My name is Emily Mossberg, and I am a coordinator with the Opioid Response Network. I want to acknowledge that funding for today's presentation was made possible in part by a grant from the Substance Abuse and Mental Health Services Administration, or SAMHSA. The SAMHSA-funded Opioid Response Network assists organizations and communities by providing free training and technical assistance on topics related to prevention, treatment, and recovery for opioid and stimulant use disorders. And to do the work that we do, we work with consultants in all 50 states who can respond to local needs, and anyone can submit a request for assistance on our website at opioidresponsenetwork.org. We are honored to be partnering with Lane County Treatment Program to bring you today's training on contingency management. This training will be led by our consultant and trainer, Al Hassan, who will now introduce himself and take the lead. Oh, Al, I realize I never said your last name before. Hopefully, I just said that correctly. But yeah, I will go ahead and pass it over to you to introduce yourself and get us going. It's all great. Thank you, Emily. I appreciate it. And it's nice to see everybody in Lane County there. My name's Al Hassan. I've been fortunate enough to have recently retired from work at the UCLA Integrated Substance Abuse Programs. I was there for about 20 years. Prior to that, I worked at the Matrix Institute on Addictions, where we developed a matrix model. You may be familiar with that, a CBT model to treat stimulant use disorder. I've opened and operated many opioid treatment programs here in California, both in Northern and Southern California. Recently opened an opioid treatment program for the Pinoleville Pomo Nation up in Ukiah, California, not too far from you all. And more recently, been working with a number of state agencies in terms of developing programs for contingency management, addressing both opioid and stimulant use, and have been working for a little bit with the Opioid Response Network and Emily and some of the folks down here at the UCLA Integrated Substance Abuse Programs. So it's great to meet with you all. I do miss being in the program and having the hustle and bustle of the day-to-day activities. It's always nice to be able to do that. So today what we're going to cover, some national trends in stimulant use. I know that you're an opioid treatment program, but my guess is that you probably have a fair number of individuals who are using stimulants, probably most likely methamphetamine, maybe some individuals who are using cocaine along with the opioids. And the reason we're going to talk so much about stimulants today is really the research support for contingency management is primarily centered on the work for stimulant use disorder. There's a number of medications that are in development for the treatment of stimulant use disorder, including the combination of extended release naltrexone and extended release wellbutrin for methamphetamine use disorder, and also the combination of extended release naltrexone with buprenorphine, believe it or not, for cocaine use disorder. So the trial for methamphetamine is called ADAPT. The acronym, I always forget that, but it can be, ADAPT can be, you can access information on that on the clinical trials network, the CTN dissemination library, CTN dissemination library. And the second trial is CURB, cocaine use reduction with buprenorphine. So I'll put those into the chat a little bit later. We're going to talk about the research support for CM, the psychological and behavioral principles around CM, really the essential ingredients to have an effective CM program, and then some of the challenges that you might encounter. So in terms of drug overdose poisonings or deaths, this is an older visual, but really why I have this is really to demonstrate what we saw from right around 2014 through current. And that is that synthetic opioids, while they were the primary driver of opioid overdose deaths, stimulants in the blue line here were pretty much keeping pace with what was going on with primarily fentanyl. What we saw last year, or at least the most recent data that we have, is that all drug mortality as related to overdose deaths increased by about 16%. That's this column here. Heroin use is down, and subsequently the overdoses from heroin are down. Natural and semi-synthetic opioids, along with methadone, really haven't been much in the way of drivers for overdoses, but as you can see, semi-synthetic opioids up 25% from the period ending November of 21, beginning November of 20. And you're probably seeing this within your community, is that there isn't so much in the way of heroin in the drug supply these days as much as there is fentanyl. Cocaine overdose deaths increased by about 20%, while as other psychostimulants, primarily methamphetamine, increased 36%. So you can see what the drivers are these days. One of the biggest challenges that programs are facing these days, and it's not just here in the West, is the combination of stimulants and fentanyl, primarily methamphetamine in the more rural areas, and cocaine in the more urban areas. One of the biggest challenges that we have with methamphetamine these days, and as you can see, the early part of this graph here is from 2000 to 2004. And what we're looking at is the purity and the potency of methamphetamine. So this here, this graph is really looking at the purity. And around 2004, the purity was about 57%. It was diluted significantly. When you flash ahead to 2016 to 2020, and currently, the purity is well over 96%. So the drug that we're seeing today on the streets is not the same drug that we're seeing that was produced early in the early 2000s. This is the purity and the potency. The potency is what we're looking at in terms of the red line, and the purity is what we're seeing in terms of the blue line. So people that are using methamphetamine these days, they're going to be impacted at a much, much greater level than they would have been 20 years ago. And you're probably seeing this in folks who have cognitive, really being impacted cognitively. They're not able to think clearly. They're not able to make decisions about their own health care as easily as they once might have been. They're having more difficulty maintaining relationships with significant others, and additionally, may not be able to hold down a job as they once might have been able to just because their inability to really, one, be social and to be able to process information in the way that they used to be able to. Now this is another overdose death graph involving psychostimulants. The blue line here, the blue bar, is really just all psychostimulants. The yellow line here is psychostimulants in combination with synthetic opioids other than methadone. And so what you can see is that the combination of methadone, or not methadone, but synthetic opioids, primarily fentanyl, and psychostimulants is certainly continuing to increase. And I would imagine, though I'm not 100% sure, that you're probably seeing the same in your area. And my question to you then would be, about what percentage of your patients who are currently maintained on methadone or buprenorphine are testing positive for methamphetamine? Somebody can just yell it out. 50-plus, I'd say. 50-plus percent, OK. Yeah. You know, I would say that, thank you very much for sharing that, you know, we're working with programs in Indiana, West Virginia, South Dakota, and also Minnesota, but we're seeing upwards of 50-65% in terms of the concurrent use of methamphetamine, along with methadone at this time, but also primarily people entering treatment who are using fentanyl. Some of the clinical challenges that we're facing these days are really the lethality of the drugs that are out there these days. You know, for the longest time, people were completely unaware that they were using fentanyl, or that there was fentanyl in the drug supply. I think there's no mystery about that anymore. I think that more often than not, I think people are expecting to have fentanyl in the drug supply. Sometimes what they're not expecting is, you know, to either have methamphetamine if they're primarily seeking an opioid in the drug supply, but the reverse of that is those individuals who are using methamphetamine are generally not expecting to have an opioid, you know, in the sample