Margaret C. Wardle

Fentanyl-related, cocaine-overdose deaths have drastically increased, yet research on how people who use cocaine perceive fentanyl adulteration is limited. This study developed the novel Adulterated Cocaine Purchasing Task, a modification of the original Cocaine Purchasing Task, to quantify how people respond to fentanyl adulteration in cocaine. In the Adulterated Cocaine Purchasing Task, participants indicated how much cocaine they would purchase when cocaine had no (0%) versus some (10%) probability of fentanyl adulteration. Study aims were to (a) determine how possible fentanyl adulteration affects cocaine demand and (b) determine which individual characteristics predict continued demand for cocaine despite fentanyl adulteration. This Amazon Mechanical Turk study included self-reported cocaine purchasers (N = 64), who completed self-report questionnaires (demographics, substance use history, depression/posttraumatic stress disorder symptoms, fentanyl knowledge quiz), and the Adulterated Cocaine Purchasing Task. Results showed (a) that a greater probability of fentanyl adulteration (10%) lowered cocaine demand, but only for intensity (Q₀; amount of cocaine consumed when free; p < .001); (b) no effect on other demand indices (O_max, P_max, essential value, breakpoint); (c) significantly more zero responders with 10% probability of fentanyl adulteration than 0%, p < .001; and (d) that opioid couse, depression, age, posttraumatic stress disorder, fentanyl knowledge, and cocaine use severity did not moderate the relationship between fentanyl adulteration and intensity. Overall, fentanyl adulteration reduced cocaine demand but only for volume preferred at minimal cost, not general motivational drive for use, illustrating the dangerous insensitivity to toxic contamination. The internal validity of the paradigm provides proof-of-concept for this approach to identify individuals at risk from fentanyl-adulterated cocaine. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Background: Incentive programs are an effective yet underutilized behavioral intervention that can improve outcomes in medication for opioid use disorder (MOUD) treatment. Contingency Management (CM) is a rigorous incentive program run per seven evidence-based principles (e.g. objectively verifiable target behaviors, frequent opportunities for incentives). Prior implementation attempts have focused on implementing CM in specialized addiction clinics with methadone as the primary medication treatment. However, many people get MOUD from less specialized, more accessible family medicine clinics. These clinics might also benefit from the use of incentive programs, yet present unique challenges for implementation. For example, family medicine clinics typically use buprenorphine as their primary medication, which requires less intensive dosing schedules than methadone and thus provides fewer incentive opportunities. As an initial step in user-centered design of a CM-informed incentive program for the family medicine context, we conducted qualitative interviews with patients and staff in the buprenorphine treatment program of a family medicine department. We gathered and analyzed qualitative data on CM knowledge, preferred program parameters, and implementation considerations. Method: Participants ( N = 24) were buprenorphine treatment staff ( n = 12) and patients ( n = 12). Participants completed 30–50-minute semi-structured interviews, analyzed using rapid matrix analysis. Results: Participants had little experience with formal incentive programs, but generally viewed incentives as acceptable, appropriate, and feasible. Interviewees coalesced around having staff who were not MOUD prescribers run the program, consistent rather than escalating payments, and physical rewards delivered in-person. Potential challenges included medical record integration, demands on staff time, and confirmation of patients’ goal completion. Conclusions: Patient and staff feedback was well-aligned, especially regarding rewards as an opportunity for staff-patient connection and the need for simplicity. Comparing end-user suggestions with the literature, some consensus suggestions (e.g. non-escalating rewards) highlighted feasible places to compromise on ideal effectiveness to gain implementability. However, others (e.g. use of self-report to verify goals) conflicted directly with CM principles and indicate where more intensive education, support, and monitoring will be needed for implementation fidelity. These findings inform user-centered design and iteration of an incentive program for this accessible, non-specialized family medicine setting.

Background Contingency management (CM) is an effective yet underutilized behavioral intervention that uses rewards to improve outcomes in medication for opioid use disorder (MOUD) treatment. Prior implementation attempts have focused on specialized addiction clinics, using intensive daily treatment with methadone and high reward values (e.g. >$200 total). However, many people get MOUD from less specialized, more accessible, family medicine clinics. These clinics could also benefit from CM, yet present unique challenges for CM. Family medicine clinics typically use buprenorphine as their primary medication, which requires less intensive dosing schedules and thus provides fewer CM opportunities. They may also have lower institutional willingness to use high-value rewards. As an initial step in user-centered design of a low value reward (<$75 total) CM program for the family medicine context, we conducted qualitative interviews with patients and staff in the buprenorphine treatment program of a family medicine department. We gathered and analyzed qualitative data on CM knowledge, preferred program parameters, and implementation considerations. Method Participants ( N = 24) were buprenorphine treatment staff ( n = 12) and patients ( n = 12). Participants completed 30–50-minute semi-structured interviews, analyzed using rapid matrix analysis. Results Participants had little experience with CM, but generally viewed CM as acceptable, appropriate, and feasible. Interviewees coalesced around having staff who were not providers with prescription privileges conduct CM, consistent rather than escalating payments, and physical rewards delivered in-person. Potential challenges included medical record integration, demands on staff time, and confirmation of patients’ goal completion. Conclusions Patient and staff feedback was well-aligned, especially regarding rewards as an opportunity for staff-patient connection and the need for simplicity. Some consensus suggestions (e.g. non-escalating rewards) conflict with extant CM literature. Implications for implementation of CM in this setting are presented. These findings inform user-centered design and iteration of a CM program for this accessible, non-specialized family medicine setting.

