Adapting Contingency Management for Stimulant Use Disorder for Homeless-experienced Veterans in Permanent Supportive Housing

About This Grant

Significance to VA. U.S. homeless-experienced Veterans (HEVs) are three times more likely to die by drug overdose than non-homeless Veterans. The use of psychostimulants, such as cocaine and methamphetamine, is the leading risk factor for drug overdose deaths. Beyond overdose, stimulant use disorder (StUD) contributes to marked impairments in social functioning, cognitive deficits, cardiovascular disease, psychosis, suicide, violence, and housing instability. Contingency management (CM), the most effective treatment available for StUD, is significantly underutilized among HEVs with StUD. CM is a psychosocial intervention that consists of providing immediate rewards to reinforce reductions in stimulant use. Permanent supportive housing (PSH), delivered through the VA’s U.S. Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) program, offers an ideal setting to implement CM due to its structured environment and integrated support services that would facilitate CM engagement. This project focuses on adapting CM for StUD for HEVs in PSH, aligning with the VA’s mission to improve outcomes for HEVs and end Veteran homelessness. Innovation and Impact. This application has potential to reduce stimulant use, increase engagement in substance use disorder services, and enhance HEV’s recovery and social functioning. Currently, no published studies have applied implementation science methods to adapt CM for StUD in homeless service settings, within or outside the VA. This project addresses a critical gap among HEVs in the treatment of StUD, which contributes to significant social, medical, and psychological challenges in an already vulnerable population. Building from available evidence, and engaging with HEVs, VA staff and leadership, and national experts, this application is novel in proposing to design, and in a future CDA-2 application, implement and test a CM intervention tailored to PSH. Adapting CM for PSH may foster new research on how the VA can improve engagement and effectiveness of SUD interventions for HEVs to support recovery and community integration. Specific Aims. 1) To develop a tailored CM intervention for StUD for HEVs in PSH using key informant interviews and an expert panel. 2) To identify a strategy to support the implementation of CM for StUD in PSH in a future trial using implementation mapping methods. Methodology. This project involves qualitative data collection and implementation science methods to guide intervention adaptation. Aim 1 will adapt CM for StUD for HEVs in PSH utilizing key informant interviews with VA staff (n=15), HEVs (n=15), and subject matter experts (n=5), followed by an expert panel (n=6-8). Interviews in Aim 1 will explore facilitators and barriers to CM implementation as well as potential intervention adaptations. Synthesized interview findings will be shared with an expert panel in a single-round modified Delphi process to build consensus around intervention adaptations. While Aim 1 focuses on intervention development, Aim 2 will identify strategies (e.g., staff training, technical assistance resources) that support the implementation of CM in PSH, drawing from the same key informant interviews and expert panel as Aim 1. In addition, Aim 2 will utilize Implementation Mapping, an evidence-based approach to identify implementation strategies, along with a focus group with VA Greater Los Angeles (GLA) PSH and SUD stakeholders to co- design implementation strategies in preparation for a future trial. Path to Translation/Implementation. The findings of this project will inform a future CDA-2 study to evaluate the adapted intervention and implementation strategy in two PSH settings at GLA. This effort represents a critical step toward the ultimate goal of nationwide implementation in VA PSH and other homeless service settings, aiming to enhance recovery and social functioning among HEVs with StUD.