Contingency management programs benefit cocaine use disorder treatment

Treatment for adults who actively use cocaine may benefit from contingency management programs, according to results of a systematic review and meta-analysis published in JAMA Network Open.

“Meta-analyses of contingency management programs, which comprise positive reinforcement of drug abstinence, have indicated beneficial outcomes; however, these analyses have been limited to studies with distinct populations, studies with specific comparison groups, or studies that exclusively examined contingency management interventions,” Brandon S. Bentzley, MD, PhD, of the department of psychiatry and behavioral sciences at Stanford University, and colleagues wrote. “Furthermore, leaders in the field of substance use disorders continue to classify contingency management as a treatment with limited benefits, making its comparative role in the treatment of cocaine use disorder unclear.”

The investigators conducted a meta-analysis of clinical trials published in PubMed or the Cochrane Database of Systematic Reviews between Dec. 31, 1995, and Dec. 31, 2017. They included 157 studies, comprising 402 treatment groups and containing 15,842 participants, that had the term cocaine in the article title, were written in English, enrolled outpatients aged 18 years or older who actively used cocaine at baseline and reported treatment group size, treatment duration, retention rates and urinalysis results for cocaine metabolites presence. They excluded studies with more than 25% of participants who were not actively using cocaine or with more than 80% of participants who had negative test results for cocaine metabolites presence at baseline, as well as those that reported only pooled urinalysis results that indicated the presence of multiple substances but did not report the specific proportion tests results that were positive for cocaine metabolites.

During data extraction and synthesis, Bentzley and colleagues placed treatments within the categories of psychotherapy, contingency management programs, placebo, opioids, psychostimulants, anticonvulsants, dopamine agonists, antidepressants, antipsychotics, miscellaneous medications and other therapies.

Results showed psychotherapy and contingency management programs were the largest treatment groups across all studies, with mean numbers of participants of 40.04 and 37.51, respectively. The investigators observed a significant association with higher likelihood for having a negative test result for the presence of cocaine (OR = 2.13; 95% CI, 1.62-2.8) only for contingency management programs. In all sensitivity analyses, this association remained significant.

“There may not be a case for therapeutic pessimism regarding cocaine use disorder,” Bentzley and colleagues wrote. “Prioritizing implementation research that informs health care systems regarding beneficial and viable adoption approaches (eg, examining current limits on patient incentive programs) may produce greater public health benefits than additional efforts to assess whether contingency management programs are generally beneficial for the treatment of cocaine use disorders.”