Good morning. Morning. Thank you all for joining us. I think it looks like everyone is connected. So my name is Emily Mossberg. I am a regional coordinator for the opioid response network. Before we dive into the training, I'm just going to share briefly about the opioid response network and the work that we do. So we started back in 2018 in response to the opioid crisis in our country. We are funded by a grant through SAMHSA to provide no-cost training and technical assistance to support and enhance prevention, treatment, and recovery efforts across the nation. To do this work, we rely on a pool of consultants and multiple partner agencies who are located all over the country and who are able to provide the expertise and support. Additionally, everything we do is tailored to the specific needs of the requester. We don't take a one-size-fits-all approach. And we do operate on a request basis, which just means that anyone can submit a request for assistance on our website at opioidresponsenetwork.org. And today, we are honored to have Kate and Kelsey with us from our partner agency, Prisoner Collaborative. They will be providing an introductory overview presentation on contingency management. And I do want to note, we are recording this session, and the recording will be available for viewing and sharing within about a week or two. Also, if you have questions, feel free to either put them in the chat or raise your hand, and we will try to get to them in real time. And lastly, I just wanted to mention that we usually do an evaluation survey at the end of these events, but unfortunately, I don't have the link for that yet. So, I will be sending that out within a few days. And this survey is required by our grant, so we greatly appreciate your taking a few minutes to fill that out. It's very brief. It's only five questions, but our continued funding does depend on it. So, we very much appreciate your help in doing that so we can continue to provide free training. All right. I think that is everything I needed to address. So, with great gratitude, I will now pass it over to Kate and Kelsey to introduce themselves and start us off. Thank you so much, Emily, and thank you, everyone, for joining us or letting us join your monthly meeting. So, we're really excited to be here and chat with you all about one of our favorite topics, contingency management. So, Kelsey, I am not seeing the slides yet, if you want to just go ahead and pull them up. But I am Kate Hirschak, and I'm an assistant professor at Washington State University. And I am a descendant of the Eastern Shoshone tribe and have a bunch of other European ancestry, mainly Italian. But I've been really privileged to work with tribal communities over the last 15 years, and that's been mainly in research. And now we've really shifted to training around contingency management for stimulant use disorder. So, next slide, Kelsey. Thank you. So, WSU is a land-grant-grab institution, and so we like to highlight that there's been a lot of harms past, present, and continue to be. And there are 42 tribes that are MOU tribes and connected to WSU. And so, we have a wonderful Office of Tribal Relations that has really worked at addressing some of these harms and continue to do so. And I encourage you to check out that website if you're at all interested in learning more. I'm currently calling in from the beautiful lands of the Squaxin, known more commonly as the Olympia, greater Olympia area in Washington State. We can go to the next slide. We have some disclosures and a few disclaimers. So, we don't have any conflicts of interest to disclose beyond that we do training and research around contingency management and other evidence-based interventions. And this is really an overview for educational purposes to give you a better sense of contingency management and how this might look in your organization. It's not sufficient to totally implement a program, although we will give you a lot of different tips and tricks. And it's also important to think about how this fits within your own organization and working with your compliance office to ensure that you're implementing it in alignment with the federal regulations. Let's go to the next slide. So, we just hope to chat with you about contingency management, give you a better idea of what that is and how it has been tailored with Native communities. We've worked both in research and practice with Alaska Native communities, mainly through South Central Foundation. So, we're excited to discuss some of the work that has been done with that partnership and really focusing on stimulant use programs within the Tribal Opioid Response Grantee sort of framework. So, looking forward to chatting with you about that as well. Let's go to the next slide. And thank you, Kelsey, for sharing your screen and driving us here. Okay, so we always like to start out in a good way, and I don't know if anybody has opening remarks or anything that they would like to say before we get started, but we're big fans of Wellbriety and the White Bison movement around just total health and holistic wellness. So, we offer this meditation and elder sort of practice as we get going today, but I will give you all a second if anybody wants to provide any remarks. Okay, so I will just go ahead and read this. So, the term Wellbriety is an affirmation that recovery is more than the removal of alcohol or other drugs from an otherwise unchanged life. Wellbriety is a larger change in personal identity and values, and a visible change in one's relationships with others. It is about the physical, emotional, spiritual, and relational health, and I would also add mental. Wellbriety is founded on the recognition that we cannot bring one part of our lives under control, while other parts of our lives are out of control. It is the beginning of a quest for harmony and wholeness within the self, the family, and the tribe. So, I just offer that as a reflection as we move through the training today. Next slide. Okay, we wanted to also highlight our team. We're really proud of our training team and the work that is done. So, not joining us today is Dr. Sarah Parent and Alex Granboy, who really help with furthering the cultural centering of our training and technical assistance work. Next slide. Sarah's claimed to fame, and she's done over 1,000 contingency management visits, so it's always really nice to have her be able to sort of consult with us as we do different projects. She's not able to join us today, but always can rely on her as a resource. Let's go to the next one. Dr. Mike McDonald and Michelle Peavy, who've been really instrumental in the research process. Dr. Lisa Ray Thomas, I don't know if any of you know her, but she's famous and also has done a lot of work around prevention and harm reduction. Our awesome learning and training design folks, Debbie Vogel and then Diana Tutunic. Next slide. Let's go to the next slide, and then I'm going to turn it over to Kelsey to do some very quick round of introductions with everybody. Hi, everyone. I'll also go ahead and introduce myself. My name is Kelsey Badgett, and I'm a social scientific assistant at WSU, and I've been supporting Kate and her work in contingency management training for about four years now. So now I'll go ahead and pass it around. So just saying your name, your role, and your favorite part of work or why you're in the field. Maybe we could go ahead and start with the folks that are in person together. If you guys want to go around the room and start us off. I'm Mikayla. I'm our behavioral health office manager. I guess the favorite part of my work is being able to make all of our clinicians jobs easier so they can just focus on their clients. My name is Emily. My name is Emily. I am a behavioral health clinician, and my favorite part of the work that I do is helping people get to the point of life where they feel content. My name is Stephen. I'm the behavioral health director. I think I'm in the field, and my favorite part is the stories. I think people are a story, and sometimes they get to write their own chapters of that story, and I enjoy helping them do that. Hi. I am Kayleen. I am a behavioral health clinician. I would say as of so far, my favorite part is probably the building of attunement with my client. Hi. I am Melissa Anderson. I am a behavioral health lead clinician, so my role has kind of changed, but I enjoy working with my clients but also working with this team. So it's nice to meet you all. Thanks for starting us off, and now I'll just go ahead and call on people from my view of the screen just so it's easier to keep track of. So Tasha. Hi. I'm Tasha Peterson. I am the substance use program supervisor, and my favorite part of my work is just kind of building relationships both with clients and my peers and staff. Also, just really quick, I wanted to plug, like, I'm not sure if everybody here knows exactly, or, you know, you may have read the email, but why we're having you all here, and is it okay if I say that now? Okay. Essentially, we are, Matthew's not here to explain more of the nitty gritty with the grant, but we are going to be starting a contingency management program for our SUD team, or for our SUD clients, essentially, but we think it would be really important for everybody to be aware of what we're doing, because it's pretty significant, and to understand the purpose and the process, and if anybody's interested in being more involved, to be able to have the opportunity to do so, but also, contingency management, I know we'll break it down more, but it's essentially providing, and maybe y'all don't use the word incentives, but essentially providing some sort of incentives for people to continue in treatment. So, just wanted to let folks know if they were curious as to why they're here, and like I said, we'll get more into