, be talking about both cocaine and methamphetamine. I do have to say the current literature on methamphetamine, 2023, is that it's a much more potent and lethal drug than it was 10 years ago, due to the new formulas that cartels are using to manufacture it. I think the cocaine is pretty much the same cocaine. So I suspect people with methamphetamine use disorder probably are more likely to have pretty severe impairment, certainly cognitively, than people with cocaine use disorder. And of course, both of them have fentanyl in the drug supply. So it really is a different environment in 2023. What I'm going to give you is an overview of some of the research, the clinical strategies that have been used with people with stimulant use disorder. It's become very timely because as the effort has moved forward in providing effective medication treatment for opioid use disorder, there's been tremendous expansion of opioid use disorder. And all of that has been a wonderful, positive development. But as in some places, as people have reduced their opioid use disorder when inducted and treated with buprenorphine and methadone, stimulant use disorder can occur in that population. Joe Sepovita, a psychiatrist from San Diego, has quoted somewhere 60 to 70 percent of his patients on buprenorphine are using methamphetamine. It varies around the country as to what that proportion looks like. Here in Vermont, it's much lower than that. But it is a big problem, not to mention primary stimulant use disorder. So I'll be covering all of that. And I do want to, one sort of editorial comment that I'm working on with a group is to, our goal is to get contingency management more widely used. And one of the things that has been very poorly understood is the role that stimulant use has in the overdose crisis. In many places, you see the, I mean, you look on the media and the, you know, the hail of information on the overdose crisis. It's in many cases referred to as the fentanyl overdose crisis or the opioid overdose crisis. But upwards of 50 percent of all the overdoses that occur in the United States have stimulants, either cocaine or methamphetamine, as part of the toxicology report. It may not be that that's what killed the individual, but for many of them, it was their stimulant use disorder that drove their drug purchasing and what drove their outreach to use drugs. So it may not have been the cocaine or meth that caused the fatality because that may have been due to the fentanyl that was in their drug supply. But without treating stimulant use disorder with effective evidence-based treatment, we leave those people at very high risk for overdose death. And I think the role of treatment of stimulant use disorder has been poorly understood and poorly appreciated as part of the strategies we need to effectively reduce overdose deaths. You know, you can put as much methadone and buprenorphine and naloxone out there in the community as possible, and we should and we need to. But for people who have a primary stimulant use disorder that's driving their drug purchasing, they're going to continue to be at risk no matter how much MOUD we have out in the community. And we really do need to beef up the treatment efforts we have for people with primary stimulant use disorder. Okay, I mentioned the overdose lethality of the current available mesamphetamine. So it's in a lot of the parts of the country where I'm talking about this, including here in New England, you know, I mentioned the fact that in Vermont, 60% of the overdose deaths, which are now all contain fentanyl, 60% of them also contain cocaine. And when you point that out to people, they say, well, yeah, that cocaine, there's a lot of it out there and people are using it. But, you know, it really isn't the main event. The main event is fentanyl. And so we need more treatment for opioid use disorder. As I just mentioned, that's not the whole picture and are getting effective treatment for stimulant use disorder is a very effective opioid overdose prevention strategy. And part of the challenge is the limited understanding by the individuals who use stimulants of the fact that they're addicted. In terms of what are the challenges of getting this group of people into treatment, many of them don't recognize they're addicted. They kind of view their use of cocaine and methamphetamine as something that they enjoy, that's under volitional control, that they can stop whenever they want. They don't have withdrawal like people addicted to opioids. And so they can stop and start on their own. So they're not really addicted. And so that's one of the challenges. And once when they recognize that they don't have, they think that they're not addicted, they perceive it not being addicted. They're ambivalent about whether they need to stop their use or reduce their use. And so then they're also ambivalent at best about needing treatment. So one of the major challenges we have is that our treatments to be effective have to draw people into treatment. We're familiar with that with buprenorphine and methadone. I mean, those medications, part of their magic is the fact that when patients are in withdrawal or fear withdrawal, they can reach out for those medications and they feel better. They have a positive attraction for people with opioid use disorder. Well, with stimulant use disorder, because as we'll mention, we have no medications with robust efficacy or FDA approval. If we're going to use behavioral treatments, we have to think about what are the behavioral treatments that will draw people into treatment and retain them in treatment. Because as I understand the literature, the individuals with stimulant use disorder, if they're in treatment, they're at about a one third risk of dying of overdose than if they're out of treatment. And that's treatment in the broadest sense of the word. That could be in regular primary care treatment or in harm reduction activities or formal treatment. But being engaged in some kind of effort, health promotion effort, hopefully that addresses your drug use, if you're actively involved, your overdose risk drops to a third. So getting them in, keeping them coming in is really the name of the game. And they don't see it that way, certainly on the front end of getting into treatment. Impulsivity and poor judgment stimulants have, you know, impair the prefrontal cortex and produce a cognitive impairment and poor memory. We've seen lots of brain imaging studies to explain what the anhedonia is that they experienced during the first four to 12 weeks or so of their abstinence. The dopamine depletion produces this state of anhedonia where they feel like nothing is enjoyable and they say things like, if this is how it's going to feel to be sober, I can't live my life like this. And so I'm going to use. So that anhedonia is a real challenge, particularly in retaining them in treatment. During their use, they're often hypersexual. During when they discontinue their use, they often become hyposexual or have difficulty performing sexually, which, of course, is a great concern to them. Violence and psychosis, if you look at different violence and psychosis related to specific types of substance use disorders, with methamphetamine, it has about a three times higher rate of association than with drugs like opioids. Alcohol actually is similar, but certainly more than opioids and the other categories of illicit drugs. Methamphetamine is associated with violence in almost always when the individual is under the influence of methamphetamine and is experiencing some methamphetamine paranoia and psychosis. If you think of the sort of the nub, the core of opioid addiction as being the avoidance of withdrawal, that is the thing that most drives their drug seeking and actually treatment seeking, is worrying about going into withdrawal, fear of withdrawal, craving for opioids. With stimulants, that's not the same