that they're using, and in many instances, that is sort of what's driving the overdose deaths, you know, relative to methamphetamine. You know, most people who are using stimulants, really, they don't have a great understanding of the impact that stimulants have on them, and don't really think of it in the same way that one might think of either, you know, alcohol use disorder or alcohol addiction or opioid use disorder. It used to be that, you know, and this was years and years ago, that people thought of stimulants like potato chips, you know, you eat a bunch of potato chips, once the bag is gone, you know, everything's cool, we're good, but that's not the case, and the fact is that people pretty much do have a limited understanding of stimulant addiction, primarily because it doesn't mimic what we see with other substance use disorders, you know, the typical withdrawal pattern isn't the same with stimulants as you would see with alcohol or with opioids, and therefore, lots of times people think that, you know, that they don't really need treatment. Maybe they can go a day or two days or three days without using, sometimes maybe even longer, but there's the tendency to return to use, and so in some instances they think, you know, I don't really need to, you know, to get care. We clearly know that people have, you know, impulsivity and poor judgment relative to what's going on, either in terms of their education or their employment or family issues. We do know that there is significant cognitive impairment and that individuals' memories are impacted, and then, not necessarily above all, but what we're seeing is that anhedonia, that inability to experience pleasure, things that used to bring them pleasure are no longer, you know, providing sort of that same outlet that it once might be, you know, going to their kids' baseball games or sporting events or dance events or things of that nature, just doesn't cut it anymore. You know, family get-togethers are not that enjoyable, so it's that gray film over their eyes that really defines, you know, their, you know, sort of existence at this point in time, and we define that as an anhedonia. We have hypersexuality initially, you know, when it comes to stimulant use. People are oversexual, you know, and in terms of, you know, their drive and their ability, and then as their use continues and exacerbates, it's more hyposexuality. They want to engage in, you know, in sexual activities, but they don't perform nearly like they did, you know, initially. There's the psychosis and the violence that goes, you know, along with it, and then that Pavlovian, you know, the trigger-craving response that, for some people, is really difficult to understand. You know, why is it that, you know, when they go in a certain neighborhood or they run into a certain individual, you know, why is it that they begin to have a physiological response that mimics, you know, how they would feel when they're under the influence of a stimulant, and it's that craving, that trigger-craving response that's really useful to explain to individuals who are using stimulants. Those individuals who are using opioids, you know, it's more of a timed sort of event for them. You know, they wake up, they have to use, they have to use, you know, two to four hours, you know, throughout the course of the day, and their body just tells them that. Usually there isn't, you know, I mean, there may be some environmental cues, but their trigger-craving process really isn't driven by, you know, environmental cues like it is with individuals who are using meth or cocaine. We see elevated, you know, rates of psychiatric comorbidity, you know, the number of ED visits relative to methamphetamine has increased significantly across the nation. It's a challenge to engage folks in treatment, and then once we get them engaged, it's really difficult to keep them in treatment, and their retention rates are significantly lower than what we see in the treatment for opioid use disorder. The fact is, is that, you know, even within your population, my guess is it's more difficult to keep people who are concurrently using methamphetamine and on, you know, and either receiving buprenorphine or methadone in treatment than individuals who are primarily or solely using either methamphetamine or cocaine. And so my question to you is, what would you say the dropout rate for individuals who are using both methamphetamine and are in treatment for an opioid? Yeah, the majority of the folks that drop out of our program, I would say at least 90% are using methamphetamine. I had a little, I had a little trouble hearing you, I'm sorry. So out of the 50% that we were talking about earlier, 90% of those drop out that are using methamphetamine. Is that 9 or 9-0? 9-0. Wow. Okay. So, so yeah, it's, you know, that's a huge, that's a huge number. And so, you know, it's, if, if there's anything we can do to reduce that rate, I mean, 90% is huge. And, and I guess the question that I would, I would have is what is the average retention rate, you know, in terms of length of time for those individuals? Less than a year. Less than a year. Okay. And, and, and what would you say the comparative rate is for individuals who are not using methamphetamine? Five plus years. Five plus years. No, that's, that's terrific. Boy, I'll tell you what, if, if, if we could get other programs to have retention rates as high as yours, boy, we'd be doing a great job because we're not seeing five-year retention rates in programs across the country. Nice job with that, by the way. So, as you know, I mean, retention is the name of the game. I mean, the longer we can keep people in treatment, the greater likelihood we're going to get them engaged in educational opportunities, keep them employed, keep them with their family, keep them out of jail. So, you know, certainly with individuals who are using stimulants, if we can engage them and retain them, we've done something significant. So, let's take a look at, there was a study done by McMahon, you know, and he was looking at syringe programs in Washington State, and they had a sample of about 600 individuals, excuse me, the majority of whom were going to the needle exchange primarily for opioids, about, you know, three quarters, you know, were going for opioids, and another quarter were going in because their primary drug of choice was methamphetamine. Of those people who were asked, 82% of the individuals who were reporting using opioids as their main drug expressed an interest in actually stopping or reducing their opioid use, while only half, or just about half, of those who were using methamphetamine, primarily methamphetamine, expressed an interest in, you know, cutting back. And so, what we see is that, you know, this was that, this goes back to that ambivalence about really the need or the desire for treatment. Now, there was a meta-analysis done by Lappin of in-person psychosocial SUD treatment, and it looked at dropout rates for the first 90 days of treatment. They looked at 150, you know, over 150 studies, over 25,000 individuals, and they came up with, in some ways, predictors of dropout rate. And one of the biggest predictors was what the substance was that individuals showed up with, right, or were in treatment for. As you can see, the dropout rate for individuals using heroin or in treatment for heroin was about 25%. Tobacco was about 25%. Alcohol, just a little bit greater than that. For cocaine, nearly 50%. And for methamphetamine, over 50%. So, you can see that, you know, what we're providing to individuals specific to stimulant use is probably not hitting home the way it might be for heroin use, and and heroin, tobacco, or alcohol, for that matter. And I think it's primarily because, you know, we have effective medications for the treatment of heroin use, for tobacco cessation, to help, you know, maintain individuals in treatment for alcohol use, but we haven't done such a good job in terms of coming up with medications for the treatment of stimulant use disorder, even though we've tried any number of combinations. One of the things that's really important for us to do is to engage in, you know, harm reduction. People are now talking about really addressing, like, low barrier interventions, just trying to get people engaged in any way we can, providing them information about, sort of, the impact that meth has