Well, nice to meet you all, or nice to have you all here with us. My name is Emily Mossberg, and I am a regional coordinator for Region 10 of the Opioid Response Network. So in Region 10, that includes Oregon, Washington, Alaska, and Idaho. Before I hand it over to our trainers for today, I'm just going to briefly share some background information 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 federal grant through SAMHSA to provide no-cost training and technical assistance to enhance evidence-based prevention, treatment, and recovery efforts across the nation. So to provide this assistance, we rely on a pool of consultants and multiple partner agencies who are located all over the country and who are able to provide local expertise. Additionally, all of the support that we provide is tailored to the requester's unique needs. We also have a team dedicated to working with Indigenous communities and ensuring that all TA provided is culturally sensitive and relevant. I actually have Stephanie Stillwell here with us as well, who is our new Indigenous Communities TPS position team member in Region 10. And additionally, we offer it on a request basis, which just means that assistance is provided in response to requests that are submitted on our website, and anyone can submit a request for free assistance at opioidresponsenetwork.org. Today, we are very grateful to Kate and Kelsey, who are here with us from our partner agency PRISM Collaborative. They will be providing an introductory overview presentation on contingency management. I did want to note that we are recording this session, and it will be available for sharing in about a week. If you have questions, we are happy to answer, we're happy to address them as they come up. If you all want to, I guess you can just speak up if you have a question, or raise your hand, whatever you're comfortable with. Lastly, we will also be sharing a link and QR code to a brief survey at the end of the presentation. This survey is required by our grantors, and our continued funding depends on getting responses, so we greatly appreciate your taking a minute to fill that out so we can continue to provide resources. All right, I think that is everything I was going to go over. It is my honor to now pass it over to Kate and Kelsey to introduce themselves and dive in. Yeah, thank you so much, Emily and Stephanie and Stormy and the team. We're really excited to be here with you today virtually, and glad to see that you all are able to meet in person. And looks like you're eating some yummy pizza, so very jealous of that. We're also a really informal group, so please feel free to get up, get food or drink or whatever else you might need as we move through. We're also open to questions at any time, so please feel free to interject. Or if you have your computer or tablet in front of you, you can also type some questions into the chat, but it doesn't look like many of you do. As Emily mentioned, Kelsey and I are with Washington State University, and I am an assistant professor at WSU, and we have a land acknowledgement that is developed by the Office of Tribal Relations out of WSU, so I invite you to look this up if you are interested. We're doing a lot of great work, but we really just want to acknowledge that WSU is a land grab grant institution, and so we are working to partner with indigenous communities across Washington State and other states, and currently have some MOUs with tribal partners to address some of the harms that were created in this process over the years, and so they've been doing a lot of great work around this. But I am a descendant of the Eastern Shoshone Tribe out of Wind River Indian Reservation in Wyoming, and also have other mixed European ancestry, various European ancestry, mainly Italian, and am currently calling out of the traditional lands of the Squaxin Island Tribe in what is now known as Olympia, Washington. So we have some disclosures and disclaimers, mainly that WSU and Kelsey and I are providing educational materials, and so we don't view this as enough, really, of a support to get your own contingency management program up and running, but is a first sort of educational and initial step in that direction, and that our programs mainly support contingency management for stimulant use, although we do have partnerships and research around contingency management for alcohol, and we'll get a little bit more into our focus around stimulant use as well. So we just really hope to outline some of the theories and principles behind contingency management, and be able to help you all learn more about the research that's been completed around that, and some ways that you might begin to think about how you can implement contingency management and adapt it for your organization and community. And so, do you all have an opening prayer or any sort of opening remarks that you all would like to share? Stormy, I don't know if you wanted to provide additional context around this, or if you had any thoughts that you wanted to share. Sure, so I think everybody here is pretty new to the idea of contingency management, but it's been something that I've been hearing at conferences for a while, and we have an opportunity to implement this through one of the grants that we have. It will help pay for this, and help pay for us to get some policies and procedures up and going. So this is really the first step, is to kind of get everybody on the same page about what it is, and how it can work, and the research on it's pretty amazing, as far as keeping individuals engaged in treatment services. So this is something we're going to be implementing, but like I said, this is kind of the first step for it, and so we have some pieces to put in place before it happens, but I'm really hoping it's sooner rather than later. And it's a pretty awesome thing that I've wanted to do for a while, and so I was really excited about this opportunity, and I just want to thank everybody that is presenting today for being here today, and helping to educate us, and providing all this wonderful information for us, so that we can move forward and help a lot of people in our community. Awesome, thank you. Yeah, we're really excited for you, and hoping to support you in this process moving forward as well, beyond today. So we also have a team at WSU that's really dedicated to helping folks implement contingency management. So you heard a little bit about me, and then we have Kelsey from the team joining today. Oh, it looks like we need to update your title there, Kelsey. Social Scientific Assistant at WSU, and then we have Sarah Parent and Alex Granboy, and then Dr. Mike McDonald has led a lot of the research with tribal partners that we've had. And then people may know Lisa Ray-Thomas, Dr. Ray-Thomas, she's pretty well known across Washington state as well, and so she's a part of our team. All right, so this is always people's least favorite part, maybe, but we don't have a true icebreaker, but we have more of an icebreaker for us to learn a little bit more about you, and you all know each other. So thank you for bearing with us while we learn a little bit more about you all. So I will pass it over to Kelsey to help guide the introduction, although since you're in person, it might actually be easier, Stormy, if you're able to have folks start. Yeah, so I'll start, and then Becky can go, and then we'll just go around the table. So my name is Stormy. I am the Treatment Program Manager here at Clown Counseling Services. We're an outpatient substance use disorder treatment program, and my favorite part of the work is just getting to meet a whole bunch of new people and seeing the changes that they make in their lives. It's really inspirational, and I really just want people to be leading the life that they