Okay, we're just going to give people a minute here to join. And then we yeah, I just, I'm sorry. I was gonna say, I just got to see detail and the opioid response network logo. It's beautiful. Okay, well, we'll turn it over to Dr. Martinez to get us started. Well, Aku Aku everyone, I'm Art Martinez. I am originally from the coast, the central coast of California, and I have served many years as a psychologist and active member of my tribe and our tribal communities. As the moderator for today's session, I'd like to welcome you to the Opioid Response Network and the Tribal Opioid Response webinar series. I come to you today from Carson City, Nevada, in the tribal lands and spiritual lands of the Washoe people. And so with their in recognition of the spirits of this land and the elders of this land, we would like to thank them for allowing me to be here as I would invite you all to allow the spirits of your land to recognize where we are and the traditional lands within which we sit. And to further that, I'd like to this up with a cultural recognition by Joshua Seaverns. Joshua is Anishinaabe and Dakota with the Little Shell tribe. He serves as a behavioral health and substance abuse disorder advisor for Kauffman and Associates and is a clinical social worker, has advanced certification in substance abuse and as a substance abuse counselor. He has brings a wealth of background as a firefighter and emergency response and first responder. Background to his work where he is completing at this point, a PhD in Indigenous health at Montana State. So with that, I'd just like to welcome Joshua and ask him to give us an appropriate opening for today's session. Hello all my relatives. I recognize you as all my relatives. I shared my Indian name, which is a Dakota name, means the warrior in the hills. I'm an enrolled member of the Little Shell tribe. I'm also Indian Dakota in Gros Ventre. I'm tuning in today from the lands of the S'Cheech Oonch, here from northern Idaho, and I honor them in a good way. My clan is the Bear and I hold the colors red and purple, the colors of the sunset. And I'm happy to be here and part of completing my PhD in one of the main authors I cited was Dr. Art Martinez. So I'm very fortunate and glad to be able to connect in a good way today. So thank you all for allowing me to share the space with you. I'm going to open us up just by sharing just the importance of land and recognizing the spirits that hold and that reside within that land. There's an old story that I think resonated with me this morning I was reflecting on. So it's the story of Chingavis. And Chingavis is a young duck and he decided one winter that he wanted to stay in his northern home. And up where my people are from, the homelands, we call it the north woods, it gets very cold up there. And so Chingavis is a duck and he decides, I'm not going to fly south for the winter, I'm going to stay here on these lands. And so in the fall, he gathers his firewood, he gathers all the necessary items, all the food, starts piling them up, and he starts building a cabin. And rather than a wigawam, which is our traditional dwelling, he builds a cabin. And he puts a stove in there. And as winter comes, old man Northwind, his headdress is made of icicles rather than feathers. And he comes from the north. And when he breathes, he freezes over the entire land. And Chingavis is just sitting in his cabin, staying warm by his fire, and he's singing a song to himself just to be in a good state. And old man Northwind notices Chingavis, he notices the lodge, and he sees the smokestack coming out of the cabin. He gets very angry. And old man Northwind goes and tries to blow, freezes everything. But because Chingavis is inside and he's singing to himself his good songs, and he's thinking positive things, he's still going in a good way. And so Chingavis waits for a little bit, and he goes out to the pond that's frozen over and he digs himself a hole. And in that hole, he's able to get fish. And so he hops in, gets his fish, brings it back home. And he's able to fill his belly. And old man Northwind notices this. And again, gets very angry. And he goes and he freezes over the pond so that Chingavis can't fish anymore. And so Chingavis notices this, and he's still grateful for his fish that he caught, and he still has some frozen or some dried berries. And he just continues singing his song to himself and thinking in a good way. Once again, old man Northwind gets very angry and he goes into Chingavis' cabin. And he has no power in that. Chingavis is warm, he's sitting by his fire, he's thinking good thoughts. And old man Northwind has no power in that place. And actually, as Chingavis sings his song, once again, old man Northwind starts to melt, starts to notice his icicles from his headdress start to drip. He runs away fast and he gets out of Chingavis' cabin. Chingavis, once again, in celebration, sings his songs. He goes out to the pond that day again and gets his fish again. And he's steadfast in the dead of winter. And he's made it, he survived. And his people, Chingavis' people come and return in the spring. And they celebrate Chingavis for being able to withstand the winter and the power he had over old man Northwind. So that story is told from our people and it's told in several variations. It's traditional protocol to take what you need from that story and use the teachings. But for me, that story represents the power of what can happen when we approach things with positive intent and we focus on our resilience rather than our deficits. And so, again, I thank you for letting me share the space this morning. I will turn it back over to Dr. Martinez. Thank you. Thank you, Josh. Those are great words and a great story that paints a context for our discussion today. To begin that discussion, I'd like to start out with a little introduction of our gathering and the subjects that we're going to be covering over the next few weeks as well as today. I'd like to turn to Kelly King, who's a descendant of the Meskwaki and Ponka Saqqaqs, Saqqaqs tribes. She works as a technology transfer specialist with the opioid response network. And she is the Indigenous Resilience Coordinator for Women and Associates. She's, I believe, coming to us from Fort Collins today. How are you doing, Kelly? I'm good. Thank you for the introduction, Dr. Martinez. So if we could go to the next slide, please. So we'll start off by acknowledging that today's webinar is funded by SAMHSA. We do have ORN and SAMHSA staff on the call today, as well as leadership and project officers. The opioid response network is funded by SAMHSA to provide free training and consultation to communities across the country. The ORN can assist with requests related to opioid and stimulant use prevention, treatment, recovery, and harm reduction. Next slide, please. The ORN has a pool of over 300 consultants that help provide training and consultation for TA requests. The ORN also has designated teams spread out across the country to provide local expertise to help fulfill TA requests. Next slide, please. In our work, we always assume Native brilliance, that Native communities possess strengths and are experts in their tribal traditions, cultures, and values. We work to support tribal sovereignty and will first look to the communities we are working with to ensure we're providing culturally responsive assistance and support. Next slide, please. This is a photo of the Indigenous communities response team. This is a team that ORN developed to provide support for TOR requests and other tribal requests. We work in duos and respond to requests from the five U.S. TOR regions. The opioid response network has also created the Indigenous communities work group. These are individuals who have experience and expertise