dynamic. For people with stimulant use disorder, the sort of the core of it is this Pavlovian triggering response that they have when they come in contact with a stimulus that's been previously associated. So money, for example, cash, parts of town, old friends, alcohol is typically a trigger for people with stimulant use disorder and they don't understand it. They can be cruising along, doing their best to staying sober, feeling pretty good. And all of a sudden, without understanding it, they have this overwhelming craving that they don't understand when somebody gives them a $20 bill and it sets off this Pavlovian response. This group has obviously elevated rates of psychiatric comorbidity, and they're very difficult to engage in treatment, and they have poor retention and outpatient treatment, as I will demonstrate. These are some of the individuals who have most challenges. The first two categories in all of the studies or many of the studies that I've done and other people have done with people with stimulant use disorder, people who inject and people who use daily are different. It's not sort of an incremental difference. You have people who use sporadically on weekends and binges, and then you have the people who use daily. When you ask them, in the last 30 days, how many days have you used? They say 30. That person is going to have more challenges than the person who uses more sporadically. Also, people who inject. The prognosis for those two categories of people is much more challenging, and they often need to start at a higher level of care to have a chance of benefiting from treatment or from actually reducing their use. They can benefit, but not be able to reduce their use. These other groups, women, men who have sex with men, people under the age of 21, severely addicted, and people without housing, all of these groups certainly require special consideration in putting together treatment protocols for them. And individuals on medication treatment for OUD. That's a population that it's an interesting population. I've done a lot of interviews with people who here in Vermont who are on buprenorphine and methadone about how they view their stimulant use, whether they see it as a problem, what they might like for treatment. And it's a bit different than for people who are sort of in the category of primary stimulant users. And I'll talk about that. This data from the state of Washington on. This is a program that used buprenorphine. They recruited, in this case, in 2015, between 2015 and 2018, they recruited about 800 people into buprenorphine treatment. About a third of them had concurrent methamphetamine use disorder at the time of admission, and two thirds of them did not. Two thirds of them were there for their opioid use disorder and didn't have co-occurring methamphetamine use disorder, and a third did have that. These are the retention curves. The top line are the people with opioid use disorder. The dotted line is people with opioid use disorder and methamphetamine use disorder. So with that population that are using both when they enter treatment, you see a much higher dropout rate. Now, since this study was done between 2015 and 2018, or the people were recruited during that time period, it's likely that some of those dashed lines, the drop-off in the first 100 days, is not people dropping out of treatment, it's people being kicked out of treatment, because, and I don't think this group really needs to hear this, but we did see in many places during the, in some places we still see it, where people who are on buprenorphine for their opioid use disorder, if they continue to use anything, stimulants in particular in this case, while they're on buprenorphine, they'll be given warnings, they'll be given threats, and if they don't behave themselves and stop their stimulant use, they're kicked out of treatment. That's a bad idea. That's a horrible idea, and I presume you all know that, and I'll leave it with that. But in many other audiences I talk to, I spend a lot of time talking about, in 2023, don't kick people out of treatment. And for some, that's a hard pill to swallow, that someone should be continued in treatment, even if they're not doing the treatment the way we want them to, but I'll leave it there. This same program in Washington in a syringe exchange up there with about 600 people, again, two thirds of them were primary users of opioids, about a third of them were people who used methamphetamine, and they did some surveys with these people in the syringe exchange, and the thing to note here is that over 80% of the individuals who used opioids, when you talk to them about their perception of the future, about over 80% said they realized at some point in the future they would need to reduce or stop their use or get into treatment or both, less than half of those who used methamphetamine. So there's this idea with individuals who use methamphetamine really have a really different perspective on the significance of their drug use and the need for treatment or for addressing this as a problem. This is a meta-analysis published a couple of years ago on dropout rates from behavioral treatment or from treatment period, outpatient treatment. This is dropout rates in the first 90 days of treatment, 151 studies, they looked at patients with different substance use disorders. For people with heroin use disorder, 25% drop out in the first 90 days. Now, obviously if we didn't have buprenorphine and methadone that percentage would be much higher, but we do. So in general, we retain about three quarters of the people with heroin use disorder in treatment. Actually, I think that number has gone down with fentanyl, but it's still, we have good tools to engage and retain that group, to retain that group in treatment. Tobacco treatment, about 25% dropout within 90 days. Alcohol, about the same proportion. With cocaine, it's more, it's about double and with methamphetamine, it's more than double. So that, those are data to reflect that this is, people using these stimulant drugs are harder to get into treatment and harder to keep in treatment. And we know if there was a sort of a bullet point of what's the most important thing we can do to reduce their overdose death risk, it's keeping them engaged. So this is a particularly challenging population. With, this has been interesting for me in talking to treatment groups about the fact that we, I just had a, I did a session at noon today and some of the folks who are treatment providers were sort of having a little bit of trouble with the fact that, okay, so we're supposed to keep people in treatment, whether they're using or not. And it's like, yes, we need to try to keep them connected. Well, what do we do with them if they're not reducing their use? Well, these are some of the things that can be provided to them. Certainly for someone with a stimulant use disorder who's still struggling and not able to get some time abstinent, they do have, giving them Naloxone is important for their opioid overdose since everything has fentanyl in them. Talking to them about not using drugs alone, talking to them about when they buy a new batch of drugs, testing it before they take a full dose, talking to them about if they're with a group of other people and they're all using to take turns, not everybody used at the same time. We just had a, I live about a half an hour from the Killington Ski Area here in Vermont. And early this winter, we had a situation in one of the motels down at the ski area where three people were found dead of fentanyl overdose. And it was pretty clear. They brought some fentanyl into their hotel room. They all used at the same time and they all died. Had one of them gone first and overdosed, the two that were not yet intoxicated would be able to use Narcan, call the ambulance, whatever. So this idea of taking turns is encouraged. And some other things, certainly syringe