on psychiatric and medical conditions, providing individuals with overdose education, you know, syringe exchanges, new syringes, naloxone, of course. I mean, boy, where would we be these days without naloxone, you know, just in terms of making it available to individuals and individuals, families who are, who are using opioids, whether it's prescription, you know, or not. Talking to people about not using drugs alone or using, sort of, a test, you know, you know, trying it out a little bit before, before injecting the whole bolus. Taking turns, you know, monitoring, you know, each other, you know, as a way to be safe. Have, you know, some of the, some states that we work at, you know, have safe injection, safe injection sites. I'm not sure if you have those in Oregon. I believe that they had them in Portland. Maybe I'm mistaken, but certainly in New York City, there's, you know, safe injection sites where you can monitor the individual, where they can, sort of, get cleaned up, you know, and come down off the initial high and then go about their business. Condoms, safe sex, antibiotic creams, ointments, you know, wound care, those sorts of, those sorts of things are, are incredibly helpful, especially with, with xylosine, you know, these days. Are you seeing much in the way of xylosine in the drug supply in your local community? Yeah, definitely. Yeah. Boy, it's hideous, isn't it? I mean, what, what you're, what we're seeing in terms of what it does to individuals and, you know, in, I'm working with a program in Philadelphia, a mobile unit that's going into Kensington Gardens, which is like ground zero for, for the xylosine, you know, epidemic. And, and one of the things that, that people won't do there is they won't use drugs with other people because what ends up happening is when they do use bad thing, you know, with other folks, unless it's somebody that really cares about them, bad things happen. And so they're, they're using, you know, off by themselves. And, you know, when you're off by yourselves, you can't really combat an overdose using, using Narcan. So it's a, it's a dual edge sword there. Any questions or comments so far with where we're at? Firstly, I'm kind of blown away by your statistics as far as 97% pure methamphetamine, when nowadays it's only 10% of the price on the street that it used to be in the eighties. It's like a complete different, you know, I don't, it's just a complete different product nowadays. It stays in the system for, I mean, I have patients where they stopped using, I can tell they've stopped using and it's taken four to five weeks for it to leave their system when it used to take, used to take me 72 hours. Yeah. I'm so glad you mentioned the cost. I mean, that it's, it's crazy because the cost as the potency and purity has come down, the gone up, the cost has come way down. It's as, it's as cheap as I'm, I'm really glad you mentioned that it's as cheap as it's been in 20 years, you know, and, and that combination, I, you know, is just it's deadly. And, and like you say, it, it really takes a while for a person's brain to heal over a period of time. And, and I think for some folks that's incredibly frustrating, even though, you know, they're, they're doing everything right. They're doing everything within their power to not use, but yet sort of their thought processes and cognitive capacity isn't responding nearly as quickly as it once did. So yeah, what, what you're seeing is, is fairly common, you know, throughout, throughout the nation these days. Yes, sir. Go ahead. Where can we find more information about the effects on the brain that's used in neurons Oh, okay. I, so there are the, the, the best resource that I have for this is the work done by Edie London, Edith London. She's a brain imager at, at, within the, the UCLA department of medicine. You can, you can just, you can Google her work and, you know, her, her papers on she's, she's done some of the foremost work on the impact that, that, that stimulants specifically methamphetamine has had on, on, on cognitive functioning. She's done some work there. Sarah Simon is another individual who's, who's done some work in that area. She's been retired for a bit. Her work is a little bit older, but Sarah Simon's another, another individual. And the, the last person that, that one of the other person is Linda Chang, C H A N G. She's at the university of, of Hawaii, and she's done significant work on the, the cognitive impact on, on brain functioning and cognitive capacity in methamphetamine users. Yes. You know, most of those individuals, they're, they're not usually treatment providers. Sarah Simon was a treatment provider. Edie London and Linda Chang are not, are not treatment providers, but I, I can probably sort of ferret out a couple, maybe resources in terms of well, I can actually talk to you about what to do treatment wise for those individuals who are having difficulty. We, we can talk a little bit more. We can talk a little bit more about that. You know, it's, it's one of those things that you have to go slower, right? You have to give them an opportunity to be able to respond to you. So you have to be patient. You can't just jump in and sort of cut them off because it may in fact be that they are thinking about their response, but you know, the, the, the synapses aren't working as well as they used to. Multimedia, having videos, using a, you know, a dry erase board. You know, those things are really important. Having fewer words on a piece of paper so that they don't have to read or sort of, sort of giving them bits of information in smaller doses. Group length and group size. So shorten the length of the group or provide breaks. Having smaller group sizes so that people can process information. One of the things that we like to do is to have increased the frequency of the group, but the problem is getting people in, right? So that can be a challenge sometimes. So those are some of the things that we've found incredibly useful with working with individuals who are experiencing, you know, the, the, the cognitive sort of impact. Now I can, I'll go ahead and, and try to come up with some additional resources for you and, and, and send those along to Carla so that she can distribute it. Okay. Thank you. Great. Great question. I have a question. Can you hear me? I can go ahead. I was curious, you had shower and quiet rooms in your harm reduction bullet points, and I was wondering how that worked. Yeah. So, so, you know, I don't know if you have sobering centers in, in your community, but one of the, here in, in California, certainly in San Francisco and in Los Angeles, we have sobering centers where we can, you know, where usually first responders are, instead of taking these guys to jail or taking them to the emergency department, they're taking them to a sobering center where they can, you know, they can rest, they can, you know, they can get some sleep, they can get some food and, and they can, you know, be placed in a room. It's not locked where, where they can sort of settle down and calm down a little bit, get a shower, get some food, those sorts of things. So if, if, if you have those, they can, you know, they can be an opportunity to engage individuals, maybe in sort of thinking about accessing care, think about entering treatment. It's a, it's an avenue to sort of, you know, that, that reducing any barriers to care. Yes, sir. What if those resources aren't restful? So there are fewer resources for homeless people. So where the resources are, are also homeless people together and they're not good to each other. Yeah. Yeah. You know, it's, I tell you what the homeless issue is, I think is, is sort of one of the more significant barriers to getting people engaged in treatment, because once you, you know, you can get somebody engaged in treatment or you can get them to, you know, one of the sobering centers and then they're right back where they, right where they were. And, you know, it's a, it's an incredible challenge. You know, here in LA, you know, we're still at like 50,000 homeless individuals. And anytime you go downtown, you know, you can see how devastating, you know, how it just, just how troubling it is. So, yeah, I don't have an answer to that, to be completely honest with you, but, but I concur that that is, that is a big challenge that many communities are facing. So let's take a look at