working in and with Native communities across the nation. Regional TTSs are able to reach out to this work group for guidance on any TA requests they need assistance with. Next slide, please. Okay, here is the map of the five TOR regions to give you an idea of how we operate. I currently respond to the Tribal South and Tribal Mountains regional requests with my ORN partners. So I cover the purple and the rust color in the middle. And then my colleagues respond to the other regional requests with their ORN partners. Next slide, please. These webinars are recorded and will be available at opioidresponsenetwork.org slash TOR within two weeks. Next slide, please. Okay, together we can make a difference. We're so pleased you're joining us today, and we hope you're able to take some of what you learn and use it in your communities. At this time, I'll hand it back over to Dr. Martinez. Thank you so much for that overview. Today we're going to be exploring with the leadership of our presenter here today, Dave Herzog, who is a doctorate in MPHA, descendant of the Eastern Shoshone people, assistant professor in the Department of Community and Behavioral Health. As well as promoting works and promoting research initiatives and substance use and mental health services. She has worked very hard at Washington State University. And over the past 15 years, Dr. Herzog has collaborated on contingency management and opioid use disorder treatment research with more than 25 Native American and Alaska Native communities and organizations to enhance health equity and well-being. So I'd just like to turn it over to her at this point. Dr. Kate, welcome. Yes, thank you so much for the opening and for the story, Joshua. And I want to thank also the ORN KI team. Really excited everybody else for joining us. As well as my co-presenters, Monica and Kelly Webb. Looking forward to hearing from you both as well. We can go to the next slide. So hoping to chat with you all and by the end, you'll have a better sense, hopefully, of reinforcement-based substance use disorder interventions. Be able to discuss ways to culturally center contingency management treatment among American Indian and Alaska Native communities and within your own communities. And identify culturally responsive implementation strategies using the case studies that we will be talking about today and the stories that we will be sharing today. So next slide, please. So I always like to start out with acknowledgments and as Dr. Martinez highlighted, we've been very fortunate to work with many tribal partners and Native orgs across the US. Due to our data sharing agreements and other considerations about confidentiality, we don't share who our partners are specifically. We love to be claimed, though. So whenever folks work with us, we are happy to share with that sharing. But otherwise, we try to keep our partners confidential. We also have an amazing WSU team and that's who I work with is Washington State University. And I'll be talking a little bit about how we kind of move from research to practice. And then, of course, our funders, super important. NIAAA, NIDA, NIH Institutes, as well as SAMHSA. So we can go to the next slide. Thank you so much for driving this. So I would also like to highlight that WSU has a land acknowledgement that I wanted to share. And I'll go ahead and read the bold parts, but there are 42 tribes, 35 of which are federally recognized that share traditional homelands and waterways in what is now Washington State. Some of these nations and confederacies that represent multiple tribes and bands. As a land grant institution, we also recognize that the Morrill Act of 1862 established land grant institutions by providing each state with, quote unquote, public and federal lands, which are traced back to the disposition of indigenous lands. We owe our deepest gratitude to the Native peoples of this region and maintain our commitment towards reconciliation. And I am calling in from the traditional lands of the Squaxin. And so just really important to recognize this in the work that we do. So next slide please. All right, so this should be fun. We wanted to go ahead and introduce a poll. So contingency management goes by several terms. It's also referred to as motivational incentives. But we were just curious how many folks have heard of contingency management or even are implementing or thinking about implementing. And so far we're getting about 82% of folks have heard of contingency management. It's dropping a little bit to 75% now. We're still getting folks responding. We'll just take a minute to let that All right. So it looks like we're at about 74% have heard of contingency management. Okay, great. So that's exciting. So we have a little bit of knowledge or experience. And then I'll go ahead and share these results. Okay, wonderful. So that is exciting. I'm going to go ahead and close it out. Okay, so if we could go to the next slide. So whenever we talk about substance use. So within this context, a lot of our previous work with contingency management was focused on And over the last several years, we really switched to focusing more on stimulant use disorder. Using contingency management. And so I think we're all aware of the variations in substance use among people. But I think it's really important to push back on stereotypes and stigma. And specifically with alcohol use within native communities. Those rates really vary. And so Some native communities actually have higher abstinence rates compared to non Hispanic whites. And so I think it's really important to push back on stereotypes and stigma. And specifically with alcohol use within native communities. Those rates really vary. And so Some native communities actually have higher abstinence rates compared to non Hispanic white adults. And so I think it's really important to highlight that we also see variations in regions so Communities in the southwest tend to use alcohol less frequently than native communities in the northern plains regions. Native communities in the northern plains regions. I think another important point is to think about how these health related inequities. Related to substance misuse do negatively impact native communities at disproportionate rates. And I think that it's really important to place that within a settler colonial context and then also thinking about the policy factors related to that. So really, really pushing back on the stigma here and then also thinking about the need for culturally appropriate interventions for substance related health issues. You know, thinking about tribal sovereignty and how native communities get to decide what gets implemented, how it gets implemented. And the factors that contribute to that. So I think that's a really important piece when we're thinking about contingency management as well. So if we could go to the next slide. Okay, so I'm really proud of our team. So I wanted to take a moment to highlight the folks that are on our WSU team. So as I mentioned, we have been completing contingency management research with tribal communities for more than a decade now, which has been really exciting. And then during the height of the pandemic, we really shifted to working more with sort of providing training and technical assistance. And so our work has really shifted from research to practice, which has been really exciting. So we have Kelsey Baggett, who coordinates everything and is just really such a great asset. Sarah Parent, who's completed more than 1000 contingency management visits. So she's got a wealth of experience and can share that as well. Hopefully, we are able to chat more with you all in the future and you'll be able to visit with these people as well. And then we have Alex and she actually helped with some