it, but just wanted to put that out there. Yeah, thank you, and thank you so much for providing context for everyone, and then I'll go ahead and pass it to Colby. I'm Colby Perez. I'm a behavioral health clinician, and the thing I like about the field is every day is different. Hi, Kimberly. Hi, I'm Kimberly. I'm the behavioral health intake coordinator, and my favorite part is working with the team, and watching what they do, and seeing their success stories now and then. Awesome. Jordan? Hi, I'm Jordan. I'm a behavioral health clinician as well, and my favorite job is probably just seeing my clients when they have those aha moments where things start to click, and you know, you kind of, you get to play a part in that, so yeah. Is it Leanne? Hi, I'm Leanne. I'm the behavioral health case manager, and my favorite part is every day's different, and every client's different, so it's always exciting. Every day's a new day. Hope? I'm Hope. I'm a sub-counselor, and my favorite part is watching when people's self-esteem starts, like, growing again, and yeah. Leah Hona? Hello, everyone. My name is Leah Hona-Taylor. I am the health grants program specialist, so one thing favorite about my job is, like, I like to meet deadlines. Megan? I love that response, Leah. Megan Ellis? I'm the wellness and prevention supervisor, and I'm fairly new, but so far, my favorite part is seeing the impact of education, mental health education, on the individual. Did you say Alicia? Sorry. Oh, okay. Yay. Thank you. I'm Alicia Flores. I'm a cultural peer support specialist. My favorite part of the job is sharing traditional knowledge that I've learned from, not only from my upbringing from up north, but also around here among the Sioux people. And I love listening to their stories, how their lives have been on this wonderful island and yeah, thank you. Did you say Andrea? Sorry, Robert. Can everyone hear me. Okay. Hi there. I'm Robert. I'm an SUD counselor. My favorite part of the job, I was a peer support before. So it's kind of connected but just being able to meet people where they are and kind of walk alongside them in their recovery journey. Megan. Can you call me? Okay, so all the screens change when people turn their cameras on and off. I'm sorry about that. And Jean. Good morning. I'm Jean. I'm a behavioral health aide in Old Harbor. My favorite part of the job is watching someone succeed in their treatment. Stephanie. Hi, I'm Stephanie. I'm actually with the opioid response network. I am new and I am here just to learn from Emily and yeah, so just a fly on the wall today. Thank you for letting me be here. Josh. I'm Josh Flores. Prevention specialist. My favorite part of the job is seeing an event come to fruition after months of planning. My name is Holly Rozelle and I work as a cultural peer support specialist. My favorite part of my job, because I am a person with lived experience, my favorite part is reaching out to people that are going through similar situations that I went through and helping them through that. Casey. Hi, good morning, everybody. I'm Casey Peavy. I am the peer support supervisor. And I think my favorite part of the job. So we're a newer program having peer support at Canada and I've really enjoyed seeing the professional growth of my staff and the growth of the program and the integration into behavioral health. Andrew. Good morning. I'm Andrea Baskovsky. I'm the behavioral health aid out in Uzinki. And I'd have to say this is a two part question. Two favorite things I really enjoy about the job is serving elders and then also the second is providing a safe space for youth to learn and grow. And then Heidi, I know you hopped on a little after but we're just introducing ourselves, our role and what's your favorite part about the job. Okay, I'm Heidi Christensen, lead cultural peer support specialist. My favorite part about my job is getting to share my lived experience also with others that are struggling with their mental health or substance use and also being a resource for others that are seeking help or guidance. Awesome. And I think that was everyone. Is there anyone who didn't get to introduce themselves yet? Thanks, Kelsey. And thank you, everybody. That was so wonderful to hear what excites you about your work and I can agree and relate to each of those things. Building community is especially a big one for me as well. So Kelsey, I guess we can share the slides again. And we're a pretty informal group. So please feel free just to put questions, comments in the chat or unmute yourself and interrupt me. I'm happy to have conversations with you all. And also feel free to attend to whatever you need to during this training as well, since I know stuff can come up. Okay, so let's go to the next slide. And I really appreciated Tasha sort of grounding us and bringing us all together. And we always really encourage folks across an organization to learn more about contingency management when a program is being developed and getting up and going. And so, again, really appreciate you taking the time to learn with us today. So if you go to the next one, Kelsey. So as Tasha alluded, we really think about contingency management as using positive reinforcement to shape behavior. And so we're really rewarding the behavior of folks who are engaged in contingency management. So as Tasha alluded, we really think about contingency management as using positive reinforcement to shape behavior. And so we're really rewarding the behavior that we want to see more of. And contingency management is a behavioral intervention or therapy, and it is based in the theory of learning around operant conditioning that really does use positive and negative reinforcement to encourage behavior change. And so simply in contingency management, and the program that we'll be talking about today is focused on stimulant use disorder and stimulant use. And so within that context, because contingency management can be used in various settings, we think about it as providing a tangible reinforcer, which is usually a gift card. But we will get more into that as we go because it doesn't always necessarily need to be a gift card, but some sort of tangible incentive or reward that is provided after a person achieves a negative stimulant urine test. And so it is a 12 week program where folks come in twice a week and are provided an incentive for a negative urine drug screen. And so it's a really strength based approach. It has decades of evidence behind it for different substances, reducing different substance use and leading to abstinence. But it's especially important within the context of stimulant use because there are currently no FDA approved medications to treat stimulant use disorders. So we really need this as a tool to help address that. And so, as I mentioned, we've done our own research in partnership with American Indian and Alaska Native communities and have completed two clinical trials around that, really in the context of addressing stimulant use and alcohol use. So let's go to the next slide. So when we're thinking about positive reinforcement, it really is the key to contingency management. And I think we have a lot of different ideas around what that can look like, mainly within the realm of like parenting, where you're encouraging your child by saying good job or something to that effect, or within the school setting where we're getting gold stars for different activities. And so we're really thinking about how you provide that desirable and pleasant stimuli right after the performance of the behavior. And so we're really looking to connect that reinforcer to the behavior. And when we experience that, we're more likely to do it because it feels good. And then when we do it once, we start to get warmed up and we do it more and more and more. And so we're just meeting that positive reinforcement to meet that behavior. And I think another sort of simple example, we're always throwing around examples of positive reinforcement, but taking one from me personally is around earrings. So my family and I, we are obsessed with jewelry. We love it. And Kelsey and the team were really sweet. It was my birthday recently, and they got me a pair of earrings, which I'm wearing right now. But I tend to wear earrings more frequently, the ones that people compliment. And then when sometimes I wear earrings that I don't get compliments on, I'm like, well, what? So I tend to wear the earrings that I get more compliments on. And so that's just one example of how we are positively reinforced. And when we aren't reinforced, we tend to do the behaviors less. And so much of what we do is really under that control of reinforcement, both positive and negative. But with contingency management, we're really focusing on the positive. So let's go to the next slide. So there are behavioral principles, of course, that underpin this. And here we like to highlight how those are applied within the contingency management program. So of course, focusing on that behavior, the reward or incentive, and then making sure that you pair the two. And so with the behavior, we really want something that's focused, achievable, and measurable. And this is why we focus on stimulant use, because we can assess it independently through a urine drug test. And we're able to identify when the sample is negative or positive, and we can document that. So it needs to be something that can be documented and addressed. We also think that it's achievable because folks can remain abstinent for a couple of days between tests. And so it's something that really helps encourage that behavior change. And then when we're looking at the incentive or the reward, we really want it to be tangible, desirable, and escalating. And so when we think about tangible, again, a gift card or another culturally meaningful item, which we'll talk about more in a