exchange and other activities can be useful. Education about the effects of meth for some patients can be helpful. All of this stuff is, for some of the folks doing treatment, this is kind of a new idea of being more working on a harm reduction framework than on the one framework we've always worked on, which is abstinence from stimulants. It's a little bit, I see patients in Vermont here now and it is a little strange talking to people about how they should be injecting and what they're, I mean, yeah, that happens in syringe exchanges but not in treatment programs. Well, maybe it needs to happen in treatment programs. Okay, for people with stimulant use disorder, some of the acute challenges include these acute psychosis. When I was seeing patients in Los Angeles and working in the emergency departments at UCLA and at Harbor UCLA, there were periods of time where if someone came in psychotic, it was assumed they were using methamphetamine. And I don't know if that's still the case in California, but there's a very high rate of psychosis with people who use methamphetamine. Auditory hallucinations predominate, although there are visual hallucinations and other forms of hallucinations. And paranoid delusions are almost universal. Paranoia, whether it's at a full psychotic level of paranoia or just more of a general suspiciousness is a hallmark of methamphetamine and to some degree cocaine, although it's not generally as common with cocaine or as severe, but with methamphetamine, it's part of the nature of the beast. There is no specific medication to reverse the psychosis of someone. Some general antipsychotics, risperidone, lansipine, you know more about that than I do. Certainly monitoring for hyperthermia because with a methamphetamine overdose, it's not breathing, your breathing isn't affected, it's hyperthermia that becomes the issue of concern. Now, of course, with everything having fentanyl in it, you also have to worry about breathing from the opioid, but from methamphetamine, the overdose is as different dangers. For intoxication, euphoria, hyper excitability, hypersexuality, agitation, all of these things are very common. Again, there's no particular, there's no methadone or buprenorphine to help get someone sort of stabilized, but generally letting time pass, talking them down, certainly being aware of de-escalation strategies. It's remarkable how often I talk to mental health counselors and talk about, do they know about de-escalation, which I guess police and first responders know about. Many of our mental health staff don't really know about this. They really haven't ever heard of it as a necessary skill to have, how some of the things they need to be aware of in dealing with an individual intoxicated on methamphetamine. Benzodiazepine can be useful, obviously, for management of that to help get the person to keep them from being a danger to themselves or others. There is a withdrawal syndrome from stimulants that just a paper published last year by the USC group on stimulant withdrawal. Lasts longer than a few days, but the pattern is typically the severe fatigue, cognitive impairment, severe craving, depression, anxiety, and all of that at the front end. We used to call that the crash. Then they all go through a period of days of starting to feel some better. And if they're allowed to sleep and eat, they'll often become, you know, get their energy back and get back to feeling better. They'll often go into a period of anhedonia where craving comes back and they become high-risk to relapse again. There's no medication regimen that has been fully accepted or tested, but I'm sure you know, working with this population, dealing with them, sometimes they need some assistance sleeping and dealing with anxiety. Okay, so treatment of stimulant use disorder. I started seeing people with cocaine use disorder and methamphetamine use disorder in the early 1980s. The first paper I published on this was in 1980 on the Annals of Internal Medicine of all places on where we tried a brief course of imipramine for the treatment of methamphetamine use disorder and it didn't work. And so we published this negative finding and it was the first in my distinguished career of publishing papers on medications that don't work for stimulant use disorder. I have a dozen or 15 publications of things that don't work for stimulant use disorder and imipramine was the first of them. And so we've been looking at this issue systematically for going on 40 years and our treatment thinking has emerged over time. First off, when the early 80s, we had question about whether people actually had addiction to stimulants, the textbooks of the time talked about how people could use too much, they could develop compulsive behavior, they could, but it was presented not as a true addiction because there was no physical symptoms of withdrawal and it was viewed more as a bad habit than as an addiction. And so a lot of our initial efforts in addition to a couple of medication trials were various forms of behavioral treatment. I set up a nonprofit called The Matrix Organization with some partners in 1984 and it was our intention to try to use whatever data we could come up with to shape behavioral treatment and over time continue to shape it based on the evidence. A lot of the very initial stuff that we used came from David Smith and Don Wesson and the folks at the Haight-Ashbury Clinic who had done some really good videos and informational stuff on speed kills and what do amphetamines do to people. And they were one of the few groups that were actually writing about stimulant use and that this was a problem. So we started with information like that, we used information from Alan Marlatt who was doing work on relapse prevention and we developed something called the Matrix Model in the mid 80s and we're using it in this network of clinics that we had in Southern California. At one point we had about 14 clinics throughout Southern California and we manualized it, we protocolized it, we conducted some evaluation studies with it. It's been used all over the place, translated into a bunch of languages and I'm wandering around the world doing consultations for WHO. People are like, oh, the Matrix Model, it's like, it's amazing to me. It was, that was never the intention. The intention was to have a framework and put in new stuff as we found that it worked. And here's your first pop-up question as you can see is like, how many of you are familiar with the Matrix Model? And so just check off one of those so we can see what the level of familiarity there is with this. And I guess somebody will read us the result when people fill this out. But it's, it really was never my intention at least and I wrote most of it and it's a big old fat manual and SAMHSA. I met with a group in the early 90s as the methamphetamine problem was expanding and there was a call for what do we have that can possibly work for these folks because it's a problem around all over the Western United States. And at the time there really wasn't anything else. I presented data on the Matrix Model and SAMHSA said, all right, we're gonna take this and we're gonna disseminate it around the country. Oh, great. So for those of you who've never heard of it, we'll give you a little information. And it really, at the time we, it was basically started with a cognitive behavioral framework and the manual outlined session by session, groups and individual sessions over a six month treatment program. It was our basic perception at the time that the key timeframe for helping someone get their meth use stopped or cocaine use was about six months. So it was this big old manual that then SAMHSA published and it's still available as a public document. And I said, as it's being used. Next slide. But it was really in my mind was, I wanted to develop a framework and then we could add things like contingency management or medications