research implementation. So that was really awesome. And now she's helping us with some of our training and technical assistance. We can go to the next slide. Thank you. Then we have, of course, Dr. Mike McDonald, and he's really our CM expert. He has about 15 plus years of experience around that. And then Michelle Peavy and Lisa Ray Thomas joined us within the last couple of years and really expanding our ability to provide TTA to Native communities, as well as Debbie and Diana, who really helped to think about the delivery of our content and its design. So I just really wanted to show that we have a lot of members of our team and that it takes a lot of people to do this work as you all know. So let's go to the next slide. So I wanted to share sort of the big picture of this partnership, which originally started with addressing alcohol use, as I mentioned. And I tend to be a big picture thinker. So this was a activity that we completed as part of our research partnerships with three communities. And it really started with, you can see at the very tip of our river here, it really started with thinking about what culturally responsive interventions we might want to implement and thinking about what substances we wanted to address. And so back in 2012, we did a lot of community consultations, events with several community partners. And going back to that significant slide, really thinking about what exactly, what intervention would be culturally responsive and what would be important to the community. And what we heard was that contingency management, it seemed to folks like it would align. So it was something that they were interested in partnering on. And then we also heard that alcohol was one substance that continued to impact the community in a way that they really wanted to add a tool to their toolbox of how to address that. So this River of Life is an activity that can be completed with organizations or with communities. And I highly recommend it. Dr. Nina Wallerstein out of University of New Mexico has really helped develop this tool. But basically you think about the history of your partnership and looking at the successes and the barriers. So you can kind of see it's a little small, but we have some successes of getting the grant into the funding agency and then it being awarded. And then we have some boulders here though. One community was not able to continue to participate due to changes in leadership and other impacts around setting. And then we also had another site that left in year three, community partner that left in year three. And then again in year four. And so we're now in this post-study phase of the work. And ultimately the partners decided to name the partnership honor. So helping our native ongoing recovery. And so it's one of the largest clinical trials for alcohol and contingency management in rural communities. And so it's really exciting that this work was done in partnership with native communities. So I'm really happy to share that with you. So I just wanted to provide sort of this big picture look at the details that I'll be talking about as we move through the slides today to kind of give you a sense. Another piece that I think is really important, whether it be university partnering with communities or work completed within your own organization or setting is really thinking about community-based participatory research or working in a community engaged way. And I really think that community engaged work is super important in terms of recognizing that community is the authority, really helps to build strengths and resources of the community and really facilitating that collaborative partnership in all phases. Another thing that I think is really important about it is that it is a bi-directional learning process and really helps to continuously think about the reflexive process of power sharing and really making sure that you approach the work in a strength-based way. So yes, we were excited to see that contingency management was something that could be implemented and that folks felt that it was a culturally, potentially a culturally responsive approach, which we'll talk more about. So if we could go to the next slide, thank you. Okay, so for folks who are wondering what I keep talking about with CM, so there's a lot of reinforcement-based interventions based in operant conditioning. And basically, if you don't remember your psych 101 class, basically operant conditioning is a theory of learning where positive or negative reinforcement is used to modify behavior. And contingency management focuses on positive reinforcement side of that. So that could be like getting a gold star for positive, completing your homework in class for an example, whereas negative reinforcement would be that everyone in class behaves well, no one gets homework. So we're really focusing more on that positive gold star. So reinforcing the behavior that does occur. And then operant conditioning also underpins several other psychosocial substance use disorder interventions, but really the most simplistic way to describe CM is that it's a behavioral therapy that provides a reinforcer, like a gift card in exchange for evidence of substance use abstinence. And this is usually determined by a point of care urine drug test. I think that CM is just a really strength-based approach to behavior change as we all know that behavior change of any kind is really difficult. And especially when we're thinking about these big life choices of either stopping or cutting down our stimulant use or substance use. So we really want to be able to do that in a way that is strength-based and doesn't stigmatize or isn't punitive. And I believe that CM offers that opportunity to people, as I mentioned, not only does it have evidence with native communities, but it also has decades of evidence across different and diverse settings, communities, internationally even. And the other important piece with contingency management is that it's the only effective treatment for stimulant use disorder because there are currently no FDA approved medications. So that's another factor to consider in this context. We do sometimes encounter folks that, you know have some hesitation around contingency management or maybe feel like there might be concerns around how it aligns with their treatment philosophy. But we have found that CM works well in many different contexts, including harm reduction or even, you know, different treatment philosophies within rural communities as well. And so we've really learned that having open conversations around this is really important. If you're thinking about implementing CM, thinking about, you know, leadership, who in the community you might wanna chat with, and then just really offering those opportunities for education around what CM is and how you vote to implement it. But as I mentioned, I'm really excited that Kelly Webb is joining us today from Doi Natsu. She's a leader and expert in CM with native communities. So she'll have a lot of helpful information along with Monica Lewis, who is a real model program for TOR program. So really excited to have them included. So let's go ahead and move to the next slide. So going back to the honor study specifically, as I mentioned, we wanted to see if a culturally adapted version of CM led to reductions in alcohol use. And our partnering communities were in a rural area, an Alaska Native Healthcare Center, and then a city in the Northwest. And here are the specific goals, again, just to maximize the acceptability and feasibility and determine if CM impacted alcohol use, both for abstinence and reductions in alcohol use. So let's go to the next slide. So for the research study, we had participant relatives who self-identified as American Indian Alaska Native and