Contingency management is effective in promoting abstinence and retention in treatment among crack cocaine users in Brazil: A randomized controlled trial

A Systematic Review of the Efficacy of Contingency Management for Substance Use Disorders in Low and Middle Income Countries

BACKGROUND

The impact of illicit substance use is especially devastating in low-resourced countries where factors such as poverty, unemployment, and inadequate services impede successful treatment. Contingency management (CM) is a treatment for substance use disorders that has shown to be effective in eliciting behaviour change. The efficacy of CM interventions in low and middle income countries (LMICs) has been under explored.

METHODS

The aim of this systematic review of randomized controlled trials was to assess measures of CM efficacy in addressing substance use disorders, while also considering contextual moderators of CM in LMICs. A search of PubMed, Scopus, and Cochrane library databases yielded 18 studies for inclusion, from which relevant data were extracted using modified versions of the Cochrane Characteristics of Studies tool.

RESULTS

Two studies were located in a low-income country, two in lower-middle income countries, and fourteen in upper middle-income countries. Overall, estimated efficacy estimates were similar to those from higher income countries. However, context-specific challenges that warrant further investigation included limited access to trained staff and structural and financial constraints.

CONCLUSIONS

While CM in LMICs is in its early stages of development, efficacy estimates were not substantially different compared to high income countries. Challenges such as costs, willingness to implement, and the stigma associated with addiction sets the stage for further research in these contexts.

Use of Transdermal Alcohol Sensors in Conjunction With Contingency Management to Reduce Alcohol Consumption in People With Alcohol Dependence Attending Alcohol Treatment Services: Protocol for a Pilot Feasibility Randomized Controlled Trial

BACKGROUND

Wearable technology for objective, continuous, and reliable alcohol monitoring has been developed. These are known as transdermal alcohol sensors (TASs). They can be worn on the wrist or ankle with the sensor pressed against the skin and can measure sweat vapors being emitted from the skin, to record transdermal alcohol concentration (TAC). Previous studies have investigated the accuracy and acceptability of the available TAS brands, but there has been little research into their use in people with alcohol use disorders (AUD).

OBJECTIVE

This feasibility randomized controlled trial aims to explore the feasibility, strengths, and limitations of using a TAS to monitor alcohol consumption in individuals in treatment for AUD with or without contingency management (CM) to promote abstinence or low-level alcohol consumption.

METHODS

The target sample size is 30 (15 randomized to each group). Participants will be recruited through poster adverts at alcohol services. Both groups (control and CM) will wear the TAS (BACtrack Skyn) for 2 weeks in the context of their usual treatment, meeting with the researcher every other weekday. In the last meeting, the participants will complete a postwear survey on their experience of wearing the TAS. The CM group will also receive small financial incentives for low or no alcohol consumption, as measured by the TAS. On days where the TAC peak is below a set threshold (<115.660 g/L), CM group participants will be rewarded with a £5 (US $6.38) voucher. There are financial bonuses if this target is achieved on consecutive days. The researcher will monitor TAC for each day of the study at each research visit and allocate financial incentives to participants according to a set reinforcement schedule.

RESULTS

The first participant was enrolled in June 2023, and the last in December 2023. Data analysis is underway and is estimated to be completed by June 2024. A total of 32 participants were enrolled.

CONCLUSIONS

Most TAS brands have had limited application in clinical settings, and most studies have included healthy adults rather than people with AUD. TAS has the potential to enhance treatment outcomes in clinical alcohol treatment. The accuracy, acceptability, and feasibility of TAS for people with AUD in clinical settings need to be investigated. This is the first study to use TAS in specialized alcohol services with diagnosed AUD individuals currently receiving treatment from a south London alcohol service.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN46845361; https://www.isrctn.com/ISRCTN46845361.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/57653.

Psychosocial interventions for stimulant use disorder

BACKGROUND

Stimulant use disorder is a continuously growing medical and social burden without approved medications available for its treatment. Psychosocial interventions could be a valid approach to help people reduce or cease stimulant consumption. This is an update of a Cochrane review first published in 2016.

