The cigarette purchase task (CPT) is an efficient and safe method to simulate cigarette demand. In prior research, the CPT demand intensity index (estimated consumption if cigarettes were free) overestimated actual consumption. This study had three aims: (a) further examine concordance between demand intensity and actual consumption; (b) compare their relative sensitivity to individual differences in smoking risk; and (c) examine overestimation prevalence and predictors. Participants were adults who smoked daily with comorbid psychiatric disorders or socioeconomic disadvantage. Participants completed the CPT prior to receiving free usual-brand cigarettes for 7 days, with daily consumption recorded via interactive voice response. Aim 1 (n = 326): Demand intensity overestimated interactive voice response smoking by an average of 3.46 (standard error of the mean, 0.06) cigarettes smoked/day (p < .001). Aim 2 (n = 326): CPT and interactive voice response were concordant in discerning differences in smoking risk by opioid use disorder (p < .001), age (p = .012), and education (p < .001). Aim 3 (n = 1,101): 72.39% of participants overestimated demand intensity, with lower baseline cigarettes smoked/day, younger age, and nonmentholated cigarette use predicting overestimation (ps ≤ .038). Overall, this study demonstrates that CPT demand intensity often but modestly overestimates actual consumption, while nevertheless remaining equisensitive to differences in smoking risk as actual consumption, thereby supporting its utility and construct validity. Demand intensity overestimation is independently predicted by lighter smoking, younger age, and use of nonmentholated cigarettes. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

OBJECTIVE:To pilot test the efficacy of contingency management (CM) for stimulant use disorder (StimUD) among syringe service program (SSP) recipients. METHODS:This randomized, parallel-groups, 12-week pilot trial was conducted in Burlington, Vermont from 02/24-07/24. Twenty-seven individuals with StimUD participating in SSP services were randomized to health education (HE) plus CM for session attendance (HE+Att-CM) (n = 13) or HE plus CM for stimulant abstinence (HE+Abs-CM) (n = 14). Stimulant use monitoring was examined twice-weekly using point-of-care urine drug tests (UDTs). HE+Att-CM participants earned incentives for UDT samples independent of results. HE+Abs-CM participants earned incentives for stimulant-negative UDT samples. The primary outcome was the percentage of participants stimulant-negative by week. Missing UDTs were treated as stimulant positive. Outcomes were compared between conditions using repeated measures mixed models for categorical data based on generalized estimating equations using a logistic link function. RESULTS:The percentage of participants stimulant-negative was greater in the HE+Abs-CM condition averaging 22.6% (weekly range, 7.1%-28.6%) compared to 3.2% (weekly range, 0%-7.7%) in the HE+Att-CM condition (p = .014). CONCLUSIONS:Findings provide preliminary experimental evidence that CM reduces stimulant use among individuals participating in low-barrier services at a community-based SSP.

INTRODUCTION:Expanding access to effective treatment for stimulant use disorder (StimUD) is increasingly urgent as US fatal drug poisonings involving stimulants have rapidly increased. Limited information is available regarding interest in StimUD treatment among syringe service program (SSP) participants including interest in contingency management (CM). METHODS:We surveyed SSP participants in Burlington, Vermont regarding their interests in reducing and stopping stimulant use, participating in CM, and examined associations between sociodemographics, drug use, and health/treatment variables with interest in reducing and stopping stimulant use using multivariable logistic regression. RESULTS:Among 139 participants, 64.6 % reported interest in reducing and 59.7 % in stopping stimulant use. Overall, 82.8 % of participants reported interest in CM to reduce or stop stimulant use. Interest in reducing use was greater (odds ratio[95 % CI]) among participants currently receiving substance use disorder (SUD) treatment (3.84[1.61-9.14], p < .01), without Hepatitis C viral (HCV) infection (2.61[1.14-5.98], p = .02), and being somewhat (19.29[2.25-165.65], p = .01) or very (19.65[2.34-164.84], p = .01) concerned about anxiety. Interest in stopping use was greater among participants currently receiving SUD treatment (4.98[1.97-12.62], p < .01), without HCV infection (2.87[1.22-6.74], p = .02), participants whose primary drug was opioids compared to both stimulants and opioids (28.13[2.95-267.93], p < .01), and participants whose primary drug was stimulants compared to both stimulants and opioids (12.81[1.45-113.43], p = .02). CONCLUSIONS:Results demonstrate interest in stimulant use treatment among this sample of SSP participants, with strong interest in CM. As community-based programs with high social acceptability for their non-judgmental services, SSPs are a novel setting to examine providing evidence-based CM for StimUD.