or other things into it and see it continually evolving. I forgot that I'm running the slides. These are the components. It was cognitive behavioral therapy. We used a compassionate, engaging, nonjudgmental approach which at the time was considered enabling patients. At the time before Bill Miller wrote the book, we were doing something that was vaguely like motivational interviewing. And I remember presenting it in the community in Los Angeles and people saying, oh, you're not confronting their denial. You're not helping them recognize that they're hitting bottom and all that. And it was what seems pretty reasonable at this point. Now that that time was pretty controversial. There was a researcher at the University of Pennsylvania, Stanton, who did work on family therapy. We integrated that. We had patient education. A lot of that came from the Haight-Ashbury folks. We used 12-step facilitation. It wasn't really 12-step facilitation. That hadn't really been developed, but we would encourage people to participate in 12-step program and we did urine testing. And that was the package of what went into the matrix model. And it was operationalized in handouts and worksheets and guides for therapists for using it. Next slide. And for most of the 90s, it was a framework that the workforce understood, seemed to find useful. And so it got a lot of use around the country. We thought it would help them create a structure and sort of a set of expectations for patients, provide a positive collaborative relationship, provide some teaching and concepts that would be useful. We did a lot of positive reinforcement. We didn't have contingency management built into the matrix model, but there was a lot of positive reinforcement. The family involved, encouraged self-help and used urinalysis. And our use of urinalysis at the time in the 80s was considered pretty unconventional. We used it as a way of educating patients and talking to them about how they're doing, not catching them using drugs and shaking our finger at them, which was the standard of the time. So it was a bit of a game changer in that it tried to take all of this stuff and package it into a way that therapists could use information, a good deal of which had some evidence of usefulness and try to apply it in a somewhat systematic way. Unfortunately, in my opinion, unfortunately the matrix folks, I was at UCLA and the folks who ran the Matrix Institute had the thing published also by Hazleton and it kind of became frozen as a model that what I wrote in 1989 and 1988 became frozen forever as the matrix model. And I used to harass the people at the Matrix Institute about, hey, it's 2005, there's a lot of new information you should be incorporating but that never really happened. And it's kind of an interesting relic that I think some people still find useful, but that's what we were doing as sort of a background of historical context. And this was the schedule that people came in over a period of, well, intensively for 16 weeks and then ongoing support for a few more months. So moving on to what is currently effective, what are the evidence-based approaches for stimulant use disorder? This is pretty easy. The evidence is overwhelming. Contingency management or the use of positive reinforcement in a structured manner has by far the most robust evidence of effectiveness and I'll give you a little bit of overview. So pop-up question, how many people are familiar with contingency management? And you're gonna be hearing more and more about contingency management because as the ongoing problem with stimulants and overdose and the non-availability of medications that are effective, contingency management will make its way progressively into more utilization, I'm certain. And so let's see what we have for a total on contingency management. People are very familiar or somewhat. Okay, great. So people know that it's good. That's any of you who are familiar with the VA contingency management's used there. The other things that have some evidence of support and I'll go into those a little bit of detail are cognitive behavioral therapy. Dr. Kathleen Carroll at Yale spent much of her career collecting data on CBT for people with stimulant use disorder. Community reinforcement approach we'll talk about in a minute also has a bit of evidence. Although motivational interviewing doesn't have a lot of dedicated scientific assessment, certainly working with this population, motivational interviewing is an essential skill in engaging them and retaining them in treatment. And I'll give you some data on the use of physical exercise. One I don't have on here, which is starting to get more serious assessment is transcranial magnetic stimulation. I don't have anything systematic to say on that other than I know in the clinical trials network that's currently being evaluated in a controlled trial. And there are some preliminary studies saying TMS may be useful for the treatment of stimulant use disorder. But that's all I'll say about that for now. What is contingency management? Just because I'm gonna be talking about it, going over some data, but it's a technique involving the systematic delivery of positive reinforcement for desired behaviors in the treatment of stimulant use disorder. Generally now gift cards or rechargeable credit cards are used and people earn tangible amounts of credit, $10 vouchers, or we often start off for $10 gift cards for giving stimulant negative urine samples. That's kind of the basic paradigm. You come in, give a stimulant negative urine sample, you get a $10 gift card. You do that three times in a row and the value goes up to $15. And we can do this over the next 12 to 24 weeks depending on the protocol. The protocols differ in length and in the amounts, but that's it, that's contingency management. Now you can use other target behaviors like such as attendance or accomplishment of therapeutic assignments to reinforce those. But the basic one that's being most widely implemented is reinforcing stimulant negative urine samples as the basic paradigm. And with that, I'm just gonna click through a number of these meta-analyses. I believe there have been seven meta-analyses or systematic reviews for treatment of stimulant use disorder, psychosocial interventions for individuals with cocaine and amphetamine addiction. This one was done by a group out of Oxford University. It's a WHO group. They do lots of meta-analyses of all sorts of things. And they took on stimulant use disorder and did analyze the literature at the time. This was as of, I think they did this in 2015 to 2017. Looked at 50 studies, 6,000 some participants, 12 different interventions. And their conclusion was the combination of contingency management and the community reinforcement approach was most efficacious and most acceptable treatment both in the short and the long-term. So that was the first one. Actually, there was an earlier one back in 2008 that had sort of a soft, similar finding. But this one was the first one that really came out with this as a definitive conclusion. This group from Taiwan published in Drug and Alcohol Dependence, a review of the literature for methamphetamine use disorder, non-pharmacologic interventions. Published this in Drug and Alcohol Dependence in 2020, 2044 studies. Their conclusions, while contingency management intervention showed the strongest evidence, there was some efficacy for CBT alone or CBT together with contingency management. A newer study even is Bensley in 2021. They looked at a comparison of treatments for cocaine use disorder meta-analysis. They looked at 157 studies and they found in their meta-analysis contingency management programs were associated with reductions in cocaine use among adults. And the only contingency management showed clear evidence of efficacy for cocaine use disorder. This one was published by my colleagues last year or two years ago, I guess