OBJECTIVES

To assess the efficacy and safety of psychosocial interventions for stimulant use disorder in adults.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, three other databases, and two trials registers in September 2023. All searches included non-English language literature. We handsearched the references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any psychosocial intervention with no intervention, treatment as usual (TAU), or a different intervention in adults with stimulant use disorder.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included a total of 64 RCTs (8241 participants). Seventy-three percent of studies included participants with cocaine or crack cocaine use disorder; 3.1% included participants with amphetamine use disorder; 10.9% included participants with methamphetamine use disorder; and 12.5% included participants with any stimulant use disorder. In 18 studies, all participants were in methadone maintenance treatment. In our primary comparison of any psychosocial treatment to no intervention, we included studies which compared a psychosocial intervention plus TAU to TAU alone. In this comparison, 12 studies evaluated cognitive behavioural therapy (CBT), 27 contingency management, three motivational interviewing, one study looked at psychodynamic therapy, and one study evaluated CBT plus contingency management. We also compared any psychosocial intervention to TAU. In this comparison, seven studies evaluated CBT, two contingency management, two motivational interviewing, and one evaluated a combination of CBT plus motivational interviewing. Seven studies compared contingency management reinforcement related to abstinence versus contingency management not related to abstinence. Finally, seven studies compared two different psychosocial approaches. We judged 65.6% of the studies to be at low risk of bias for random sequence generation and 19% at low risk for allocation concealment. Blinding of personnel and participants was not possible for the type of intervention, so we judged all the studies to be at high risk of performance bias for subjective outcomes but at low risk for objective outcomes. We judged 22% of the studies to be at low risk of detection bias for subjective outcomes. We judged most of the studies (69%) to be at low risk of attrition bias. When compared to no intervention, we found that psychosocial treatments: reduce the dropout rate (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.74 to 0.91; 30 studies, 4078 participants; high-certainty evidence); make little to no difference to point abstinence at the end of treatment (RR 1.15, 95% CI 0.94 to 1.41; 12 studies, 1293 participants; high-certainty evidence); make little to no difference to point abstinence at the longest follow-up (RR 1.22, 95% CI 0.91 to 1.62; 9 studies, 1187 participants; high-certainty evidence); probably increase continuous abstinence at the end of treatment (RR 1.89, 95% CI 1.20 to 2.97; 12 studies, 1770 participants; moderate-certainty evidence); may make little to no difference in continuous abstinence at the longest follow-up (RR 1.14, 95% CI 0.89 to 1.46; 4 studies, 295 participants; low-certainty evidence); reduce the frequency of drug intake at the end of treatment (standardised mean difference (SMD) -0.35, 95% CI -0.50 to -0.19; 10 studies, 1215 participants; high-certainty evidence); and increase the longest period of abstinence (SMD 0.54, 95% CI 0.41 to 0.68; 17 studies, 2118 participants; high-certainty evidence). When compared to TAU, we found that psychosocial treatments reduce the dropout rate (RR 0.79, 95% CI 0.65 to 0.97; 9 studies, 735 participants; high-certainty evidence) and may make little to no difference in point abstinence at the end of treatment (RR 1.67, 95% CI 0.64 to 4.31; 1 study, 128 participants; low-certainty evidence). We are uncertain whether they make any difference in point abstinence at the longest follow-up (RR 1.31, 95% CI 0.86 to 1.99; 2 studies, 124 participants; very low-certainty evidence). Compared to TAU, psychosocial treatments may make little to no difference in continuous abstinence at the end of treatment (RR 1.18, 95% CI 0.92 to 1.53; 1 study, 128 participants; low-certainty evidence); probably make little to no difference in the frequency of drug intake at the end of treatment (SMD -1.17, 95% CI -2.81 to 0.47, 4 studies, 479 participants, moderate-certainty evidence); and may make little to no difference in the longest period of abstinence (SMD -0.16, 95% CI -0.54 to 0.21; 1 study, 110 participants; low-certainty evidence). None of the studies for this comparison assessed continuous abstinence at the longest follow-up. Only five studies reported harms related to psychosocial interventions; four of them stated that no adverse events occurred.

AUTHORS' CONCLUSIONS

This review's findings indicate that psychosocial treatments can help people with stimulant use disorder by reducing dropout rates. This conclusion is based on high-certainty evidence from comparisons of psychosocial interventions with both no treatment and TAU. This is an important finding because many people with stimulant use disorders leave treatment prematurely. Stimulant use disorders are chronic, lifelong, relapsing mental disorders, which require substantial therapeutic efforts to achieve abstinence. For those who are not yet able to achieve complete abstinence, retention in treatment may help to reduce the risks associated with stimulant use. In addition, psychosocial interventions reduce stimulant use compared to no treatment, but they may make little to no difference to stimulant use when compared to TAU. The most studied and promising psychosocial approach is contingency management. Relatively few studies explored the other approaches, so we cannot rule out the possibility that the results were imprecise due to small sample sizes.

Cocaine abstinence during the "critical period" of a contingency management trial predicts future abstinence in people with cocaine use disorder

BACKGROUND

Contingency Management (CM) is being piloted as a treatment for stimulant use disorder in several US states, highlighting the need for treatment optimization. One important goal of optimization is decreasing drug use during the early stages of treatment, which has predicted success in other interventions. However, this "critical period" has not been reported in CM trials. The purpose of this analysis was to determine if, after accounting for baseline abstinence and incentive condition, abstinence in a CM trial for people with Cocaine Use Disorder (CUD) could be predicted by cocaine use during a first-week critical period.

METHODS

Eighty-seven participants with CUD were randomized to receive contingent high or low value incentives for cocaine abstinence or were in a non-contingent control group. Generalized estimating equations (GEE) were used to analyze urine test results over 36 timepoints during the 12-week intervention. To assess for a critical period, the first three visits were included in the GEE as a covariate for remaining urine test results.

RESULTS

Participants who provided more negative samples during the critical period were significantly more likely to produce a negative urine sample during the remainder of the trial, though some effects of group remained after controlling for the critical period.

CONCLUSIONS

These results indicate that a critical period exists for CM trials, and it can explain a substantial amount of future performance. Early contact with an abstinence-contingent high magnitude alternative reinforcer may explain additional performance beyond the critical period, further justifying the use of high magnitude alternative reinforcers.

Can Contingency Management Solve the Problem of Adherence to Antiretroviral Therapy in Drug-Dependent Individuals?