bit, it needs to be something that motivates people to want to change behavior. So again, for me, that might be earrings, but for someone else, maybe not. So we really need to identify what that is when we have conversations with the participant relative coming into our contingency management program. And then we also want to ensure that those incentives and rewards build over time as people are either remaining abstinent or cutting down on their stimulant use. And then we want to make sure that the two are paired so that the incentive is provided because a negative urine sample for stimulant use has been provided. We want to make sure that the reward or incentive is provided immediately and that it's frequent. And so as I mentioned, our programs that we recommend are participant relatives coming in twice a week for 12 weeks. So let's go to the next slide. So another conversation that we think is important, and it sounds like everybody here is very aware and understanding of different reasons why folks might use substances, but we like to highlight that thinking about positive and negative reinforcement and why folks might use substances is that it feels good. And that can be reinforcing to people to remove the negative feelings that might be occurring. And so with substance use, it really can change the reward pathways in our brain. And so slowly, the substance use can really replace all other reinforcers and become very primary in our lives. Let's go to the next slide, please. Oh, wow. This is fancy. I didn't realize it was staged. Maybe go ahead and just put the whole. Awesome. Okay, thank you. So when we're having these conversations, sort of thinking about stigma and addressing stereotypes around substance use in our trainings where we have a bit more time, we and my colleagues really like to pose this question around why do people use stimulants? And we really want to think about how sort of exploring these conversations can really also help build empathy. And maybe to yourself, you can kind of think about why folks might use stimulants in particular. But some reasons that we've heard is that it helps folks feel safer if, say, they're unhoused. They're able to stay awake and feel safe. It helps them feel like they're performing better at their job. It gives them more energy. It might be to address trauma or feelings of depression or painful memories. And so really, again, people use stimulants because it falls likely into two categories of it feeling good and removing negative feelings. And so we really want to think about how that reinforcement continues to increase behavior because, again, that underpins contingency management. And so we really want to start to think about how we can jumpstart people's natural reinforcers. And that's what contingency management can do. So it can help jumpstart the emphasis on reconnecting with family or assisting with employment or these other things that we think of that can be beneficial in our lives and are naturally occurring. So let's go to the next slide. So, again, when substance use or stimulant use really becomes the primary reinforcer in our lives, it's something that, you know, becomes the sole focus. And so when we're thinking about behavior change, we then need to think about how do we kind of tip the scale on that? And help folks get back to other natural reinforcers in their lives. And this is especially true when we think about some of the positives that folks might be feeling around their stimulant use that we highlighted in the previous slide, too. So people may be really finding that this is the real focus of their sort of world at this point. And so behavior change can be really hard. And that's true of, I think, any sort of behavior change, you know, whether we're thinking about cutting down on coffee or whatever it might be. So we really need to have that encouragement to make those changes and to really start to shift that balance into thinking about things that are reinforcing outside of substance use. And so that's what contingency management help does. And it helps jumpstart that for many folks. Let's go to the next slide. Oh, okay. Oh, cool. Sorry. Kelsey, you're so much fancier than I am. So basically, that is what I was just saying is that thinking about how we tip that decisional balance. And contingency management can help do that. Yay. Okay. So when people have whittled down all of their reinforcers to substance use, it's really just important to continue to encourage them. And through that, we're really focusing on, again, the behavior that we want to see, which is that negative urine drug screen. And I think that's an important point is really thinking about how we do that in designing your program in a way that meets the needs of your community. Let's go to the next slide. So the big takeaway with this is that people change when they feel good. And CM is based on that idea of really helping people to shift the focus to celebrating the things in their life that are outside of substance use. It's a really positive approach to doing that and really focusing, again, on emphasizing what we want to see more of and making sure that it is a inviting and sort of strength-based way of interacting with folks. I think a lot of people have had – oh, yeah. Thanks, Kelsey. If you would just go ahead and put everything on the slide. I think if folks are hesitant or maybe haven't had positive experience in the past around stopping or reducing their stimulant use, this can be an option for them that can help them feel good and motivated around the change in behavior that they are hoping to achieve. So let's go to the next slide. And go ahead and just populate the whole thing. Thank you, Kelsey. So, sorry, I'm only seeing part of it. I think they disappear as you click on them. Okay. All right. Awesome. So I will just verbally talk through this then a bit, and it may or may not be on your screen. So another way that we like to think about it is what contingency management is and isn't. And if you haven't noticed already, I flip back and forth between contingency management and CM. And that is one of the first things that folks usually want to change is the name because it's just so clunky and not very inviting. So we welcome your ideas around what you would call your program. Certainly doesn't need to be contingency management. But anyway, so we have our two columns here. And, you know, sometimes we hear folks talk about how they're doing contingency management and we get really excited. And then we learn that they are providing an incentive for a one-time behavior. So for an example, getting an incentive for getting a vaccine. And we really like to highlight that that is the use of incentives in health care, which we think is great. And we want people to do more of it. It's not contingency management, though. Contingency management is, as I mentioned, a behavioral therapy with decades of evidence in support of its use for addressing stimulants. And it is something that is really addressing a very difficult behavior change. And so it's really helping folks to achieve something that is not at all easy. And so it's not a candy bowl on a desk, although I do love those. And that's what my colleague always says. She loves them. She will go visit you more if you have one. I think we all do. And while that is reinforcing, that's not contingency management. And contingency management is also not paying people to use substances or to not use substances. This is what we hear a lot. Oh, you're just paying people not to use. But that is also a framing that can lead to some stigma and stereotype, folks. And so that that's not what is occurring. We're delivering an evidence based intervention. And people are changing their behavior because they've decided that they want to reduce their use or they want to be abstinent. And they're not just doing that for a gift card. They're doing it because of all of the other factors that are involved. The therapeutic alliance with the individual, providing the reward or incentive, the desire to reconnect with family, perhaps, or, you know, issues around employment or housing. And so these are big decisions. And contingency management supports that in a way that is bigger than the belief that it's just about paying people not to use. So we really encourage not framing it in that way or thinking about it in that way, but really highlighting more of these bullet points under what CM is. And really discussing it in that way and framing it in that way, not only within the organization, but with participant relatives coming in as well. So, Kelsey, do you have any other thoughts or comments on this? Are there any questions or thoughts so far? Because now that you have a sense of what contingency management is and some of the principles behind it, we were going to shift to talking a little bit more about how we might culturally center CM and how we have done this work in partnership both in research and in training and technical assistance work. So if there aren't any other or any questions so far, let's go ahead and keep it rolling. So next slide, please. Okay. So we completed two clinical trials, as I mentioned earlier, led by Dr. Mike McDonald and others on the team. And we partnered with, they were two clinical trials. Several partners across each, as I mentioned, Alaska Urban Native Area was included in the Helping Our Native Ongoing Recovery study. But across the two clinical trials, we had 272 participant relatives randomized to receive either contingency management for alcohol abstinence or other substance use abstinence compared to control or treatment as usual. And we found some really powerful, exciting impacts of contingency management on both stimulant and alcohol use. And so with the stimulant use, folks were four to eight times the odds more likely to return a