Is contingency management associated with outcomes for treating comorbid substance use and treatment nonadherence among patients receiving medication for opioid use disorder?
In this systematic review and meta-analysis that included 74 randomized clinical trials and 10 444 adults receiving medication for opioid use disorder, the efficacy of contingency management was associated with abstinence from 4 types of substance use (psychomotor stimulants, polysubstance use, illicit opioids, and cigarettes) and improved treatment attendance and medication adherence.
These results provide evidence supporting the use of contingency management for addressing common and serious clinical problems among patients receiving medication for opioid use disorder.
Medication treatment for opioid use disorder (MOUD) is efficacious, but comorbid stimulant use and other behavioral health problems often undermine efficacy.
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.
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.
Prospective experimental studies of monetary-based contingency management among participants receiving MOUD.
Data Extraction and Synthesis
Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline, 3 independent investigators extracted data from included studies for a random-effects meta-analysis.
Main Outcomes and Measures
Primary 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.
The 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.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Stephen T. Higgins, PhD, Department of Psychiatry, University of Vermont, 1 S Prospect St, UHC, MS482, Burlington, VT 05401 (firstname.lastname@example.org).
Accepted for Publication: May 29, 2021.
Published Online: August 4, 2021. doi:10.1001/jamapsychiatry.2021.1969
Correction: This article was corrected on January 26, 2022, to fix errors in the Figures.
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Bolívar HA et al. JAMA Psychiatry.
Author Contributions: Dr Bolívar and Mr DeSarno had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Bolívar, Coleman, Higgins.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Bolívar, Klemperer, Coleman, Higgins.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: DeSarno, Skelly, Higgins.
Obtained funding: Higgins.
Administrative, technical, or material support: Bolívar, Klemperer.
Supervision: Bolívar, Higgins.
Conflict of Interest Disclosures: Drs Coleman, Higgins, and Klemperer have research support from the National Institute of General Medical Sciences and the National Institute on Drug Abuse. No other disclosures were reported.
Funding/Support: This project was supported by a Centers of Biomedical Research Excellence award from the National Institute on General Medical Sciences (P20GM103644) and Institutional Training award from the National Institute on Drug Abuse (T32DA007242).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The content of this report is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of General Medical Sciences and the National Institute on Drug Abuse.
Meeting Presentation: Data from this project were presented at the National Institute of Health’s Helping to End Addiction Long-term (HEAL) Meeting—Opioid Use in the Context of Polysubstance Use: Research Opportunities for Prevention, Treatment, and Sustained Recovery meeting; April 14, 2021; virtual and HEAL Principal Investigators Meeting; May 18, 2021; virtual.
Additional Contributions: We extend deep appreciation to Tyler D. Nighbor, PhD, for his help developing and conducting the initial search for relevant literature. Dr Nighbor was not compensated.
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