Drug misuse among people living with HIV (human immunodeficiency virus) is associated with higher mortality. It is a frequently observed reason for treatment abandonment, with people who misuse drugs showing a 10 to 25 times higher risk of HIV than the general population. The authors conducted a systematic review and meta-analysis to assess the efficacy of contingency management (CM) to improve adherence to antiretroviral therapy in people living with HIV and substance use disorder (SUD). The inclusion criteria consisted of studies written in English, Italian, Spanish, German, and French; studies conducted with humans; and clinical trials that combined SUD treatment with CM for people living with HIV. Two hundred twenty-two articles were identified, five met all inclusion criteria, and three provided enough data to perform the meta-analysis. We considered treatment adherence by measuring the increase in the CD4 count as our primary outcome. We found a significant increase in treatment adherence in the patient group compared with the control groups during the intervention phase. Positive findings did not persist after the cessation of the incentives. The meta-analysis showed that the intervention improved patient adherence by 2.69 (95% confidence interval: [0.08, 0.51]; p = .007) compared with the control group during the intervention period. All short-term CM studies converged on a positive result for adherence to antiretroviral therapy.

Adjunctive Medication Management and Contingency Management to enhance adherence to acamprosate for alcohol dependence: the ADAM trial RCT

Background

Acamprosate is an effective and cost-effective medication for alcohol relapse prevention but poor adherence can limit its full benefit. Effective interventions to support adherence to acamprosate are therefore needed.

Objectives

To determine the effectiveness of Medication Management, with and without Contingency Management, compared to Standard Support alone in enhancing adherence to acamprosate and the impact of adherence to acamprosate on abstinence and reduced alcohol consumption.

Design

Multicentre, three-arm, parallel-group, randomised controlled clinical trial.

Setting

Specialist alcohol treatment services in five regions of England (South East London, Central and North West London, Wessex, Yorkshire and Humber and West Midlands).

Participants

Adults (aged 18 years or more), an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis of alcohol dependence, abstinent from alcohol at baseline assessment, in receipt of a prescription for acamprosate.

Interventions

(1) Standard Support, (2) Standard Support with adjunctive Medication Management provided by pharmacists via a clinical contact centre (12 sessions over 6 months), (3) Standard Support with adjunctive Medication Management plus Contingency Management that consisted of vouchers (up to £120) to reinforce participation in Medication Management. Consenting participants were randomised in a 2 : 1 : 1 ratio to one of the three groups using a stratified random permuted block method using a remote system. Participants and researchers were not blind to treatment allocation.

Main outcome measures

Primary outcome: self-reported percentage of medication taken in the previous 28 days at 6 months post randomisation. Economic outcome: EuroQol-5 Dimensions, a five-level version, used to calculate quality-adjusted life-years, with costs estimated using the Adult Service Use Schedule.

Results

Of the 1459 potential participants approached, 1019 (70%) were assessed and 739 (73 consented to participate in the study, 372 (50%) were allocated to Standard Support, 182 (25%) to Standard Support with Medication Management and 185 (25%) to Standard Support and Medication Management with Contingency Management. Data were available for 518 (70%) of participants at 6-month follow-up, 255 (68.5%) allocated to Standard Support, 122 (67.0%) to Standard Support and Medication Management and 141 (76.2%) to Standard Support and Medication Management with Contingency Management. The mean difference of per cent adherence to acamprosate was higher for those who received Standard Support and Medication Management with Contingency Management (10.6%, 95% confidence interval 19.6% to 1.6%) compared to Standard Support alone, at the primary end point (6-month follow-up). There was no significant difference in per cent days adherent when comparing Standard Support and Medication Management with Standard Support alone 3.1% (95% confidence interval 12.8% to -6.5%) or comparing Standard Support and Medication Management with Standard Support and Medication Management with Contingency Management 7.9% (95% confidence interval 18.7% to -2.8%). The primary economic analysis at 6 months found that Standard Support and Medication Management with Contingency Management was cost-effective compared to Standard Support alone, achieving small gains in quality-adjusted life-years at a lower cost per participant. Cost-effectiveness was not observed for adjunctive Medication Management compared to Standard Support alone. There were no serious adverse events related to the trial interventions reported.

Limitations

The trial's primary outcome measure changed substantially due to data collection difficulties and therefore relied on a measure of self-reported adherence. A lower than anticipated follow-up rate at 12 months may have lowered the statistical power to detect differences in the secondary analyses, although the primary analysis was not impacted.

Conclusions

Medication Management enhanced with Contingency Management is beneficial to patients for supporting them to take acamprosate.

Future work

Given our findings in relation to Contingency Management enhancing Medication Management adherence, future trials should be developed to explore its effectiveness and cost-effectiveness with other alcohol interventions where there is evidence of poor adherence.

Trial registration

This trial is registered as ISRCTN17083622 https://doi.org/10.1186/ISRCTN17083622.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 22. See the NIHR Journals Library website for further project information.

Demonstration of an app-delivered digital therapeutic program for methamphetamine use disorder

This study assessed the feasibility and utility of a digital, all-virtual program designed for treatment of methamphetamine use disorder (MUD). Forty-nine adults with moderate- to severe-level MUD (per DSM-5 criteria) commenced the 8-week intervention. All aspects of the program were delivered via smartphone-based app. Intervention components included counseling (cognitive behavioral therapy in group and individual sessions), app-based therapeutic tasks, remote biological drug testing, medical oversight by psychiatrists/nurse practitioners, and contingency management procedures (including rewards for methamphetamine-free saliva drug tests, accomplishing tasks, and engaging in assigned activities). Of the 49 participants who commenced treatment, 27 participants (55%) completed the program. Repeated-measures mixed-model analyses show that participants were more likely to test negative for meth use from week 1 to week 8 (OR = 1.57, 95% CI [1.28, 1.97]; p = 0.034). Well-being and social functioning improved among the majority of participants. These results demonstrate the utility of the all-virtual, digital therapeutic program and its ability to help individuals with MUD to reduce or cease methamphetamine use. The program was efficiently implemented and was well received by participants and clinical personnel, indicating its ability to deliver comprehensive, effective care and to retain the difficult-to-engage population of persons with MUD. Of the 27 completers, 16 responded to a 1-month follow-up survey and reported no meth use in the month since completing the program.