stimulant negative sample compared to treatment as usual. So that was super exciting. And then folks also reduced their alcohol use by 70%. And what was also really exciting about this work is that it highlighted that there were off behaviors or off-target behaviors that were also impacted. So even though people were, say, only receiving incentives for stimulant abstinence, they reduced their alcohol use. Or if they were only receiving incentives for alcohol abstinence, they actually significantly reduced their cannabis use. And so that's a really exciting finding as well, is that even though we're focusing on one behavior, it can also have an impact on other behaviors. And this is especially important among clinicians and others who are concerned about the potential for other substances to come more online when folks are addressing a particular one. But our results have not indicated that, so that has been really awesome to see. And these interventions were very community-engaged and community-centered, and we did a lot of different work around thinking about how we can better align them with the community. Different focus groups and other interviews and community events and meetings helped us with that. And so we provide some of these as examples to kind of help think about how you all might better align contingency management with your program and community, and we're always excited to hear ideas and ways of doing that. So hopefully we can think about that a little bit more as we go. So let's go to the next slide. So what we found with our research and training and technical assistance work is that contingency management does align with the cultural values of many Native communities, and that's because contingency management really is about trust and respect. It's about building social support, and it provides opportunities for families to connect with one another, to do activities together, to have family night. It's about recognizing an individual's efforts within their community, and that has been something that's really been highlighted as super important to folks, and thinking about how that looks within a given setting. Different incentives can be, as I mentioned, really impactful and elicit behavior change in folks, which is the whole point of contingency management. But one of the things that we've found to be very reinforcing is the gift cards and folks having an option or the choice of where they can spend that gift card, and especially it being an opportunity to share with family or purchase materials or gifts for kids, your kids, or having birthday parties or other things that really bring people together. And so that has been really highlighted within our work. And so as we kind of go through some of the slides, I welcome you all to start to think about some of the ways that this might align with your organizational values or community values and what incentives or rewards or gift cards might be meaningful to the relatives that you have coming in. Let's go to the next slide. So we do have some digital success stories that we will share the link with you all. I think in the interest of time, we might either save that for the end or just link it out to you all. Hopefully that works. Let's go to the next slide. So some of the ways, in addition to the alignment of values, has been thinking about how contingency management fits within concepts or the philosophy of recovery, both within the organization and with the participant relative coming in. And so we have a slide that's coming up that highlights some of the ways that we've done that with our partners focused on the medicine wheel. And that is a very meaningful metaphor in my community and other communities in the Northern Great Plains area. It's of course not, doesn't resonate with all tribal communities. And so we really encourage you to think about how it fits within cultural frameworks or concepts of recovery within your own organization or community. Again, importance of family and thinking about ways to involve family within the recovery process and the contingency management process has been really wonderful, whether that be through community events or family nights or other opportunities to engage folks has been really great. Sharing worldview and teachings when and where appropriate, thinking about if that's something that elders are interested in sharing or if that's appropriate. We've had also staff who are really respected elders in the community deliver the intervention and that has been really awesome. They've been able to engage folks in a way that others aren't able to. And so that has been really a wonderful approach. And I think we had a picture of one of the elders who helped implement the intervention in one of the previous slides and he was just really great in encouraging people of all ages to get involved and he would have different events where he would teach people how to put up a tipi, for an example, or create other cultural touch points. And so on the right here of the screen, you can see a quote from a participant relative who was in the program with him. Let's go ahead and go to the next slide. So as I mentioned, we put the contingency management visit within the context and framing of the medicine wheel and the medicine wheel is really looking at how we create harmony and balance within our lives, thinking about the mental, emotional, physical, spiritual, the four seasons, the different stages of life. So it's just a really wonderful way to think about holistic health and within the contingency management visit, how we contextualize this and was another thing that the elder helped us with in one of our projects, Albert, was thinking about starting in the East, always in the East, and how you build that relationship with the participant relative coming in. As we mentioned, what you might think of as like what might be called therapeutic alliance. So really building that kinship with the participant relative coming in through introductions, checking in on how things are going, on their recovery goals, and then moving down to measure. And this is when you would collect the urine sample and make sure that your office is set up where you have access to your bathroom and all of those different pieces, of course, would be identified beforehand, but having that visit workflow include that. We usually walk the individual down to the bathroom. We really like to reframe drug screens in a way that is focusing on a person's journey and story. And so while many folks have experienced UAs in a negative way, this is an opportunity to reframe that. And the one way that we do that within our work is that we don't observe the UAs. But again, we leave that up to the policy of each organization. And then once we have the urine collected and we move over to reinforce. And so when we're thinking about reinforcing, again, we're only reinforcing when the urine sample is negative for stimulant use. And that's when it's a real celebration. People get really excited. They're usually telling people what they're getting or what they got. And so it's a real opportunity to encourage folks around that. And then if the urine sample is positive for stimulant use, it's an opportunity to remain judgmental, nonjudgmental, and use it as an opportunity to check in with people and to see where they're at and to continue to encourage them to meet their recovery goals and connect them with additional necessary resources. And then we move to record the outcome. And this is really important in contingency management since it is a different intervention because it deals with money. And when you're dealing with money, there's a lot of policy and regulations to consider around that. So we really want to make sure that we are reporting that the incentive or reward was provided because there was a negative drug test. And then from there, we move to gratitude and continuing to, as you all highlighted, one of the favorite things in many of your work is that connection with the relative and supporting them in achieving their goals. So let's go ahead and move to the next slide. So some additional ideas around cultural centering. It sounds like you have a sense of where your contingency management program will be located. We have found that it really being integrated into outpatient treatment settings has been really helpful. Also aligning with services or programs outside of the treatment context has also been helpful. So we've had some through housing or other cultural programs, but within settings where folks come in less frequently, there are additional implementation considerations. We've had folks who've implemented within primary care settings, and that can lead to thoughts around how do we get folks in more frequently since people don't generally go into primary care settings twice a week. And so those are things you want to think about as you develop your program. And then also thinking about, and your program likely already does these things, but I think folks are really surprised about recruitment that they just are so excited about it themselves that they think people are going to be banging their doors down to get in on this contingency management program. But actually, there are considerations around recruitment that Kelsey will highlight in a bit. So thinking about maybe providing transportation or bus passes or sort of outlining what those barriers to care are ahead of time and thinking about ways that we can address them. So, we encourage that. Let's go to the next slide. So, with our work with South Central Foundation, part of their positive reinforcement was including speaking the language and having positive affirmations in the various languages of the participant relatives they serve. And so, they had, they included Yupik and Athabascan languages and different ways of just encouraging, you