want to live, like leading their best life, and being able to help somebody do that and see that happen is pretty incredible, and I have a really amazing group of co-workers as well, too, so that are all very dedicated and all really great to work with. I'm Becky Shimko. I'm the Lead SUDP. My favorite part of the job is working with people. I'm also in this field because I'm also in recovering myself. I'm Jessie Poque. I'm an SUDP. I am in this field because I like to be witness to people's friendship. I'm Casey Quadman. I'm an SUDPT. I just started here last week. Why I'm getting into the field is to help people through their recovery journey. I'm Jamie Sheraton. I'm an SUDPT. I'm also in recovery, and I'm drawn to this field for the same reason that's already been mentioned. I love being a part of watching lives change, especially here at KCS. I'm Roxy Charles. I'm Peer Support, and I chose Peer Support because I really feel like it's taking off and growing into different aspects of every where it can, and also, I really enjoy working with people, and I'm a people person, so I just want to be able to be I just want to be able to be someone for somebody that may need somebody. My name is Joe Silos. I'm an SUDPT, and I got into this field to walk alongside people on their path to recovery. Hi, I'm Cindy. I'm the one that they make sit in the corner, but I know my place. I'm a counselor here. I retired from another profession and then from another profession and then lived with my son who used for 10 years, and I needed to figure out a way to help him, and he's now got four years clean, and I'm still here for everyone else, but I'm going to retire in November or December or January. Since this is being recorded, for the record, maybe put herself in the corner. I'm Donny Tyler. I'm an aspiring SUDPT, and I'm in this field of work because I am also in recovery. I'm Amy O'Neill, and I'm a patient services representative, and I like working here because I like to see people overcome things that they didn't think was possible. I'm Angela Raycraft. I'm the PRC coordinator for the tribe, and I also do SUD billing, and I just meet amazing people every day. We have one more back on the side. Alicia Adams. I am a SUDPT, and my favorite part of this job is seeing growth in other people, and I'm honest with you because Becky said I should. Awesome. Thank you. Yeah, it's really great to hear what makes this so meaningful for everybody and the important work that you're doing, so that's why I'm in the field is just to really support folks like you all who are really doing important things for their community and tribal members. I will pass it over to Kelsey. She didn't really get to introduce herself at all, so Kelsey, do you want to say a little bit about yourself? Yeah, thank you, and thank you all for allowing us to be here with you folks and support you on your work. My name is Kelsey Badgett. I'm a social scientific assistant, as Kate said. I am Filipino, but I was born and raised in Hawaii, but I'm physically located in New York, and my favorite part of this work is just being able to work with communities and give back and meet so many different people. And Emily, you kind of said hi, but do you want to chime in? I think I introduced myself, but yeah, I'm the regional coordinator here in Region 10, and I'm actually, I didn't think, I don't think I said, but I'm located in Washington in the greater Seattle area. What do you love about your work, or I guess we said favorite thing? Oh, favorite thing about the work? Oh, I think it's just getting to interact with so many different communities and organizations, so since we take requests, we do get to interact with lots of different, lots of different people, and it's always something new, and it always keeps it exciting because it's not just the same thing every time. It is exciting. Awesome. Thank you. And Stephanie? Stephanie, if you're on mute, so if you're speaking, we can't hear you. Sorry about that. Can you hear me? Hi, yeah. So I'm Stephanie. I'm the TTS. I work in this field because I'm personally connected to it, and I have just always wanted to make a difference in a bigger way for myself and for my family. And so I really appreciate being able to continue to help people who are in recovery and help support those who are working in this field as well. OK, awesome. Thank you so much, Emily, Stephanie, and everyone else for sharing that with us. So we wanted to go ahead and jump in. So unless there's any other comments or questions before we do. All right, looks like we are good then. So as Stormy was saying, you all may have heard about contingency management, or you may be more or less familiar with it. But basically, what contingency management is, is it's focusing on positive reinforcement to shape behavior. And it's rewarding the behavior that we want to see more of. And so that's kind of the most simple way to put it. What that looks like practically is folks receiving incentives or rewards for verified abstinence from stimulants. And this is verified through point of care urine tests. And so contingency management is based in operant conditioning. And that's basically a theory about learning. And so as I just mentioned, it's really focusing on positive reinforcement and is very much based in celebration and is strength-based. And the other important thing about contingency management is that it is the only effective treatment for stimulant use right now because there are no FDA-approved medications. And so Stormy mentioned that there's a lot of evidence to support this approach. And we'll be going over a little bit of that that's been completed by our team with tribal communities. But we've really focused our work now on providing training and technical assistance for stimulants. And some of our research is also focused on alcohol. And so that's why we were saying we can kind of support both. But the one that your funding is supporting right now is addressing stimulant use. So as I mentioned, positive reinforcement is the key principle in contingency management and helping people change. And folks think of different things when they hear of positive reinforcement. But it might be something like receiving gold stars for homework or high fives or some sort of hat on the back. And those are all great examples of positive reinforcement. But a more behavioral definition is more about the introduction of a desirable or pleasant stimuli after the identified behavior has occurred. And so we're really thinking about how we can continue to reinforce the behavior that we're wanting to see. And by doing that, we are shaping that behavior so that it'll occur over and over again. And so we've had various examples that we've used that my colleagues like to use. And Kelsey and this group are probably tired of hearing about my obsession with earrings. But one example that's unrelated to substance use that can help us simply think about positive reinforcement using me as an example is that I have an obscene collection of earrings. And even though I have a ton of different earrings, I'm more likely to wear the earrings that I get compliments for. And so when I'm out and about and not just in a virtual setting and people are like, oh, I like your earrings, then I remember that. And I'm like, the next time I'm going to put them on, I'm like, oh, I'll put these on because I got a compliment. And so I tend to wear the earrings that I get more compliments from more frequently. And so that's basically a simple example of how my behavior is getting shaped and my earring obsession is getting reinforced in a simple way that's not substance related. So there's plenty of other examples related to that. But we basically are thinking about how a lot of our behavior is learned and it's