Addressing the Urgent Need for Effective Stimulant Use Disorder Treatment in Vancouver’s Acute Care Settings
Stimulant use, particularly crystal methamphetamine and cocaine, is a growing public health crisis in North America, leading to increased rates of illness and death. Vancouver, a major urban center, is significantly affected by this issue. Effective, evidence-based treatments for stimulant use disorder are urgently needed, especially within acute care settings in Vancouver. Currently, contingency management (CM) programs are recognized as a leading treatment strategy. These programs use positive reinforcement to encourage behavior change and reduce substance use. However, access to these programs is often limited. Hospitals offer a crucial opportunity to initiate substance use disorder treatment. Adapting CM programs for inpatient acute care in Vancouver hospitals could significantly improve patient care and broaden access to effective treatment for stimulant use disorders in this region.
Case Study: Contingency Management Program Success in a Vancouver Hospital Setting
This case study highlights the clinical journey of a patient with complex medical needs, admitted to a Vancouver urban hospital for osteomyelitis. His hospital course dramatically improved after enrolling in a pilot contingency management program specifically designed for the acute inpatient setting. This example demonstrates the potential of “Acute Care Program Vancouver” initiatives to transform patient outcomes.
Discussion: Adapting Proven Treatments for Vancouver’s Unique Healthcare Landscape
This case underscores the importance of adapting successful treatment models to fit different environments, especially when existing options are insufficient or inaccessible. Vancouver’s healthcare system, like many others, faces challenges in providing comprehensive addiction care within acute settings. Integrating “acute care program vancouver” initiatives, such as inpatient contingency management, can bridge this gap.
Keywords: acute care program vancouver, stimulant use disorder, contingency management, inpatient treatment, addiction medicine, cocaine use disorder, amphetamine use disorder
INTRODUCTION
Stimulant use disorder is a critical and escalating health concern in North America, contributing to alarming increases in hospital admissions and fatal overdoses (Winkelman et al., 2018; Kariisa et al., 2019). Vancouver, with its dense urban population, experiences a significant burden from stimulant-related harms. Acute hospital admissions present a vital window to engage individuals with substance use disorders in treatment. Research consistently shows the positive impact of inpatient interventions on substance use outcomes (Liebschutz et al., 2014; Eisenberg et al., 2016). However, effective programs tailored for stimulant use disorder treatment within Vancouver hospitals, or similar acute care settings, have been notably absent. This gap highlights the urgent need for “acute care program vancouver” initiatives focused on addiction.
Psychosocial interventions are the cornerstone of stimulant use disorder treatment. Contingency management (CM) programs stand out as the most evidence-based approach (Prendergast et al., 2006). CM programs utilize reward systems to positively reinforce reduced substance use. The two most common methods involve providing vouchers, redeemable for goods or services, with increasing monetary value for negative urine or breath samples, or using a “fishbowl” random draw for varied value rewards based on the same negative biological samples. Compared to other psychosocial treatments, CM has demonstrated superior effectiveness in reducing stimulant use and improving treatment retention, outperforming cognitive behavioral therapy, non-contingent rewards, 12-step programs, and combined treatment approaches (De Crescenzo et al., 2018). The implementation of “acute care program vancouver” strategies using CM is therefore highly relevant.
While CM programs have been successfully implemented in outpatient and residential treatment settings, their application within acute medical wards, particularly in a city like Vancouver, has been limited. Given the unique opportunity hospitalization provides for initiating treatment, inpatient CM interventions hold significant potential to decrease stimulant use, improve hospital retention, and enhance overall health outcomes within “acute care program vancouver” settings. This case study details the positive impact of an inpatient CM program on the clinical course of a complex medical patient struggling with severe cocaine use disorder in a Vancouver hospital.
CASE DESCRIPTION
A 38-year-old male was admitted to a Vancouver hospital due to infected sacral decubitus ulcers. These were secondary to T9–10 paraplegia resulting from a past motor vehicle accident. His medical history included neurogenic bladder and hardware from a previous femur fracture. He lived independently in subsidized housing, supported by a governmental disability assistance program. He had a history of frequent hospitalizations, with seven admissions in the preceding year for similar issues, including three discharges against medical advice (AMA) related to his substance use. This pattern highlights the challenges faced by “acute care program vancouver” services in managing patients with concurrent medical and addiction issues.
His substance use history was extensive, primarily involving smoked crack cocaine and heroin. He reported no methamphetamine use and no history of injection drug use. He was a daily marijuana user and a former cigarette smoker. In the past year, he had been on methadone for opioid agonist therapy but had recently transitioned to buprenorphine/naloxone treatment, which effectively reduced his opioid use. He had previously attended inpatient treatment programs for stimulant use disorder, though details were unclear, and he had never participated in a CM program. This lack of prior CM experience further emphasizes the novelty and importance of “acute care program vancouver” CM initiatives.
