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medication, withdrawal should be managed according to standards of care using medications to help wean patients from the drugs on which they are dependent, and the patient should be transitioned to appropriate additional treatment services. Withdrawal management service provider should arrange for additional care as needed including scheduling appointments, arranging transportation and other “warm handoff” type of logistics arrangements, as well as overdose education and naloxone access. Agencies should review and update their policies to include these services in an effort to decrease fatalities associated with withdrawal management programs. I. Review and revise regulations to support low-barrier buprenorphine programs. (Agencies Involved: HHS/SAMHSA) Low-barrier to entry buprenorphine programs are controversial in part because they involve letting patients start treatment without complete abstinence from other drugs.226,227 To help mitigate this risk, the regulations and guidance to providers for buprenorphine treatment outside of Federal Opioid Treatment Programs should be revised to address needed risk mitigation like issuing naloxone, educating the patient about the dangers of benzodiazepines, and recommending monitoring to prevent overdose. « « « « « « NATIONAL DRUG CONTROL STRATEGY 53 J. Review and update opioid treatment program regulations. (Agencies Involved: DOJ/DEA; HHS/SAMHSA) Existing federal regulations for opioid treatment with methadone pose barriers like requiring people under 18 to “fail first” on non-medication treatment before starting methadone.228 They also do not require overdose prevention education, access to naloxone, or training on naloxone’s use. ONDCP is currently supporting a review of these regulations by an independent organization. Once that is completed, and if warranted and approved by the interagency, Federal Opioid Treatment Program regulations should be updated to permit safer and better access to methadone treatment for OUD, and to require overdose prevention education and naloxone training. Regulators should consider allowing methadone dispensing from pharmacies as is done in the United Kingdom because of their greater accessibility in most communities relative to OTPs. Veteran Health Administration’s Contingency Management “Incentives” Intervention Contingency management interventions use incentives in the form of tangible goods or services for completing certain treatment related activities or for maintaining abstinence. They are among the most effective treatments for stimulant use disorder but they are rarely used outside of research settings.1,2 The Department of Veterans Affairs supports contingency management (CM) incentive interventions by offering incentives linked to drug negative urine samples which patients enrolled in treatment can then spend in the VA hospital canteen.3 To be effective at engaging patients with anhedonia, a condition of disinterest similar to depression that can occur following stimulants cessation, contingency management interventions should offer incentives at values shown effective in research trials or risk failure.. Much developmental research has been conducted on ways to decrease the overall cost of incentives while maintaining the effects and new models like prize drawing protocols have been shown to be cost-effective.4 The VA is the first organization to implement this evidence-based treatment on a wide-scale. Its experience can serve as a model for other health care systems interested in using incentives to treat stimulant use disorder, particularly its training and supervision. Sources: 1. Higgins ST, Kurti AN, Davis DR. Voucher-Based Contingency Management is Efficacious but Underutilized in Treating Addictions. Perspect Behav Sci. 2019;42(3):501-524. Published 2019 Jul 29. doi:10.1007/s40614-019-00216-z _Article_216.pdf 2. Rash CJ, DePhilippis D. Considerations for Implementing Contingency Management in Substance Abuse Treatment Clinics: The Veterans Affairs Initiative as a Model. Perspect Behav Sci. 2019;42(3):479-499. Published 2019 Jun 26. doi:10.1007/s40614-019-00204-3 _204.pdf 3. Petry NM, DePhilippis D, Rash CJ, Drapkin M, McKay JR. Nationwide dissemination of contingency management: the Veterans Administration initiative. Am J Addict. 2014;23(3):205-210. doi:10.1111/j.1521- in a population of cocaine- or opioid-dependent outpatients4 NATIONAL DRUG CONTROL STRATEGY Principle 3: Supporting At-Risk Populations To substantially decrease overdose deaths and the burden from SUD, we must strategically address the barriers for treatment among those groups that are most at risk for overdose deaths and other negative consequences. One example is individuals who are incarcerated or reentering after incarceration- a disproportionate number of whom are Black, Indigenous or People of Color (BIPOC).229 Although it would be ideal to treat people before or, where appropriate, as an alternative to arrest, bringing treatment “behind the walls” is an underutilized opportunity to treat people with SUD. Certain populations could benefit from treatment but it may be close to impossible for them to participate without first having met their needs for shelter, childcare, or other health issues resulting from drug use 

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