also under the control of reinforcement. So the behavioral principles for contingency management are thinking about the behavior that we are wanting to see more of. And in this case, we are wanting to see more abstinence from stimulant use. And so we want to make sure that the behavior that we're addressing is focused and identified. So that's a good example of that. And we want to make sure that what we're addressing is achievable. And so we have identified stimulant use as achievable in terms of thinking about how we are able to monitor that through urine drug screens. And folks can achieve a couple of days of abstinence generally. So that's the way that we're focusing on that behavior. And then as I just mentioned, it is measurable because we're not relying on self-report. It is monitored through urine drug tests. And then we're pairing that with the reward. And so in this case, we could just use incentives or gift card incentives as an example. And as we go through the talk today, doesn't necessarily have to be gift cards. It could be other culturally meaningful rewards. But for this example, we'll just say a gift card to Walmart. And that needs to be something that's really desirable to the relative coming in. So we're always wanting to make sure, because that's another piece that's really important to contingency management, is that the person really wants it. And then escalating. And so with our work that we do for folks who are abstinent, the more that they're abstinent and for longer duration, they receive more incentives and more gift cards to Walmart, for an example. And then pairing the two, we just really want to make sure that the gift card to Walmart is only provided when a relative returns a negative urine sample for stimulant use. We want to make sure that that gift card is given to them immediately so that it's really, they're excited about it. They're getting it immediately so that within their own mind, they're pairing the behavior with the reward. And then we want to make sure that the reward is given frequently. And so that's why contingency management programs are usually about twice a week. So the relative comes in twice a week to have their CM visit. So when we're thinking about addressing stimulant use, we like to have a quick conversation around why people may use stimulants and drugs generally. And I think that it's an important conversation to have to kind of think about empathy and other ways of addressing behavior. So when we're thinking about substance use, we're thinking about how it can help people feel good. And it can also decrease other negative feelings, so trauma or other sort of mental health impacts. And so this can then really reshape the reward pathway in a person's brain to the point where even when they're no longer really wanting to use stimulants as much as they are, at this point, it's the way that they feel balanced in life. And so that can begin to really take over, even to the point of impacting family, even to the point of impacting family negatively or job loss. And so we just really want to think about how we can address that and ways that folks might feel about their substance use. So here's another way of looking at it. Simply put, people may use substances because it helps them feel good or it helps them feel better. And I think that also really being aware of other reasons folks may use substances, like to feel more awake or to feel safe if they're in a housing situation where they may feel like they're at risk. So there's a lot of reasons why people may use stimulants and that that really is something that we were talking about reinforcement, so then it really increases the behavior. So then when we're thinking about stimulant use, then we're also thinking about, well, if folks, if relatives do want to cut down on their substance use, what are ways or avenues to do that? And one of the things about it is that when substance use has become the primary reinforcer, then really thinking about not using becomes really challenging. And so any sort of behavior change is challenging, even just thinking of simple things like cutting down on caffeine or not eating as much candy. But when we're thinking about something as big as stimulant use, then it can really become even more of a sort of decisional balance on what helps tip folks into either wanting to cut down on their stimulant use or stop using stimulants altogether. And so this is really the point where people are contemplating behavior change. And we're really wanting to think about how to help folks sort of re-shift the reward pathway in their brain. And one tool that does that is contingency management because it's using positive reinforcement to really help folks identify other reinforcers in their life that are meaningful to them outside of their substance use. So that could be reconnecting with family as something that was really meaningful. It can be re-engaging with employment. So contingency management really helps folks jumpstart that behavior change by honing in on positive reinforcement. And so once folks start to have more of those natural reinforcers, the reinforcing quality of stimulant use can fall sort of away. So as I just mentioned, we really think about this as a way to change the reward pathway in the brain, moving away from the reinforcing effects of stimulant use to tangible, non-drug-related reinforcers. So again, that could be gift cards or other community activity or more immediate cultural engagement as well. So the other part is celebration. Yay. And so this is really, contingency management is really strength-based and positive. And it can really help folks to connect with not only the person delivering CM, but also thinking about relationships with other people but also thinking about relationships that they have with friends and family. And when we're thinking about the celebration piece, we're really thinking about how the person delivering contingency management is focusing on the positive. They are approaching folks in a non-judgmental way. They're supportive and connecting relatives to needed resources and thinking about that shift of something that maybe previously has felt punitive for folks to something that can become a recognition of their efforts, both personally and within the community. So when we're talking about what contingency management is, we also want to highlight what contingency management also is not. So when folks talk about contingency management, sometimes they think that maybe they're doing it. And one of the things that comes up is like, for an example, when we were getting incentives to receive the COVID-19 vaccine. And so it was like a one-time incentive for that behavior. So that's like an incentive program, but that's not contingency management. Because contingency management is identifying one behavior that is being repeatedly reinforced over a longer period of time. So it is a behavioral treatment and not a one-time thing like somebody having a candy bowl on their desk or something like that. So we're really thinking about how we can repeatedly reinforce the change in behavior. So it really is about, it is purposeful and is based in operant conditioning. So it has the science behind it besides the randomized control trials that have been completed over the decades. Again, it's repeated over time. We like to re-emphasize the point that it's really a behavioral intervention and not something that is meant to fill in for other resources needed or other services. That it really is one form of treatment. And then we also want to push back on potential stigma or stereotyping that contingency management is about paying people not to use. We really try to avoid that type of thinking and framing because it's not just about receiving incentives. It really