INTRODUCTION:This study assessed the substitutability of plausible combustible menthol cigarette alternatives (MCAs) for usual brand menthol cigarettes (UBMCs) in adults who smoke menthol cigarettes. METHODS:Following three in-lab sampling sessions, 80 adults aged 21-50 who smoke menthol cigarettes chose their preferred MCA: (1) a menthol roll-your-own cigarette (mRYO), (2) a menthol filtered little cigar (mFLC) or (3) a non-menthol cigarette (NMC). Participants were instructed to completely substitute their preferred MCA for their UBMC for 1 week and complete daily diaries documenting adherence and subjective effects. At the final lab visit, participants completed concurrent choice and cross-price elasticity tasks with their substitute product and UBMC as the comparator. RESULTS:Most (65%) participants chose mRYO as their preferred product, followed by NMC and mFLC. Adherence to MCA was high for all products across the week (range: 63%-88%). Positive subjective effects for mRYO decreased over time but remained numerically higher than the other MCA products; craving reduction also decreased for NMC across phases. In the progressive ratio task, participants chose their UBMC in 61.7% of choices; this did not differ by preferred MCA, although the median breakpoint was highest for mRYO and similar for mFLC and NMC. Cross-price elasticity comparing UBMC and the preferred product indicated high substitutability of each MCA at phase 3 (I values -0.70 to -0.82). CONCLUSIONS AND RELEVANCE:mRYOs were the most preferred MCA among the study products, but all MCAs were acceptable substitutes for UBMC using behavioural and economic measures in a short-term trial period. Trial registration number NCT04844762.

OBJECTIVE:This study investigated rural disparities in cigarette smoking among U.S. women by age (18-65+ years) across survey years (2002-2022). METHODS, DATA SOURCE:Data came from the National Survey on Drug Use and Health. Women were categorized by rural-urban residence and age. We examined associations between residence, age, and time on current-smoking prevalence and quit ratios in two-year bins using weighted logistic-regression adjusting for race/ethnicity, education, annual income. RESULTS:Effects of residence on current-smoking prevalence interacted with time (t[df = 430,180] = 4.51, P < .001), with reductions over time among urban (AOR = 0.95, 95 %CI: 0.94-0.96, P < .001) but not rural residents (AOR = 0.99, 95 %CI: 0.98-1.01, P = .66). Residence interacted with age (t[df = 430,180] = -4.90, P < .001), with greater smoking among rural women in younger (AORs≥1.23, 95 %CI: 1.01-1.44, Ps ≤ 0.008), but not older age brackets (AORs ≤1.04, 95 %CI: 0.74-1.35, Ps ≥ 0.688). Rural residence predicted lower odds of quitting smoking (AOR = 0.80, 95 %CI: 0.71-0.91, P < .001). CONCLUSIONS:There is a growing disparity in smoking prevalence that disproportionately impacts rural women ages 18-49 years raising concerns about multigenerational adverse effects as this demographic is most likely to be pregnant or parenting young children. There is also a rural disparity in quitting smoking across age groups underscoring a need for greater access to smoking-cessation services among rural women.

OBJECTIVE:Examine changes in cigarette smoking prevalence among US adolescents by rural-urban residence, gender, and time. METHODS:We compared trends in smoking prevalence by rural-urban residence and gender using 18 years of cross-sectional data (2002-2019) from 298,530 respondents aged 12-17 in the US National Survey on Drug Use and Health. The two primary outcomes were past-month and daily smoking prevalence. Weighted logistic regression models tested whether smoking prevalence varied by rural-urban residence, gender, and time along with two-way and three-way interactions of these variables. RESULTS:Past-month and daily smoking declined over time for all four rural-urban residence and gender combinations. Regarding past-month smoking, there was a significant rural-urban residence by time interaction (p < .001) with higher prevalence and slower rates of decline among rural (adjusted odds ratio [AOR] = 0.86; 95 %CI = 0.85,0.87) versus urban participants (AOR = 0.83; 95 %CI = 0.82,0.84). A significant gender by time interaction (p < .001) was also observed. The rate of decline was faster among females (AOR = 0.82; 95 %CI = 0.81,0.83) versus males (AOR = 0.85; 95 %CI = 0.84,0.86) with prevalence initially higher (2002-2003) yet ending lower (2018-2019) among females. Regarding daily smoking, there was a significant rural-urban residence by time interaction (p = .005) with higher prevalence and slower rates of decline among rural (AOR = 0.82; 95 %CI = 0.80,0.85) versus urban participants (AOR = 0.79; 95 %CI = 0.78,0.80). CONCLUSIONS:Findings provide novel evidence of shrinking yet persistent rural disparities in both past-month and daily smoking, and less declines in past-month smoking among males over time. Together, findings support continued need for tobacco control and regulatory efforts to reduce adolescent smoking and specific efforts to reduce rural and gender disparities.