were 18 years or older. And they met criteria for alcohol dependence based on the DSM-IV. And another piece of this was folks who used alcohol more than other substances were eligible to participate. The intervention period was 12 weeks and folks came in twice a week. And one group received incentives for not using alcohol. And the other group received incentives for essentially attending study visits and coming in regardless of what their urine test indicated. Let's go ahead and go to the next slide. So, as I mentioned, we are looking at alcohol use and other substance use. And then some folks on the team, not me, did some fancy stats, generalized estimating equations and single logistic generalized linear mixed effects models, let's try saying that 10 times fast, to assess the impact of CM on alcohol use. So let's go to the next slide. So now that we have sort of a big picture look at the honor project, a little bit more about the study design itself and the eligibility criteria, I just wanted to take a few minutes to think about sort of the cultural adaptation process and how to align CM, how we aligned CM with the partnering communities, as well as ways that you all can think about how to integrate CM within your setting as well. So in addition to community gauged processes that I mentioned earlier, I think some other important things to consider is thinking about sort of the way that you want to go about implementing. So basically we offer four sort of strategies here. There's no real consensus on the best approach for culturally adapting evidence-based treatments. So we just offer a few ideas here that we have implemented in our work. And one of those is surface versus deep adaptations. And so I would say that CM definitely falls within more of that sort of tension and the sort of thinking about the form and the function of the intervention. And so there are some key elements that make contingency management work, and we do know what those are. So for an example, the magnitude of the reinforcer or the amount of the incentives, the frequency. So it's really important that the reward be given as closely to when the negative urine test is received as possible. And then making sure that folks come in at least twice a week for 12 weeks. And so duration is another piece of what makes contingency management effective. But the form of contingency management is really very flexible. And so Dr. Lau discusses sort of the surface versus deep adaptation process. And so I think you can really get creative on sort of the delivery of contingency management and the way that you present the intervention. So long as these other sort of key ingredients are maintained with fidelity. And then another strategy that we have thought about and Dr. Kamala Venner, who I work with in culturally adapting evidence-based treatments. Another one that she really likes and recommends and that we've done some work around is thinking about Dr. Bernal's eight dimensions of ecological validity model. And so with this, we really think about the language of how the intervention is delivered, whether you're able to integrate local native language, you think about the person delivering, you think about sort of the appropriateness of metaphors or how that might be integrated along with the content, you're thinking about the goals of the overall intervention and how those might need to be sort of tailored to your setting, as well as the methods, whether you are collecting data and if that's appropriate or how you wanna utilize that. So those are some considerations. And then we also kind of think about within this context, sort of that tension between culturally grounded versus culturally adapted. And I think that this is definitely a Western evidence-based approach, but there is a lot of opportunity to continue to tailor it to fit the needs of the community that you're working with. And we get really excited about all of the different forms that that might take. So always happy to chat more with you about this, but we do have some examples that I want to kind of provide or share with you all on the next slide, if we could go to that slide. So some sample cultural adaptations that have occurred as I mentioned, we really have shifted from just research to more training and technical assistance over the last couple of years. And shout out to the Kauffman folks in this work as well, Krista and Kelly King and Holly Echo Hawk, who have been really instrumental in really thinking about how we tailor some of these strategies. So what we kind of initially did though is completed qualitative research with community partners. And from this work, we conducted about nine focus groups and thought about the alignment of the intervention, what rewards might be the most beneficial. And so participant relatives really emphasize the importance of both culturally meaningful rewards. So whether that be like beadwork supplies or medicine kits were really popular along with items that are practical. So gift cards to gas stations, to be able to purchase gas or grocery stores to purchase food or other items that might be needed were really highlighted as important. And so the other piece that we really thought about too here was concepts of recovery and what that means within sort of a relational context. And so on the next slide, I have an example, but one thing that kept coming up both with informal conversations and the qualitative research was really thinking about the importance of family and that the rewards could be used with children or for children purchase different items or have a birthday party or go out to a restaurant. So that was really emphasized as super important in this along with opportunities to connect with culture or reconnect with culture for folks who were interested in that. We kept hearing the importance of personal choice. And so not everything works for everyone. So just really having that opportunity to tailor and that's also super important in contingency management because if a participant relative doesn't feel like the incentive is reinforcing to them, their behavior change may not occur. So you really wanna make sure that you're really meeting the participant relatives needs and interests and so constantly sort of checking in around that is really important. But we heard that if there's staff that can speak the native language or if there's teachings that are maybe appropriate to share that that would be a nice way to really allow folks to engage with their culture. Another important piece was around having an elder or some respected community leader that could lead the intervention. And so we actually did have an elder and we have some digital success stories that I can share with you where he talks about his experience but that was super impactful having an elder that could lead the intervention. They were able to really engage people in a way that other folks would not be able to. And so there was opportunities for that. He would just roll up on people and be like, hey, you should be in this intervention which I don't know that our IRB was so happy about but it was a really, he had a real way of engaging people that the community was really receptive to and enjoyed. And then another factor was thinking about how to recognize and honor folks in their recovery journey. And that's another message that comes through a lot is whether that be having a sort of graduation or participation ceremony or having some sort of event in the community, a feast or a dinner to really highlight the person, the participant relatives efforts in their recovery and their contributions to the community in that. So here we have a quote from one of the participant relatives from one of the clinical trials, and hopefully you had a chance to look at that. So