In this module, we talked specifically about substance use disorders for which there are medications that are FDA approve. But some substance use disorders don't have any evidence-based approved medications, for example, for stimulants or for marijuana. So what are the best treatment strategies, for instance, methamphetamine and cocaine use disorder? >> I think that's where we end up using a lot of our evidence-based psychotherapy. So if we're doing cognitive behavioral therapy or motivational enhancement therapy. But really, psychotherapy is what we have when we don't have pharmacotherapy available. And so, it gets to your question early on, what do you do for the person who's not wanting to engage in a psychotherapy of sorts, whether it's individual or group? And so, it becomes all the more important to try to engage them. And there might be waiting list to get into that that's hard to overcome. But I think that's really sort of what we have to offer. >> That is what we have. We have psychotherapies and we also have behavioral therapies. Probably one of the most best researched therapies is contingency management for cocaine use disorder. And in some places this can potentially be controversial, but it works. So this is where you actually reward people when they give cocaine negative urines. And the number of consistent cocaine negative urines they get to draw from a fishbowl of prizes. And a lot of times those prizes are atta girl or atta boy, you've done a great job, maybe an inspirational quote. But sometimes they draw and they actually win a prize or get a reward. At our facility, I work at the VA, veterans can go up to our canteen, and sometimes there's even a big prize of close to $200. That's the big major prize. But we're investing in this because it works, and there aren't medications for cocaine use disorders. But this does show consistently and multiple randomized controlled trials to improve the the number of cocaine negative urines that we receive. >> Does the does the size of the award matter or is it just the dopamine release that comes with any kind of reward that's why contingency management does seem to work? >> These are good questions. I do think it speaks to we are trying to move motivation. We target motivation. It's not if patients are motivated, right? But what are they motivated for? All of us are motivated, and so motivational interviewing techniques really get at ambivalence and trying to understand what a patient's motivated for. And then, help them move in the direction of positive and healthy changes. And contingency management is also a behavioral therapy that can help to shift that motivational balance. >> We similarly do that in one of the primary care clinics that I work in. And instead of having it be a fishbowl draw, they earn increasing amounts over time, which gets at this idea of keeping them retained in care. And as patients will tell you, and a common quote that they say in NA is having more more time under my belt, more time away from the substance. And so, I think it's just another piece, especially when we don't have a draw to come into clinic for giving a medication prescription or dispensing a medication. That reward that comes with keeping patients engaged and continuing on that relationship with their provider or their healthcare team can be also rewarding for the patient.