The U.S. Food and Drug Administration has proposed a nicotine-limiting standard, which would increase the unit price of nicotine in cigarettes and could cause people who smoke and are unable/unwilling to quit nicotine to switch to other products. This study examined the substitutability of little cigars/cigarillos (LCCs), e-cigarettes, and other nicotine products for cigarettes using the Experimental Tobacco Marketplace. Participants (N = 145) recruited through Amazon Mechanical Turk completed hypothetical purchases for 7 days' worth of nicotine/tobacco products in the Experimental Tobacco Marketplace. Purchases required participants to allocate their usual weekly expenditure across products at five escalating cigarette prices while alternative product prices remained fixed. Purchases were made in three marketplaces: (a) with a range of products, including e-cigarettes and LCCs, (b) without e-cigarettes, and (c) without LCCs. Participants were 45.7 (mean; SD = 10.3) years old and primarily female (70.3%) and White (82.1%) and smoked 17.6 (mean; SD = 8.9) cigarettes/day. Cigarette purchasing decreased as price increased (p < .001). When all products were available, the most appealing substitutes were e-cigarettes, followed by nicotine replacement therapy, LCCs, and chew (p < .05). Findings were similar for products other than e-cigarettes and LCCs in marketplaces without e-cigarettes and LCCs, respectively. Findings demonstrate the potential for noncombusted and combusted products to substitute for cigarettes, with experimental evidence that LCCs substitute for cigarettes, although less effectively than other products. Results underscore the importance of regulation that limits the potential for LCC substitution for cigarettes and maintains noncombusted alternatives in the marketplace to promote harm reduction among those unable to quit nicotine. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Importance:Interest in contingency management (CM) as a treatment for opioid and stimulant use disorders has increased because of the ongoing dual opioid/stimulant crisis, rising stimulant drug deaths, and demand for effective treatments for stimulant use disorder. The success of the US Department of Veterans Affairs nationwide rollout and the launch of California's Recovery Incentives Program provide evidence that this treatment can be translated into effective clinical practice. Objective:To provide data-driven inflation-adjusted incentive estimates for modern CM protocols that can be customized for intervention duration. It is essential for CM protocols implemented in clinical care to use efficacious, research-supported parameters, including incentive magnitude. Evidence Review:This review included 112 published CM protocols that involved reinforcement of stimulant- and/or opioid-negative urine drug tests, categorized each protocol in terms of impact (small/medium/large effect size) relative to a non-CM comparator condition, and computed weekly inflation-adjusted incentive magnitudes for voucher- and prize-based CM protocols. Findings:Drawn from protocols with medium to large impacts on patient outcomes, weekly median magnitude estimates are $128/week for voucher protocols and $55/week for prize protocols. For the most common duration of 12 weeks, these estimates translate to $1536 for voucher and $660 for prize protocols. Conclusions and Relevance:These incentive magnitude estimates can be used to inform clinical, policy, and advocacy related to CM implementation. Practical suggestions (eg, starting values, escalation) for building protocols that meet these incentive magnitudes are provided and implications are discussed.

Understanding psychosocial factors that underpin smoking disparities is important for developing targeted interventions to reduce tobacco use and its associated adverse health consequences. This study investigated associations between cumulative psychosocial risks, age, and the interplay of these two factors in U.S. smoking disparities over time. Participants included adults aged ≥ 18 years in the 2002–2019 US National Survey on Drug Use and Health. Psychosocial factors were combined into a cumulative-risk index with four levels: No-, Low-, Moderate-, and High-risk. Logistic regression analyses tested whether smoking prevalence varied by risk level and age over time. Greater cumulative risk was associated with higher smoking prevalence. Using No-risk group prevalence (4.2