is changing behavior in the reward pathway in the brain. And so it helps with relatives building confidence, enhancing morale among both relatives coming in and delivery staff. And that's what we hear a lot about is how much folks even delivering contingency management really enjoy it. It becomes a really positive part of their job. And we've heard folks that have said that basically they don't want to do anything else related to their job. They just want to do contingency management visits because it creates such a strong therapeutic relationship between the relative coming in and the person delivering CM. And it's positive and strength-based in a way that some forms of other interactions may not be. And especially for the relative coming in, being recognized in this way is something that they maybe have not experienced before. And so it can feel really supportive. Oops. OK, so before we move into the second part, are there any initial questions or thoughts? Does not look like it. Doesn't look like OK, awesome, so as Stormy said, there's been decades of evidence in support of contingency management for all kinds of different substances. The two clinical trials that were completed by Mike McDonnell and team were the rewarding recovery study and are helping our native ongoing recovery. And these two studies had a combined sample of 272 folks who are randomized. And one of these studies focused on reductions in alcohol stimulants and cannabis and the other study focused on just reductions in alcohol. But what we found was reductions in alcohol were not reductions in both substances that were being reinforced. So or abstinence that was being reinforced as well as secondary impacts. So even though folks were say only receiving incentives for abstinence from alcohol, they still cut down on cannabis use. And so we saw really big impact on all these substances and stimulant use especially. So that was really exciting to see. And then some of the work that we did around that was thinking about how contingency management aligns with Native communities and we had conversations with tribal partners. We had focus groups that we completed and then we also had community advisory boards that helped guide that guided the work and from that and then also implementing the clinical trials. We found that folks really felt like CM aligned with many cultural values within their community. They felt like it was an opportunity to build trust and respect and connection not only for folks that were implementing contingency management but also for relatives and their family and really enhance their social support and well-being. It was also in alignment with honoring and encouraging relatives through gifting and so that was something that folks felt like really aligned. And then another benefit for folks was the ability to use incentives and gift cards with family. So there were opportunities to, you know, go do fun activities whether that be go out to eat or go to the movies. So folks really appreciated that as part of their recovery as well. So one thing that we have folks think about as we move through our webinar today is what are traditional or cultural values within your community that may align with this idea of rewarding people in their efforts and in their recovery journey and what do you think would be rewards or gift cards that relatives that you see and serve, what might they find really exciting and motivating? So I don't know if anybody has, if anyone's brave and has any initial ideas of some incentives that maybe would be beneficial. We do have success stories from tribal partners that we can share. Sometimes we play them during the talk, but I can just also share the link with you all and you can check them out later. But are there any sort of initial thoughts or ideas on how contingency management might look in your setting? I'll take this as an opportunity to drink my coffee and wait. This is Stormy. I'll say I think gift cards are really big, especially for people that are in early recovery who are kind of starting over. We do some gift card incentives for GPRA studies and they complete the first GPRA and when they complete the second, they get a gift card. And we've actually had really good success with people completing that second one because they get a gift card at the end and we try to do gift cards for a variety of different things like local businesses, bigger stores, the movies, the swimming pool, all kinds of things. So there's a huge variety, a little something for everyone, but I think those would be pretty well received by our clients. Awesome. Yeah. So that's also an ongoing conversation too and with relatives as they come in and seeing what they're interested in and what items that they might want to use, but that's really exciting that you've already had the opportunity to start to think about some of that. So some of the other ways that we identified culturally centering contingency management with some of our tribal partners was thinking about the concept of recovery and one of the ways I have on another slide coming up here was thinking about it through the holistic approach of the medicine wheel and that resonates with my community and some of our other community partners, less so probably in the PNW, but it just is a really nice way to represent the spiritual, emotional, mental, and physical aspects and domains of health and that balance of harmony and well-being, the four seasons, the four directions, all that sort of balance. And so we had an elder in the community, one of our community partners, who was able to really conceptualize this for relatives coming in and then was able to place contingency management within that medicine wheel and then also the person's recovery within that medicine wheel. And so we really encourage the use and identification of appropriate sort of cultural metaphors or concepts that can be shared with both. So, of course, that's only one example. So we would, you know, definitely be happy to think about what would be more fitting in your setting. But another way that we have thought about culturally centering is the importance of family. And so we have a lot of partners that have family activities that they really engage family as a part of treatment and recovery. And so this was also, as I mentioned, really highlighted with the incentives so that it's something that, you know, folks can use to buy their kids birthday presents or whatever that might look like. But that was really emphasized throughout both the research and now within the training and implementation support that we have been doing. The opportunity to share worldview and teachings when and where appropriate from community. And then, as I mentioned, we had an elder that was able to really implement contingency management and create buy-in and was a real champion for the program in a way that I don't know that other folks would have. And so people were just open and willing to listen and they were able to help address skepticism. That's another thing that we really emphasize, too, is when you're starting your contingency management program or beginning to think about implementing it, having conversations with folks around treatment philosophy and feelings around sort of this approach and identifying those ahead of time can really help because then you're able to have the conversations of, you know, how this might fit or maybe not. And if there's ways to provide additional education or resources to folks who might be a little more skeptical, that is another thing to kind of consider at this point as well. And we're also happy to help with those conversations, too. Because despite my love of contingency management, folks may have questions or a little bit of hesitation around this approach. So it's really