know, like, good job and keep it up. And then another way to continue to align the program with cultural language, if at all appropriate, is having different affirmations around the office, folks who can speak their native language. We've had a lot of success around that again with elders. Another thing that we heard from the Alaska Native folks that we worked with is thinking about referring to reinforcers incentives more as rewards and really framing that as a way to increase their sense of accomplishment and self-respect and that it is really something that is, you know, encouraging them in that way. And so, that's another use of language that has been really meaningful within some of the programming that we've had. Let's go to the next slide. So again, you know, really recognizing somebody's efforts in their own life and in their community and changing their behavior. So, one of the things that's been really meaningful for folks is to have some sort of ceremony or recognition of their participation in the program and what they've accomplished along the way in achieving their goals. And one of our partners also not only sort of had an honoring ceremony, but creating an honor song or singing honor songs to our participant relatives in the program has been also really meaningful. So, that's some other ideas around that. Let's go to the next slide. So, any thoughts or questions so far? Okay, awesome. So, we were talking about thinking about what some of these incentives or rewards might look like in your setting. And for the folks that we've worked with, some of this has looked like creating little medicine kits for folks that include cedar or sweetgrass, opportunities to provide feeding supplies. We've had folks that have then been able to use some of their rewards to then create regalia or other jewelry or art that then they were able to sell, which then increased not only their motivation, but also enhanced some of their small business hustles, which was really cool. We've seen people, like I said, really center their family in the rewards or gift cards that they have found really meaningful to them. And one of those were movie passes. I don't know how, if people are going back to the movies, maybe more now. I've heard it's a generational thing. Younger people are willing to go back to the movies more than us older folks, but that's also one of the things that folks mentioned. Also, gift certificates or gift cards to local restaurants have been really popular. So, those are some ideas that were highlighted also within our work with South Central Foundation. So, let's go to the next slide. Okay. So, there are a couple of ways to develop a program, and one of them is the prize draw approach, and one of them is voucher contingency management. And within our trainings, we recommend the voucher approach because it can make the delivery of incentives or rewards a little bit easier. And so, with this approach, the voucher equates to a monetary value, and you're essentially keeping track of those points and then delivering those associated either to the gift card that it's exchanged for or for an item. So, you can still provide other items or culturally meaningful incentives in this approach, and we have another slide on that. And so, each time a negative urine drug test is provided, as I mentioned, the person will receive a voucher, and this can be tracked in Excel or through other online tools. And just as an example, you might start out with, depending on your budget, which Kelsey will get into a little bit more about this, but say your voucher is $10. So, you would track this, and then, as we mentioned, you would continue to increase the amount of the voucher as the person comes in each visit with a negative urine drug test. And part of how we do that is with what we call bonuses. And so, folks will have an increase of an additional $2 for each negative UDT. And so, it really helps to build and encourage that long-term abstinence, or at least reduction in stimulant use. So, let's go to the next slide. So, here's a table kind of thinking about how we might do that. So, some communities really prefer physical gift cards, and this is especially true in rural areas where there may not be some of the big box store options. Electronic gift cards can also be really handy, though. And then, thinking about culturally meaningful rewards or incentives and how we mix the two. And so, when we're thinking about tangible, again, physical gift cards, they're immediate. They're right there. So, that's why there's a plus sign there. And then, thinking about electronic gift cards, while it really can enhance the desirability, as we see in the second row, less tangible in some ways. But in terms of tracking, it can also be handier for your program. And then, with the tangible, in terms of culturally meaningful rewards, that we've found that that also is really great to have folks be able to identify different items that are already on hand. But then, again, you have to know what people want. And so, there's considerations around that. Again, thinking about immediacy, the physical gift cards can sometimes be a bit delayed because sometimes folks, and we've heard different things in rural areas, sometimes businesses are able to work with programs in a way that bigger box store places are not. But sometimes, with the physical gift cards, there's only like a $5 increment. And if somebody has an uneven voucher amount, this will delay, usually, them getting that incentive or that reward until the next visit. So, that's a consideration of how you have your gift cards and in what increment. So, that's a consideration that electronic gift cards can help to sort of alleviate because they tend to allow for odd numbers. And then, thinking about cultural meaningful rewards, again, it's a great opportunity around immediacy. And then, thinking about program budget, really looking at what exactly the desirable incentives are and whether it might be better for your program in terms of ease of implementation to think about electronic versus physical. So, these are things to kind of consider both program, finance, and organizational leadership levels. So, okay, thank you, Hope. So, let's move on to the next slide. So, some of the takeaways is that contingency management can align with American Indian Alaska Native communities. We really encourage focusing either on addressing stimulants or alcohol. And within the Tribal Opioid Grant world, we really encourage focusing only on stimulant use. You really want to do just one behavior. Keep it simple. Contingency management is really flexible. There are these key principles and implementation considerations. But thinking about how it can align within your organization, there is some flexibility there. And thinking about how we integrate contingency management across the organization. So, again, thank you for all the different folks who have shown up today from the different departments. And really troubleshooting as much as you can potential barriers ahead of time. Of course, you likely won't be able to identify all of them. But being able to think about necessary resources to address like transportation or housing can go a long way. And let's go to the next slide. I think I might be is this the end of my is this where I turn it over to you, Kelsey? Yeah, it is. Okay. Are there any questions, comments, thoughts, concerns before Kelsey starts to discuss a little bit more of the practical implementation? Yeah, I was just curious, you know, we this has been specifically about like stimulant use or stimulant use along with alcohol use. And like at our program, it changes quite a bit kind of kind of who we're seeing and what people's, you know, substance choices. And lately, it's been mostly alcohol for folks involved in our groups. Maybe a couple folks who are using stimulants, not even very much opioid use right now. So yeah, I just I would love to be customizing in that sense to to fit our current clientele. Is that something that can be factored in? Yes, that can definitely be factored in. Great question. So what immediately jumps to mind is thinking about your funding source. So if this is tribal opioid response funding, you really will only be able to address stimulant use disorder. They did say that you could also focus on treatment attendance. We don't support that model simply because reinforcing that behavior can become a little tricky. Because how are you defining it? How are you making sure that it's being achieved? Sometimes it's not just as simple as attending an appointment. So that's why we really like stimulant use disorder as a behavior, because there are those other components where it's easier to measure and achieve. And you can see real lasting results around that. And the other point related to focusing on the actual substance use versus treatment attendance is, again, looking at the behavior that we're wanting to decrease. And so when you're focusing on something like attendance, you're not directly focusing on folks cutting down or stopping use. And so you don't see as big of an impact on that behavior. So that's the other reason why we just encourage focusing on the specific behavior that you are wanting to see reduced. Another consideration is around doing too many behaviors at once. So we really would encourage you to think about starting with one substance and just focusing on that program for a while. And then maybe as you gain your feet around your program, addressing other substances. But we really have found in the research and in practice that it's important to just focus on one behavior at a time. And so we have the ability to support, you know, the program focusing on alcohol, but again that would be a consideration for your program about funding and how that might look. Because that's what we heard too, that's why