OBJECTIVE:This study is part of a programmatic investigation of rural disparities in cigarette smoking examining disparities in smoking prevalence and for the first-time quit ratios among adult women of reproductive age (18-44 years), a highly vulnerable population due to risk for multigenerational adverse effects. METHODS:Data came from 18 years (2002-2019) of the U.S. National Survey on Drug Use and Health (NSDUH) among women (n = 280,626) categorized by rural-urban residence, pregnancy status, using weighted logistic regression models testing time trends and controlling for well-established sociodemographic predictors of smoking (race/ethnicity, education, income). Concerns regarding changes in survey methods used before 2002 and after 2019 precluded inclusion of earlier and more recent survey years in the present study. RESULTS:Overall smoking prevalence across years was greater in rural than urban residents (adjusted odds ratio [AOR] = 1.11; 95%CI, 1.07-1.15; P < .001) including those not-pregnant (AOR = 1.10; 1.07-1.14; P < .001) and pregnant (AOR = 1.29; 1.09-1.52; P < .001). Overall quit ratios across years were lower in rural than urban residents (AOR = 0.93; 0.87-0.99; P < .001) including those not-pregnant (AOR = 0.93; 0.88-1.00, P = .035) and pregnant (AOR = 0.78; 0.62-0.99; P = .039). Interactions of rural versus urban residence with study years for prevalence and quit ratios overall and by pregnancy status are detailed in the main text. CONCLUSIONS:These results support a longstanding and robust rural disparity in smoking prevalence among women of reproductive age including those currently pregnant and provides novel evidence that differences in smoking cessation contribute to this disparity further underscoring a need for greater access to evidence-based tobacco control and regulatory interventions in rural regions.

Behavioral skills training and on-the-job feedback are effective in changing staff behavior as evidenced by years of staff-training research. However, community programs for adults with intellectual and developmental disabilities (IDD) often do not utilize these best-practice training methods. The purpose of the current study was to train four empirically derived practices to staff who work with adults with IDD. We trained the staff to provide positive interactions, provide effective instructions, provide correct responses to problem behavior, and promote consumer engagement with items and activities. We used behavioral skills training and on-the-job feedback to increase staff implementation of these practices on a large scale in a community-based organization despite some barriers such as high staff turnover rates. Overall, results showed that our training procedure was effective in increasing staff implementation of the four practices in many homes and programs.

Background Understanding current substance use practices is critical to reduce and prevent overdose deaths among individuals at increased risk including persons who use and inject drugs. Because individuals participating in harm reduction and syringe service programs are actively using drugs and vary in treatment participation, information on their current drug use and preferred drugs provides a unique window into the drug use ecology of communities that can inform future intervention services and treatment provision. Methods Between March and June 2023, 150 participants in a harm reduction program in Burlington, Vermont completed a survey examining sociodemographics; treatment and medication for opioid use disorder (MOUD) status; substance use; injection information; overdose information; and mental health, medical, and health information. Descriptive analyses assessed overall findings. Comparisons between primary drug subgroups (stimulants, opioids, stimulants-opioids) of past-three-month drug use and treatment participation were analyzed using chi-square and Fisher's exact test. Results Most participants reported being unhoused or unstable housing (80.7%) and unemployed (64.0%) or on disability (21.3%). The drug with the greatest proportion of participants reporting past three-month use was crack cocaine (83.3%). Fentanyl use was reported by 69.3% of participants and xylazine by 38.0% of participants. High rates of stimulant use were reported across all participants independent of whether stimulants were a participant's primary drug. Fentanyl, heroin, and xylazine use was less common in the stimulants subgroup compared to opioid-containing subgroups (p < .001). Current- and past-year MOUD treatment was reported by 58.0% and 77.3% of participants. Emergency rooms were the most common past-year medical treatment location (48.7%; M = 2.72 visits). Conclusions Findings indicate high rates of polysubstance use and the underrecognized effects of stimulant use among people who use drugs-including its notable and increasing role in drug-overdose deaths. Crack cocaine was the most used stimulant, a geographical difference from much of the US where methamphetamine is most common. With the increasing prevalence of fentanyl-adulterated stimulants and differences in opioid use observed between subgroups, these findings highlight the importance and necessity of harm reduction interventions (e.g., drug checking services, fentanyl test strips) and effective treatment for individuals using stimulants alongside MOUD treatment.