great to have those conversations ahead of time. So as I mentioned, we sort of put the contingency management visit within the medicine wheel. And so what folks are kind of surprised to hear sometimes is that a contingency management visit is like 10 to 15 minutes. So it's pretty brief. And the program that we support, we encourage a 12-week program. So people are coming in twice a week for 12 weeks. And thinking about that structure within the medicine wheel is really having the person come in, starting in the East, really greeting them and building that relationship and the kinship ties that you all might have with folks coming in. Then, you know, seeing how they're doing, how the last few days have been. Then moving down to measure. And this is when we would collect the urine sample. And we leave it up to whatever program protocol is, but we don't really encourage observing urine collection. So we usually just walk the relative down to the bathroom and they collect their own urine sample and bring it back to us in our designated office area. And so then we're able to move to reinforce and that's when we are really happy and excited and encouraging to the folks when they return a negative urine sample. But if the urine sample is positive for stimulant use, then we're also really supportive and checking in around additional resources that might be needed, checking in around recovery goals and where they're at with that. It's also an opportunity to remind folks that they've been, you know, they've returned negative samples in the past and they can do it again. And so it's a really nice time to check in around what is going on in the person's life. And then within the visit, we then also go to record the outcome. And this is really important in contingency management because it is an intervention that deals with money. So we really want to make sure that we are only providing that incentive or that reward for the negative urine sample and that's really important so that there's no issues with Medicaid or any sort of fraud, waste, and abuse. And so we usually have different tools. One example is in Excel where we're able to document the individual's outcome and then the reward and we're able to track the amount of incentives provided. So that's a really handy tool that we have. And then we always have gratitude at the center to really recognize the participant relative and their journey and maintaining sort of that recognition throughout the interaction. So another thing that we have learned through our research and training is thinking about addressing barriers that can be identified ahead of time. So thinking about program location, a lot of folks have had contingency management sort of as a part or an offset of their outpatient treatment services. Some folks have thought about having their CM program in locations that maybe aren't as common. So we've seen it out of housing or other cultural programming. It does tend to align better in settings where folks are more accustomed to coming in more frequently, but of course there's always ways to think about implementation if folks are wanting to meet somewhere where that occurs less frequently like if it's in a sort of a primary care facility setting. And then the other things that we have heard about that I think are pretty common for a lot of folks is thinking about how to address transportation challenges. So whether your program offers transportation or can provide bus passes or other sort of ways of accessing the program that can really help with retention and engagement. Another idea is thinking about how contingency management can help with cultural and language support and revitalization. And so we've heard a lot of folks that have found ways to integrate that whether that be like through positive affirmations within the office space, whether it be elders and residents who are able to sort of help with delivering or creating opportunities for learning. And then these are pictures of one of the Alaska Native partners who created positive reinforcement sayings on tokens and the pictures just illustrating a few of the languages you pick in Athabascan I think are mainly some of them right in here. Another thing that has been really important to folks is thinking about how to recognize and honor the relative in the program. So whether that be through having participation certificates or feasts in the community or some sort of opportunity to celebrate has been really great for relatives. And then that's another opportunity to have families involved. So that is something that folks have really mentioned and then some folks have had like blanket ceremony, another group has done honor songs or developed honor songs that they sing to the relative at the end of the program or as they progress through it. So some quick ideas to around potential culturally meaningful rewards have been creating little beading kits or medicine kits, opportunities to make cedar bags or other sort of regalia, having traditional foods as a reward and then thinking about some of the more as I mentioned family-oriented activities as well, whether that be more cultural or also like going to the movies as we have listed here and has been mentioned previously, but we're always excited to hear the different ideas that folks have about this and it can get very creative. So these are only a couple of examples. So another part that's more practical related to contingency management is really the voucher system of contingency management. And so basically what this part of tracking your system is, is that voucher points equate to monetary value. And so when you have your tracking system, whether it be an Excel or you're really applying your monetary value to your point system and how then that translates to incentive disbursement. And so again, participant relatives are getting those vouchers or those incentives each time they submit their negative urine drug test. And vouchers are really, again, either a gift card or that reward. And we also really support a system where you're getting, where the relative is receiving a bonus each time that they are abstinent. And then that continues to grow over the 12 week period. So another sort of implementation consideration is around gift cards versus rewards, and then physical gift cards versus electronic gift cards. And so this table just briefly sort of highlights some of the positives and negatives to each approach. And so sometimes folks are concerned about electronic gift cards because relatives don't maybe have access to email or there may be other challenges. And so some folks feel like the physical gift cards, especially in rural areas, might be more appropriate. And so we can see in terms of the four areas that we really highlight with incentives, tangible, desirable, immediate, and then more of the practical consideration related to your program budget, looking at that first line, physical gift cards, electronic versus culturally meaningful, in terms of how tangible it is, physical gift cards are preferable because they'll be in the relative's pocket right then and there. And so it's a little bit less immediate with the electronic gift card, even though it immediately goes to their email. And we use Tango, which is an online retailer that has every imaginable business chain that you can think of, but it may not be so great, again, in rural areas, unless there's like Walmart or some other box store options. And then culturally meaningful in terms of tangibles, that's also really great. And then thinking about desirable with the physical gift cards, again, you have to do a lot of sort of check-in with relatives around what places they're gonna want gift cards to. So that's where the physical can be a plus. And then why electronic is double plus