now, in JAMA on treatment of individuals who are on MOUD and are also using stimulants. What works to reduce their stimulant use disorder? They found that contingency management was the only treatment showing efficacy and reducing stimulant use disorder and that it produced an array of benefits, not just the reduction of stimulant use disorder. This study by Brown and DiFulio looked at, they just looked at the CM studies, the contingency management studies for methamphetamine use disorder. And there've been 27 of them to look at what benefit contingency management had for people with meth use disorder. And they found that in 26 of the 27 studies, there was reduced methamphetamine use. In the majority of studies, there was longer retention in treatment with contingency management, more therapy sessions attended, higher use of medical and other services, reductions in risky sexual behavior, increases in positive effect and decreases in negative effect. People felt better. So not only does contingency management help people reduce their use, it has these additional benefits with or without concurrent other therapies. It's a very robust treatment. As I mentioned, I'd been doing work with the matrix model and CBT and MI for probably 15 or almost 20 years when I got a grant to look at contingency management for stimulant use disorder. And it was an eye-opener. It was like, well, we thought this was pretty useful, but this really works. People actually stopped their use. One of the studies I did was in an OTP within the inner city of Los Angeles with tough population. Many were unhoused. Many had psychiatric comorbidity on methadone using cocaine every day. And we thought, well, maybe contingency management can reduce their cocaine use. I won't go into, I don't think I brought the data into this, but very profound reductions in way beyond my expectation with that population. And many of them would say, you know, I didn't really have any interest in stopping my cocaine use, but when you offered me this intervention and I could earn up to $1,000 over six months by giving stimulant negative urines, that got my attention. And that's what we hear over and over again. This is an intervention that is attractive to patients. They find it very useful and it engages and retains them in treatment. So it really has been a real bright light in the area of stimulant use disorder. This Ronsley study looked at a whole array of other treatments for a stimulant use disorder. And the strongest body of evidence was for contingency management. Pharmacologic treatments, no data is insufficient. Other interventions found predominantly negative results. So it really, in a world of what should we be doing for people with this disorder, rarely is it ever as clear that we have one thing that really works well, contingency management. Oh, here's the study I did. This was, I published this in the Archives of General Psychiatry in the early 2000s. 120 patients all on methadone, all using cocaine. Randomly assigned, they all stayed on methadone obviously, and a quarter of them got contingency management, a quarter of them got cognitive behavioral therapy, a quarter of them got both, and a quarter of them got just regular methadone treatment with standard services. And we have lots of data, but the most clear is simply the two groups that got contingency management, CM and CM plus CBT had about twice as many drug stimulant negative urine samples as the CBT alone group. And they had about twice as many negative samples as the standard treatment group. So the CBT did produce some effect, but cognitive behavior, but the contingency management treatment was far superior and produced very robust reductions with or without CBT. There was no particular indication of a combined effort effect. As I mentioned, the VA has used contingency management for stimulant use disorder for about 10 years now. And they've recently published some data on their effect. I believe they've treated about 5,000 individuals in the VA, which is a good start, but there's obviously a lot more people receiving services at the VA that could benefit from this. And there have been a lot of obstacles. Some VAs won't allow you to use point of care testing, which you need to do because you need to provide the reinforcement immediately. When somebody comes in and gives a urine sample, you have to be able to test it right now and give them the incentive because do you know anything about reinforcement theory, BF Skinner, 1938. For a reinforcer to work, you have to deliver it immediately to work optimally. And if you're gonna have a urine sample and the person gives the urine sample and it has to be sent to the lab and you're not gonna get the results till next Thursday, and then you provide the reinforcer when they may have used in the interim, it really doesn't work. So you have to have, and some VA systems, the pharmacies don't allow them or the lab doesn't allow them to use point of care testing. So there's been obstacles in it in the VA, but the VA is the one place in the world, as far as I can tell, where contingency management has been used on a relatively widespread basis. And when it was being researched by NIDA, it was also called motivational incentives, which was tremendously confusing because we have motivational interviewing. And so it was, I think, a particularly bad choice of a second. So we're using contingency management now as the treatment. As I mentioned, this is the basic paradigm. You're using positive reinforcement. There's not negative reinforcement, there's not punishment. It's solely a positive reinforcement approach. The person provides the target behavior, they get the reward immediately. They either don't give the sample or the samples positive, they're not punished, they're not scolded, they're actually encouraged to come back for the next session. They're told it's great that they're working on this, all kinds of positive affirmations for participation. Often they can be given some behavioral strategies for how to accomplish a negative sample, but it's all about positive reinforcement and the application of positive reinforcement. You need to have a defined and achievable behavior. Improving someone's attitude is not a target behavior. You have to have a measurable behavior. You have to provide a tangible reinforcer or incentive. Pat on the back, good boy, we're gonna give you a great parking space, blah, blah, blah, all that stuff. All those things are nice and positive stuff and treatment is great, but it's not contingency management. For contingency management to work, the magnitude of the reinforcer has to be significant. We're, as I'll talk about in a minute, that's our biggest obstacle right now outside the VA is that people have some of the money that we have from SAMHSA and HRSA doesn't allow us to use adequate levels of incentives. And this is a stubborn, tough behavior that we're trying to modify. You need a pretty powerful intervention. Giving people a candy bar for coming to group or a McDonald coupon isn't gonna do it. They need to have a robust reinforcement system and it has to be immediate. They only get the incentives when the behavior occurs and it needs to be done on a frequent basis. Generally, we're looking at twice a week now in most protocols. So again, I won't beat this to death, but the target behavior has to be measurable, objective. The result has to be able to be acted upon immediately with immediate reinforcement. And if you're doing the urine testing as the target behavior, if you're gonna do a Monday and Friday test or Monday, Thursday, you wanna make sure that the intervals are long enough that one use on Sunday isn't gonna show up on Wednesday as well as Monday. So we space it out by three or four days. And this is the current favorite protocol in the protocols that are being used around the country. Twice a week using these point of care tests is