Introduction The Food and Drug Administration (FDA) has issued proposed product standards banning menthol as a characterising flavour in cigarettes and cigars. The public health benefits of these product standards may be attenuated by the role of plausible substitutes in the marketplace. Therefore, the present study examined the addiction potential of plausible combustible menthol alternatives compared with usual brand menthol cigarettes (UBMC). Methods Ninety-eight adult menthol cigarette smokers completed four visits, smoking their UBMC at the first session and three menthol cigarette alternatives in random order at the subsequent visits: (1) a preassembled menthol roll-your-own (mRYO) cigarette using menthol pipe tobacco and mentholated cigarette tube, (2) a menthol filtered little cigar (mFLC) and (3) a non-menthol cigarette (NMC). Measures of smoking topography, exhaled carbon monoxide (CO), craving and withdrawal, subjective effects and behavioural economic demand indices were assessed. Results Compared with UBMC, menthol cigarette alternatives resulted in different puffing topography and CO exposure (except mRYO), and lower levels of positive subjective experience and behavioural economic demand indices. Among the alternative products, participants reported the highest level of positive subjective experience and higher demand for mRYO, compared with mFLC and NMC. Similarly, participants were significantly more likely to want to try again, purchase and use the mRYO product regularly compared with mFLC and NMC. Conclusions and relevance mRYO cigarettes were the most highly rated cigarette alternative among study products, suggesting their potential appeal as a menthol cigarette substitute and needed inclusion of menthol pipe tobacco and cigarette tubes in FDA’s proposed ban.

Background Understanding disparities in adolescent cigarette smoking is important for effective prevention.Methods We investigated disparities in adolescent smoking based on cumulative reported psychosocial and health risk among respondents ages 12-17 years in the US National Survey of Drug Use and Health from 2002 to 2019. Multivariable regression estimated associations of cumulative risk, survey years, and their interaction predicting past-month and daily smoking. Eleven psychosocial and health variables associated with youth smoking formed composite measures of cumulative risk, categorizing risk as low (0-2), moderate (3-4), or high (>= 5). The main outcomes were weighted past-month and daily smoking by cumulative risk and time, examining prevalence and proportional change across years.Results Among 244 519 adolescents, greater cumulative risk predicted higher smoking prevalence across all outcomes. Compared with the low-risk category, past-month smoking odds (adjusted odds ratio) were 9.14 (95% confidence interval [CI] = 8.58 to 9.72) and 46.15 (95% CI = 43.38 to 49.10) times greater in the moderate-risk and high-risk categories. For daily smoking, odds were 14.11 (95% CI = 11.92 to 16.70) and 97.32 (95% CI = 83.06 to 114.03) times greater among the moderate-risk and high-risk categories. Regarding proportional change, the low-risk category exhibited the steepest decline (-85.1%) in past-month smoking from 2002-2003 to 2018-2019, followed by the moderate-risk (-79.2%) and high-risk (-65.7%) categories. Daily smoking declined more steeply among the low-risk (-96.5%) and moderate-risk (-90.5%) than high-risk category (-86.4%).Conclusions Cumulative risk is a robust predictor of adolescent smoking. Although record-setting reductions in adolescent smoking extend across risk categories, disparities favoring youth with fewer risks are evident throughout. Recognizing cumulative risk can inform the development of more targeted and effective prevention efforts.

Introduction Considering recent and proposed bans on menthol cigarettes, methods are needed to understand the substitutability of potential menthol cigarette alternatives (MCAs) for menthol cigarettes. This study examined the prospective relationship between behavioral economic demand indices and subjective effects of usual brand menthol cigarettes (UBMC) and preferred MCAs with subsequent performance on a laboratory-based concurrent-choice task comparing UBMC and MCAs.Methods Eighty participants who typically smoked menthol cigarettes completed this clinical laboratory study. After sampling each product, participants completed the cigarette purchase task (CPT) and modified cigarette evaluation questionnaire (mCEQ). Following 1 week of substituting their preferred MCA for their UBMC, participants completed a 90-minute concurrent-choice self-administration (SA) task comparing their UBMC and preferred MCA. Linear regression models explored associations between CPT demand indices and mCEQ subjective effects in the laboratory with subsequent response effort for UBMCs on the concurrent-choice task.Results Three demand indices for UBMC were positively associated with UBMC response effort: essential value (EV; p = .02), Omax (p = .02), and breakpoint (p = .04). Four CPT demand indices for the preferred MCA significantly corresponded with UBMC response effort: EV (p = .03), price associated with maximal expenditure (Pmax) (p = .04), maximal expenditure (Omax) (p = .03), and breakpoint (p = .03). Subjective effects captured by the mCEQ were not associated with response effort.Conclusions Demand indices reflecting Persistence (ie, sensitivity to escalating price) predicted effort to obtain UBMC puffs on the concurrent-choice task. Among this sample, the CPT captured information on the relative reinforcing value (ie, addiction potential) of combustible tobacco products similar to the longer SA task.Implications In an ever-changing product market, assessing the reinforcing efficacy of menthol cigarettes and putative substitutes quickly and with validity is an important methodological tool for understanding abuse liability. Results suggest that behavioral economic demand indices of CPT efficiently capture information on the relative reinforcing value of UBMC and plausible alternative tobacco products, similar to a 90-minute in-laboratory SA task.

