Methamphetamine is an addictive psychostimulant that is the second most implicated drug in overdose deaths in the United States. Overdose death rates involving methamphetamine have more than tripled in the last ten years (Jones et al., 2022), and methamphetamine use is associated with numerous adverse medical outcomes including cardiovascular disease, bloodborne pathogens, psychosis, and suicidality (Darke et al., 2008). Despite the scope of this epidemic, individuals with methamphetamine use disorder (MaUD) face systemic barriers to treatment including high rates of homelessness, psychosocial barriers, and stigma against disclosing use (Cumming et al., 2016; Kenny et al., 2011; Lappan et al., 2020; Tsui et al., 2020). People who use methamphetamine are often ambivalent regarding use—indeed they may perceive benefits of use— and reluctant to seek treatment (Banta-Green et al., 2020; McMahan et al., 2020). The majority of persons with MaUD report a history of childhood trauma and may therefore experience distrust with treatment settings, which are often perceived as prioritizing opioid use disorder treatment and inexperienced in treating stimulant use disorders (Cumming et al., 2016; Tang et al., 2021).

There are no medications approved or highly effective for treatment of MaUD, and contingency management is the best evidence-based treatment for MaUD (Khalili et al., 2024). Contingency management is a behavioral therapy in which positive behaviors are incentivized through material rewards. For treating MaUD, contingency management programs might entail providing rewards to patients for negative toxicology tests or participation in recovery activities. Contingency management programs often utilize reinforcement schedules in which rewards are provided not every occasion but rather with some unpredictable variation; this intermittent reinforcement pattern is more likely to result in enduring behavioral changes. For example, an addiction counselor using contingency management might have a patient spin a wheel after a negative toxicology test. Despite its benefits, contingency management is often unavailable due to funding and regulatory barriers (Glass et al., 2020; Scott et al., 2021).

Care navigation interventions can help patients overcome barriers to care and successfully engage in treatment. Generally, navigation interventions use dedicated staff who work with patients to facilitate treatment adherence. Navigators may assist with issues related to transportation and insurance; remind patients of appointments; and educate patients on addiction and treatment services. Such linkage-to-care models are considered the standard of care for HIV treatment (Mayer, 2011) and show promise in improving outcomes among patients with substance use disorders, particularly after encounters in emergency settings (Menon et al., 2016; Worthington et al., 2022).

As part of the Beginning Early and Assertive Treatment for Methamphetamine Use Disorder (BEAT Meth) study, we developed a care navigation model to support treatment entry after methamphetamine-related acute care and hospital encounters The goal of the current paper is to describe development of the care navigation model, characteristics and care needs of subjects receiving the intervention, and intervention engagement outcomes.

One-hundred and ninety-three participants were recruited into the study. One participant left the study after baseline completion. After excluding two of 96 intervention patients from analyses who had no initial contact with the navigator after randomization, data from 94 participants are analyzed here. The flow diagram in Fig. 1 describes the recruitment process and intervention cohort. Patients were primarily male (80%), unemployed (83%), and unstably housed (85%) (Table 1). Patients commonly reported daily alcohol use (24%) and use of opioids (27%) or other stimulants (31%). Over half (64%) of participants engaged in two or more intervention sessions, and those received a median of 5 (interquartile range, IQR 2–9) sessions.

The domains most commonly endorsed in the initial visit as substantially impacting recovery were a need for substance use treatment (79%), housing (68%), treatment adherence (50%), and communication challenges (25%) such as access to a phone or interpreter services. Table 2 summarizes the proportion of patients with substantial need by each domain, the portion among those with a need that received an intervention for that need, and the proportion with that a substantial need that engaged in the intervention. Domains related to citizenship, disability, and additional psychiatric services were not identified as substantial barriers at the first encounter; these domains and potential interventions are detailed in Online Resource 1.

Navigators documented a median of 17 (IQR 11–30) intervention elements were provided for engaged patients across 352 study visits. The most common interventions across all visits where a substantial need was identified were referring participants to substance use services, educating participants on treatment, and addressing or enhancing participants’ motivation for treatment. The care manual in Online Resource 1 provides a list of additional possible interventions. Among the 60 engaged patients, 307 (87%) sessions included a contingency management spin. Over the entire intervention, the average engaged patient spun a median of 4 (IQR 2–8) times and total mean earnings was $58 (SD ± $48; median $45 IQR 20–81; range $0–205). No adverse events were reported in relation to this intervention. One patient died of an unintentional overdose unrelated to the study intervention.

We conducted exploratory analyses to identify domains of need that might correlate with engagement. There were no demographic differences between the engaged and unengaged groups (Table 1). Because patients who engaged had more opportunities for needs assessment over time, we focused on social needs identified at the first encounter so as to not incur observation bias and underestimate needs among the participants who did not engage. The Table in Online Resource 2 compares domains of substantial needs between cohorts.

Despite significant social barriers—including high rates of homelessness, unemployment, and lack of phone access—over half the participants engaged in the care navigation intervention. This paper describes the domains of need, frequency of interventions, and a manualized approach for working with this population who have a high risk of overdose and other adverse psychiatric outcomes. Successful engagement in this care navigation intervention might presage successful clinical outcomes including participation in evidence-based treatment and recovery.

The appeal of this intervention for patients with MaUD reflects our emphasis on therapeutic rapport and delivery of practical, recovery-focused supports. In our preliminary patient interviews, patients often shared how their past experiences of trauma and stigmatization affected their willingness to engage with healthcare and recovery treatment (Rinehart et al., 2024). Accordingly, we designed the initial visit to focus less on logistical assistance and more on understanding patients perceived barriers to care and building trust. This approach also recognized that patients may be experiencing symptoms related to recent substance use, withdrawal, or other medical and psychiatric symptoms during their index encounter in an acute care setting. The navigator then allowed this discussion of patients’ needs to drive what services were provided to patients. This patient-guided approach resulted in high rates of engagement with the care navigator. The observed engagement rates are comparable to other linkage-to-care interventions for at-risk patients with substance use disorders (Schwarz et al., 2022; Worthington et al., 2022). Future work will assess whether this intervention and engagement levels result in improved subsequent health outcomes.