contingency management and, and the research for it. There were some, a number of systematic reviews and meta-analysis where they, they, they looked at a whole bunch of trials. And, and really what they found is that relative to the treatment of stimulant use disorder, CM has the most robust evidence, you know, in terms of its effectiveness. Other sort of approaches with lesser sort of impact, but, but there's still evidence of support is, is the use of CBT and the use of the community reinforcement approach. Motivational interviewing is helpful regardless of what interview, what, what intervention you're engaging in. Anytime that you can, you know, engage people, you know, in a, in a process of talking about their recovery, talking about their addiction, getting them to sort of recognize the, the, the, the value of treatment and create sort of that disparity between where they are right now in life and where they would like to be in a couple of weeks, a month, a couple of months, you know, or a year is, is really, is really helpful. Combining that with a shared decision-making approach, I think is, is really helpful, but also getting people engaged in exercise. If, if you can possibly do that, we, we did a trial here in Los Angeles. Rossin, Dr. Rossin was the investigator. We did a trial at play program, residential program called CryHelp, and we got some really good results in terms of being able to improve cognitive capacity, improve, you know, physical conditioning and, and engagement in recovery by getting people to exercise and, and, and having exercise equipment available to them. So Ashrani and Bensley basically came up, they did, you know, again, a, a, a meta-analysis and they basically said, look, contingency management is the most effective way to help people stop using. There's been over 60, you know, studies that demonstrate that CM works to reduce stimulant use for people who are receiving MOUD. So, you know, if you just target, you know, for those people who are on methadone or on buprenorphine, if you just target their stimulant use, it can be effective. CM has higher retention rates. This goes back to Steve Higgins' work and at the University of Vermont going way back into the, the 90s. The effects of CM can, you know, has shown that the intervention, even after the intervention ends, you know, can have a pretty significant impact. If you, if you target other behaviors, including alcohol use, smoking cessation, it, you know, it, it, it can be effective as well. And it's, it's cost-effective as shown by Nancy Petrie's work back in the early 2000s. We know that it's, you know, culturally, it's been accepted in a number of different countries. Ying Sir here at UCLA had done some work in China with CM, and it was shown to be incredibly effective. Mike McDonald at Washington State University has adapted it to fit American Indian and Alaskan Native communities. It's been shown to work with MSM by Steve Shopta's work at UCLA. It's also shown to be, you know, to work with co-occurring, you know, mental health disorders as well. That was Mike McDonald's work. Some of the more recent evidence, you know, in terms of, you know, the more broader benefits of CM, it has greater drug adherence. And when we talk about adherence, it's really, you know, you're looking at adherence to either, you know, medications for opioid use disorder or medications or medications that are being, you know, used to treat mental health conditions, impact on utilization of medical services. We see that it's done that. And in reduction in risky sexual behavior. So CM, it's worked for HIV management. There are some, you know, published studies on that. We know that voucher reinforcement or prize systems, you know, providing, you know, cash incentives, which is really not what not recommended. Certainly we don't recommend that you provide cash incentives, but it's been shown to reduce, you know, HIV risk behavior and HIV medication adherence. I'm not sure if it's actually been tested on PrEP adherence, you know, at this point in time. Controlled studies on the topic of TB and, you know, TB care, hepatitis, and basically what we're seeing is that contingency management is effective across the treatment of, and implementation of medications or use of medications in other infectious diseases besides substance use disorders. Now the, the, any, any questions or comments so far? I try to keep the, yeah. Yes, sir. Yeah. I love that question. You know, and it's, it's really important. So really what we try to use is gift cards, gift cards that individuals cannot use to buy alcohol or to buy tobacco products. However, that doesn't mean that somebody can't sell their gift card. Okay. I mean, we, we, we know that that, that that stuff goes on, but, you know, asking your patients sort of, you know, what sort of gift cards would they find useful? And, and what we've seen is that people like gift cards for gasoline, for groceries, you know, for convenience stores, you know, whether it's dollar stores or Walmarts or those sorts of things. Yes, sir. Have there been any successes with like items that are not money, like a book or like a quote on a shirt or jacket? Oh yeah, absolutely. So, you know, there's, there's a, there's a difference between what we refer to as CM, contingency management, and incentives. Okay. Smaller rewards are generally considered incentives. One of the first projects that I ever worked on was at a needle exchange. And we used to get donations from the, you know, Starbucks. We got donations from a number of the music industry. They would give us CDs when CDs were incredibly, you know, useful and popular, which they're not now, but t-shirts and things and things of that nature, right? Somebody would come in, they would exchange their, their needles for, for clean new needles, and they would get to choose from the prize box. I mean, which was, which is great. Leslie Amos working with pregnant and parenting moms at our OTP, at the Matrix OTP in Los Angeles would get donations of diapers and, and, you know, baby clothes. She would get formula and all sorts of donations from the community. And she'd have a prize, you know, a prize closet. And she would, when people would come in and provide a negative UA, or if they would attend group, they would get a choice out of the prize, you know, closet and people love that sort of stuff. So there's a number of things that you can do. Donuts, you know, donuts at group, you know, I know that people, people push back against the sugar and stuff like that. But I can tell you when I'm walking down a hall going to group, and I got a pink box of donuts, and people are asking me, Al, can I have a donut? I say, yeah, come on to group. I'll give you a donut and a hot cup of coffee. Group attendance improves. There's no question about it. So there's a lot of things that you can do to, you know, to, you know, to provide incentives. But what we're specifically going to talk about is, is contingency management and sort of the level of reward that we need to achieve in order to be able to refer to it as contingency management and have its greatest impact. CM is, is really the systematic delivery of positive reinforcement for specific desired behaviors, specific desired behaviors. It can't be that people have to guess what that desired behavior is and what the reward is going to be. Everybody has to know what that is from your, you know, the administrator to, you know, the, the, the, the, the person working in the reception area to, you know, you know, to the counselors, patients, dispensing staff, they have to know what that is. And it's usually a voucher or a gift card. And there's a number of ways that that can be delivered. It can be delivered electronically because there's a number of sort of app-based programs that can be used for this, or you can give it in the form of just a, you know, one of the regular plastic gift cards. So I, you know, that's, that's, that's really what CM is. We're, we're looking at targeted behaviors. In this instance, what we really like to see are stimulant-free urine samples. I mean, it's, it's that, it's that precise and, and, you know, confined to that. There's completion for other, other target behaviors. We'll talk about that later. Now, where this is based on is really classical conditioning, you know, and, and operant conditioning. So we, we know