The current overdose and broader public health crisis involving illicit drug use is often referred to as the "opioid" or "fentanyl" crisis. Clearly there is extensive data on the profound damage done by opioids over the past 20 years and specifically by fentanyl in the past 5 years. However, there is an extensive array of data that suggests there is more to the current crisis than opioids/fentanyl. Much recent evidence indicates that methamphetamine and cocaine are playing a substantial and increasing role in the illicit drug crisis in the US-the 4th wave. This paper reviews data that illustrate the role of psychomotor stimulants in fatal overdoses, nonfatal overdoses, and emergency department visits. Despite the major detrimental role that stimulants are having on the public health in the US in 2023, there is virtually no evidence-based treatment available in practice for people with stimulant use disorder (StimUD). Although there are no medications with FDA-approval for the treatment of StimUD, there is a behavioral treatment, contingency management (CM), with over 3 decades of robust research supporting its efficacy for individuals with StimUD. Despite the overwhelming evidence supporting CM, it is not being widely used in routine treatment outside the VA healthcare system. This paper reviews some of the (a) evidence for CM, (b) CM protocol design elements that require consideration, (c) current obstacles to the widespread imple-mentation of CM, and (d) strategies for addressing these obstacles. Overcoming these obstacles is a priority to allow routine use of CM as a treatment for StimUD.

Contingency management is one of the most effective treatments for substance use disorders in not-pregnant people. The most recent quantitative review of its efficacy among pregnant and postpartum women who smoke cigarettes concluded with moderate certainty that those receiving contingent financial incentives were twice as likely to be abstinent compared with controls. We aimed to update and extend previous reviews. Five databases were systematically searched for randomized controlled trials (RCTs) published before December 2022 that assessed the effectiveness of incentives for abstinence from substance use. Data from trials of smoking abstinence were pooled using a random-effects meta-analysis model (restricted maximum likelihood). Results are reported as risk-ratios (RRs) with 95% confidence intervals (CIs). This study is registered with PROSPERO, CRD42022372291. Twelve RCTs (3136) pregnant women) were included. There was high certainty evidence that women receiving incentives were more likely to be abstinent than controls at the last antepartum assessment (12 RCTs; RR = 2.43, 95% CI 2.04-2.91, n = 2941, I2 = 0.0%) and moderate certainty evidence at the longest postpartum assessment while incentives were still available (five RCTs; RR = 2.72, 1.47-5.02, n = 659, I2 = 44.5%), and at the longest postpartum follow-up after incentives were discontinued (six RCTs; RR = 1.93, 1.08-3.46, n = 1753, I2 = 51.8%). Pregnant women receiving incentives are twice as likely to achieve smoking abstinence during pregnancy suggesting this intervention should be standard care for pregnant women who smoke. The results also demonstrate that abstinence continues into the postpartum period, including after incentives are discontinued, but more trials measuring outcomes in the postpartum period are needed to strengthen this conclusion.

The United States is currently in the fourth wave of the overdose crisis wherein stimulants together with fentanyl are the major drivers of overdose deaths. To date, there has been limited effort outside the US Veterans Administration Health System health system to disseminate evidence-based treatment for people with stimulant use disorder. Contingency management, a behavioral intervention in which positive reinforcement is provided for a target behavior indicating treatment progress, has decades of empirical support but limited implementation in real-world, non-US Veterans Administration Health System settings. The purpose of the report is to provide an overview of contingency management, the barriers to adoption, and recommendations for overcoming these barriers.

The United States is currently in the fourth wave of the overdose crisis wherein stimulants together with fentanyl are the major drivers of overdose deaths. To date, there has been limited effort outside the US Veterans Administration Health System health system to disseminate evidence-based treatment for people with stimulant use disorder. Contingency management, a behavioral intervention in which positive reinforcement is provided for a target behavior indicating treatment progress, has decades of empirical support but limited implementation in real-world, non-US Veterans Administration Health System settings. The purpose of the report is to provide an overview of contingency management, the barriers to adoption, and recommendations for overcoming these barriers.