Cultural Factors and Alcohol Use in American Indian Adults: Results From a Culturally Tailored Contingency Management Intervention

OBJECTIVE

American Indian and Alaska Native (AI/AN) populations experience greater health disparities in alcohol use outcomes compared with the general population. This secondary data analysis examines cultural factors related to alcohol use in reservation-based American Indian (AI) adults (N = 65; 41 males; mean age = 36.7 years) in a randomized controlled trial of a culturally tailored contingency management (CM) program. It was hypothesized that individuals with higher rates of cultural protective factors would have lower rates of alcohol use, whereas individuals with higher rates of risk factors would have higher rates of alcohol use. It was also hypothesized that enculturation would moderate the relationship between treatment group and alcohol use.

METHOD

Generalized linear mixed modeling was used to calculate odds ratios (ORs) for the repeated measure, biweekly urine tests of the biomarker, ethyl glucuronide (EtG), across 12 weeks. The relationships between alcohol use (abstinence [EtG < 150 ng/ml]) or heavy drinking [EtG > 500 ng/ml]) and culturally relevant protective (enculturation, years lived on the reservation) and risk factors (discrimination, historical loss, historical loss symptoms) were examined.

RESULTS

There was a negative association between enculturation and probability of submitting a heavy drinking urine sample (OR = 0.973; 95% CI [0.950, 0.996], p = .023), indicating that enculturation may serve as a protective factor against heavy drinking.

CONCLUSIONS

Cultural factors (e.g., enculturation) may be important constructs to assess and incorporate into treatment planning with AI adults engaged in alcohol treatment.

Contingency Management for Treatment of Cannabis Use Disorder in Co-Occurring Mental Health Disorders: A Systematic Review

Amongst individuals with a mental health disorder, a comorbid diagnosis of cannabis use disorder (CUD) is associated with numerous adverse consequences, including more severe symptom profiles, poorer treatment response, and reduced psychosocial functioning. Contingency management (CM), a method to specifically reinforce target behavior attainment (e.g., substance use abstinence), may provide an effective intervention in treating cannabis use in patients with a dual diagnosis of CUD and a mental health disorder. A systematic search examining the effects of CM on cannabis use, clinical, cognitive, and psychosocial outcomes in patients with a mental health disorder on PubMed, PsycINFO, and EMBASE databases up to November 2022 was performed. Six studies met inclusion criteria for our review. We found CM to be efficacious in producing cannabis use reductions and abstinence amongst individuals with a psychotic-spectrum or major depressive disorder. Additional longitudinal studies with larger sample sizes, other psychiatric populations, and longer follow-up periods are needed to evaluate the sustained effects of CM.

Contingency management for alcohol use disorder reduces cannabis use among American Indian and Alaska Native adults

OBJECTIVE

Determine whether a culturally tailored contingency management (CM) intervention targeting alcohol abstinence resulted in secondary effects on cannabis use among American Indian and Alaska Native (AI/AN) adults.

METHODS

The research team conducted this secondary data analysis to examine cannabis abstinence using data from a randomized control trial of CM for alcohol use among three AI/AN-serving organizations. One hundred and fifty-eight adults met the randomization criteria (i.e., submission of 50% or more urine samples and one alcohol-positive urine test during a 4-week, pre-randomization, observation period). For 12 weeks after randomization, participants received incentives for submitting a urine test negative for ethyl glucuronide (EtG < 150 ng/mL, CM group) or incentives for submitting a urine sample regardless of abstinence (Non-contingent [NC] Control group). Generalized linear mixed effects models assessed group differences in cannabis abstinence during the intervention, verified by urine tetrahydrocannabinol negative tests (11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid <50 ng/mL).

RESULTS

At baseline, 42.2% (n = 35) of participants in the NC group and 40.0% (n = 30) of those in the CM group had a cannabis positive urine test. An overall intervention by time interaction was detected for a cannabis negative urine test (χ2 = 13.40, p = 0.001). Compared to the NC group, the CM group had 3.92 (95% CI:1.23-12.46) times higher odds of having a cannabis negative urine test during the intervention period and 5.13 (95% CI:1.57-16.76) times higher odds of having a negative cannabis test at the end of intervention period.

CONCLUSION

CM addressing alcohol misuse may be an effective strategy for decreasing cannabis use among AI/AN adults.

TRIAL REGISTRATION

ClinicalTrials.gov number, Identifier: NCT02174315.

A preliminary investigation of schedule parameters on cocaine abstinence in contingency management

Contingency management (CM) interventions are the most effective psychosocial interventions for substance use disorders. However, further investigation is needed to create the most robust intervention possible. This study investigated the effects of 1) reinforcer magnitude; and 2) fixed and escalating and resetting incentives on cocaine abstinence in an outpatient trial. In this analysis, 34 treatment-seeking individuals with Cocaine Use Disorder received either high or low value incentives for providing a benzoylecgonine-negative urine sample or were in a control condition and received incentives for providing a urine sample regardless of the results. Participants received either escalating and resetting incentives, wherein the value of each incentive increased with consecutive negative samples and reset to the initial level upon a positive sample (Experiment 1), or fixed incentives, wherein they received the same value incentive for each negative urine sample they provided (Experiment 2). Large incentives produced more abstinence, although escalating and resetting reinforcer values did not have a differential effect. Large, fixed incentives promoted abstinence faster than other reinforcers, whereas smaller incentives resulted in poor abstinence and took many visits to achieve initial abstinence. Future research comparing different schedules on cocaine abstinence in a randomized control trial with a larger sample size is required.