that, you know, in terms of classical conditioning, if we associate a neutral sort of event, person, place, or thing with something that produces a powerful physiological response, then before too long, that either event, that person, place, or thing is going to be so closely associated with that powerful physiological response that just the sight of that thing is going to produce the response. And in, in the labs, in Edie London's lab, you know, we've shown paraphernalia to individuals who have a stimulant use disorder and monitored what happens in terms of the dopamine receptors, and it produces as powerful a response as the drug itself does. Now we, we show those same things, those same sort of triggers, or those same pictures to individuals who have never used stimulants, and we don't get a response at all. It's almost like showing them a hammer. There's, there's no response. And so what we know is that this association can be incredibly powerful to where it'll drive the individual towards using. And so that's really that what we're talking about is the development of, of, of trigger craving response as it relates to a substance use disorder. Now, in terms of operant conditioning, what we know is that positive reinforcement increases a targeted behavior. All right. You know, when you get paid to go to work, you know, you tend to show up to, you know, to work because you're getting paid when, when you do something and your, and your boss says, Hey, that's that, you know, I really like, you know, that you went that extra mile. That's a, you know, that's a positive, positive reinforcement, much the same way that, you know, if you have children, you give them that, you know, sort of positive reinforcement, even, you know, either through sort of words of encouragement, or you give them an allowance for engaging in a certain behavior. Then there's negative reinforcement, negative reinforcement increases a targeted behavior as well. Sometimes we get that confused with punishment. Let me ask you something. Give me, describe something that you, something in the, that you engaged in today, that is an example of negative reinforcement. Putting on a helmet when I rode my scooter. Say that again? Putting on a helmet when I rode my scooter. Okay. So, so, but what was, what was the reinforcer? I would be avoiding a ticket and personal injury. Okay. So part of that is actually punishment. Okay. Avoiding a ticket. You know, that's the potential of punishment, right? It decreases the targeted behavior, which is so, which is why you put your helmet on for somebody. Okay. How did you wake up this morning? Alarm clock. There you go. That's, that's a negative reinforcement. It, it caused you to engage in a behavior, right? To reduce, right? To reduce that noise, to reduce that sound. How about when you got in your, for those of you who drove today, what'd you do when you got in your car? You put, why'd you put your seatbelt on? Hey, you wanted to get, you wanted to get rid of that annoying sound, right? And so those are, that's an example of negative reinforcement. And thank you for sharing the example of, of how punishment decreases, you know, a certain behavior, right? Not wearing your helmet. So you put your helmet on because you didn't want to get a ticket. That's awesome. That's good to hear too. So can, CM primarily works through the use of positive reinforcement. And I'm going to show you right now, an example of positive reinforcement. Let me know if you can, if, if this works for you. Are you finished? Well, thank you. How thoughtful. Would you like a chocolate? Uh, yeah, sure. Oh, sorry, Sheldon. I almost sat in your spot. Did you? I didn't notice. Have a chocolate. Thank you. You're here a lot now. Oh, am I talking too much? I'm sorry. Thank you. Chocolate. Oh, hey, Kim. Yeah. You know what? Hold on. Let me take this in the hall. Okay. I know what you're doing. Really? Yes. You're using chocolates as positive reinforcement for what you consider correct behavior. Very good. You can't train my girlfriend like a lab rat. Actually, it turns out I can. Now, were you able to hear that? Okay. Or no. Okay. All right. Um, this is, this was the next one is the example on negative reinforcement. I'm not really going to go into detail on that one. Cause I find this, this video somewhat annoying, but you get the idea of negative reinforcement primarily because, you know, with, with your, um, uh, with, with your seatbelt, but let's take a look at punishment. Turkey chili. Medium crab. You get any bread, just forget it, but a Coke. Oh, excuse me. Uh, I think you forgot my bread. Two dollars extra. Everyone in front of me got free bread. You want the bread? Yes, please. So you can, you can be reassured that he's not going to ask for bread the next time, right? And if he does, he's going to pay for it. All right. So let's take a look at, all right, let's take, let's take a look at reinforcement versus punishment. We know that both can change behavior. Most people obviously would prefer, you know, reinforcement over the, over the punishment, but, but what we do know is that punishment doesn't teach a new behavior. It only tells us what not to do. And, and, and the, the challenge is that punishment, you generally lacks that, you know, immediacy to be effective. If somebody goes out and steals something, it may be that they don't get caught right away. It may be that it, that it comes later. And so in order for something to be reinforcing one way or another, there has to be an immediacy. It has to, you know, it, it has to occur right near about the time that we identify the behavior. Positive reinforcement teaches new behaviors in a way that builds self-esteem and self-efficacy. And that's really what we're trying to do with CM. We see that with token economies in terms of, especially with, with, you know, adolescents, inpatient psychiatry, autism, you know, spectrum disorders, parenting interventions, you know, in terms of, you know, giving, you know, an allowance or sticky, you know, sticky notes or charts or, you know, AA or NA, we see that with 30-day chips. And, and, you know, we see that when you're engaging in MI, when you're, you know, you know, when you're validating what an individual, you know, says just in, you know, in, in, in terms of their engaging in, in change talk. Everyday life, I mentioned this, a positive comment from your boss, rewarding your team with an afternoon off, or for that matter, you know, buying the team lunch, you know, that's, you know, for, for, you know, having done something well. Those are examples of, of positive reinforcement. Now, in order to be effective, the behavior has to be achievable. I mean, it can't be something that is going to be too hard, too difficult to achieve. So for instance, in terms of negative UAs, if we, if we say that after your fifth negative UA, you're going to get a gift card, people aren't going to do it. It's going to be, it's going to be, you know, difficult, if not impossible to be able to achieve, achieve that. It has to be desirable. The incentive has to be something that, that, that they find of value. The timing of the incentive has to be paired right away, right with when, when that desired behavior is, is demonstrated, we have to give them the gift card right away. That's why it's important to have point of care testing so that, you know, we, we get the test, we get the sample, we test it. It's, it's either negative or positive. If it's, if it's positive, we provide additional, you know, some, you know, some encouragement. Hey, thanks for coming in anyway. What can we do maybe to help you reduce your use? If it's negative, hey man, great job. Hey, here's that $10 gift card or $15 gift card to Walmart or wherever it is that you have the gift cards with. It's only, the incentive is provided only when that behavior is demonstrated, only. And it has to be, the behavior has to be sort of frequently observed. And when it is observed, it has to be incentivized. So having, for instance, urine samples taken once or twice a week and incentivized once or twice a week, you're more likely to get that desired behavior. What we know is that drugs make us feel good. That's why people use it. You know, that's why, you know, it reduces anxiety, it reduces depression. And so that's, you know, the continued behavior of drug use is primarily because it makes us, it changes