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How Can Contingency Management Support Treatment for Substance Use Disorders? a Systematic Review

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How Can Contingency Management Support Treatment for Substance Use Disorders? a Systematic Review ISSN 2315-1463 EMCDDA PAPERS How can contingency management support treatment for substance use disorders? A systematic review Content: Abstract (p. 1) I Background (p. 2) I Methods (p. 3) I Results (p. 7) I Discussion (p. 11) I Conclusions (p. 12) I References (p. 13) I Annex 1 (p. 20) I Annex 2 (p. 38) I Acknowledgements (p. 46) Abstract: Contingency management (CM) is treatment and improved abstinence. In terms a general behavioural intervention technique of the cost-effectiveness of CM, the evidence used in the treatment of drug dependence to is not strong enough to recommend its systematically arrange consequences and it is systematic implementation. designed to weaken drug use and strengthen abstinence. We included three studies on the economic analysis with evidence for cost-effectiveness The main elements of CM interventions analysis: one review (based upon nine are behavioural reinforcers and monitoring, published studies) and two additional studies. which aim to promote social reintegration by The review confirms that evidence for cost- sustaining compliance, abstinence and/or effectiveness has limited generalisability attendance at work. beyond original research. We performed a systematic review of Our limited analysis shows that CM is a studies on the effectiveness of CM alongside feasible and promising adjunct to treatment pharmacological treatment of dependence. interventions for drug users. We included 38 studies on opioid users Keywords treatment of drug use (n = 20), cocaine users in methadone contingency management therapy (n = 14), cocaine users (n = 3) and methamphetamine users (n = 1). We found systematic review that CM was useful for reducing drug use among cocaine users and opioid users in Recommended citation: European Monitoring Centre for substitution treatment for reducing and Drugs and Drug Addiction (2016), How can contingency management support treatment for substance use disorders? abstaining from cocaine use. In opioid A systematic review, EMCDDA Papers, Publications Office of detoxification, CM increased retention in the European Union, Luxembourg. 1/46 EMCDDA PAPERS I How can contingency management support treatment for substance use disorders? A systematic review Background I work. Reinforcers are benefits, which can be cash, vouchers, prizes or other kinds of perceived privileges, such as taking I Description of the interventions home doses of methadone (Higgins et al., 2004; Petry, 2000; Stitzer and Petry, 2006). The patient will gain or lose reinforcers Contingency management (CM) is a general behavioural according to whether he/she can consistently and regularly intervention technique used in the treatment of drug achieve the expected outcomes or not. The duration of the CM dependence that aims to alter drug use by systematically intervention can vary. For example, we found that descriptions arranging consequences; this technique is designed to weaken of interventions ranged from 8 weeks (Petry, 2000) to 52 weeks drug use and strengthen abstinence (Griffith et al., 2000). (Silverman et al., 2004). CM has been used in many types of addictive behaviour. It has been extensively used in different CM is one key element of a broader behavioural approach substance use disorders, such as problematic use of marijuana belonging to the theory of operant conditioning (West, (Stanger et al., 2009), opioids (Chopra et al., 2009) and 2013). Operant conditioning assumes that individuals are cocaine (Barry et al., 2009; Silverman et al., 2004), as well as in conditioned by the consequences of their behaviour. Pleasant nicotine dependence (Yi et al., 2008), methamphetamine use consequences reinforce some behaviours and punishment disorders (Roll et al., 2006), alcohol dependence (Petry, 2000) discourages them. This model originates from the experiments and polydrug abuse (Silverman et al., 2002). of Burrhus Frederic Skinner (1938) on learning processes in animals, in which he noticed that behaviours that are not For the treatment of substance use disorders, CM is provided, reinforced are easily abandoned. for example, in detoxification clinics, psychosocial counselling services and methadone maintenance programmes (Stitzer Various techniques are derived from operant conditioning and Petry, 2006). theory, including techniques to shape the behaviour of pupils in the classroom (Altman and Linton, 1971), psychiatric CM approaches, whereby rewards (e.g. cash, vouchers, prizes hospital inpatients (in particular through the token economy or other privileges such as therapy delivered at home) are system (Ayllon and Azrin, 1968)) and drug users (Weaver et al., contingent on