Incorporating contingency management into this care navigation intervention is novel. Contingency management is the best evidence-based treatment for MaUD, and we integrated contingency management into the intervention to incentivize connection with the navigator and to also familiarize patients with this treatment modality. The immediate goal of the intervention was to address patient areas of need and to connect patients to ongoing, evidence-based addiction treatment. As our goal was engagement in treatment rather than sobriety, we did not incentivize toxicology screening (which also would have been logistically difficult for patients being seen in community settings). Acute care visits in ED, hospital, and social detoxification programs are opportunities to offer treatment to patients during a period when they are receptive to discussing addiction treatment and recovery (Lindsay et al., 2024; Zhang et al., 2021). While we cannot definitively assess the impact of contingency management as all intervention patients received it, this study suggests promise for including discussion, demonstration, and even enrollment into contingency management as part of a care navigation intervention. The benefit of contingency management likely encouraged participation across the breadth of the intervention: In addition to contingency management (Brown & DeFulio, 2020), there are additional mechanisms by which this intervention can improve future engagement in care. The care navigator has the opportunity to build rapport with patients who often experience stigma and distrust of healthcare systems. This rapport is founded on an empathetic, trauma-informed relationship as well as a commitment to addressing patient-identified concerns in accessing treatment. Through this relationship, the patient is supported to contemplate treatment and problem-solve barriers to care. The navigator is also able to advocate for patients entering services, as by completing referrals or providing treatment programs with necessary clinical background.

Our description of key areas of social need among patients with problematic methamphetamine use can guide clinicians and policymakers in improving care for this population. The high frequency of needs related to accessing substance use was predictably high and likely reflects our recruiting patients during substance-related healthcare encounters. Navigators also recognized barriers related to housing and shelter in most patients and aiding in treatment adherence through patient education and communication with other providers. Other common issues related to assisting with means of communication (as by providing a cell phone) and transportation needs. Few patients appeared to share significant needs related to certain domains, which may reflect idiosyncrasies of this population or health system and will vary in other locales. (For example, patients did not describe barriers to accessing psychiatric services in the first encounter—likely, patients’ psychiatric care needs were categorized as relating to substance treatment, which is somewhat moot in a system that closely integrates psychiatric and substance treatment care.) Patients who received specific interventions related to these areas of need appeared to engage with the care navigator at high rates. Yet whether these interventions resulted in higher engagement rates is difficult to discern due to observation bias—we were able to report more instances of interventions among patients who were engaged for longer. Sometimes a domain of need was recognized, and a plan made to provide more specific interventions at a subsequent visit. Our results more readily speak to the demand for these specific services among this population rather than their differential impact on outcomes. The most commonly delivered care interventions entailed assisting with referrals for ongoing care, enhancing motivation for and education on treatment, anticipating strategies for adherence, and communicating among providers. It is paramount that navigators be familiar with systems of care and accessible treatment options.

Delivering this intervention highlighted opportunities for improvement. Although our care navigators worked in a large integrated health system, there was a frequent need to partner in patients’ care with outside organizations—as for arranging housing, alternative treatment services, or other needs. Developing these relationships requires significant time, and growing the size of the navigation team would facilitate this work. This model of care is labor intensive and entails frequent patient outreach, including through community meetings and in prioritizing warm hand-offs prior to discharge to begin to establish a relationship. Our navigators’ caseload size was naturally limited by the pace of study recruitment. Implementing this intervention in practice will inform appropriate case load size, which we estimate to be about 10–15 patients depending on level of need. We used up to two care navigators at one time; larger teams will see greater heterogeneity in styles and effectiveness among providers.

There are limitations to this study. While we manualized the intervention to improve replicability, there is still likely variation in implementation owing to different skills and styles among navigators and supervisors. Similarly, we defined areas and severity of need using a standardized domain assessment structure (Online Resource 1), but this domain structure has not been validated separately. Implementing this intervention in context of a randomized controlled trial will allow us to assess its effectiveness in achieving clinical outcomes beyond the duration of this intervention; however, this approach limits generalizability to a population of patients who are willing and consenting to participate in a scientific study. We had a high proportion of patients contemplating behavioral change—which may reflect that we recruited a population with interest in study participation or observation bias. Participant characteristics suggest that we were indeed successful in recruiting individuals with substantial social and economic barriers to addiction treatment. Future work will extend these findings to understand the impact of care navigation on medical and psychiatric outcomes including treatment entry, overdose rates, service utilization, and recovery. These data support care navigation and contingency management as a promising framework for engaging patients with methamphetamine use disorder, and future replication can further optimize the duration, frequency, or other processes of this intervention.

Patients with MaUD face many recovery challenges individual motivation, the lack of evidence-based treatment in many communities, social and financial barriers, co-occurring medical and mental health conditions, and morbidity and lethality related to ongoing substance use. New approaches for engaging this population and facilitating treatment entry are urgently needed. While many patients and clinicians despair of the difficulty of MaUD treatment, this intervention suggests that most patients can be successfully engaged through an intervention that emphasizes therapeutic rapport, trauma-informed care, contingency management, and practical care navigation support. These solutions cannot come soon enough for patients, families, and communities who are struggling amid our contemporary methamphetamine epidemic.

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s10597-025-01570-w.