we focused on alcohol in our research is that it was still the primary concern. Right, yeah it makes the like focusing on the behavior make sense. And I don't know, I'm thinking about attendance as much as it's when you're saying it's kind of tricky for us. We do have the IOP and OP programs that folks are expected to attend all groups and sometimes attendance is an issue. So and I don't know, I'm just trying to think of how we can reach more of our participants. But yeah, talk more about as we get into like creating the program, but I just kind of wanted to get an idea. Yeah, that's a really important question because like you said, you do really want to address the need within your setting. So yeah, continue to have that conversation and let us know how we can help support that as well. Support that as well. Thank you, Tasha. I'm not seeing or hearing any additional questions so far. I will turn it over to Kelsey. All right, so now we're going to go ahead and talk about some CM implementation considerations. So this section will be a little like high level of what we would cover in a more like in-depth training of how to do and how to implement CM. So here we're going to kind of talk about an example program using those principles that we learned earlier. So for the behavior, as Kate mentioned, you want to define that behavior and in this case, we teach stimulant abstinence or you could even do alcohol abstinence. And again, just keeping it to that one behavior that's attainable and just focused. And you also want to make sure it's measurable. So for stimulants and alcohol, we have used point of care urine tests and those tests make it easier. It's immediate. It's easier to see the results. So you're able to really tie that reward into it for that specific result, which is a negative stimulant test or alcohol. And then again, for reinforcement, you want to make sure that reward or incentive is tangible. So whether it's those electronic or physical gift cards or those culturally meaningful prizes. So something that's desirable and immediate and as Kate mentioned before, escalating. And then last of all, you want to make sure that the reinforcement is frequent and feasible. So what we usually recommend is that folks come in twice weekly for 12 weeks. And then here are some challenges when it comes to using CM. So we have heard of a little resistance to the idea of incentives, but for that we try to reframe the process. So instead of tying it to the idea of incentives, this is where we talk about the recovery goals and how reducing their use is in alignment with their goals. And we've also heard about harm reduction versus abstinence. People have different approaches and it's really hard to go cold turkey and just go straight into abstinence, but we see that CM kind of aligns with harm reduction and that even though people may not become fully abstinent from stimulant use, it's still a tool to help them reduce that use. Maybe they get a few negative tests, that's still helping them along in their recovery journey. And then right before this, Kate mentioned funding. So with TOR funds, they focus on stimulant use, but you also want to think about sustaining the program beyond those TOR funds. So looking into tribal funds or opioid settlement funds to help with your incentives. And relatives do get taxed on amounts greater than $599, but TOR funds allow your incentive budget to go up to $750 per relative per year. And there are some Office of the Inspector General guidelines, which is a document that I think we can send you folks after the training. But it also mentions that not to advertise the incentives in a way where you're trying to get people to your program. We encourage advertising the program, but not focusing on the incentives. Just focusing more on that this is a program or intervention to help people on the recovery journey. And this is where this slide may be a little confusing. But there is those guidelines that say incentives shouldn't exceed $570 per year. But within the research, we see that there's less evidence for programs that have incentives less than $500 for a 12-week program. And we recommend budgeting for up to $599 per participant relative, just so they're under that tax amount and so that it's still evidence-based. But realistically, we know that it's a difficult thing to do. So not all participant relatives will reach that $599 amount. So you can estimate spending up to 50% of that budget. So we recommend staying within a range of no less than $350 and maybe no greater than $599 for your incentive budget per participant relative per year. And now getting into recruitment. It was a great question, Tasha, that you asked to kind of get this started. So identifying who the program is for and kind of thinking of some inclusion criteria. If you were going to do stimulants, would they need to have like a stimulant use disorder diagnosis? Or are you going to get folks in who have used in the last 30 days or are currently using? So those are some things to think about. And whether you'll be accepting people from like the MAT program or any other programs that you currently have. And when it comes to some strategies, it's always good to do some outreach and education. So getting referrals from any of the community partners you work with. And then again, emphasizing that changing the idea of punitive testing into positive testing. Urine drug screens definitely have a lot of negative connotations with that. But we like to reframe that story. So those tests are a way for your relative and you to build that therapeutic relationship. It's an objective way to be on the same page in the recovery journey. So maybe if they've had, when they have negative tests, that's your way, your cue to celebrate them. They were abstinent that day, go ahead and give them all the props. But sometimes they'll have a positive test. And that's totally fine. That's your way to check in with them, ask them if they need any resources and keep encouraging them to continue the program. Because even though they may have gotten a positive test once, there's always the next time that they can come in to try again. And when you're outreaching to folks, it's always about building positive connections. So telling tribal leaders, elders, talking with people who are skeptical about the program, just like letting them know that it's a tool for people on the recovery journey. It's not about the incentives, but it's how can we use this program to align with the recovery goals. And as Kate mentioned, identifying community champions. So she mentioned that elder who was in one of the previous studies, who would talk to folks, invite them to do cultural activities, but also invite them into the program. So think about who is that one person that gets along well with the community that could kind of champion the program for you and let people know about it. And always just create an affirming and supportive dialogue whenever you speak with people. And here are some other like high-level considerations to take in. So you want to make sure you have funds for the urine testing materials, the test cups, validity strips, and gloves. And then again, as we mentioned earlier, thinking of the different meaningful prizes or incentives that you'll have for relatives. And again, no less than $350, that 50% of total earnings. And then you also want to think about staff time. And these are some roles that I'll talk about in the next slide. And thinking of space. Do you have a room to have visits in? Is there a bathroom nearby? So just some logistical things like. And so these are some staff roles that we've kind of identified. You don't necessarily have to stick to them, but one of the roles is a CM mentor. And that could be someone outside your agency who knows about, who's well-versed in CM. They can schedule coaching calls or on-demand consultations. So that might be like our role at WSU. And then you have your program lead who's been trained in the protocol and is monitoring the overall program. So maybe that would be Matthew or Tasha. And then you have your CM delivery staff. These folks are the day-to-day people who will see relatives, do the urine tests, give out the incentives. So these folks would probably definitely need to be at the implementation training to get all the nuts and bolts of how to do CM. And then you also have your CM support staff. So they could be people who identify and recruit relatives or help schedule and remind clients of their visit. And with the delivery staff and support staff, these roles, they could be combined. The staff could also do the same thing. But it's really up to the capacity of your program and your staff. Any questions before we get into the activity? Thank you, Kelsey. Are we going to be taking a break anytime soon? Oh, sorry, a break? Yes. So due to the sort of shortness of the training, we didn't build a break in. We have 35 minutes left. So we could take a break now, or we could just have folks who need a break, take it and continue on with the training. What do you all prefer? I think because we're recording, you're good. If anyone needs to step away, you guys can step away real quick. Okay. So just to also highlight, we're really excited that the SAMHSA budget has been increased to $750 for incentives. This is just a change that happened in the last couple of weeks. So we're really excited about it. Before, it was capped at $75. So this does provide a lot of additional flexibility that we were really excited about. And then while we really encourage different sources of recruitment referrals in terms of building a program that is more in alignment with some of the rules and regulations, there's a real encouragement these days to think about having a provider who's licensed, who can do the initial referral to the program. And then also thinking