Stimulants constitute a new and deadly fourth wave of the opioid epidemic. Contingency management is the most effective intervention for stimulant use and is an evidence-based adjunct to medication for opioid use disorder. Yet, uptake of contingency management in opioid treatment programs that provide medication for opioid use disorder remains low; in fact, access to contingency management is arguably one of the greatest research-to-practice gaps in the addiction treatment services field. The goal of this study is to conduct a type III hybrid effectiveness-implementation trial to evaluate a multi-level implementation strategy, the Science of Service Laboratory, to install contingency management for stimulant use in opioid treatment programs. The Science of Service Laboratory has three core components: didactic training, performance feedback, and external facilitation.

Utilizing a stepped wedge design, a cohort of public sector addiction specialty treatment programs will be randomized to receive Science of Service Laboratory across four cohorts. Each of the programs will provide de-identified electronic medical record data from all available patient charts on contingency management delivery and patient outcomes. Staff from each program will provide feedback on contextual determinants influencing implementation. This study will rigorously evaluate whether a multi-level implementation strategy developed by one of the longest-standing national intermediary purveyor organizations-the SAMHSA Technology Transfer Centers, will improve both implementation and patient outcomes.

Stimulant use among persons with opioid use disorder is associated with an array of serious consequences. Among those with opioid use disorder, stimulant use has been associated with more persistent opioid use; higher risk of HIV infection; higher levels of family, medical, legal, and vocational problems; and increased risk of fatal overdose. Contingency management is an evidence-based intervention for stimulant use and an evidence-based adjunct to medication for opioid use disorders. Medication for opioid use disorder is the first-line, evidence-based treatment for opioid use disorder, but does not specifically reduce stimulant use, and there are not yet efficacious medications for stimulant addiction. Moreover, individuals who continue to use stimulants while receiving medication for opioid use disorder have worse treatment response in terms of both retention and abstinence from opioids. Contingency management targets stimulant use via reinforcing incentives for attaining abstinence. Despite an abundance of research evidence, contingency management uptake in opioid treatment programs remains low due to barriers at both the provider- and organizational-levels. Effectively addressing the contingency management evidence-to-practice gap could advance both the field of implementation science and the quality of care in specialty addiction treatment settings. This project evaluates a multi-level implementation strategy, the Science to Service Laboratory, to install contingency management for stimulant use in opioid treatment programs. The Science of Service Laboratory employs three core components: didactic training; performance feedback; and external facilitation.

Utilizing a type III hybrid effectiveness-implementation trial with a stepped wedge design, we will enroll public sector addiction specialty programs across two states (Rhode Island and Illinois) to receive the Science of Service Laboratory. Data collection will leverage multiple sources. Programs will be enrolled across 4 cohorts - 1 in Rhode Island and 3 in Illinois. Each program will receive the multi-level Science to Service Laboratory and will extract de-identified electronic medical record data on contingency management implementation and patient outcomes. In addition, program staff will report on contextual determinants of implementation. Results will evaluate whether a multi-level implementation strategy initially developed by one of the longest-standing intermediary purveyor organizations (SAMHSA Technology Transfer Centers), will improve implementation and patient outcomes. In addition, the project will advance implementation science via specification and evaluation of contextual determinants.

The Specific Aims and corresponding hypotheses are:

Specific Aim 1: To test the effectiveness of the Science of Service Laboratory on implementation outcomes, including contingency management Reach, Adoption, and Implementation.

Specific Aim 2: To test the effectiveness of the Science of Service Laboratory on patient outcomes, including: Stimulant Abstinence and Treatment Retention.

• Opioid Treatment Program Counselors:

  • Inclusion criteria: 1) provide ongoing psychosocial support to medication for opioid use disorder patients (e.g., intake sessions, individual counseling, and/or group counseling sessions), and 2) have an active caseload
  • Exclusion criteria: Younger than 18 years of age, unable to provide informed consent

• Persons on Medication for Opioid Use Disorder [Not recruited, via electronic medical records only]

  • Inclusion criteria: must be newly initiated on medication for opioid use disorders (within the past 30 days) and have concurrent stimulant use (indicated by self-report of past 30-day stimulant use or positive toxicology screen within 30 days).
  • Exclusion criteria: Younger than 18 years of age, Does not have electronic medical records

This study protocol is embedded within a Center of Excellence funded by the National Institute on Drug Abuse. In coordination with other center project components, the study protocol and statistical analysis plan for primary outcomes will be submitted for publication to either an addiction (e.g., Addiction, Journal of Substance Abuse Treatment) or implementation science (e.g., Implementation Science, Implementation Science: Research and Practice) journal. Additional data (analytic code, participant-level data) can be requested from the Principal Investigator. Analysis files will be constructed from the electronic data and will be stripped of identifying information. Specifically, participants will be identified with a numeric identifier that is not related to any element of their personal identifying information. No names, addresses, telephone numbers, email addresses, medical record numbers, etc. will be retained in the de-identified files.

Protocol will be submitted for publication in coordination with other project components, with a target submission date in 2023. Analytic code and participant-level data will be made ready for distribution within 12 months of study completion.

Data will only be shared with external investigators when a data use agreement (DUA) is executed between Northwestern University and the requester's institution. The DUA will specify the requested data elements (each of which must be justified), the specific research question, the timeline for the project, and schedule for data destruction.

Outcomes will be exported from electronic medical records. Data analysts will not know who was receiving the intervention at what time point.