During this hospitalization, a CT scan revealed ischial osteomyelitis, and a six-week antibiotic course was initiated. His hospital stay became prolonged due to complications, including recurrent wound infections and seeding of the femur hardware. Plastic surgery and orthopedic surgery consultations deemed him a high-risk surgical candidate, partly due to his ongoing substance use. This complex scenario underscores the need for integrated “acute care program vancouver” approaches that address both medical and addiction needs concurrently.
Throughout his admission, the Addiction Medicine Consult Service, a multidisciplinary team including physicians, nurses, and social workers specializing in substance use disorders, followed his case. He remained on buprenorphine/naloxone in the hospital and abstained from illicit opioids during his stay. However, his ongoing cocaine use was a significant obstacle to his care. He frequently left the hospital to use cocaine, including one AMA discharge four months into his admission. These absences disrupted his antimicrobial therapy and contributed to recurrent infections, leading to frustration among healthcare providers and extending his hospital stay. This cycle illustrates the critical role of “acute care program vancouver” programs in breaking the link between substance use and negative healthcare outcomes.
Recognizing the high prevalence of substance use in its urban patient population, the Vancouver hospital had previously implemented various innovative strategies to improve health outcomes for patients with substance use disorders. Two months into his hospitalization, an inpatient CM program for stimulant use disorder was launched as part of a research study to address this unmet need (Table 1). This “acute care program vancouver” initiative was designed to provide accessible, evidence-based addiction treatment within the hospital. Program participants met with staff twice weekly to set health-related goals and provide urine drug tests (UDT). They earned prizes through a gift card-based fishbowl reward system for UDTs negative for stimulants and for achieving their health goals. Program participation could last up to twelve weeks during their admission, and upon discharge, connections to nearby outpatient programs were facilitated.
Table 1.
Contingency Management (CM) Program Process
| In-hospital Visit Type | Description of Intervention | Prize Draws* |
|---|---|---|
| Initial visit by the Addiction Medicine Consult Team following identification of a possible substance use disorder | Referred to CM Program if meets screening criteria: estimated 2+ week hospital admission, diagnosis of stimulant use disorder, open to exploring changes to stimulant use | N/A |
| Enrollment in CM program | Eligibility screening: diagnosis of stimulant use disorder, either active or in early remission ( | N/A |
| Follow-up A (Tuesdays) | Urine drug test (UDT), set health-related goal, and self-report any stimulant use | Prize draw(s) for:- Achieving SMART† healthcare goal set in previous week (ex. “get new phone”)- UDT negative for stimulants (cocaine or amphetamines) |
| Follow-up B (Fridays) | UDT | Prize draw for:- UDT negative for stimulants |
| Hospital discharge | Referral to outpatient CM program | N/A |
*Fishbowl for draws contains 63 chips: 47x$5, 15x$20, and 1x$100. Prize draw completed immediately after negative UDT and/or goal achieved.
†SMART goal: S=specific, M=measurable, A=achievable, R=relevant, T=time-bound.
Upon enrolling in the “acute care program vancouver” CM program, the patient’s cocaine use rapidly decreased, and his engagement in care significantly improved. He attended regular program meetings, setting goals such as increasing mobility and discussing depression treatment options with a prescriber. He experienced two periods of cocaine use relapse, each lasting 1 to 3 weeks, during times of high stress: once before planned surgery and again as discharge approached (Table 2). Between these episodes, he achieved multiple weeks of stimulant abstinence, confirmed by both self-reports and UDTs. Concurrent with reduced cocaine use, he completed his antibiotic course and underwent successful surgery to remove the infected femur hardware. In program evaluation surveys, he reported that the program helped him complete his medical treatment and increased his confidence to refuse his addiction. His total hospital stay was 195 days (including a one-day AMA discharge on day 145). He was discharged home and connected to an outpatient CM program for ongoing stimulant use disorder management, demonstrating the lasting impact of the “acute care program vancouver” inpatient intervention. Prior to discharge, informed consent was obtained for publication of this case report.
Table 2.
