Use of Contingency Management Addresses Clinical Issues in OUD Treatment

Stephen T. Higgins, PhD

Although medication for opioid use disorder (OUD) is effective in reduction of illicit opioid use, an increase in comorbid stimulant use among those with OUD is concerning, as it often works against the efficacy contributing to premature treatment termination.

A recent study examined the association of contingency management, wherein patients receive material incentives on the basis of objectively verified behavioral changes, with end-of-treatment outcomes for the comorbid behavioral problems.

Investigators, led by Stephen T. Higgins, PhD, Department of Psychiatry, University of Vermont, found evidence in support of the dissemination of contingency management for clinician use to address key clinical problems in patients receiving medication for opioid use disorder (MOUD), particularly for comorbid psychomotor stimulant misuse.

Study

Investigators performed a systematic search of PubMed, Web of Science, and Cochrane Controlled Register of Trials (CENTRAL) databases to identify studies exploring contingency management with patients receiving MOUD.

Until May 6, 2020, the team searched using the terms vouchers, contingency management, or financial incentives, where a total of 1443 reports for initial screening were included.

After screening for eligibility, a total of 213 reports were advanced for full-text review to meet criteria of a prospective, experimental study of monetary-based contingency management among patients receiving MOUD. They were left with a total of 74 studies that met full inclusion criteria.

Then, investigators extracted data from studies for the analysis. They noted the primary outcomes included the association of contingency management at end of treatment assessments with 6 clinical problems.

The clinical problems included stimulant use, polysubstance use, illicit opioid use, cigarette smoking, therapy attendance, and medication adherence.

The team used random-effects meta-analysis models in order to compute weighted mean effect size estimates (Cohen d) across 3 categories assessing abstinence and 2 assessing treatment adherence outcomes.

Results

Data show the 74 studies included 10,444 adult participants receiving MOUD, with 60 studies eligible for meta-analyses.

Further, they observed 22 studies tested the efficacy of contingency management in increasing abstinence from psychomotor stimulant use and 18 (82%) reporting significant abstinence at the end-of-treatment assessment.

The team noted contingency management had an association with end-of-treatment outcomes for all 6 problems examined separately in the medium-large range. Data show stimulants had a Cohen D score of 0.70 (95% CI, 0.49 - 0.92).

For 9 studies, the team found contingency management had a medium-large effect size on abstinence in illicit opioid use (Cohen d = 0.58; 95% CI; 0.30 - 0.86) and in 3 studies, it showed a medium-large effect on increased abstinence regarding cigarette use (Cohen d = 0.78; 95% CI, 0.43 - 1.14).

In addition, contingency management was associated with a small-medium effect size on abstinence compared with controls in polysubstance use in 18 studies (Cohen d = 0.46; 95% CI, 0.30 - 0.62). With therapy attendance, they noted a small-medium effect size on increasing therapy attendance (Cohen d = 0.43; 95% CI, 0.22 - 0.65).

With medication adherence, all studies showed an overall medium-large effect size on medication adherence (Cohen d = 0.75; 95% CI, 0.30 - 1.21).

Finally, across abstinence and adherence categories, contingency management had a medium-large effect size for both abstinence (Cohen d = 0.58; 95% CI, 0.47 - 0.69) and treatment adherence (Cohen d = 0.62; 95% CI, 0.40 - 0.84) in comparison with control.

Conclusion

At the conclusion, investigators noted the association between contingency management with treatment of varied clinical problems that were common in patients receiving MOUD.

"The results support a position that policy makers including CMS should make concerted efforts to support broad dissemination of contingency management to the many community clinics throughout the US currently struggling with the challenges of the opioid crisis, especially concomitant psychomotor stimulant use among patients taking MOUD,” investigators wrote.

The study, “Contingency Management for Patients Receiving Medication for Opioid Use Disorder: A Systematic Review and Meta-analysis,” was published online in JAMA Psychiatry.