Contingency Management for Patients Receiving Medication for Opioid Use Disorder

Abstract

IMPORTANCE Medication treatment for opioid use disorder (MOUD) is efficacious, but comorbid stimulant use and other behavioral health problems often undermine efficacy.OBJECTIVE To examine the association of contingency management, a behavioral intervention wherein patients receive material incentives contingent on objectively verified behavior change, with end-of-treatment outcomes for these comorbid behavioral problems.DATA SOURCES A systematic search of PubMed, Cochrane CENTRAL, Web of Science, and reference sections of articles from inception through May 5, 2020. The following search terms were used: vouchers OR contingency management OR financial incentives.STUDY SELECTION Prospective experimental studies of monetary-based contingency management among participants receiving MOUD. DATA EXTRACTION AND SYNTHESIS Following Preferred Reporting Items for SystematicReviews and Meta-analyses (PRISMA) reporting guideline, 3 independent investigators extracted data from included studies for a random-effects meta-analysis. MAIN OUTCOMES AND MEASURESPrimary outcome was the association of contingency management at end-of-treatment assessments with 6 clinical problems: stimulant use, polysubstance use, illicit opioid use, cigarette smoking, therapy attendance, and medication adherence. Random-effects meta-analysis models were used to compute weighted mean effect size estimates (Cohen d) and corresponding 95% CIs separately for each clinical problem and collapsing across the 3 categories assessing abstinence and the 2 assessing treatment adherence outcomes. RESULTSThe search identified 1443 reports of which 74 reports involving 10 444 unique adult participants met inclusion criteria for narrative review and 60 for inclusion in meta-analyses. Contingency management was associated with end-of-treatment outcomes for all 6 problems examined separately, with mean effect sizes for 4 of 6 in the medium-large range (stimulants, Cohen d = 0.70 [95% CI, 0.49-0.92]; cigarette use, Cohen d = 0.78 [95% CI, 0.43-1.14]; illicit opioid use, Cohen d = 0.58 [95% CI, 0.30-0.86]; medication adherence, Cohen d = 0.75 [95% CI, 0.30-1.21]), and 2 in the small-medium range (polysubstance use, Cohen d = 0.46 [95% CI, 0.30-0.62]; therapy attendance, d = 0.43 [95% CI, 0.22-0.65]). Collapsing across abstinence and adherence categories, contingency management was associated with medium effect sizes for abstinence (Cohen d = 0.58; 95% CI, 0.47-0.69) and treatment adherence (Cohen d = 0.62; 95% CI, 0.40-0.84) compared with controls. CONCLUSIONS AND RELEVANCE These results provide evidence supporting the use of contingency management in addressing key clinical problems among patients receiving MOUD, including the ongoing epidemic of comorbid psychomotor stimulant misuse. Policies facilitating integration of contingency management into community MOUD services are sorely needed.

Drug Overdose Mortality Among People Experiencing Homelessness, 2003 to 2018

“…Although evidence-based treatment options for other drug use disorders are somewhat limited, contingency management has been found to be an effective treatment strategy for both opioid use disorder and stimulant use disorder. 42 , 43 Polysubstance use can be intentional, but individuals who use drugs are sometimes inadvertently or unknowingly exposed to other drugs, particularly synthetic opioids. The same harm-reduction strategies mentioned earlier, in addition to a low-barrier, safer drug supply 44 and educational efforts that address unintentional opioid exposure, need to be accessible to all homeless-experienced individuals who use drugs.…”

The impact of methamphetamine/amphetamine use on receipt and outcomes of medications for opioid use disorder: a systematic review

“…Research is also needed to directly assess the impact of MOUD dose and receiving psychosocial treatments on MOUD retention and outcomes among people who use methamphetamine/amphetamines. Randomized controlled trials have found that providing contingency management and cognitive behavioral therapy to patients who used stimulants in MOUD reduced stimulant use, suggesting that offering concurrent, co-located treatments for multiple substance use disorders can benefit patients [ 70 – 72 ]. While there are currently no FDA-approved medications to treat amphetamine use disorder, ongoing work to advance pharmacologic treatment may also create opportunity for better simultaneous treatment [ 67 ].…”

Care-engaged individuals with polysubstance use in Northeastern US are undertreated for methamphetamine use disorder: a retrospective cohort study

“…It involves the provision of positive reinforcements, such as money or gift cards, for target behaviors such as drug abstinence. Multiple randomized controlled trials have demonstrated the efficacy of contingency management in reducing methamphetamine use and increasing treatment retention [ 24 – 27 ]. However, contingency management is not widely available and generally underutilized as a treatment [ 28 ].…”