is, again, there may be way more opportunities for them to identify various online retailers that they can purchase items from. So people have been really excited about that. And then in terms of culturally meaningful, some of the most impactful have been items that were made by other people, artists in the community. And so folks have really enjoyed that. And then in terms of immediate, again, with the physical gift card, sometimes local retailers may or may not be able to provide gift cards at the right increment. And so folks might have like an increment amount that they're not able to receive their gift card at that visit. And so then they'd have to wait for another visit. So that reduces the immediacy. Whereas again, with electronic gift cards, you're getting it right then and there through your email account. Same issue with the program budget. Sometimes the physical gift cards are hard because people will only do like five, 10, $15 increments. So you have to check with the local retailers that you're working with around that. And then there can be a plus or minus related to that with the culturally meaningful rewards if you're having to purchase items that then turn out to be maybe not as popular as you had thought. There was an example of that with like having the right sports team. And if you're having like a bunch of jerseys that people don't want, we have found that that can be, that they can collect dust. So you just wanna make sure that you're having those continuous conversations with relatives. Any thoughts or comments about that? Okay. So as I mentioned within your CM program, your Contingency Management Program, you're identifying the behavior. So you're only reinforcing one, which is stimulant abstinence. And that's because it's attainable and focused because the urine drug screens can observe use within the last couple of days. So it is attainable to demonstrate that abstinence. People can achieve that. Again, it's through the point of care urine tests and not self-report. So it makes it measurable, objective, and immediate. And then the reinforcement is thinking about those gift cards or other incentives such as cultural rewards. And you're making sure again that it's desirable, immediate, and increases the more that folks are abstinent from stimulants. And then, as I mentioned, our program, we encourage programs that are 12 weeks long with folks coming in twice a week. And that is frequent and feasible. From what we have heard and been able to support over the last several years. So that's just a quick highlight of the structure in form of a Contingency Management Program. And so some of the big takeaways that we've just went over is that contingency management for stimulant use does align with community cultural values, that it can be adapted to meet cultural and community needs, and that we think it's important to think about barriers as much as possible ahead of time. And you all are experts in that, but it's nice to have those conversations when you can. So before I turn it over to Kelsey, we did not have a break built in, but I don't know, do you all wanna have a break or do you wanna power through or questions or thoughts? Can we take a quick break? We're good. Okay, awesome. Welcome back. Hopefully you had a good few minutes to get up and stretch and maybe get some more tasty pizza or drinks, but I'm gonna go ahead and pass it over to Kelsey, who's going to talk a little bit more about some implementation considerations. Yeah, I'm just looking at your earrings. I know, I was just looking at your earrings. They're pretty. Are they beaded? They're quill. See, you all are, you're just now, I'm gonna be wearing these all the time. I'm like Stormy's our earring gal. Oh, are you? Cause Stormy, you also have really nice glasses, right? Oh yeah, thank you. Oh yeah, very nice. I have two different pairs. So yeah, maybe it's glasses for you. Earrings and rings actually for me, but thank you. Okay, Kelsey, we'll turn it over to you. All right, thanks Kate. And are you going to be sharing your screen or should I pull it up? Yeah, is that okay or do you need me to? Okay, no, I have it open. Just give me one second. Okay, perfect. Sorry, working off one screen today. Oh, it says I can't share screen. Oh, there we go. All right, so can everyone see that okay? Yes, and we can see your notes though. Oh, oh no. Not in presenter mode. Okay. There we go. Yeah, there you go. Perfect. All right, so for these next couple of slides, as Kate said, I'll be talking about more some high-level implementation considerations. So for our first discussion, we'll be talking about the incentive budget. So we know that there is a safe harbor for healthcare incentives. And that usually doesn't exceed $570, but CM doesn't have a safe harbor. So we really do need one. But based on our research evidence, it's known that higher incentive values are way more effective. And there's not really evidence for anything less than $500 for a 12-week program. But we also know that changing behavior is hard. Stopping use is really hard. So we can't expect everybody to 100% get all the incentives that they can. So you can estimate spending about half of the maximum possible earnings. So for our minimum budget per person, we usually recommend it to be at least $350. And then I'm going to drop down to this $599. So for our maximum, we recommend that folks budget their incentives per relative for no greater than $599, because folks do get taxed on amounts greater than that. But with TORG funds, we recommend that they be taxed for no greater than that. But with TORG funds, you can actually budget up to $750 per relative annually. So that is exciting, but there's still the tax issue that people have to worry about. And then moving on to where the funding comes from, you have the TORG grant. You can use tribal funds or opioid settlement funds just to keep the program going, even after this grant. And going back here to the top, we talked about some resistance. Some people think, oh, these incentives, you're just like paying people not to use. But as we discussed earlier, it's evidence-based and it's just a way to help them kind of shift that reward system. And there's also a challenge about harm reduction versus abstinence, because this is an abstinence-based program. But when you think about it, contingency management is kind of like harm reduction, and it kind of aligns with harm reduction, because even though people may not completely stop using during the program, if they can at least cut down and get at least one negative test or two negative tests, they're still cutting down on their use. And one last thing, just making sure to comply with the Safe Harbor guidelines. And when it comes to kind of recruitment and advertising your program, just make sure not to use those incentives or don't really highlight incentives as the main reason for contingency management, or don't use the incentives to be like, hey, come to our program, we have incentives. So just make sure to really focus on this is a program that's gonna help people on their recovery. And then moving on to recruitment, trying to think who the program is for. So for this program in particular, we're looking at folks who use stimulants, and we recommend having a clinician refer them to the program and having that stimulant use disorder or something in their treatment program that marks that they're going through contingency management to help them treat their stimulant needs. And then for outreach and education, we're always wanting to build a positive connections with our tribal leaders, elders, and people who are skeptical. So even this overview training is really helpful for people to get to know what contingency management is about and to help get that buy-in. And another strategy