Chronic use of cannabis has been linked to psychological and physical health consequences, including increased risk for psychiatric disorders , decline in cognitive function, impairment in learning and coordination, reduced educational and 3 Clear and convincing evidence indicates that there are multiple studies of a treatment and that the large majority of studies are of high quality and consistently find that the treatment is either effective or not effective. workplace outcomes, and lung inflammation/chronic bronchitis. It is not clear to what extent cannabis use increases the risk of mortality related to these health consequences. It is estimated that 2,782 Californians are seen in EDs and 543 are hospitalized for cannabis related issues each year. For many patients with SUD, attitudinal barriers are the most significant barrier to treatment initiation and persistence. The stigma of SUD and the ability to acknowledge an SUD affect patient desire to seek care, even more so for those who have co-occurring psychiatric conditions. Many people with SUD believe they can solve the problem themselves. Another barrier for patients participating in treatment specifically using CM is the requirement to travel to the provider’s office, sometimes up to two or three times a week. This can cause more of a burden for patients who do not have flexible schedules and those who are living in areas with a shortage of providers administering CM programs. However, when CM is administered as an adjunctive component of psychosocial treatments in the context of intensive outpatient programs , patients are already traveling to attend therapy the required two to three times per week.Some interventions in proposed mandates provide immediate measurable impacts while other interventions may take years to make a measurable impact . When possible, CHBRP estimates the long-term effects to the public’s health that would be attributable to the mandate. As there is no research that examines longterm impacts of CM for SUDs treatment on health care utilization, it is not possible to estimate the long-term health and cost impacts of SB 110.

CHBRP anticipates the demand for treatment of SUDs would continue as relapsed patients reattempt abstinence and first-time initiators would join the pool of patients seeking care. However,hydro tray limited patient readiness for SUD treatment and limited number of providers remain significant barriers to care. To the extent that SB 110 results in an increase in SUD treatment with CM, and the extent to which this leads to long-term abstinence, it is possible SB 110 would contribute to reductions in substance use– related morbidity and mortality, such as cardiovascular disease, cancer, HIV, and hepatitis C. Stimulants are a class of drugs that includes prescription medications to treat ADHD as well as drugs such as cocaine and methamphetamine. Repeated misuse of stimulants can lead to psychological consequences, such as hostility, paranoia, psychosis, as well as physical consequences of high body temperatures, irregular heartbeats, and the potential for cardiovascular failure or seizures . The DSM-5 characterizes stimulant use disorder as a pattern of stimulant use that results in significant impairment or distress. People meeting at least two of 11 specified criteria within a 12-month period are diagnosed with mild, moderate, or severe substance use disorder depending on the number of criteria met . Stimulant use disorder prevalence in the United States is relatively low compared with other substances, with 0.2% of the population reporting a prescription stimulant use disorder, 0.4% of the population reporting a methamphetamine use disorder, and 0.4% of the population reporting a cocaine use disorder . In California, it is estimated that 33% of all admissions to state- and county-contracted SUD programs are for stimulant use disorders – representing nearly 50,000 admissions annually . The pattern seen in California and other western states, where stimulants such as methamphetamine are the leading cause of overdose deaths, is significantly different from the pattern seen in eastern states, where opioids such as fentanyl are the leading cause of overdose deaths . For example, in Region 9 , the leading cause of death from overdose was methamphetamine , followed by heroin , fentanyl , and cocaine . Across the United States the leading cause of overdose death is fentanyl , followed by heroin , cocaine , and methamphetamine . In 2018, 1,954 Californians were seen in EDs for amphetamine overdose and 536 Californians were seen in EDs for cocaine overdose . The rise in methamphetamine use in California is particularly concerning due to the increased use of fentanyl in methamphetamine and, as a result, an increase in fentanyl-related overdoses.

An estimated 3,035 deaths are from stimulant use disorder in California each year . There are disparities in rates of stimulant use and stimulant use disorder by gender and sexual orientation. Women tend to start using stimulants at a younger age and are more sensitive to the effects of cocaine and methamphetamine, and can become more dependent on methamphetamine than men . Sexual orientation is also a predictor, with gay, lesbian, and bisexual men and women having higher odds of stimulant use as their heterosexual counterparts . Cannabis, also known as marijuana, is the most commonly used psychoactive drug in the United States, after alcohol . Acute effects of cannabis use include nausea, vomiting, and abdominal pain, while chronic impacts include cognitive impairment, pulmonary disease, and sleep disturbance. Chronic use of cannabis has been linked to psychological and physical health consequences, including increased risk for psychiatric disorders , decline in cognitive function, impairment in learning and coordination, reduced educational and workplace outcomes, and lung inflammation/chronic bronchitis . It is not clear to what extent cannabis use increases the risk of mortality related to these health consequences . It is estimated that 2,782 Californians are seen in EDs and 543 are hospitalized for cannabis related issues each year . Although 19.4% of Californians 12 years and older report cannabis use in the past month, only 2.1% report having cannabis use disorder . Research suggests that 9% of adults who use cannabis will become dependent, and that this increases to 17% in individuals who initiate cannabis use during youth . In California, it is estimated that 15% of all admissions to state- and countycontracted SUD programs are for cannabis use disorders – representing more than 22,000 admissions annually . To date, 36 U.S. states have medical cannabis laws and, of these, 14 states have recreational cannabis laws, including California . Research estimating the impact of recreational cannabis laws with cannabis substance use disorders indicate that these laws have increased the proportion of the population experiencing cannabis use disorders . This research looks at early adopters of recreational cannabis laws and does not include data on California which legalized recreational use in 2016. The impacts of legalization of recreational cannabis use in California on the rates of cannabis use disorder have not yet been established in the literature. The rates of cannabis use disorder vary by gender and race/ethnicity. Although women tend to be less likely to use cannabis or have a cannabis use disorder than men, women with cannabis use disorder are more likely to experience more severe withdrawal symptoms when attempting to quit .