how we feel, either improves how we feel or it, well, generally improves how we feel or maintains our certain feeling. It's highly rewarding. And there's usually no guesswork involved. People know how they're gonna feel when they use. In terms of cocaine reward, this is work done by Higgins. And basically what we saw is that for people given the choice of either taking the drug cocaine or using or getting a reward, for a nickel people weren't gonna give up the cocaine. For a dollar, right, people tended to give up the cocaine. For $2, basically they would choose the reward over the drug. And so what we know is that the reward has to be of some significance in order for people to not use. $2 is a pretty low reward these days. I mean, especially, you know, but that was done back in the mid 90s. Today, 10, $15 reward usually gets people's attention. So CM offers a non-drug reforcer in exchange for abstinence. Small rewards can be effective, but sometimes not effective enough to get people to stop using. So for instance, you know, giving, you know, small rewards like, you know, a cup of coffee, a donut, you know, a granola bar, maybe toothbrush or toothpaste, things of that nature. Maybe some, you know, of course, you know, these days nail polish and, you know, and makeup or things of that nature are pretty expensive. So in fact, they might be pretty powerful rewards. What we know is that we're competing against something that really produces huge bolus, a huge release of dopamine in, you know, in our brain. And what we know is that even sex in, you know, in many instances can't compete with the impact that methamphetamine has. We get generally about a five times greater release of buprenorphine or dopamine in our system with methamphetamine as opposed to a sexual encounter. So the four real ingredients that we need to, for CM is, again, clearly defined target behavior, a frequently measured behavior, tangible incentives provided immediately upon recognition that the behavior is observed. And we have to withhold the incentive when we don't observe that behavior. So it doesn't mean we chastise or punish people, but rather we encourage them to engage in the behavior, encourage them to keep coming back. Those are the real ingredients in terms of what we're looking at. The behavioral goal, it does not require abstinence from other substances. So somebody may come in and, you know, if you're targeting stimulant use and somebody comes in and uses benzodiazepines or cannabis, but they have a negative stimulant UA, we give them the incentive, okay? This isn't all or none. Basically what we're looking at is targeting a specific behavior. We're not relying on self-report. What we're relying on are urine drug screens. Having, you know, the point of care testing and not sending it out is crucially important. And making sure that, well, we know that it's cost effective and it doesn't take any specialized training. However, what we do know is that we, it's important for us to keep track of these incentives from the moment we order them, you track it like medication. You know what I mean? You know, being in an OTP, you get and you understand, you know, how important it is for somebody to keep track of your buprenorphine supply or your methadone supply. It should, you should apply sort of the same rigor in it, rigorousness, rigor, as it relates to keeping track of your gift cards as you would for your medication. I mentioned this, that I think the best way to go is, you know, is through urine drug screens, making sure that the days are not sequential. So, I mean, if somebody tests, you know, positive on Monday, in all likelihood, they're going to be positive on Tuesday. So either you want to separate it by about three days, having a test on Monday and Thursday or a test on Tuesday and Friday, so that the drug has an opportunity to clear an individual system. Having an incentive manager, having somebody that pays specific attention to ordering gift cards, ensuring the safety, the security of those gift cards, not having every staff member, you know, have access to those gift cards, much the same way that, you know, not every staff member has access to medication. Here, they're talking about having a sort of increasing value for a negative, you know, every subsequent negative urine drug screen. I wouldn't necessarily go that direction. I would set a limit and keep it at that, either $10 or $15 and keep it at that. The challenge that we have right now is in many programs, you know, across the country, they don't have an 1115 waiver to where they can exceed the Office of the Inspector General's $75 annual limit. And so that's what you're having to work with if you don't have an 1115 waiver, is that you have a $75 limit on the amount you can provide. No incentive is given when the urine test is not submitted or is positive for stimulants. If it's positive, again, as I mentioned, encourage support, you know, offer, you know, sort of additional sort of opportunity to access counseling or to increase the interventions. So the stimulant abstinence is measured by point of care. Urine tests twice weekly is usually good. I mean, if you can do it once weekly, that's good too, because if an individual has so much control over their use to where they can come in once a week and test negative, that's a positive thing. But ideally we want twice weekly. So again, no recovery incentive is given when a urine test is not submitted. I don't like the escalation necessarily because it's cumbersome, you know, to provide a $1.50 increase for every negative UA and then you have to reset it when a person provides a positive UA. So if you start at $10 and somebody gets to 13 or 14.50, and then they provide a positive UA, you have to take them back to $10. In some ways that feels like they're being punished. So I don't really like the escalation. This goes into the escalation, so I won't go into a lot of detail, but we do have a number of, of programs that can do the escalation for you. I'm gonna move through this. In terms of, you know, this question came up a little bit earlier in terms of the, you know, coffee or donuts, you know, providing a pizza or, you know, upon graduation, you know, a random drawing for, you know, where people attend group and they put their name in and, you know, every time they attend group, they get the drop their name into a fishbowl or entered into a drawing. That's not really, you know, contingency management. You know, that's an opportunity to incentivize sort of a specific behavior. So Al. Yes. Before you go forward, so can you go back to the random drawing? Yes. So if it's incentivized, then what are you giving them? So if you're putting clients in a monthly or, you know, a jar and pulling them out, what are they putting? Okay. So if you look at sort of the more traditional sort of fishbowl techniques as developed by Nancy Petrie and Nancy, she's not with us anymore. She passed away, unfortunately way too early, but what she wanted to do was to reduce the amount of money it took to incentivize people, right? So she had 500 chips that she would place in a fishbowl of which the majority were something that said like, nice job or words of encouragement. And when I say the majority, she was talking, you know, you're talking about 400 of the 500 said, good job. 50 of them might've been like a small prize, like a new toothbrush and toothpaste, you know, any sort of very small prize that they can get, you know, a water bottle, things of that nature. And then she would have things like, so those would be small prizes. She would have a medium prize, like a $5 gift card. And then she would have a large prize that was like a $20 item, maybe something that you got from, you know, a donation like headphones or perfume or tickets to a movie theater, you know, things of that nature. So it was usually pretty difficult to get a large prize. More often than not, people got kind words or words of encouragement when they did draw from it. Carla, I hope that answered your question. Yeah, that was helpful, thank you. Okay. The positive approach, again, not everybody's gonna, you know, gonna do it right the first time or the second time. But basically, you know, we have to remain positive. We have to continue to encourage them to, you know, to sort of be excited about being able to participate in it. But when they do submit that negative