is to identify community champions. So Kate mentioned earlier that we had an elder who would talk to people and helped us with the medicine wheel and just encourage folks to join the program, check it out. If you have a community champion in mind, that would be a great person to have and teach them about the program and have them help recruit people. And then also just think about the referrals and all your other community partners that you work with. If they can identify people and send them your way, that's awesome too. And then we're also turning punitive testing into positive testing. And I think I kind of heard a little conversation during the break that folks were really excited about this because we know that with drug testing, there's all these stigma and negative connotations, but for contingency management, the tests are more to help you tell a story or to help relatives tell their story of their recovery journey so they can see where they're at. You can see where they're at. And if it's a positive test, then it's tough, but it's always an opportunity to encourage them, turn them to different resources that would help them and turn them back to their recovery goals to help them keep going. So really contingency management is just, it's a really positive program and it's always about creating affirming and supportive dialogue. And for some other considerations, you wanna plan a budget for the urine testing materials, the point of care tests, zip cards, gloves, validity test strips. And we already talked about the prizes and incentive budget. So no less than $350 and no greater than $599. And then you also wanna think about staff time, which I'll talk a little bit more about in the next slide. But for staff time, thinking about if you're gonna hire new folks to do the program or if you're gonna have current folks wear multiple hats, that's something to think through. And then you also wanna think about space. So is there a room that you can have the visits in? Is it near a bathroom? Do you have space to store like the incentives, the gift cards or whatever rewards that you choose to have and where to store all the tests and things like that. Now, going into staffing, we talk about the CM mentor. So someone outside of your agency that can help you with the program. So that's kind of like Kate and I. And then you also have the program lead, which I think would be Stormy, someone to monitor fidelity, who knows the program in and out. And then you also have the CM delivery staff who will actually be doing the visits with the relatives. So they'll be doing the urine tests, giving the rewards. And we recommend having at least two people just in case someone's sick or someone's out, you at least have one backup person to be able to do the visit. And we also have CM support staff, which could be anyone. They can help recruit people or help schedule people for their next visit. They could be like the front desk folks who check people in. And the thing about these roles is that people can be in multiple roles. They could be the delivery staff and the support staff. It's really up to you and your organization's capacity. And then any questions so far on those considerations? We're a very non-questioning group today, I guess. It's because you brought us pizza. Awesome, everybody is happy and satisfied. So now we're gonna go into an activity. So to set it up, we're gonna do a little activity around someone getting a positive urine test. So you wanna think through what might that person be feeling? What do you see and hear from the person. There's been instances where sometimes people get a positive test but they're really in a tough spot and there have been some staff who have still given folks the gift card just because they were going through it and having a tough time. But we want to make sure that we're sticking to the evidence and only rewarding the behavior that we want to keep encouraging. So even though they got a positive test and maybe they really needed that incentive, again we just want to keep encouraging them. Don't give them the incentive but let them know that there's always a chance to get it at the next time. So here's a little a little cartoon. Hopefully you guys can see it because I know the font's a little small and you're all looking at one big screen. But this is just an example of someone getting a positive UA and just being supportive, encouraging them and letting them know that they're always welcome to come back and try again. So what we're going to do now is we're going to partner up and we're going to practice having that conversation with each other. So just practicing how you would have that conversation about not giving the reward while staying positive and encouraging. So I think we can do maybe five minutes. So for the next five minutes find someone to practice with. Feel free to move around sit together. Good so you're warmed up then. Yeah that's awesome. I think we're all pretty good at partner up. All right good to hear the laughter. Does everybody have enough time to practice? Okay awesome. So Kelsey I'll turn it back over to you. All righty. So does anyone want to share what strategies they use or what kind of situation that they talked about with the group? I'll go. Thanks Stormy. So we talked about, we actually like I said talked about this on break but I think this is really kind of a practice that everyone here does already is that we acknowledge that the positive UA happened and you know let them know hey we're going to have to notify probation or DOC or whomever but then we don't dwell on it and we look at the future and what we need to do to keep moving forward. So it would be something like you know you have a positive UA like we can talk about like what happened around that so that we can take a look at what we need to work on. You know I'm going to have to send this to your reporting source but let's also spend you know the rest of our session looking at what we're going to do to move forward. You're not getting a gift card today but let's take some steps so that you can earn that gift card for your next visit and so that then I can provide a new new report to your reporting source that you know indicates that you're back in compliance and you're doing the things that all the positive things. Yeah that's awesome. I like that you guys work with them to have a plan to move forward. That's really good. Anyone else want to share maybe other strategies that you thought of or other things that you folks do? I said Stormy said no. Having a good policy and procedure in place right? Stormy said no. I like that. Any other takers? I pretty much talked about the exact same thing you were saying. Just kind of addressing what the situation was and how to move forward. And that's one reason I think contingency management is going to be so great for our program is that kind of a lot of the things we've talked about we sort of do anyway. Like we try to you know emphasize the positive and be cheerleaders and help people keep moving forward. So this is going to just really I think slide in nicely. That's great to hear that there's alignment. So I think that Kelsey is that basically what we got for folks? Yep that's it. Okay so I think we also have the GPRA slide right that we please if you have a moment encourage you to take it. But this is an opportunity for questions or comments. One of the things too with contingency management is that no matter where the program is physically located we do encourage it to have its own policy and procedure just like exactly what you're talking about around having the steps for a positive UA. We also encourage that contingency management be the policy and procedures be separate from wellness court or other sorts of approaches just so that folks do feel