Contingency Management applied to Alcohol Use Disorder: Systematic Review

Abstract This systematic review evaluated the efficacy of applying Contingency Management (CM) to Alcohol Use Disorder. We followed the PRISMA recommendation and consulted the following databases: Cochrane Library, MEDLINE Complete, PsycINFO and Pubmed. A total of eight randomized controlled trials were included in this review, all of them with good methodological quality. In seven of these, CM was more efficacious in promoting continuous abstinence. Both trials that evaluated treatment retention found statistically significant results favorable to CM. On two of the three trials presenting follow-up results, CM was more efficacious in promoting abstinence. The large-scale application of CM can promote substantial public health improvements and should be encouraged.

Manejo de Contingência Aplicado ao Transtorno por Uso de Álcool: Revisão Sistemática

Resumo Esta revisão sistemática avaliou a eficácia do Manejo de Contingência (MC) no tratamento do Transtorno por Uso de Álcool. Para isso, foi utilizada a recomendação PRISMA e consultadas as bases de dados: Cochrane Library, MEDLINE Complete, PsycINFO e Pubmed. Foram incluídos oito ensaios clínicos randomizados nesta revisão. Em sete, o MC foi mais eficaz em promover abstinência continuada. Dos dois que avaliaram a retenção no tratamento, ambos encontraram resultados estatisticamente favoráveis ao MC. Dos três que apresentaram resultados de avaliação de seguimento, em dois o MC foi mais eficaz em promover abstinência. Todos apresentaram boa qualidade metodológica. A aplicação do MC em larga escala pode promover melhorias substanciais para a saúde pública e deve ser encorajada.

Effectiveness of incorporating contingency management into a public treatment program for people who use crack cocaine in Brazil. A single-blind randomized controlled trial

BACKGROUND

Smoked cocaine (i.e., crack use) is a severe health problem in Brazil, with the country being reported as having the largest crack market in the world. The objective of this study was to evaluate the effectiveness of incorporating Contingency Management targeting cocaine abstinence into a public treatment program in Brazil.

METHODS

Single-blind randomized controlled trial conducted at Unidade Recomeço Helvétia (URH), a public ambulatory treatment program for persons who use crack and live in the "Crackland" region in downtown São Paulo, Brazil. In total, 98 treatment-seeking individuals who use crack were randomized to one of two treatment conditions. Participants allocated to the control condition (n = 48) received 12 weeks of the standard treatment provided at URH. Participants allocated to the experimental condition (n = 50) received the same treatment in combination with Contingency Management (URH+CM). In URH+CM, participants were provided with vouchers with monetary value for submission of negative cocaine urinalysis twice weekly.

RESULTS

Compared to the URH group, the URH+CM group was significantly more likely to submit a negative cocaine urinalysis during treatment, with odds ratios ranging from 4.17 to 6.78, depending on how missing data was accounted for (p<0.01). Participants receiving Contingency Management also had higher odds of achieving three or more weeks of continuous abstinence (OR= 8.07; 95% CI [2.48, 26.24]), achieved longer durations of abstinence (B = 2.14; 95% CI [0.67, 3.61]), submitted a higher percentage of negative urinalysis (B = 19.85; 95% CI [6.89, 32.82]), and were retained in treatment for a longer period (B = 3.00; 95% CI [1.04, 4.97]), compared to those receiving URH alone (p<0.01 for all).

CONCLUSIONS

The incorporation of Contingency Management was effective in promoting cocaine abstinence and treatment retention. The large-scale dissemination of Contingency Management may be an effective strategy to treat Brazilians with cocaine use disorders.

Comparison of Treatments for Cocaine Use Disorder Among Adults: A Systematic Review and Meta-analysis

IMPORTANCE

In the US and the United Kingdom, cocaine use is the second leading cause of illicit drug overdose death. Psychosocial treatments for cocaine use disorder are limited, and no pharmacotherapy is approved for use in the US or Europe.

OBJECTIVE

To compare treatments for active cocaine use among adults.

DATA SOURCES

PubMed and the Cochrane Database of Systematic Reviews were searched for clinical trials published between December 31, 1995, and December 31, 2017.

STUDY SELECTION

This meta-analysis was registered on Covidence.org (study 8731) on December 31, 2015. Clinical trials were included if they (1) had the term cocaine in the article title; (2) were published between December 31, 1995, and December 31, 2017; (3) were written in English; (4) enrolled outpatients 18 years or older with active cocaine use at baseline; and (5) reported treatment group size, treatment duration, retention rates, and urinalysis results for the presence of cocaine metabolites. A study was excluded if (1) more than 25% of participants were not active cocaine users or more than 80% of participants had negative test results for the presence of cocaine metabolites at baseline and (2) it reported only pooled urinalysis results indicating the presence of multiple substances and did not report the specific proportion of positive test results for cocaine metabolites. Multiple reviewers reached criteria consensus. Of 831 records screened, 157 studies (18.9%) met selection criteria and were included in the analysis.