something that we're generally recommending. The rewards have to be something that they want. For example, in Burlington, where we have a contingency management project, we were using Walmart gift cards as the reward. Well, the Walmart in Burlington, Vermont is about 10 miles outside of town. And as they do with many Walmarts, they put it out outside of town. And for many of the people who are living in the city who don't have transportation and Walmart cards, they didn't really like Walmart cards. What they wanted was Champlain Farms, which was this like gas station, fast food place. And it made a big difference in terms of people's interest in the project and their behavior. So you have to find incentives that people want and that they value. And currently gift cards to many of the patients we see who are unhoused and don't have regular income are valuable for their eating and for their gasoline for their cars and for other essential things. It makes a difference to these patients and they value them. And they see every time they get one, it's that they've succeeded. They have tangible evidence that they did it. They accomplished what they tried to do. There's a big project underway now in California and the incentives are electronically delivered. So in this case, the person gives a urine sample and on their cell phone, they have an electronic credit card. They get a $10 credit that they can use for almost anything. These electronic credit cards are restricted that you can't buy alcohol, tobacco, or lottery tickets or cannabis. I don't think you can buy cannabis with any credit card. So we've tried to make it push toward use for things that are not gonna be problematic. If people don't have a phone, they can get a paper copy. So it's not like they have to have a phone, but I think this use of the electronic system will allow us to keep track of things much better and give them immediate response. If people, it's contingent. If people come in, they give a urine sample and it's positive for stimulants, they don't get the credit. Again, they don't get punishment, but they don't get the incentive. And that's something that we're really working on trying to in our training is when they come in and they're positive, the message is positive. Great, you're still in treatment. This is great, you're still work. And as opposed to being scolded for a positive test. Another issue that often comes up here is the target behavior that we're recommending is stimulant negative urine samples, not entirely negative urine samples. We're using this as a treatment for stimulant use disorder. If somebody has positive cannabis, or even if they have a positive opioid, we will counsel, we'll talk to them about MOUD, we'll talk to them about taking naloxone, all of that stuff. But they get the incentive based on their stimulant use. And there's a whole long discussion about why it's important to limit what you're asking, where you set the bar for the patient to get the incentive is really important as to the effectiveness of the intervention. So lots of programs use incentives and they call it contingency management. Oh, we have a contingency management program. People come in, if they attend group, they get to draw a slip of paper and they can get a gift card. And that's great. And I don't wanna discourage that, but that's not contingency management. It's positive incentives or positive reinforcement. We're recommending that if people are doing this and they really systematically wanna do it in a large treatment program, they have a designated person or two designated people who handle the contingency management in much the same way as you would have a nurse handling dispensing of medication. You don't want willy nilly gift cards being handed out because I can tell you from my own experience that can turn into a mess. And so the skills of somebody who's gonna deliver contingency management involve doing all of these things. And it's an important task that really does require some pretty intensive training. They're one of the big obstacles to contingency management was this thing called the, a group called the Inspector General who saw contingency management as giving patients kickbacks. And that stopped contingency management in California in 2008. I was doing a project. We got stopped by the Medicaid auditors and they said, you can't do this. This is broad. That put a quick stop to that for about 10 years. That's been resolved. That's no longer a concern. And as long as you keep track of what you're doing. And so similar to a medication dispensing program, there needs to be accountability as to who can do it, how it's tracked, how the records are kept and all of that stuff to make sure that it's done properly according to the protocol. The other big problem is right now in much of the federal money, there's a $75 cap on contingency management protocols. That's way too low. Adequate protocols are gonna be anywhere in the neighborhood of a couple hundred dollars a month as the maximum they could earn. So if 12 weeks, $200 a week, so you could possibly earn $600 over 12 weeks is a standard amount right now. There's evidence to support that level. There's no evidence to support $75. In fact, Nancy Petri did a study showing $75 doesn't work. So one of the big challenges we're working on right now, every day, I met with Senator Peter Welch from Vermont on Monday to try to get him to get the Health and human services to remove the $75 limit. Now, California has their own project that they've gotten through a Medicaid waiver where they are using $600 per patient, which is just getting underway right now. Some of the other challenges we have, last week in Seattle, where they have a pilot project, there was a Fox News thing about what a ridiculous thing this is to pay addicts not to use drugs. What a ridiculous idea this is, and it's part of our welfare state. That's one of the areas of resistance that we're running into. We're overcoming that, but it's still in many places is a challenge. I did a New York Times thing a couple of years ago and got an email from Rand Paul's office saying, never in America are we going to pay addicts to not use drugs. That's one of our challenges. This $75 thing is a problem. We need to have higher amounts to make it work. We need to deliver a clear evidence-based protocol. There needs to be a protocol based on the research, and the staff need to be properly trained with fidelity. That's never been a strength of the substance use disorder field, doing things with fidelity and doing them with accountability. It's always been a much more of a loosey-goosey. That's going to be one of the big challenges. Very quickly, you all know about this stuff, so I won't go over it. There is evidence that cognitive behavioral therapy can be useful in giving people knowledge and skills to reduce or stop their stimulant use, to get initial abstinence, and then prevent relapse. Looking at things like this functional analysis, looking at when they use, where they use, why they use, who they use with, and what happens, and helping them understand the landscape of their use, and then working with them on finding ways to address high-risk situations. Community reinforcement approach is an approach that involves, it's again based on positive reinforcement, but not a tangible thing that you provide to them, but you're helping them get the world to pay off in more ways, helping them engage in behavior that's more reinforcing. This is, here's your poll as to whether people have ever heard of community reinforcement, and we'll let you respond to the poll, but it is, it's a technique by Bob Myers from the University of New Mexico developed it. It's been around a long time, started primarily with treatment of alcohol use disorder. It's pretty complicated in training. There's not a lot of trainers. It's not in widespread use, but there is some evidence that it's useful