Background: Stress maintains problematic alcohol use, so it is particularly important to identify interventions that effectively reduce the desire for alcohol even in the context of high stress. Reinforcer Pathology Theory suggests that stress increases alcohol demand by inducing short‐term thinking. One intervention that targets this mechanism is episodic future thinking (EFT), which involves vividly imagining personal future events and has been shown to reduce short‐term thinking and accompanying preferences for immediate rewards like alcohol. These shared mechanisms suggest that EFT may be particularly effective at reducing alcohol demand in the context of higher stress. This study first assessed the relationship of stress with preference for immediate rewards and alcohol demand, and the impact of EFT on preference for immediate rewards and alcohol demand. This study then tested whether EFT may be particularly effective in the context of higher stress.Methods: One hundred thirty‐nine adults with problematic alcohol use completed an online survey through Amazon Mechanical Turk (MTurk), including self‐report measures of past month stress and baseline momentary stress, an EFT or episodic recent thinking (ERT) procedure, a delay‐discounting task, and an alcohol purchase task. Univariate correlations assessed the relationship of stress with delay discounting and alcohol demand intensity. Path analyses assessed hypothesized models relating EFT/ERT, stress, delay discounting, and demand intensity.Results: Consistent with Reinforcer Pathology Theory, higher baseline momentary stress was correlated with increased preference for immediate rewards. EFT intervention increased preference for delayed rewards, which contributed to decreased alcohol demand. However, the effect of EFT on delay discounting was not moderated by stress.Conclusions: EFT does not appear uniquely effective at reducing desire for alcohol in the context of higher stress, but equally, EFT's efficacy was not significantly affected by stress level. Findings emphasize the opposing roles of state stress and EFT in the behavioral economics underlying problematic alcohol use.

Posttraumatic stress disorder (PTSD) symptoms are common in people with cocaine use disorder (CUD), and even sub-threshold PSTD symptoms result in worse treatment outcomes. Difficulties with reward functioning may drive this comorbidity. Impairments in reward functioning are prominent in both PTSD and CUD and contribute to development of substance use problems after trauma. There are three distinct reward processes that may be involved in the PTSD/CUD overlap: consummatory reward (ability to experience pleasure), motivational reward (willingness to exert effort for rewards), and reward learning (adapting behavior based on reward history). Here we test whether impairments in these reward functions account for the relationship between PTSD and CUD symptoms. This is a secondary analysis of data from a clinical trial (NCT02773212) that measured of PTSD symptoms, CUD severity, consummatory reward, motivational reward, and reward learning in 53 treatment-seeking people with CUD. Greater PTSD symptoms related to (1) more severe CUD and (2) less ability to learn from reward; however, impaired reward learning did not significantly account for the overlap in PTSD and CUD symptom severity. The observed relationship between PTSD and CUD symptoms was not accounted for by reduced ability to experience pleasure from rewards, reduced motivation for rewards, or reduced ability to learn from rewards. Thus, treatments that attempt to enhance reward functioning seem unlikely to address this complex comorbidity.

Cocaine use disorder (CUD) is a major public health issue, and greater cocaine use severity has been associated with worse treatment retention and outcomes. Therefore, greater understanding of processes that influence cocaine use is needed. Both anhedonia (i.e., undervaluation of nondrug rewards) and cocaine demand (i.e., cocaine valuation) are related to cocaine use severity and thematically related to each other at face value, but no studies have directly compared these outcomes to our knowledge. The present study represents a secondary analysis from a two-phase sequential, multiple assignment, randomized trial aimed at developing adaptive interventions for CUD. We examined the relationship between anhedonia and cocaine demand and how these measures were related to cocaine use severity. Participants (N = 116) were treatment-seeking adults with CUD. All measures were taken at baseline before treatment initiation. Analyses revealed (a) moderate and very strong evidence of relationships between cocaine demand factors (i.e., persistence, amplitude) and anhedonia (PP values ≥ 77.8%); (b) positive association between cocaine demand (both persistence and amplitude) and measures of cocaine use severity, with the exception of one relationship, which was in the opposite direction; and (c) demand amplitude continued to be positively related to cocaine use severity, even when considering anhedonia. Overall, findings from this study indicate cocaine demand relates to cocaine use severity more strongly than anhedonia. (PsycInfo Database Record (c) 2024 APA, all rights reserved).