let's go ahead and move to the next slide. Thank you so much. So I mentioned concepts of recovery. So one example of that was especially in recent centering our training materials as well as how one of the communities presented sort of the study materials and the process to participant relatives was really represented in the medicine will. And this medicine will and sort of using this as a concept of recovery and a framework resonated with a few of the tribal partners that we have. Of course, it does not resonate with all tribal communities. And so, as I always say, I'm really open and welcome to hearing other ways that, you know, might be a better fit within your community. But to me, the medicine will is a holistic representation of harmony and balance, really providing that opportunity to focus on the spiritual, emotional, mental, and physical aspects of health and that mind-body connection that's so important, along with thinking about, you know, how this framework really supports and signifies the balance in like the four directions and the four seasons and the stages of life and just really how we think about this in a whole person way. And then the medicine will also within the contingency management programs was a way to think about, you know, relationship to self and family and community and land in recovery efforts. And so, from this medicine will sort of representation that we had been using with community partners, we then thought about how this might be mapped on to the contingency management visit itself. And so, starting in the east always, we sort of thought about how you invite the participant relative in, and it's an opportunity to greet them and build those kinship ties. And then we, within this medicine will framework, moved down to measure. And so, this is when, you know, you walk the participant relative down to the bathroom. We don't observe the UDT collection. You know, we might just walk them down to the bathroom and wait for them elsewhere. But we also defer to program and clinic policies around that. And then once you have that urine collected, then you move to reinforce. And so, that's when, you know, if there's a negative urine sample, it's a real celebration. You know, it's really exciting. Folks are really happy. And it's a great opportunity to talk about, you know, what incentive they want and how they plan on using it and what their goals are for the future. But if the sample is positive for substance use, you know, we remain nonjudgmental, very encouraging, open, and just remind the person that within a few short days, you know, if they want to, they can try again. And at that point, you know, their urine sample might be negative. But just really making sure that you connect folks to resources at that point. And then going to record the outcome. This is super important in contingency management. You want to make sure that the incentive is provided for that negative urine sample. And so, ensuring that you have the tools to track that, which was another thing that we've developed over time is a handy Excel tracker to just really ensure that you're remaining compliant with that and that incentives are truly distributed for that negative urine sample. And then always at the center is, you know, just sharing the experience with the participant relative and maintaining gratitude for their recovery efforts or whatever their goals might be. Okay, let's go to the next slide. All right. So, here's a couple of examples of how we developed some of our training materials. Sorry, it's a little small. But basically, folks are always curious about, you know, how do you have conversations around providing the incentives? How do you have conversations when a participant relative does return a positive urine sample? You know, how do you have conversations around contested results? So, I hope that if you weren't already, you're getting more excited about the possibilities of contingency management within your setting. So, we'd be happy to have more conversations about this in the future. But the other piece that we identified as really important in this work is not only having these accessible sort of visuals and infographics, but also thinking about having ways to share story and storytelling. I really appreciated Joshua's story. And so, we developed a tool for that. And so, having ways to share story and storytelling. I really appreciated Joshua's story. And so, we developed a composite story of a participant relative that might be coming into your program and thinking about different ways that you might be able to engage Lance. And so, focusing not only on recovery goals, but also the strengths that Lance already has and possesses and can access within his community. But for sake of time, I will go ahead and skip over that, but happy to share these pieces with you at a later time. So, getting back to the specifics of the research study. So, here we have a table of our demographic characteristics. We can go to the next slide. So, we can see that across the two groups, folks were in their early 40s with about an 11-year age range, plus or minus. Next slide, please. And across the two groups, about half the participants were female, which is somewhat common in a lot of our other studies. We tend to see more males than females. Next slide, please. More than 80% across both groups had at least a high school education. Next slide, please. Okay. So, after all of the work around culturally centering contingency management within each community and, you know, thinking about different implementation strategies, we ultimately had 158 participant relatives who were ultimately randomized. And in this figure here, we see the data represented by week along with the negative urine sample percentage. And within the honor study, one of the strategies to help folks get accustomed to coming in twice a week and being a part of a research project was that we did not randomize them until week five. And so, the first four weeks, participants and relatives received incentives just for coming in and providing a urine sample, regardless of alcohol use. And then at week five, we can see the two groups. So, the contingency management group is represented in that orange color and the control group represented in sort of that navy color. And so, it's exciting to see here that across the 12-week intervention period, those lines are really starting to separate. And we're seeing that the contingency management group is submitting urine negative samples at about twice the amount of the control condition. And when we average across time, we're seeing that folks in the contingency management group were actually 70% more likely to submit an alcohol negative urine sample compared to the control group. So, that was something that we were really excited to see, the impact on abstinence. And then later, we also saw the impact after the fancy stats were ran that there was also an impact on reduction of alcohol use along with abstinence. So, that was really exciting. And then if you would go to the next slide, please. And then in terms of secondary outcomes, another exciting piece was even though we were only reinforcing alcohol negative urine samples, folks cut down on their cannabis use. And so, with this figure, we're seeing that the time point changes to number of visits. And we're really seeing a very large impact on cannabis use to the point where folks in the contingency management group had four times higher odds than the non-CM group of having a negative cannabis urine sample. And then at the end of the intervention, it was actually five times higher odds. So, that's really exciting to see the impact on secondary substance use. And I think it's also something that clinicians are really excited to see too. There sometimes