Can financial incentives help opioid users eliminate other addictions?

Contingency management – receiving material incentives based on behavior changes – can be an effective way to treat co-morbid behaviors such as the use of psychomotor stimulants and smoking in patients receiving drugs for drug use disorder. opioids (OUD), according to a systematic review and meta-analysis.

These incentive plans were associated with medium to large effects for four of the six comorbid behaviors that were analyzed separately, including the use of psychomotor stimulants (Cohen D= 0.70, 95% CI 0.49-0.92), cigarette consumption (Cohen D= 0.78, 95% CI 0.43-1.14), illicit opioid use (Cohen D= 0.58, 95% CI 0.30-0.86) and treatment adherence (Cohen D= 0.75, 95% CI 0.30-1.21), reported Stephen Higgins, PhD, University of Vermont at Burlington, and colleagues.

The other two behaviors were in the small to medium effect size range: use of polysubstances (Cohen D= 0.46, 95% CI 0.30-0.62) and therapy attendance (Cohen D= 0.43, 95% CI 0.22-0.65), they noted in JAMA Psychiatry.

These results are “particularly noteworthy because contingency management is the only intervention that has reliably increased abstinence from psychomotor stimulants in randomized clinical trials spanning over 30 years of research,” the authors noted.

The review included 74 studies involving more than 10,000 adults receiving medication for OUD; 60 studies were eligible for a meta-analysis. The authors searched for keywords such as “vouchers”, “contingency management” and “financial incentives” in PubMed, Cochrane CENTRAL, Web of Science and others to identify relevant studies.

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyzes (PRISMA) guideline, the team found 22 studies that tested the effectiveness of contingency management in increasing abstinence from psychomotor stimulants in people taking medications for TOU (with methadone used in 21 of 22 studies); 18 studies (81.8%) reported statistically significant effects of contingency management on abstinence during end-of-treatment assessments. The average Contingency Management time was 17.2 weeks and the average maximum daily income was $ 14.51.

Other research has shown a recent increase in the number of people taking drugs for OUD who simultaneously use psychomotor stimulants, which “may interfere with effectiveness, contributing to premature discontinuation of treatment and return to health. illicit drug use, ”noted Higgins and his team.

Regarding the use of illicit opioids, the authors found that the contingency management approach was associated with an increase in abstinence at the end of treatment in seven of the 11 (64%) included studies (with use of methadone in 9 studies, buprenorphine in one and naltrexone in one). The average length of management was 13.9 weeks and the average maximum daily salary was $ 10.25.

Although an earlier study found a negative association between contingency management and illicit opioid use, current results translate to “71.9% of patients treated with contingency management having superior results. means of control interventions “.

For the five studies that looked at smoking (with methadone use in three, and methadone and buprenorphine in two), four found that contingency management helped people taking OCD medications to quit smoking. The average length of the program was 7.6 weeks and the average maximum daily income was $ 15.09.

Finally, for the nine studies that examined drug adherence (six targeted naltrexone adherence, one targeted methadone adherence, and two targeted other drug adherence), contingency management was associated with increased adherence in six studies. The average contingency management time was 17.4 weeks and the average maximum daily income was $ 10.43.

Studies with post-treatment follow-up assessments after discontinuation of contingency management were limited, which was a major limitation, noted Higgins and colleagues. In addition, different definitions of terms such as “abstinence” were used in the studies, which may have contributed to skewed results.

A major obstacle to the implementation of Contingency Management is CMS’s reluctance to allow funds to be used for these incentive approaches, for fear of fraud. Although the authors acknowledged that there are legitimate reasons to be concerned about fraud, they “are not aware of any evidence linking contingency management to fraud or to suggest that contingency management is more likely to lead to fraud. than other medical services supported by CMS “.