DATA EXTRACTION AND SYNTHESIS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. Search results were imported from PubMed XML into Covidence.org then Microsoft Excel. Data extraction was completed in 2 iterations to ensure fidelity. Analyses included a multilevel random-effects model, a multilevel mixed-effects meta-regression model, and sensitivity analyses. Treatments were clustered into 11 categories (psychotherapy, contingency management programs, placebo, opioids, psychostimulants, anticonvulsants, dopamine agonists, antidepressants, antipsychotics, miscellaneous medications, and other therapies). Missing data were imputed using multiple imputation by chained equations. The significance threshold for all analyses was P = .05. Data were analyzed using the metafor and mice packages in R software, version 3.3.2 (R Foundation for Statistical Computing). Data were analyzed from January 1, 2018, to February 28, 2021.

MAIN OUTCOMES AND MEASURES

The primary outcome was the intention-to-treat logarithm of the odds ratio (OR) of having a negative urinalysis result for the presence of cocaine metabolites at the end of each treatment period compared with baseline. The hypothesis, which was formulated after data collection, was that no treatment category would have a significant association with objective reductions in cocaine use.

RESULTS

A total of 157 studies comprising 402 treatment groups and 15 842 participants were included. Excluding other therapies, the largest treatment groups across all studies were psychotherapy (mean [SD] number of participants, 40.04 [36.88]) and contingency management programs (mean [SD] number of participants, 37.51 [25.51]). Only contingency management programs were significantly associated with an increased likelihood of having a negative test result for the presence of cocaine (OR, 2.13; 95% CI, 1.62-2.80), and this association remained significant in all sensitivity analyses.

CONCLUSIONS AND RELEVANCE

In this meta-analysis, contingency management programs were associated with reductions in cocaine use among adults. Research efforts and policies that align with this treatment modality may benefit those who actively use cocaine and attenuate societal burdens.

Maternal crack cocaine use in rats leads to depressive- and anxiety-like behavior, memory impairment, and increased seizure susceptibility in the offspring

Crack users suffer the effects of cocaine present in the drug and the action of other active compounds from its pyrolysis. An emergent fact is an increase in the number of pregnant crack cocaine users. Studies suggest that crack cocaine and its metabolites cross the placenta, promoting premature birth, fever, irritability, sweating, and seizures in the early months of life. In children, the effects of crack cocaine have been associated with cognitive deficits, difficulty in verbalization, aggressiveness, and depression, besides enhancing the susceptibility to epileptic seizures, including status epilepticus (SE) in adulthood. Therefore, we investigated the effect of maternal exposure to smoke crack cocaine on several behavioral parameters in the offspring during adulthood. A series of behavioral tests and intrahippocampal pilocarpine (H-PILO) microinjection at sub-convulsive and convulsive doses in a rat model demonstrated that exposure to crack cocaine during the embryonic period leads to anxiogenic-like behavior and long-term memory impairment in both genders and promotes depressive-like behavior in the female. Besides, crack cocaine offspring exposed to a sub-convulsive H-PILO dose showed higher susceptibility to SE, increased seizure frequency, and neurodegeneration, while animals that received a convulsive dose of H-PILO displayed no alteration in SE severity. Taken together, our data suggest that crack cocaine exposure during the gestational period leads to an increased predilection for anxiety and depression, long-term memory deficits, and reduction in the threshold for developing epileptic seizures associated with neuronal death, which predispose crack cocaine babies to develop neuropsychological disorders.

Vouchers versus reminders to prevent dropout: Findings from the randomized youth drug abuse treatment project (youthDAT project)

BACKGROUND

Over the last few decades, evidence-based treatments for emerging adults with drug use disorder (DUD) have been developed, but dropout and inconsistent session attendance persist. This study assessed the efficacy of voucher reinforcement and/or text reminders for treatment attendance and completion in emerging adults with DUD in Denmark.

METHODS

The study compared four levels of treatment intensity, with participants randomly assigned to standard outpatient counseling only (STD), outpatient counseling plus vouchers for attendance (VOU), outpatient counseling plus text reminders (REM), or outpatient counseling plus vouchers and text reminders (REM + VOU). A total of 460 individuals aged 15-25 years seeking treatment for DUD were randomly assigned to the four treatment conditions across nine sites.

RESULTS

STD counseling had the lowest completion rate (25%), followed by REM (39%), VOU (46%), and REM + VOU (49%). Additionally, post hoc comparisons indicated that clients randomized to the REM + VOU condition differed in terms of zero no-shows from clients who were randomized to the VOU condition (χ2(1) = 6.90, p = 0.009) and the REM condition (χ2(1) = 5.87, p = 0.015).

CONCLUSIONS

Vouchers and text reminders contribute to reduced dropout and increased treatment attendance in emerging adults with DUD. The combination of vouchers and reminders in particular has the potential to reduce the number of no-shows.

Prescription psychostimulants for the treatment of stimulant use disorder: a systematic review and meta-analysis

RATIONALE

Agonist-based pharmacologic intervention is an accepted approach in treatment of opioid and tobacco use disorders.

OBJECTIVES

We conducted a systematic review and meta-analysis to evaluate usefulness of an agonist approach as treatment of (psycho)stimulant use disorder (PSUD).