sample, just, you know, being all aboard, just, you know, being all aboard and making sure that everybody sort of knew that they were negative. In terms of urine testing, you know, usually most programs focused on the consequences of a positive drug screen. Either you wouldn't get take-homes or you'd have your take-homes, you know, take-homes removed. Usually it requires abstinence from all substances. However, you're just looking to target, you know, I'm just saying this, but you might just look at target stimulant use because most of those individuals that are using stimulants drop out of treatment. Most programs use lab-based testing and that requires that we send it out and then seven or 10 days later, you know, get the results. Most programs are testing infrequently. And if you're testing, you know, if you're sending out the test or if you're testing infrequently, you're not gonna have the impact that you would if you're testing more frequently and if you're getting immediate results. And, you know, sometimes the urine test results have, you know, other impacts on child, you know, custody, probation, or parole. Usually CM, we don't, you know, we're not joining up with parole or probation or child protective services. This is strictly focused on, you know, stimulant negative UA results. The incentives are based upon the UDT results only point of care testing. We try to make it such that the intervention is about 12 weeks. And that the urine test results are really specific to negative drug screens for stimulants and not really part of the legal system. Again, motivational interviewing content, you know, that unconditional positive, you know, regard, the spirit of motivational interviewing really comes into play here. Understanding that, you know, these folks have been using for a pretty significant period of time, that methamphetamine is as strong, as pure, as cheap as it's been, it's readily available in the environment. And it's gonna take some time to, for people to actually stop using and for us to be, you know, as passionate as you have been recognize that, you know, recovery takes a long period of time. Here's some phrases that, you know, really look to engage, you know, individuals. Sounds like you had a tough weekend. I'm glad you came in today, told me about it. You'll have another opportunity to ensure, you know, earn incentives on Thursday. Is there anything I can do to support you until then? That's somebody that had a, you know, a positive test. Somebody, you know, who had a negative test, you earned your first recovery incentive today, nice job. Remember, you'll earn even more the longer you stay abstinent. Some of the implementation challenges that we have are that, you know, the Office of the Inspector General, you know, has a limit of $75 on the incentive per year. Unless you have engaged in, you know, or your state has an 1115 waiver. Even if you have an 1115 waiver, you don't want to go over $599. California has an 1115 waiver, Washington State, Montana. The reason you don't want to go over $599 is because then it kicks in where you have to have a 1099. It's important to have certain specific guardrails. You don't want to pay people to come into treatment. That's, you know, how CM really, how we got in trouble here in California, primarily because they were committing fraud. But I mean, what they were doing is paying people to come in and not engaging them in the intervention, but rather just paying them to come in and then billing as though they had, you know, had put in and had engaged in the intervention. So we want to stay away from that. You want to make sure that you keep really good records on the gift cards, you know, who orders them, who receives them, who's signing them out. You want to have the patient's initial that they received, the amount that they received, and the specific gift card that they received. You wanna make sure that it's for a specific behavior. Our recommendation, and this is what they're doing in other states as well, is that point of care, negative, stimulant, negative UA results only. So it's really targeted to that only. What we do know is that the greatest evidence for CM is specific to stimulants and the treatment for stimulant use disorder. Again, financing, you know, some programs, you know, the programs that I worked with, we used $1,200 when we were targeting cocaine use disorder and in our opioid treatment program in Los Angeles, people can earn $1,200 over 16 weeks. The reason we were able to do that is it was funded through the National Institute on Drug Abuse. So it was a research project that actually funded this project and it was stimulant negative UA results. We got incredible results. As you can imagine, you know, the opportunity for people to earn up to $1,200 can get somebody's attention and it did. Clients, they like it. They say, when I'm home and I see those rewards, I think, hey, I got this for staying sober. One of the most powerful things that I've seen are people who receive rewards and then in turn purchase something for a family member. So it's almost like they get a dual payback for that. One, they get the incentive from the provider and the encouragement from the provider. Then they go out and they buy something for a child or a family member, they give it to them and they get that positive reinforcement back from that member of the family that they gave the gift to. And so it's pretty cool when you see that. It's really powerful. Some of the challenges, you know, are internal. Sometimes our staff members think that, well, why should we pay people to be drug-free? Why should we pay people to do the things that they should normally do? And so the reason is, number one is, we don't have a medication that works like buprenorphine or like methadone for stimulants. The most powerful thing that we have right now is CM. And what we know is that CM works. So again, tracking incentives, making sure that we don't give too much, you know, beyond the $75 limit, and making sure that we comply with the guardrails that the Office of the Inspector General has set and those safe harbor sort of requirements that they have set up for us. Harm reduction. You know, when we look at harm reduction, really CM was initially developed as a way to reduce cocaine use in methadone clinics. And this goes back, there's so many studies on that. It's also been used as an approach for harm reduction by providing an incentive for people to bring in their needles, their used needles, and to be able to obtain clean needles. And so as a way to get people to engage in harm reduction and potentially to get them engaged in sort of low barrier interventions. Let's see, I'll move through that. Some of the safe harbor requirements. One is you can't advertise. Yeah, you can't put a billboard out there. You can't have sort of TV ads as letting people know that you're providing incentives. You need to document the value of CM in the treatment pan, or you have to have it included as part of your treatment plan. It should be used as part of a research-based CM protocol. In other words, you have to have a protocol in order to implement CM. It should be, you should document the outcomes, both negative UA results, but also whether it's, whether there's positive results as well. You should, the outcomes, the negative UAs are really the outcomes and what you're looking to document relative to its effectiveness. And you want to avoid tying CM visits to a Medicare or a Medicaid billable encounter. So in other words, you come in, we give you the gift card just for coming in. No, it doesn't work that way. It has to be sort of tied to a specific visit, a specific outcome. And that should be a negative, simulant negative sample. Can I ask a question? Yes. There was a study, this is unrelated in a sense, but there was a study done with Japanese parents on the way they process their child's test scores. And what they've done with Japanese parents, when their child gets a good test score, they talk to their child about how they came to get that good test score. So remember, you studied really hard. You got a really good night's sleep the night before. You ate a good breakfast. And they found American parents don't do that. They just said, great job. So I guess what I'm asking is, in giving the same gift card, so what happens once we got that negative way, is there an importance