successfully performing a particular activity (e.g. 2014). getting a job, providing a substance-negative urine sample, participating in a screening) (Figure 1) showed some promising In drug addiction studies, operant conditioning theory has results for substance-dependent patients in the USA. Their implications for the explanation of the development of application might raise particular ethical concerns in the EU addiction and for the strategies used to prevent it and to (EMCDDA, 2012); nevertheless, the UK National Institute for promote recovery (West, 2013). Health and Care Excellence (NICE) (Table 1) recommends that CM should be applied and assessed in routine clinical practice The main elements of CM interventions are targeted in the UK, identifying specific targets for application, such as contingency, behavioural reinforcers and monitoring. The increasing patients’ compliance with testing for infectious ultimate goal of CM is to promote social reintegration by diseases (Weaver et al., 2014). sustaining compliance, abstinence and/or attendance at FIGURE 1 Targets and possible use of contingency management along the treatment journey Compliance with treatment Abstinence from Abstinence and Retention Compliance with Treatment entry illicit drugs attending work in treatment social reintegration during treatment or vocational training Compliance with specic activities, e.g. hepatitis B virus testing 2 / 46 EMCDDA PAPERS I How can contingency management support treatment for substance use disorders? A systematic review TABLE 1 A protocol of a Cochrane review has been published on this Examples of resources used to deliver and implement topic, but results are not yet available (Pan et al., 2012). contingency management interventions Country Resource Website CM can be a suitable intervention to support the social International WHO ‘Guidelines http://www.who.int/ reintegration of patients; nevertheless, a comprehensive review for identification substance_abuse/ of the available studies is needed to enable decision-making. and management publications/pregnancy_ of substance use guidelines/en/ (date of This review should also consider the economic aspect to and substance use publication: 2014) determine if CM would add sufficient value to justify its costs. disorders in pregnancy’ (mentions CM) UK The Public Health http://www.nta.nhs.uk/ England website CM%20Page.aspx (accessed I Objectives has a collection November 2015) of resources to implement CM The objectives of this review are: UK NICE Guideline No 120, https://www.nice.org.uk/ ‘Psychosis with guidance/cg120 (date of § to assess the effectiveness of the CM approach in substance misuse’ publication: 2011) (mentions CM) combination with substitution treatment or detoxification USA ‘Medication-assisted http://store.samhsa.gov/ for drug-dependent people by assessing whether or not treatment for opioid shin/content/SMA12-4214/ there is an increase in the retention of patients in treatment, addiction in opioid SMA12-4214.pdf in patients achieving abstinence or reducing their use treatment programs’ (date of last edition 2014) (mentions CM) of substances, in patients’ participation in screening programmes for the detection of human immunodeficiency virus (HIV) and hepatitis B and C virus infection, and in I How the interventions may work patients’ participation in hepatitis B virus vaccination programmes; It has been noted that ‘reinforcement processes play a central § to provide an updated synthesis of the studies on the costs role in the genesis, maintenance, and recovery from substance and cost-effectiveness of CM interventions for drug users. use disorders’ (Higgins et al., 2004). CM is supposed to interfere with the drug-related reinforcement cycle by introducing a competitive source of rewarding (Higgins et al., 2004; Stitzer and Petry, 2006). When the reinforcement power of the incentives prevails over the effect of the abused drugs, Methods human behaviour consequently should change. During the process of continuous rehabilitation, CM interventions help to decrease the sensitivity of drug users to substance-related I Inclusion criteria environments (Stitzer and Petry, 2006). Types of studies I Why is this review important? We included published articles with the objective of evaluating the effectiveness of CM in treating drug use addiction that Many studies (including systematic reviews and meta- were based on randomised clinical trials and quasi randomised analyses) have been published on the use of CM for substance controlled trials and studies that looked at the costs associated use disorders (Barry et al., 2009; Benishek et al., 2014; with implementing these CM interventions. Chopra et al., 2009; Farronato et al., 2013; Griffith et al., 2000; Prendergast et al., 2006; Petry, 2000; Petry and Simcic, 2002; A particular CM intervention used for treating drug use can Petry et al., 2010;
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