METHODS

We reviewed PubMed/Medline, LILACS, and ClinicalTrials.gov databases searching for randomized, double-blind, placebo-controlled, parallel-design studies evaluating outcomes of individuals treated for cocaine- or amphetamine-type substance use disorder. We combined results of all trials that included the following prescription psychostimulants (PPs): modafinil, methylphenidate, or amphetamines (mixed amphetamine salts, lisdexamphetamine, and dextroamphetamine). The combined sample consisted of 2889 patients. Outcomes of interest included the following: drug abstinence (defined as 2-3 weeks of sustained abstinence and the average maximum days of consecutive abstinence), percentage of drug-negative urine tests across trial, and retention in treatment. We conducted random-effects meta-analyses and assessed quality of evidence using the GRADE system.

RESULTS

Thirty-eight trials were included. Treatment with PPs increases rates of sustained abstinence [risk ratio (RR) = 1.45, 95% confidence interval (CI) = (1.10, 1.92)] and duration of abstinence [mean difference (MD) = 3.34, 95% CI = (1.06, 5.62)] in patients with PSUD, particularly those with cocaine use disorder (very low-quality evidence). Prescription amphetamines were particularly efficacious in promoting sustained abstinence in patients with cocaine use disorder [RR = 2.44, 95% CI = (1.66, 3.58)], and higher doses of PPs were particularly efficacious for treatment of cocaine use disorder [RR = 1.95, 95% CI = (1.38, 2.77)] (moderate-quality evidence). Treatment with prescription amphetamines also yielded more cocaine-negative urines [MD = 8.37%, 95% CI = (3.75, 12.98)]. There was no effect of PPs on the retention in treatment.

CONCLUSION

Prescription psychostimulants, particularly prescription amphetamines given in robust doses, have a clinically significant beneficial effect to promote abstinence in the treatment of individuals with PSUD, specifically the population with cocaine use disorder.

Spending money to make change: Association of methamphetamine abstinence and voucher spending among contingency management pilot participants in South Africa

AIMS

Methamphetamine Use Disorder is prevalent in South Africa. This analysis uses data from a contingency management (CM) pilot study in South Africa to replicate and expand on a U.S.-based study showing that CM voucher spending was associated with drug abstinence behavior.

DESIGN

Participants with methamphetamine-use disorder were enrolled in an 8-week CM trial requiring thrice weekly visits and received cash vouchers in exchange for stimulant-negative urines at each visit.

PARTICIPANTS

Participants were 33 treatment-seeking individuals with methamphetamine use disorder including 22 men (66.7%) and 11 women (33.3%) with a mean age of 34 years (S.D. = 7.7). Participants reported using methamphetamine for a mean of 11.7 years (S.D. = 4.9).

SETTING

All study procedures took place in South Africa between August 2016 and May 2018.

MEASUREMENTS

A time-lagged counting process Cox Proportional Hazards model for recurrent event survival analysis examined the relationship between frequency of and participant-categorized type of CM expenditures (hedonic, utilitarian, consumable or durable) and drug abstinence.

FINDINGS

After controlling for severity of baseline methamphetamine use and accumulated CM earnings (proxied by cumulative negative urines), those spending CM earnings at a previous visit ("spenders") were more likely to produce stimulant-negative urine samples subsequently, compared to those who did not ("savers") [OR = 1.23, CI = 1.08-1.53, p = .002]. There were significantly more cumulative stimulant-negative results among spenders vs. savers, p < .001, although cumulative spending did not significantly predict abstinence once spending in the prior time period was controlled for, suggesting a recency effect tied to the underlying spending mechanism. When extending the original analyses to look at the effect of spending on current abstinence, controlling only for recent abstinence (rather than cumulative abstinence), spending was no longer a significant predictor. Spending type did not affect methamphetamine abstinence. Qualitative results suggest spending CM vouchers may support social reintegration over the course of the trial.

CONCLUSIONS

Abstinence outcomes are a function of CM spending in both the U.S. and South Africa. Findings of a significant relationship between contingency management spending and subsequent stimulant-negative urine samples across geographic locations provide guidance toward future work in optimizing CM efficacy.

Dropout rates of in-person psychosocial substance use disorder treatments: a systematic review and meta-analysis

BACKGROUND AND AIMS

Relapse rates for psychosocial substance use disorder (SUD) treatments are high, and dropout is a robust predictor of relapse. This study aimed to estimate average dropout rates of in-person psychosocial SUD treatments and to assess predictors of dropout.

DESIGN

A comprehensive meta-analysis of dropout rates of studies of in-person psychosocial SUD treatment. Studies included randomized controlled trials (RCTs) and cohort studies.

SETTING

Studies conducted anywhere in the world that examined SUD treatment and were published from 1965 to 2016, inclusive.

PARTICIPANTS/CASES

One hundred and fifty-one studies, 338 study arms and 299 dropout rates including 26 243 participants.

MEASUREMENTS

Databases were searched for studies of SUD treatment that included an in-person psychosocial component. Meta-analyses and meta-regressions were conducted to estimate dropout rates and identify predictors of dropout, including participant characteristics, facilitator characteristics and treatment characteristics. Pooled estimates were calculated with random-effects analyses accounting for the hierarchical structure of study arms nested within studies.

FINDINGS

The average dropout rate across all studies and study arms was 30.4% [95% confidence interval (CI) = 27.2-33.8 and 95% prediction interval (PI) = 6.25-74.15], with substantial heterogeneity (I²  = 93.7%, P < 0.0001). Studies including a higher percentage of African Americans and lower-income individuals were associated with higher dropout rates. At intake, more cigarettes/day and a greater percentage of heroin use days were associated with lower dropout rates, whereas heavier cocaine use was associated with higher dropout rates. Dropout rates were highest for studies targeting cocaine, methamphetamines and major stimulants (broadly defined) and lowest for studies targeting alcohol, tobacco and heroin, although there were few studies on methamphetamines, major stimulants and heroin. Programs characterized by more treatment sessions and greater average session length were associated with higher dropout rates. Facilitator characteristics were not significantly associated with dropout.