like their information isn't being shared across different programs in a way that they feel might be punitive. So that is one thing that we do highlight but then the flip side of that can be when folks are doing really well and meeting their own personal goals they do want people to know about that. So that is a thing that will come up too where they're like well we want this information shared with you know probation officers or whoever else. So it is really great to have those policies and procedures sort of thought out ahead of time so that you can think about how that might look within your setting. So that's one plug for policies and procedures. You know you're not always going to think of everything ahead of time but there are a few sort of overarching things that are just sort of universal implementation stuff. So yeah creating that separate from what you already have is something that we also encourage. So any thoughts or questions? I have a question. So we know most of this is centered around adult clients. Is the same true for youth clients? I mean will this be something that we can implement with our youth as well too that are receiving treatment services? So we have had folks that have implemented or thought about implementing with folks younger than 18 especially if that's a population that they already serve. So it is pretty similar from what we have helped support. Sometimes there are considerations around maybe some of the incentives sometimes are a little bit more like privilege oriented because they are usually still with their families or elsewhere. So some folks have focused more on incentives that families sort of help support or provide. Some folks have had reduced budgets related to incentives because younger folks may not need as high an amount and the research has supported programs. A lot of the evidence is actually with wellness court for youth addressing cannabis. So that's another setting where it's been really effective with younger folks. So there are some other considerations but you can set up your program. Similarly I don't know about TOR supporting that. So that would be another thing to check into is what population they're hoping to support. So then you'd have to think about budgeting from elsewhere if that's not something that they're covering. I'm trying to think of what else we've come across. But yeah, are you seeing stimulant use with younger folks or are you thinking more of alcohol and cannabis? Not a whole lot of stimulant use. It's mostly alcohol and cannabis. Yeah, so that would be the other thing is that TOR wouldn't support anything but stimulant use reduction. They would support treatment engagement attendance. So that would be the other thing to think about. Treatment engagement while on its face seems really simple. It actually can start to be hard to objectively quantify that. So like what exactly are they showing up for that you're reinforcing? Is it a consistent thing? Some folks have looked into like treatment homework is something that they try to reinforce. But again, that can start to get muddied across relatives that are coming in. So you just want to make sure that it's consistent for each relative, each touch point, and then figuring out what that looks like for twice a week across a 12-week period. Thank you. But yeah, that's always exciting to hear about supporting youth too. So that's awesome. Treatment engagement is one of the hardest things to accomplish that we have with youth. So I like the idea of having their program maybe being a little bit different and having a big swath of engagement. Yeah, and the reason why we do highlight engagement generally and like recruitment strategies is that, like you mentioned, contingency management has been used to increase attendance and retention, and that's really helped in various settings. And when you're helping folks who want to cut down or reduce stimulant use, recruitment can be a challenge. Because while it sounds fun generally, it's still changing behavior that's really difficult. So we have found that having like a pilot or having like a smaller number of folks that you're hoping to engage for the first six months or year could be helpful. And also like having a goal of 20 people or 25 people or whatever that looks like within your community setting is kind of nice to have a more of a realistic goal, and then also thinking about how to sort of keep that interest going. So we have different strategies and things that we talk about with folks as we help them implement. People are not going to be beating down your door necessarily to join the program. Even though it is fun and the people who find it useful really find it beneficial, but that may not be anyone or everyone. And so you want to think about how you engage folks and how you keep them engaged. And then are you seeing a large impact from stimulant use in your community too, among adults? Yep. I would say stimulants and alcohol are probably the number one thing, number one things that we're seeing. Okay. Yeah, so there's definitely a need, it sounds like, and probably an interest, but helps to get creative still with engagement strategies. Yeah. Thank you again so much for this today. I really, really appreciate it and this is gonna be, this is a great start to adding this program into our program and it was a lot of really, really good information and I look forward to getting the recording. There's a few people I anticipated being here today that aren't here so I'm really excited to be able to share that with them as well too. So yeah, thank you so much for everything. Yeah, thank you so much for having us come and join you all and sad that we're not there in person. And then the other thing that I was gonna mention too that I forgot to mention in previous conversations too is the Health Care Authority is rolling out their contingency management program through the Medicaid waiver. So I don't know Stormy if you have reached out to Laura Weed and we can provide that information to Emily to pass along. But I would highly encourage you reaching out to her to see if you can join. I think they're gonna have a phase one and a phase two rollout of community sites. So you would, they have a very brief application that you submit that you can get through Laura. And then the implementation, ongoing implementation support would be provided by us and folks at WSU. And so you're able to receive additional implementation supports above and beyond what the opioid response network would be able to sort of provide through this mechanism. So that's really exciting. So I'm glad that that's something that is timely for where you're at too and thinking about your CM program and rolling it out. Yeah, if you wouldn't mind sending me her contact information, please, I would absolutely love to get in touch with her. Okay, awesome. Yeah, we will definitely, definitely do that then. Okay, wonderful. Well, thank you again so much, everybody. And I hope that you enjoy the rest of your day. And thanks so much, Emily and Stephanie for bringing everybody together. We appreciate it. Yeah, thank you, Kate and Kelsey so much for the presentation. Any other thoughts, Emily? No, I think that is everything. Stormy, I will follow up with you and I'll share the reporting soon. I'll also email the survey link in case anyone didn't get a chance to fill it out. Okay, thank you so much, Emily. Yeah, of course. Awesome. All right. Well, everyone enjoy the rest of their day. Thank you. We'll see you later. Bye.

Opioid Response Network

Emily Mossberg

contingency management

stimulant use

PRISM Collaborative

SAMHSA

evidence-based prevention

Indigenous communities

positive reinforcement

tribal communities

behavior change

Medicaid waiver program

culturally relevant approaches