about having that within the treatment plan, having that level of care as necessary. So again, really thinking about that eligibility around the diagnosis. So I just wanted to quickly talk about those updates. And thank you, Kelsey, for walking us through those. But I'll turn it back over to you for the activity. All right. So just to frame the activity, we wanted to kind of see how folks are thinking around getting a relative with a positive UA. So just thinking around like, what might the person be feeling? What might you see and hear from that person? I know it's definitely frustrating. There will be folks who come in and say, they'll say they haven't used within the last couple of days, but then the test says that it's positive. So kind of thinking about how you would interact with that person. So we have a little example that we've kind of created around how someone would react or how a CM delivery staff would react to a relative who came in with a positive test. So here you can see, it's just staying really encouraging with that person and offering them support. So I'll give you folks a minute to take a look at that. So now for our activity, we're going to have you guys partner up and try to role play on what you would do if someone came in with a positive UA. So one person would play the role of the relative and the other person would play the role of the delivery staff. So I think in the main room, folks could go ahead and pair up with each other. And then we were going to have the folks online join breakout rooms to pair up with each other. So any clarifying questions before Emily puts you in a room for a few minutes, up to five minutes potentially. Kelsey, would you put the directions in the chat too? Yeah. Okay, so Emily whenever you're ready and able, we are ready. I'm working on it now. Awesome. Appreciate you doing that. We would be here all day if I was doing it. Okay, it should be working. Okay, I see something on my screen. Hopefully you all are seeing it on yours. Oh, you know, Emily, I think I thought you were me. So let me use. I think there'll be one room with three. Okay. Thank you. I think Andrea has still stepped away, but that's okay. That was the room I just put Emily into, so there's three in that room. Okay, awesome. Thank you again for doing that. Yeah, and that's my first time doing like one-on-one, so it's a lot of assigning. Yes, it seems like they should have more of that kind of built in when you're wanting pairs or something automatically, I don't know. You can like automatically assign, but then it would, I don't know, I just wanted to do it manually and make sure I did it right. Yeah, I think if it would have assigned us as well. Oh, right, okay, good point. We're going to about the 39 after, or no, 37 after. Yeah, I mean we could even cut it down I suppose, or even check in to see if they need longer. But yeah, if you need to step away for free. Oh no, no, that's fine. Yeah, we can check. But yeah, maybe 1136 or something like, or 1136 our time. How many times have you guys done this same training? I'm just curious, like a hundred times? Maybe not a hundred. No, I wish we could say a hundred, maybe probably less than what, 25? I want to say 25 to 50 maybe. Yeah. Over the course of, and we're always adding, changing, and there's new updates and changes and laws. Yeah, so we're not, it's not always the same, same. But yeah, so for over, I guess about, almost going on three years now. So not a ton, ton, but our other, because that's just for the Native-focused work, they do a ton more trainings and work for, yeah, for the state Medicaid programs that they work with, and then the state opioid response work that they did. That makes sense. And under your partnership with the ORN, you are able to do like the consultation piece, is that correct? So what, I think kind of where we might be landing is hosting office hours, maybe monthly, that we hope to start this month. And actually maybe you could help us think about how we would get that info out to folks. But yeah, mainly for the tribal opioid response grantees or whoever else is doing, or hoping to do CM within a Native, Indigenous context. Yeah, I think previously the ORN had a list of email contacts for all of the TOR grantees, which was useful. I haven't received an updated list, but I think we could share that with all of the TOR grantees. And I don't know if you would want to like survey for like the best time, or just like pick something because nothing's going to work for everyone. Yeah, that was kind of our thought. We'd probably just pick a time and hope it works for people, or if people start to join enough, then we could switch it to what works better for them. That makes sense. All right, what do you think? Should we call it? Yeah, I can click all the rooms here. Gizmo 60 seconds. That would be like once a month, probably. Yeah, that's what we were thinking. Maybe Wednesday mornings, last Wednesday of the month, or something like that. No, that's really helpful. That would be great, I think. All right, welcome back. That seems to be most folks. Okay, awesome. Thank you for your participation. I will turn it back over to Kelsey. All right. Um, so does anyone want to share any thoughts they had or any comments about the exercise first? Well, does any pair want to share kind of what they talked about? Or how the situation went for them? Yeah, I'll go. So we deal with this a lot here at peer support lately. We do have new clients that like to come in and speak with us and we want to keep them coming. And so I kind of was able to grab that experience really quick at the top of my head. Especially if, well, we don't really have the incentive like for them to stay sober, but just sometimes if they continue with us, you know, they get, you know, maybe some swag or maybe a gift card we might have saved up for subway and they can get something to eat. And it's really, I've been really seeing that, you know, food is a huge motivating factor, especially in this, you know, economy. And yeah, I really think, you know, having a pop up like food station maybe for people, because if they're hungry, they're not going to, you know, want to have to deal with that on top of everything else. Yeah, that would be a great idea. Everybody loves food, so that's huge. Does anyone else wanna share or talk about the role play activity? Or like what were some strategies that you guys use to help stay positive during the interaction? In our group, we talked about a specific but not detailed plan to kind of help the person get back on track. So identifying like big picture idea of the barrier that kind of got in the way this time and how we can use our existing resources to get the person back on track. So forward thinking kind of. Yeah, that's awesome. That's a really good strategy and then tying back to like their goals. Alicia, you're unmuted. Did you wanna add something? Oh yeah, I was just saying Emily did a really great job of bringing it back to like a more positive light. Like, oh, you've already done the work before, you can do it again. Yeah, Robert and I pretty much followed the script from the little demo you guys had. And I think it felt pretty natural to us because we talk about substance use all the time, but a lot of those more difficult conversations definitely come to mind when thinking about this or people's different like, you know, discomforts with having like a positive UA or just having to talk about use or even something that happened. Definitely a skill and I like the idea of keeping it as like, you know, forward focused as possible rather than punishing. Yeah, that's super important to the spirit of CM for sure. And it also highlights why having that patient agreement or relative agreement ahead of time so that folks know, you know, what your policies and procedures are ahead of time. And thinking about, you know, how you can frame that if need be. But yeah, all those strategies are really awesome and sound like you all are really encouraging to relatives coming in. So that's always great to hear. And so this would be a really natural way to continue that work. So thank you, Kelsey. Thank you everybody for participating in that. We have one question to start us off that might be of interest to the rest of you. But that was basically everything that we had planned in terms of the training itself. So now's the time to think about questions if you have any or you can always feel free to reach out to us later. But we will go ahead and open it up now to questions. So I don't see anyone immediately unmuting. So Emily Mossberg had a great question for us and she was curious about the research and what evidence there's been around sustaining abstinence once the incentives stop. And that's always a big question that folks have. That they're concerned about. And so because I am a researcher, my answer is a little long and convoluted, but basically within the larger populations, we see that abstinence remains for up to a year after stopping incentives. The strongest effect is about three to six months after the incentives are removed. Again, we like to think of substance use as a sort of in a holistic way where we do want to continue maintenance. And so I think sometimes it's unfair that folks feel like because it's substance use, it needs to not be thought of as how you would treat other health behaviors. So with other health behaviors, we have medications, we have other sort of therapies or behavioral approaches, and we know that those need to continue in order for the health of that individual to be maintained. And so I really encourage thinking of it in that way. And because of that, folks then ask, well, could we do maintenance with contingency management? And the evidence is really in support of that 12-week window. There's not much support beyond a 16-week program. But