can be a concern that if folks cut down on one substance, they might increase the use of another substance. And pretty consistently in both the native and non-native contingency management research and literature, we see that actually focusing on one substance helps folks cut down on other substances. So, let's go to the next slide. So, we were very excited to see these results and the positive impact that contingency management can have. I think that people think that there's a lot of different approaches that communities can implement. And there might be some thoughts around what might be a good fit for them. But certainly, the ability to tailor contingency management and it being really focused on individual choice is something that ultimately people felt really aligned with their community and their organization. And CM has been well-received, not only in the communities that implemented the research project, but also, as I mentioned, the demand for contingency management continues to grow in other native communities related to tribal opioid response funding, but also generally speaking, which has been exciting to see. And, you know, there's opportunities to continue to really tailor contingency management. And as I mentioned, we would love to hear more from you all on your thoughts on that. But I think ultimately, Indigenous communities have the cultural and traditional knowledge to heal from settler colonialism. And I think that's really important that we continue to emphasize that, along with the potential for CM to, you know, really enhance capacity within communities to identify strategies to prevent and treat substance use. Stimulants and alcohol for contingency management in this context anyways. Another thing that we were really excited about was not only the capacity that has been built within partnering communities, both with staff and other folks implementing, but also the opportunity for folks that were connected with the research project as like research coordinators and within other positions. They went on to enter really prestigious graduate programs and further sort of the research leadership in those institutions as well. So that was really exciting to see. We had about seven American Indian Alaska Native junior researchers who who are now in graduate school. So it's really cool. And then another piece of this is thinking about some of those barriers, you know, how you might be able to address those ahead of time. And one piece that we've really identified is the need for a champion or leaders in the community to really assist and sustain the CM program and efforts. So that's one piece to think about is who's your CM champion and also having them at different levels. So whether that be like a program director or even in admin, front desk folks are really important to have by and from. And then also, last thing that I'll mention is the need for ongoing technical assistance in this work. And, you know, being able to have access to that is really important. And so that's why it's great that there's opportunities through TOR and other mechanisms to not only support education, but also training and technical assistance. So thank you so much. I will go ahead and turn it back over. Thanks so much for the presentation and the exciting prospects that this work kind of brings to the field, particularly engaging with culturally responsive treatment and adaptation. I think I'd like to go forward at this point in conducting a podcast. With this work, we will be able to visualize in real time, actually, the ability of the program to kind of harvest your responses. And so I'm going to turn that over and talk about, I'm going to ask Kelly, if you might help me out here, in one word, how do you feel about CM? And so if you would just using the link that is provided. And so I'm going to turn that over and talk about, I'm going to ask Kelly, if you might help me out here, in one word, how do you feel about CM? And so if you would just using the link that is provided. I'll let Kelly talk about that a little bit. So, if you can scan the QR code, and then just type in one word about how you feel about CM, implementing that in your community, or just using the link that is provided. And so, if you can scan the QR code, and then just type in one word about how you feel about CM, implementing that in your community, or just your general thoughts, and they will populate on the screen. And then Dr. Hrshak, do you want to speak to some of the ones that are popping up? Sure, yes, sorry, I was busy trying to figure out how to screenshot the word cloud, hopefully we'll have access to this later. So yeah, this is awesome. So, exciting, that was the word that I had, so I'm glad you all have that as well, but really we're seeing hopeful, grateful, collaborative is bigger. We're seeing interesting, innovative, effective. But I'm really excited to see hopeful, that's a nice one. Yeah, thankful, curious, yeah. Teachable. Yes, definitely. Positive. Yeah, that's, that's what we always gets us, you know, really up and out of bed in the morning is the strength based approach of this work. And the way that it builds connections, not only between the person delivering CM and the person engaging in the program, but really at all levels. I mentioned that we had seen a lot of folks go to graduate school. After being inspired by this work. But I've been doing this work for over a decade, and the folks that I highlighted on the PowerPoint a lot longer than that so I just think that's a testament to the work as well. Both collective I like that empowering. Awesome. So I, I think we're at about 20 responses I don't know if you want to wait for a couple more go ahead and move on. We can go ahead and move on. The, the, the positive impact of your work in the way the potential for that in many of those words what we're seeing is hope. We're seeing the excitement about the cultural adaptation, and the service. So at this time I'd like to kind of invite Monica Lewis into the conversation. For those of you that don't know her Monica is a registered nurse with 14 years of experience, working in hospitals and clinics in California. She currently works with Matheson Memorial Health Clinic in Jamestown, California, which is a tribally founded healthcare system. She is a on staff. Dr Martinez, you're, you're cutting out just a little bit. Let's see if that's just a little bit better. Can you hear me now. Yes. Okay, well I just want to get into the conversation. Not sure whether you heard that Monica is an RN currently managing to substance abuse related grants with the Matheson Memorial Health Clinic in Jamestown, California. So, welcome. Thank you so much for that kind introduction, Dr. Martinez. I appreciate that. And if you can pull up my first slide for me. Oh, perfect. So I'm here to talk to you about our ICM program. Our ICM program actually started from a provider request. Our nurse practitioner that's basically the head of our MAP program, Thomas King is the one that approached me and wanted to do ICM. He had read about it, read about results with patients. We have a lot of patients in our county that struggle with stimulant use disorder. And so he wanted something since they're, like everyone's mentioned, there's not really any FDA approved medications that are very effective to battle stimulant use disorder in patients. We were lucky at the same time we found out about Washington State University's ICM pilot program and were able to participate in that. I can't tell you guys all at WSU how much I appreciate you and how much I was able to learn during that program. It really clarified things for me because I'll be honest, when Tom asked me for contingency management, the name was a little misleading and I didn't quite understand