as a behavioral treatment. It has some CBT elements, some educational elements, some family therapy elements, and is, I think, is underused, but it does have some value as part of treatment packages. Thank you. These are some of the components of CRA that go into the protocols that we use for CRA, and I'm getting real near the end. Exercise. When I was seeing large groups of patients, one of the things we recommended was that they exercise because exercise is a good thing, and you're a better human being if you exercise, and if you don't, I mean, we were, I'm being facetious, of course, but, and it actually was, it was, in just our observation of patients, in just our observation of people who did exercise versus those who didn't, you could see they generally had more energy, more clear-headed, their cognition was better, and along around 2008 or 2009, NIDA put out a RFP for exercise for stimulant use disorder, calling for research, and we got one of the grants, and I won't go into the details, but it was an eight-week-long protocol, three times a week, an hour-long exercise, 45 minutes of aerobic stuff with some strength training, had a trainer that did the exercise with them. We went to a long-term residential program where they saw lots of people with Matthews disorder, and while they were in residential treatment, they could participate in the study. Half got assigned to the exercise condition, half got assigned to an education control group, and this shows, we had, we bought treadmills that we measured VO2 max, we measured, we did EKGs, we did lots of measurements on them, it was a big study, and this shows them doing the exercise, and we got very good retention. Patients in, in the, in this big rehab, they would, they would love to go to exercise as opposed to going to another group therapy session. I think, I think the avoidance of the group therapy session was the contingency management that they went to the exercise. Anyway, they, we had scheduled 24 sessions in our protocol, and on average, they attended 22, so it was, we got very good participation. I won't go through the studies, but these, we published studies on each one of these topics. Obviously, they got in better physical condition with a variety of measures, they reduced their weight gain that often occurs in the early weeks of methamphetamine abstinence, improved cardiovascular functioning, we saw increased heart rate variability, reduced anxiety and depression, reduced craving. We did PET scans pre and post, and we found dopamine system recovery in those with exercise, and when they were discharged into the community, those who had had the exercise condition relapsed back to methamphetamine use at a lower rate, except for the very heavy users where it didn't seem, the daily and heavy injection users, we didn't get an effect with them. Anyway, almost done. These are the medicines that we are currently looking at are currently being considered for cocaine use disorder. Some of them have positive findings, some of them have negative findings, most of them have mixed findings. I'm still working on it. I'm sure you know about your, the two medicines that have a promise for methamphetamine use disorder, the combination of bupropion and naltrexone, and that work has been done in San Francisco by Phil Coffin and colleagues. Those two both have several, one or two, randomized clinical trials and are, have promised. Neither of them have been approved by the FDA. The effect sizes are pretty small. It's not like giving a person with opioid use disorder a dose of buprenorphine, but has some promise. Finally, the overarching priority with this population is to engage them and to retain them in some form of support. The, going back to the AA founders, keep coming back, it works, all of that stuff of, if you can just keep people engaged in this, it really is valuable and reduces overdose death rate by, you know, two thirds. So they, they die less often, and I have to keep coming back to many of the treatment program staff that have worked in abstinence only treatment. They need to be reminded that dead people don't recover. So it's important to work on keeping them alive as a first priority. Here's some resources on contingency management that provide some information about it and 13 minutes for questions. Thank you again, Dr. Rawson. So feel free to put the questions into the question and answer tab and we'll start off with some of the questions that are already there. So one person asked, can an addiction psychiatrist in private practice implement the contingency management protocol? If yes, then who should pay for it? Right. Yeah. Well, great question. And those are the questions that we're wrestling with right now. The focus has been predominantly on like the California project, for example, to participate in the California contingency management program with the $600 of money that you can get through the Medicaid system for incentives. You have to be a drug Medi-Cal provider, which is this special, weird carve out of the Medicaid system. On the insurance side, there are insurance organizations that are financing contingency management. And probably the most practical way to deliver contingency management in a private practice would be through the use of an app. There are a number of companies that have app based contingency management. And I know Aetna and a bunch of other insurance companies are, I don't know how widely they're approving the use. I know that these, a number of these app companies have contracts with them and they are providing care for these insurance companies. I don't know how widely it's used, but if I was in, in private practice and I had a patient population who were insured, I would be looking to see if I could get app based contingency management for my patients through either, well, there was a company called Pair, but they just went out of business, Dynamic Care, Affect Therapeutics, and something called Chess Treatment Services or app company. So there are some apps that would allow you in a, so that you as the therapist wouldn't have to implement the CM, it would be done through the app. They would, they would, they would use saliva testing for their biological testing. And then if the tests are negative and they can video it, you know, see over the, you know, phone camera. And if it's negative, they get money added to their electronic credit card. And so that's probably the most feasible way to set it up as a, if you have, say, for example, a cash practice with people, not with insurance, there have been some people who have there, and there were some studies done where with adolescents, the parents would put up the money as part of the bank for the contingency management. And the therapist would provide it through that way, but it's pretty ungainly that way. And it's, that's a limitation, but the app things, maybe we haven't, I don't, haven't seen a lot of data on them yet. And, but I know they're being marketed and there are, they are being used in some parts of the country. So can you go a little more into a little more detail about the $75 cap, how to bill within the cap? And ways to get around that in terms of alternative funding sources? Yeah, good question. The, what happened was that SAMHSA, I went down in, I don't know, 2018 to SAMHSA and did a presentation on contingency management, talked about how wonderful it was. And they decided at that time, there was some, something in the Obamacare legislation that says you can use $75 for incentives to incentivize positive health behaviors. And that became the $75 for contingency management. And that's just stuck there. And is, we, Wesley Clark and I, and a bunch of others have been working on this for two years now. And it really is a political issue at this point. And nobody in health and human services says there's no justification for it. It's simply a political thing. There's worry