because other folks have been concerned around this idea of maintaining abstinence, some of the Medicaid waivers, the 1115 demonstration waivers that have been approved in California, Montana, and Washington, but I think primarily in California, they do have a maintenance phase where folks will come in for weekly for I believe it's about three months. So they've built that in as a way to kind of address some concerns that providers had around just stopping incentives altogether. And then within Native communities specifically though, our research is a little more mixed on the long-term impact of incentives after folks complete the program. So it's certainly something to continue to consider and discuss, but generally speaking, you might see up to a year of abstinence after a 12-week program. So that's really exciting, but again, want to continue to encourage that change. And CM can be really powerful in the first sort of initial wanting to reduce use. So that's another good point of interventions earlier on. I had a question or two separate questions. One is kind of directed at Tasha. So Tasha, is this something we're looking at in like the near future, far future? Like what's kind of like, what's kind of the goal? Yeah, I think Matthew has the best answer, maybe Steven, but essentially we are working to create the program. I believe by October and start implementing. I might have the timeline a little off, but we're in the early developmental stages, very early, like learning what this is. And then we'll continue to get it up and running. So not immediately. Yeah, and I didn't think so, but I was just curious on like where we were at kind of thing. My second question is, so I guess how it's kind of along the ethics of it. And like from a therapist perspective, like we're always avoiding gifts, avoiding rewards, that kind of thing. So what kind of ethical policies kind of go into place to kind of make this work and be successful? Yes, that is an excellent question. And one that you definitely want to consider thoughtfully, because again, this does include money. And especially when you have Medicaid patients, you really need to follow all those federal guidelines. And so for contingency management, because of that safe harbor that Kelsey mentioned for the use of incentives in healthcare, that kind of covers what we were doing. So it allows us to implement contingency management, but it's not specific to contingency management. So that's really what we need the government to do is to create a policy outlining fully the appropriate use of contingency management within our settings. They say they're working on it. So hopefully we will see safe harbor sometime soon related to contingency management. But when implementing, what we do is we really focus on the eligibility criteria. We make sure that their participation in the program is noted in their treatment plan or elsewhere in their health record as a necessity because they meet this eligibility criteria for stimulant use disorder. That's why we need a licensed person to make that initial referral to the program, noting that they have the stimulant use disorder. We make sure that we have the accounting process down. And so really tying the incentive and the reward to that negative urine sample. And so that needs to be done every time. And then it also needs to be noted that no reward was provided because it was a positive UA. And then you also need to have policy around missed appointments, which generally look like a positive UA. So they didn't receive it because they didn't come in. And so just making sure that you have your policies and procedures in place around that. And then in terms of the ethics from the relative's perspective coming in, because this can be a really exciting, motivating program for people, folks who aren't eligible may begin to feel like they're getting excluded. And so one point of conversation can be that this is the only effective intervention for folks with stimulant use disorder. We have other treatments for alcohol. We have other treatments for opioid use disorder that are effective, but this is really the only opportunity for folks with stimulant use to receive effective treatment. And so really highlighting that to relatives coming in has been really helpful. Having finance really involved, disbursement of the incentive is important. Folks have encountered challenges around having gift cards at their organization. So you wanna check your policies around that. Also having one person sort of as the point on disbursement of incentives can really help, and also ongoing fidelity checking. So really checking the records consistently to make sure incentives are only provided for those negative UAs. And then thinking about, also fidelity monitoring essentially, just making sure that the behavior is happening for that reward, because as was highlighted, people come in with a lot of things going on in their lives and as caring people, you wanna be supportive of them. And so sometimes we've seen the behavior switch. So at one point the program started out as addressing stimulant use, but then suddenly there's some reinforcement around attendance. And so that would be a fidelity slip because people just want to be able to give that incentive to a relative coming in who's in need. So just really making sure that you watch those types of things can really help with the policy regulation. And as you mentioned, Jordan, the ethics around it. Thank you, that was helpful. Does this training, is it considered an overview or nuts and bolts? This is just the overview. With the nuts and bolts, there are more practical details. We have, like our incentive tracker, those sorts of pieces. We help with the policy and procedure development, thinking about workflow and those types of pieces as separate part of the Washington State University training. And so we're also thinking about getting office hours set up. And so there are some nuances around thinking about long-term implementation within the opioid response network context, but we're happy to share our office hours with you. We're hoping to develop those monthly as check-ins for people just to drop in if at all interested. So we can share that information with you as well. Those are great, important questions. Any others in the last five minutes together? I know one thing that's come up is folks, getting like a gift card for getting groceries at our local store. And that's something that it's really exciting that can be provided. Folks, some people have reported like buying alcohol with those. And I think that gets in, again, into that little ethical dilemma zone of wanting to provide this really helpful resource in a small community where we have limited options and also there being that risk there. And I'm curious how you guys typically manage that. Yeah, that's a great question. So we use places that have restrictions. So the other restrictions are like around purchasing firearms, tobacco, pornographic material, stuff like that. So some places can actually prevent that from occurring on their gift card. Sometimes we have done where we write on the card what's not allowed. Sometimes that alone prevents it from occurring. But really if you could find a place that would work with you to prevent the gift card being used in that way. So these big box store places do, like Walmart and some of the others. That's one strategy. The other thing is depending on what behavior you're focusing on. For an example, when we focus on alcohol, people don't tend to use their gift cards for that because they won't get more incentives. They'll return a positive sample for alcohol use. So some of the time you can get around it with just the actual contingency management program, but certainly as part of the safe harbor and some of those rules and regulations, the feds are very concerned about the gift cards not being used in the manner in which you mentioned, Tasha. So really thinking that through is an important component as well. Great question. Okay, so Heidi, I see your hand is up. I was just gonna give suggestion. Usually this is where peers step in and they could shop with a peer support and they could go with them and be their buddy, accountability buddy and just be like, hey, what are you gonna get? And they could also save like the receipt or whatever so we could make sure we know where the money went and it goes where it needs to go. But yeah, peer support's always willing to go out and go shopping with the individual. I've done that before with some mental health trust funds that I got for one of my clients before and we have to take them shopping at like Burlington or whatever to get whatever they needed. And we just made sure we always had that receipt and we know where that money went. Hmm. Yeah, that's an awesome solution and definitely one to explore. Yeah, thank you, Heidi. Those are really good ideas. You're welcome. All right, so I think we're just at about time. So thank you again, everybody, for letting us join your amazing group and please reach out with questions, comments, or any follow-up. Emily might have some closing remarks as well, but we also dropped our evaluation in the chat. So we'd love to hear how we can improve the training moving forward. Anything from Oren or anyone else? All right. I just wanted to say thank you so much, Kate and Kelsey, for your presentation and your time today. Yeah, so much fun. Thank you again for having us. All right. Well, thank you, Tasha and everyone else. And we'll see you later. Have a good one. Bye. Bye, everyone.

opioid response network

contingency management

Kate Hirschak

Kelsey Badgett

Prisoner Collaborative

SAMHSA

behavioral intervention

operant conditioning

positive reinforcement

abstinence

ethical standards

Native communities

cultural values

incentives

recovery efforts