what he was asking for. I had to look it up online really quick to figure out what he was even talking about. I hadn't heard about it yet. So I'm just so, so, so appreciative of everybody over there because without that program, I don't think we would have been as successful as we were. We began with our funding from the pilot program and then we're currently funded for our ICM program from our TOR grant. We have kind of a little bit simplified program that we've kind of boiled down a little bit that works better for our clinic. We are a small clinic in a rural community. We have a three-step program as far as how often we see patients. And so we've tailored our ICM to kind of align with that. So until caps are changed, you know, we do like a certain value for, you know, when patients are in phase one, phase two and phase three. So a very simplified program makes it easy for staff to participate correctly with it and not get confused. If you can go ahead and switch over my next slide. So one of the things that, you know, I can't say thank you enough with WSU is helping me with the policies because, you know, asking other groups out there, I, you know, there wasn't a lot of people that had policies on ICM. So, you know, trying to figure out, you know, and come up with a policy for a program from whole cloth is not my greatest strength. So having that help to be able to write that policy was invaluable to me. You know, we also were given all the teachings from WSU. And so being able to have the staff, you know, see those, those teachings since they weren't able to participate in them live, our schedules are pretty packed. But being able to, you know, review those on, you know, more downtime was really very helpful to staff because, you know, we did have a little bit of, you know, pushback from some staff didn't quite, you know, understand, you know, the science behind it initially. So having that being able to be clearly explained and the science and research behind it was very helpful for buy-in. You know, we also were able to get, you know, kind of boilerplate forms that we could tailor for patient compliance, you know, that went along with our policy and procedures. I was able to, you know, even just have like a sounding board with them to, you know, help me kind of work through issues to kind of, you know, get our program to be simple and effective and something that will work for our community and our clinic. So again, like I said, huge shout out couldn't have done it without you guys. Next slide. Barriers, some of the programs, how they're initially described, where they have a kind of more complicated system on the rewards, we kind of tried to do that. It was a little too complicated for us, which is why we went to the phase one, phase two, phase three, like when you're in phase one, you got, you know, certain rewards, phase two, certain rewards, phase three, certain rewards. So that way we can keep under the spending cap. I'm hoping that will change. I haven't heard any news on whether or not it has yet because I know research, the spending caps $75 a year, which I think all of us can agree in this economy, it doesn't go very far. So, you know, not as effective of a reward for our, you know, client relatives. The, so I'm hoping, you know, eventually that will change since it looks like the research has shown that, you know, 300 to $600 is kind of a more realistic per patient relative expenditure to be like an effective program. And I have to agree, you know, seeing, you know, what I've seen boots on the ground with the program, I think that's a much more realistic, you know, expenditure. And then, and then slide for me. For our successes and outcomes, 28 patients participated in 2002 and 18 patients participated in 2003. So, you know, I feel like we did have some really good success, you know, with our patients, those that participate in the program seemed very positive and encouraged with it. One of the things I really liked about the story that Josh shared is that, you know, I had a message of positivity and it's so nice seeing something in a treatment program that, you know, just keeps on reinforcing the positive. Our patients experience so much negative in their life that, you know, any opportunity for positive, you know, even if it's just, you know, like I do have to tell them you know, even if it's just, you know, like I do have to tell them you did have a positive urine. So unfortunately we're not able to give you a reward at this visit, but still, you know, being able to, you know, add the positive and like, you know, Hey, you can come back, you know, we're, we're still here for you. You know, you, you know, if anybody else that needs help, we're here for them to just trying to, you know, find the way to, you know, turn anything into like that positive, that hope for the future, I think is really, really, really important for our patients. And that's the end of my slides. I'm so sorry. I forgot to start off with my acknowledgement. I'm coming from the Miwok traditional lands over here in California. All right. Thanks so much for that. It sounds like you've, you've had a powerful experience there in the local application of this work. And so what I'd like to do at this point is just kind of invite, invite us into a panel discussion or response maybe to the implications of this work in incorrect care and how this might impact where the care is provided and considerations for, for treatment. So I'm just curious about, about some of your thoughts about that. Dr. Martinez, I'm having a really hard time understanding you. You're cutting out. I apologize. I didn't understand turning off my camera. Well, it didn't like my looks, I guess. So what I'm just, you know, curious about, you know, the, the, the stories, I'm sure that we, we have many stories of feedback about the practical application in patient care, in relative care that you see and, and how that motivation takes hold well beyond the reinforcer or the, you know, the gift that is a part of it. And so I just thought I'd invite you to a little bit of a discussion about that. Was that okay for me? Oh, just, just for both Kate and Monica, any thoughts about that? Monica, do you want to talk about that first? Um, I, I kind of, um, talked about it a little bit towards the end, you know, I see us, uh, you know, in our, in our clinic, you know, being able to give that positivity to patients, you know, continuing on throughout their day, um, continuing on, you know, then it, you know, spreads to their, their families and their communities, you know, uh, positivity, I feel like is like a seed. Once you plant it, it blooms and it, you know, kind of affects everyone. Um, so, you know, I really see it as like a very positive thing, you know, especially if you go back to the, you know, the science of addiction and how it works with, um, those that have a stimulant use disorder, um, you know, their, their brain chemicals are so altered that, you know, any kind of, you know, positivity is, is such a big thing for them because, you know, all of their chemicals are so often so low that, you know, just even, um, you know, any little tiny thing, you know, can be really, really positive, you know, going forward for them. Great. Does that seem to be consistent with your, your experience, Kate? Yes, I definitely, uh, have experienced that with not only, uh, when delivering, uh, CM, sort of that, uh, for lack of a better term, therapeutic alliance that can occur that, uh, that, uh, is really powerful. Um, you know, folks just like coming in and having, uh, someone that they can, uh, share good news with, bad news with. So that's really wonderful. Um, so not only for the participant relative coming in, but then we've also had folks that, uh, are delivering CM and