Further, cannabis use disorders are more common in Blacks, Native Americans, and Mixed-Race adults . Treatments for SUD include residential, inpatient, and outpatient care using behavioral therapy, counseling, and/or prescription medication. Mutual help groups also support those with SUDs to establish and maintain sobriety. CM is used as a stand-alone treatment or as an adjunct to typical treatments for SUD and is described in detail below. Health care professionals note that relapse is common during the recovery process for many patients, with approximately 40% to 60% of patients returning to alcohol or drug use within one year of treatment, and when relapse occurs it is important for patients to work with their provider to resume or modify the treatment plan .CM is a type of behavioral therapy in which individuals are “reinforced,” or rewarded, for evidence of positive behavioral change or achievement of specified goals . Based on principals of behavioral analysis, CM has been assessed in the context of substance use treatments and typically consists of monetary-based rewards or vouchers to reinforce abstinence from the target drug and to promote medication compliance and treatment attendance . CM has been utilized as part of treatment for SUDs, including stimulants, opioids, marijuana, alcohol, and tobacco, and is often included as an adjunct to a specific SUD treatment such as cognitive behavioral therapy , medicationassisted therapy , and community reinforcement approach, although it is also used as a standalone treatment. Much of the research on the effectiveness of CM for SUD treatment has focused on stimulant use disorder. This is in part due to the rising increase in prevalence of and mortality related to stimulant use as well as due to the lack of effective treatments for stimulant use disorder . CM relies on detection of the target substance’s metabolites to biochemically confirm abstinence from use. Metabolites can be detected via urine, saliva, blood plasma, and breath samples . Urine is most often used to detect metabolites from stimulants, cannabis, and non-synthetic opioids . Detection of opioid use in urine can be complicated by the use of MAT,planting table which may produce metabolites that are similar to those produced by opioid use . Tobacco use can be monitored through either carbon monoxide levels in breath or cotinine levels found in saliva, plasma, or urine. If nicotine replacement therapy is being used as part of therapy, the best way to accurately measure tobacco use is through breathalyzers. Alcohol use can also be monitored via breath, saliva, plasma, or urine, but the relatively short length of time that ethanol can be detected in urine can be prohibitive for outpatient treatment programs that only monitor patients twice per week . Detection method is selected based on characteristics of the target drug, costs of the detection method, feasibility, and acceptability to the patient . Since urinalysis involves self-collection of the specimen, patients are often monitored in order to ensure the sample has not been tampered with. This may cause additional discomfort and reduce the acceptability of the CM treatment to the patient. It can also be an additional burden for treatment programs to have trained staff members on hand to observe the sample collections. However, CM is not the only reason that treatments programs use urinalysis; they often do so anyway if they require abstinence to remain engaged in treatment or simply to monitor progress.

Therefore, some programs may need to make adaptations to their existing protocols whereas others may already have processes in place for monitored urinalysis collection.The goal of CM is to modify behaviors related to substance use. Common CM goals include substance abstinence, treatment attendance, and/or medication compliance . As noted by Prendergast et al. , the duration of the behavior modification also varies. Substance abstinence: Abstinence from the target substance is typically measured through collection of urine samples in order to capture all potential substance use within that week . Analysis of the urine sample is conducted either on-site through a purchased on-site test kit or sent out to an outside lab for analysis. The results from the on-site test kit can be ready within two to five minutes, whereas results from an outside lab can take between three and five days. It is preferred to conduct the analysis on site to ensure provision of immediate rewards for substance abstinence; immediacy of rewards is a defining element of behavior therapies such as CM. Treatment attendance: CM can also be employed to increase attendance and participation in SUD treatment. SUD treatment clinics typically have attrition rates of 80% or higher, particularly among outpatient mental health treatment centers. Through utilizing reinforcers or rewards that are contingent on attendance, attendance rates may improve across a variety of treatment settings . Medication compliance: The treatment of some SUDs includes FDAapproved medications. CM can target adherence to a medication regime to improve compliance through rewards for directly supervised ingestion of medications . Note: The CM specified in SB 110 is primarily used for stimulant and cannabis use disorders, for which there is no MAT. Therefore, the results described in the Medical Effectiveness section and the models estimated in the Benefit Coverage, Utilization, and Cost Impacts section do not include results related to medication compliance.