in sitting and processing that or kind of going over it? Or is it really just in that kind of linking that board? Does there need to be some bargaining? That's a, what a great question. What we do know is that when we've used electronic delivery system to deliver the incentive, it's had a positive impact. But what we also know is that there's that social currency, like you just described, that when somebody gives a negative sample in the clinic, if staff members recognize this and continue to encourage, hey man, you're doing a great job, and it's all staff members that are doing that, it has a pretty powerful impact on the individual. So yeah, CM in and of itself can work, but you don't wanna deliver it in a vacuum. You wanna get behind it and give it its greatest opportunity to work by providing that positive regard, the positive reinforcement above and beyond just the gift card. So yeah, if the whole organization is behind it, it's gonna work better. So here's some, here's some resources that, I mean, we'll get you, we'll get you a copy of the PowerPoint presentation. I should have put my name in there. You can reach me at Al Hassett, well, Carla knows how to reach me if she has additional questions. And here's an ORN evaluation. So if you can scan that and provide us feedback on the survey, we would certainly appreciate it. We have just a few moments for any other questions that you might have. I have a question on the CM. I think there was a conference prediction that initially one of the board couldn't agree. I'm gonna stop you here. Can you talk a little bit louder? Yes. Thank you. Do you want me to say it? Okay. I think it's an operant conditioning that early on you give positive, give reward with every positive outcome. But over time, you slowly start going to very random rewards. Is that correct? See, we don't want anything to be random. I'm sorry if that came across. It's just something that I remember from a long time ago. So one of the things that you might be describing is intermittent reinforcement, okay? Intermittent reinforcement is actually pretty powerful. And what it is is, so for instance, if you have a rat that presses a lever, right? And every time that rat presses a lever, they get a food, they get a bit of food, right? They're gonna know, they're gonna learn that every time they press that lever, they're gonna get a piece of food. However, and so they're only gonna press the food when they're hungry. Now, the rat that, if you have sort of a random sequence of when the food comes out, what it's gonna do is it's gonna cause the rat to press that lever incessantly because they have no idea when they're gonna get the food. It might be the second lever, it might be the third, it might be the fifth, it might be the 20th, but at some point in time, they're gonna be successful. I don't know if that's what you were describing, but intermittent reinforcement is incredibly powerful, especially when it comes to rodents. Now, the other thing, it's also very powerful when it comes to our kids. And I'm not saying our kids are vermin or rodents, but what I am saying is when they say, mom, can I have mom, mom, mom, mom, and we ignore them for the first, or dad, dad, dad, dad, and we ignore them, and then all of a sudden we give in, boy, what that does is it tells them it might not be the fifth time that they bug dad or mom, it might be the 20th, and so what it does is it reinforces that behavior of dad, dad, dad, dad, can I have this, can I have this, can I have this? That is intermittent reinforcement at its finest. Yes. I'm sorry, I didn't hear you. Can it be used in contingency management? It can, but it wouldn't be very effective, because especially, especially with stimulant use disorder, because if somebody gives us that desired behavior and we don't give them the reward, what's the incentive? Reward, does it start for always, or? Yeah, so for 12 weeks, up to 12 weeks, right? Is that what you had? Yeah, yeah. They can do it twice a week for up to 12 weeks, and every time they have a negative, you give them an award. You give them an award. That is if you have the funding for it. If you only have $75, my recommendation would be that you hit them hard, early, and fast, okay? That you give them like $15 the first time, 15 the second. You know, you're only gonna be able to do it five times if your maximum is $15, but hit them hard, hit them early, because you're gonna have the greatest impact. In California, we have a project, you know, I mean, they got a lot of dough here in California. They've devoted like $50 million to the CM project, okay? That's more than a lot of state agencies, you know, across the country have, but they're able to give up to $599 over the course of the year, and that is incredibly powerful, but they only, they are only giving it, or they're giving it twice a week, but they're only giving it for stimulant-free UAs. So UAs can have fentanyl in them. Yes. Okay, if you're targeting it for stimulants, then yes. Yes. Target more than one substance at a time. Yeah, that's exactly, so the people really know, I know it seems, you know, when we look at sort of, you know, recovery, lots of times we think of complete abstinence. This is really a measure to get people to move in the direction of healthier behaviors, and for them to realize that they do and can have control over certain behaviors, and that they'll be rewarded for it. So is it one substance at a time, or is it stimulant? So is it like cocaine and meth? Then it's like, they don't have cocaine in this one, so it's if they don't have both. So what I would do is target stimulants, period. Let me clear about what those are. Okay, cocaine, amphetamine, methamphetamine. Okay, so if somebody, look, if somebody's receiving medication for, you know, ADD or ADHD, they would not be appropriate for this, and they're using methamphetamine or cocaine, they would not be appropriate for this trial, for your study, or for your intervention. Now, this was sort of an overview of CM. We could meet to talk about how you might implement CM within your organization, specifically, really just looking to target certain behaviors within your organization, and what you can use to provide as an incentive. Yes, please. And I can, so let's see, my homework is to find some info on interventions, right, on behavioral interventions, specifically targeting stimulants as it relates to cognitive impairment, correct? Yes. Okay, all right, I'll get those to you. I'll also get you a copy of what California is doing and their sort of playbook as it relates to CM. It's probably the most sort of comprehensive CM sort of documented at this point. I'll get that to you to review. Is there anything else I was supposed to get to you? Would you be a good person to talk to about implementing a matrix? Well, I mean, I worked for Matrix for 20 years. I used the Matrix model for 20 years. I've taught CBT and Matrix and using Matrix for longer than that. I am not an official representative of CLAIR Matrix, but I can teach you how to use it. Thank you. And it won't cost you anything. So that's, you know, just letting you know. Nothing. Okay, because I don't know if you know, but Matrix and the CLAIR Foundation have joined forces. And at this point, and I'm just reporting, there are very few people from the Matrix organization that are left there. Okay, we are looking to implement a Matrix group and I'm reading the research by SAMHSA, but how to find more training and how to implement something like that. Sure. I mean, if Emily's up for it, I can certainly work with you on that and would welcome the opportunity. Right. Yeah, for sure. Very cool. Well, I just, thank you. And in closing, I have to tell you, you know, there are very few people in the world who can go home after what you, you know, and say that they've saved individual lives, that they've saved families and they've saved communities and you all can do that. And I applaud you. Keep it up. It's not easy work. Thank you. Thank you so much. Thank you, Al. Also, I will have the recording available within a week. I'll share it with Carla and she can share it with anyone who wants to revisit. Sounds good. Appreciate it. All right, you all take care. Have a great day. Thank you.

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classical conditioning

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