they don't want to do any other part of their job. They just want to do, um, contingency management because it's, um, it is a positive approach and something that you don't always encounter in a treatment context. Um, you know, and then it can really help, uh, participant relatives build on success as well. So, uh, yeah, I definitely think that, that that's great and, um, agree with what Monica said. And also I'm just really excited to, uh, hear the update, Monica, cause we haven't really, um, been able to keep in contact about all of the details. So we did not pay Monica to be so nice, but thank you for everything that you said. Um, but it's just really, uh, very impactful to hear that, you know, you've had a positive experience and that your program is going strong. So, um, we're a resource here and happy to support other folks that are interested in, in this work as well. So I don't know, Dr. Martinez to, um, if you have other comments or questions or, um, Well, just real quickly, um, it, how much is, uh, my, my thought was, uh, that there, it does seem that CM is best done in alliance with, or, you know, using a foundation of, of, um, motivational interviewing. And, um, how much is that a part of the, part of the, you know, protocol of care or engagement? Yeah. So, uh, it's not required or even a part of, uh, the contingency management protocol, but it's certainly a tool that clinicians and other folks like to integrate like motivational interviewing as part of, uh, delivering CM. And, you know, it certainly, uh, is in alignment with, uh, that philosophy. And I think it, it has been a really good approach. Um, that's also the other thing that we really appreciate, appreciate about contingency management is that it can be delivered, uh, by community members, like I mentioned, elders, uh, peer support. Um, so it is different than other interventions in that you don't need to have that higher level of, uh, credentials or, you know, letters after your name or anything like that. It really can be, uh, more accessible to, uh, communities who might not have the resources for that. Um, so it can, uh, assist with sort of workforce issues related to that. Um, of course those always, you know, have continued to be a problem and continue to impact services for many rural areas. Um, but that's one thing that we, um, do encourage is the person delivering CM, um, you know, can be, uh, can be, uh, an elder or other, uh, leader in the community. Yeah. Great. Great. It sounds like a great, um, uh, alliance of skills anyway that, that, uh, tends to happen. Um, so I'd like to move into, um, question and answers from the group. So I invite folks to, um, to either chime in or, um, to put your, your questions in the chat. Um, sorry, Dr. Martinez, we do actually have a couple of questions in the chat already from a couple of participants. So, um, I'm going to go ahead and read the first, the first one. So, um, Chantelle Graves had asked what impact on tribal healthcare operations does the eliminating kickbacks in recovery have or should be considered by health centers when discussing CM? Yeah, so great question. Um, so you might be aware that, um, safe harbors for incentives, uh, there's been some change around that in 2020, which has really expanded access to contingency management. Um, but contingency management itself doesn't have its own safe harbor. So, uh, that's why as Monica, uh, highlighted, there's the $75, uh, limit when using federal funding. Um, that's not to say that you can't use other, uh, sources of funding. So one suggestion that we've talked about in some, uh, state, uh, sites and potentially in Washington state to some of the, um, tribal communities are thinking of using their opioid settlement funds for contingency management. Um, and then we've heard that hopefully the $75 limit, um, will be lifted at some point. Um, but that is still in the works and, uh, definitely, um, sort of, um, a political factor right now. Um, so we're hoping to hear back about that soon, but it might, uh, be a little bit longer. Um, so other folks have just stuck with the $75 related to, uh, the incentive cap to maintain, uh, compliance within their program. Others have decided to supplement, um, to get that full dose of around 300 to $350. Um, there's been some other, uh, waivers, Medicaid waivers have been another approach that folks have used. Um, so, uh, in California, Washington, and then hopefully in Montana, um, uh, CM is now going to be offered as a, uh, Medicaid benefit. Um, so that's really exciting. So there's been a lot of work around, uh, this, but it's definitely, definitely a work in progress, but yeah, great question. Happy to chat more about that too, if you have follow-up questions. Great. Thank you. And I think that kind of touches on Chantel's second question, which was anything else on gift giving or renumer- renumeration when engaging with Medicaid beneficiaries is much, much appreciated. Yeah. So our general sort of, um, thought around that is just not tying the CM visit to a billable Medicaid encounter. So you can still, um, you know, have participants that, um, are covered under Medicaid. It just needs to be a separate sort of program, um, and noted separately within the, uh, client participant relative record. Um, but again, if you are in one of those states like Washington, California, Montana, um, and potentially I think they're, uh, looking into Medicaid waivers, I think in Vermont and maybe a couple other states, uh, it might soon be a Medicaid, um, benefit. So that's something to look into as well, depending on where you are. Right. Well, there's, that's great news that there's some, some developments happening in that area. Um, in respect of everyone's time, I see that we're going to shortly run out of time. So I'd like to, um, kind of move forward and, and, um, ask Kelly to, uh, go over some closing thoughts for, um, our presentations and we welcome you to participate in our next sessions and, uh, really look forward to growing our knowledge together. Thank you, Dr. Martinez. Um, so on the slide here, we have the next three webinar topics that are coming up for February, March, and April. Um, February will be over harm reduction. March 28th will be the naloxone saturation and mapping for tribal communities. April 25th, um, is around substance use with pregnant women. So, um, we will be sending out those links for registration soon. Next slide, please. Our next webinar will be held on February 29th from 2 to 3 30 PM Eastern time. We'll put the link in the chat and have provided the QR code for your convenience. Next slide, please. And we'd love to hear from you. If you have any questions or would like to submit a TA request, you can visit opioidresponsenetwork.org or email us at ornatripleap.org. And we, we thank you for all that you do. And we hope you'll submit a TA request and utilize the assistance we can provide. And I'll hand it back over to Dr. Martinez to close us out. All right. Well, I'd just like to thank everyone for this rich exchange of knowledge or your participation in today's, um, learning. Uh, as we go forward in this series, we, we, uh, look forward to your involvement and we appreciate all of the work that has been in communities and programs, uh, as well as the development of knowledge, uh, that will ultimately benefit our communities. So with that, thank you so much. And we will go ahead and close up our session for today. Thanks everyone. Have a great day. Appreciate you joining. Thank you.

contingency management

behavioral therapy

positive reinforcement

substance use disorder

cultural adaptation

tribal communities

alcohol use disorder

stimulant use disorder

community engagement

abstinence rates

reductions in substance use

recovery journey

technical assistance