Urine Drug Test Results and Outcomes Achieved Throughout the Duration of the CM Program
| Program Day | Cocaine | Amphetamine | Self-reported Stimulant Use (Collected Weekly) | Health-related Goal Achieved | Prize Drawn for Either Negative UDT and/or Goal Achieved |
|---|---|---|---|---|---|
| Day 1 | + | − | No | Goal set | N/A |
| Day 3 | − | − | N/A | N/A | $5 |
| Day 9 | − | + | No | Yes | $20 |
| Day 11 | − | − | N/A | N/A | $5 |
| Day 15 | − | − | No | Yes | $5 + $5 |
| Day 18 | + | − | Yes | N/A | N/A |
| Day 25 | + | − | N/A | Yes | $5 |
| Day 29 | + | − | Yes | N/A | N/A |
| Day 36 | + | − | No | Yes | $20 |
| Day 40 | + | − | N/A | N/A | N/A |
| Day 43 | + | − | No | No | N/A |
| Day 46 | − | − | N/A | N/A | $20 |
| Day 49 | − | − | No | No | $5 |
| Day 53 | − | − | N/A | N/A | $5 |
| Day 57 | − | − | No | Yes | $20 + $5 |
| Day 60 | − | − | N/A | N/A | $20 |
| Day 65 | + | − | Yes | Yes | $20 |
| Day 71 | + | − | Yes | N/A | N/A |
| Day 74 | + | + | N/A | Yes | $20 |
| Day 78 | − | − | No | N/A | $5 |
| Day 81 | − | − | N/A | Yes | $5 + $5 |
| Day 84 | − | − | No | N/A | $5 |
| TOTAL = $200 |
DISCUSSION
Individuals who use substances face a higher risk of hospitalization for various medical reasons. Once hospitalized, they also exhibit increased rates of discharge AMA, which is linked to elevated risks of mortality and hospital readmission (Southern et al., 2012; Ti and Ti, 2015; Ronan and Herzig, 2016). For opioid use disorder, initiating opioid agonist therapy in hospitals has proven to reduce these risks and improve treatment outcomes. However, comparable hospital-based interventions for stimulant use disorder, especially within “acute care program vancouver” settings, have been lacking.
Contingency management (CM) programs are the most effective evidence-based treatment for stimulant use disorder, yet they are often underutilized (Prendergast et al., 2006). For patients admitted to acute medical beds, inpatient CM programs, such as those within an “acute care program vancouver” framework, can achieve the dual objective of reducing substance use during hospitalization and facilitating engagement in long-term treatment. In the presented case, a patient with complex infections experienced a prolonged hospital stay, complicated by ongoing stimulant use and repeated AMAs. Upon participation in the CM program, he achieved cocaine abstinence, set health-related goals, and developed self-confidence, leading to a significant positive shift in his hospitalization course. This case highlights the transformative potential of “acute care program vancouver” CM programs.
Despite their established effectiveness, access to CM programs remains a significant barrier across North America, including Vancouver. Recognizing the potential impact of increased access, the Veterans Health Administration system in the U.S. recently launched the first large-scale CM implementation within its healthcare network. This rollout across 94 stations in the US has shown response rates comparable to those in controlled clinical trials (DePhilippis et al., 2018). This initiative not only expands access to crucial treatment but also serves as a model for implementing CM programs within other public and private healthcare systems, including “acute care program vancouver” initiatives. Integrating programs like this within acute care hospitals is another viable strategy to improve access to the current gold standard of care for patients with stimulant use disorders in Vancouver and similar urban centers.
Limitations of these programs include the necessary infrastructure for patient identification, the patient’s motivation to reduce substance use, willingness to participate, and sufficient medical stability. Resources such as trained staff, financial support for rewards, and connections to outpatient care are also essential for successful “acute care program vancouver” CM programs. However, when considering the financial burden of prolonged or repeated hospitalizations, the potential cost-effectiveness of such programs becomes evident. A key strength of the Vancouver hospital in this case is its substance use policy, incorporating harm reduction principles and not mandating complete abstinence. This approach allows for open communication and the pragmatic application of this evidence-based intervention for patients in early remission or with ongoing use, making it a valuable component of an “acute care program vancouver”.
CM currently represents the most effective known treatment for stimulant use disorder. Inpatient CM programs are a unique and valuable adaptation of this approach to support the acute care of patients with ongoing stimulant use and to link them to long-term treatment options post-discharge. This “acute care program vancouver” program example demonstrates how existing strategies for managing substance use disorders can be successfully adapted for use in non-traditional settings, improving patient outcomes and access to care within acute healthcare environments.
Acknowledgments
We wish to thank all study participants, researchers, and staff.
This case was part of a study supported by the Providence Health Care Research Challenge, the St. Paul’s Foundation Enhanced Patient Care Fund, and the UBC Partnership Recognition Fund. Paxton Bach is supported by the Michael Smith Foundation for Health Research. Nadia Fairbairn is supported by a MSFHR/St. Paul’s Foundation Scholar Award.
Abbreviations:
AMA Against medical advice
CM contingency management
UDT Urine drug test
Footnotes
The authors report no conflicts of interest.