that if they open it up to higher amounts, there's going to be political kickback that the Biden administration is paying addicts not to use drugs and that this is another, you know, excessive spending and blah, blah, blah, all of that. So it's a political issue right now. So there's a couple of things you can do. In California, we have this waiver project. Other states are getting waivers. Montana has, as a waiver, they're developing. Washington state has a waiver where they're going to be able to use higher amounts. States can get waivers to use higher amounts. It's a realistic mechanism, but it takes time. A second way that we just got approved in Vermont is the use of opioid settlement money. All the states got some big wad of money from Purdue or from the Sacklers, opioid overdose money. And Vermont has decided to use a million of its dollars next year to set up contingency management. And that will be able to probably use a range of $800 to $1,000 per patient incentive program. That isn't affected by this HHS $75 thing. And some places, Washington state, they've got a foundation to approve it. There are ways of getting around it, but it does take some work. And the simplest thing would be for SAMHSA to take off so states could use their SOR money and their HRSA money and their other money for it. So we're working on it. It's almost on President Biden's desk. I think he has other things he's working on, but we've really pushed it all the way to the top of the government to try to get it resolved. Have you come across any effective CM protocols for adolescents or young adults? There have been some studies done. I believe the group in Chicago, the Chestnut group, has done some work with adolescents with contingency management. I have a colleague at UCLA, Rachel Castaneda, who had done some pilot projects with adolescents. And it works fine. Now, you can get into the whole, do you have to have parental consent to be able to give kids gift cards for negative urine samples or attending stuff? There are some issues around that, but yeah, it works. It works fine. And I think with that population, it works particularly well because they get into the whole game, the game of it, the challenge of it. And for many of them, their level of dependence is not as severe as we see with many adults. And so it really can be quite dramatically positive results. What is your favorite response to the, we shouldn't pay people for addiction to not use drugs? Okay, well, one of them is, hey, look, I've been working with this population for 40 years. I've tried everything I can possibly think of. If I find something that works and that will reduce their risk of death, I think we should be using it. I think we should focus on saying what works. And if we've got something that works using that and how you think about it is how you think about it. But we really want to reduce the death risk for this population and this will do it. What do you think about the potential of psychedelic medications to treat stimulant addiction? I don't know a lot about it. I haven't stayed up on that literature, but way back in the 80s, I was asked by NIDA to go out and visit some of the research centers in Canada and the U.S. where they were looking at psychedelics, psilocybin, and I can't remember what the other things were they were looking at, but I was really impressed that unlike the medicines I was looking at, I was looking at odansetron and fluoxetine and I don't know what, bupropion by itself, and it was getting these non-results. And these trials, which were still in dose ranging studies in the hospital, was like, whoa, these things really are producing major shifts. I think that it's a fascinating area. I think that, I don't know, I can't say I can endorse anything because I don't know that much about it, but with stimulant use disorder, these people's brain has been substantially altered, and the intervention is going to need to be a powerful intervention. It's not going to take a small incremental effect, and if that can be produced in the proper context, with the proper dosing, with proper safety, I think it's a great area of research and has great potential. Can you comment on the durability of the effects of conclusions management? Excellent question, and yes, there have been some studies on the, if you use a six-month CM protocol, what happens at one year? You do see some relapse, as you would expect after any treatment, you see some relapse. You see some people going back, but compared to a control condition, you see much less use at one year, so there's some benefit sustained for a year, but it does beg the question of if you're going to use contingency management as part of a constellation of treatment with, say, a population of the folks you see in San Francisco and that are challenging every American city and community with mental illness and no housing, use of stimulants and fentanyl, that may need to be extended for quite a long period of time. I mean, the idea that you're going to help them out for a period of time and then they'll enjoy the reinforcers of their wonderful life may not be necessarily the way it works, and there may be a need for extended use of ongoing incentives and reinforcers for some populations, but in the study populations, I can say, like the group that we had in the study I showed you, my methadone study, at one year, we still saw a significant reduction of their stimulant use compared to the comparison condition. So, last question, and we only have a couple minutes. What are your thoughts or the evidence on the use of prescription stimulants for either methamphetamine or cocaine use? Again, my colleagues, people like Francis Levin, Steve Shoptaw, the NIDA clinical trials folks are quite positive. Francis Levin, who is probably one of the preeminent stimulant medication researchers, mostly with cocaine, has very strong evidence that she feels supports this is a very potentially useful strategy. One of the studies I was involved in did use amphetamine for people with cocaine use disorder. It was a small study. We got mixed results. We did find some patients seemed to really benefit. Others started to escalate their amphetamine dose and want more and didn't appear to be stabilizing. So, I think we need some better guidelines and more research, but I certainly think it's worth looking at. It is, you know, from what we've, and if you just take the very simple analysis with opioid use disorder of we have two medicines that are agonists or partial agonists that make people feel better, that help reduce their craving. We have an antagonist, naltrexone, that works beautifully, whereas my career started with naltrexone, but patients aren't really as interested in it. It doesn't produce much. So, I think the treatments really need to have something that attracts people, and I think a stimulant treatment for people with cocaine use disorder would have some benefits that they would find positive. The issue is, how do you do it? What are the protocols? How do you prevent problems with the medication? But I think it has potential. Well, Dr. Rossman, thank you so much for taking the time. It's so obvious how much wisdom you have on the practical understanding of this, and it seems like, you know, there's a sense of learned helplessness in some of us sometimes. So, if you kind of review the fact that we do have some things that can't work, and so to provide us with some hopeful future. So, thank you again, Dr. Rossman. Thank you. Have Melanie Harned talking about DDT. So, thank you everybody for your attention. Thank you.

drug addiction research

addiction treatment

stimulant use disorder

cocaine addiction

methamphetamine addiction

overdose deaths

contingency management

cognitive behavioral therapy

motivational interviewing

co-occurring psychiatric disorders

harm reduction strategies

transcranial magnetic stimulation

further research