CONCLUSIONS

On average, approximately 30% of participants drop out of in-person psychosocial SUD treatment studies, but there is wide variability. Drop-out rates vary with the treated population, the substance being targeted, and the characteristics of the treatment.

Contingency management is effective in promoting abstinence and retention in treatment among crack cocaine users with a previous history of poor treatment response: a crossover trial

BACKGROUND

Crack use has become a severe health problem in Brazil. Contingency management has shown robust evidence of efficacy in the treatment of cocaine use disorder (CUD) in high-income countries; however, it is still unclear how this intervention can impact treatment in low-income countries.

OBJECTIVE

To evaluate the efficacy of contingency management in the treatment of CUD among individuals with a previous history of poor treatment response in Brazil.

METHODS

Six months after the end of treatment, 32 participants previously allocated to the usual care condition (UCC) were invited to receive an additional 12 weeks of treatment in a contingency management condition (CMC), and 16 accepted the invitation. We compared data obtained from only the 16 participants (14 male) exposed to both treatment conditions.

RESULTS

Participants attended more treatment sessions and were retained in treatment for a longer period during the CMC than during the UCC (p < .01 for both). The proportion of negative cocaine samples submitted, the mean longest duration of cocaine abstinence, and the odds of being abstinent from cocaine during the 12 weeks of treatment were significantly higher during treatment in the CMC when compared to the UCC (p < .05).

CONCLUSIONS

This study provides further evidence that contingency management is effective in promoting abstinence and retention in treatment among individuals with CUD with a history of poor treatment response. Our findings argue for the incorporation of CM among public treatment services for CUD in Brazil.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov as NCT01815645 on March 21, 2013.

Comparative efficacy and acceptability of psychosocial interventions for individuals with cocaine and amphetamine addiction: A systematic review and network meta-analysis

BACKGROUND

Clinical guidelines recommend psychosocial interventions for cocaine and/or amphetamine addiction as first-line treatment, but it is still unclear which intervention, if any, should be offered first. We aimed to estimate the comparative effectiveness of all available psychosocial interventions (alone or in combination) for the short- and long-term treatment of people with cocaine and/or amphetamine addiction.

METHODS AND FINDINGS

We searched published and unpublished randomised controlled trials (RCTs) comparing any structured psychosocial intervention against an active control or treatment as usual (TAU) for the treatment of cocaine and/or amphetamine addiction in adults. Primary outcome measures were efficacy (proportion of patients in abstinence, assessed by urinalysis) and acceptability (proportion of patients who dropped out due to any cause) at the end of treatment, but we also measured the acute (12 weeks) and long-term (longest duration of study follow-up) effects of the interventions and the longest duration of abstinence. Odds ratios (ORs) and standardised mean differences were estimated using pairwise and network meta-analysis with random effects. The risk of bias of the included studies was assessed with the Cochrane tool, and the strength of evidence with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We followed the PRISMA for Network Meta-Analyses (PRISMA-NMA) guidelines, and the protocol was registered in PROSPERO (CRD 42017042900). We included 50 RCTs evaluating 12 psychosocial interventions or TAU in 6,942 participants. The strength of evidence ranged from high to very low. Compared to TAU, contingency management (CM) plus community reinforcement approach was the only intervention that increased the number of abstinent patients at the end of treatment (OR 2.84, 95% CI 1.24-6.51, P = 0.013), and also at 12 weeks (OR 7.60, 95% CI 2.03-28.37, P = 0.002) and at longest follow-up (OR 3.08, 95% CI 1.33-7.17, P = 0.008). At the end of treatment, CM plus community reinforcement approach had the highest number of statistically significant results in head-to-head comparisons, being more efficacious than cognitive behavioural therapy (CBT) (OR 2.44, 95% CI 1.02-5.88, P = 0.045), non-contingent rewards (OR 3.31, 95% CI 1.32-8.28, P = 0.010), and 12-step programme plus non-contingent rewards (OR 4.07, 95% CI 1.13-14.69, P = 0.031). CM plus community reinforcement approach was also associated with fewer dropouts than TAU, both at 12 weeks and the end of treatment (OR 3.92, P < 0.001, and 3.63, P < 0.001, respectively). At the longest follow-up, community reinforcement approach was more effective than non-contingent rewards, supportive-expressive psychodynamic therapy, TAU, and 12-step programme (OR ranging between 2.71, P = 0.026, and 4.58, P = 0.001), but the combination of community reinforcement approach with CM was superior also to CBT alone, CM alone, CM plus CBT, and 12-step programme plus non-contingent rewards (ORs between 2.50, P = 0.039, and 5.22, P < 0.001). The main limitations of our study were the quality of included studies and the lack of blinding, which may have increased the risk of performance bias. However, our analyses were based on objective outcomes, which are less likely to be biased.

CONCLUSIONS

To our knowledge, this network meta-analysis is the most comprehensive synthesis of data for psychosocial interventions in individuals with cocaine and/or amphetamine addiction. Our findings provide the best evidence base currently available to guide decision-making about psychosocial interventions for individuals with cocaine and/or amphetamine addiction and should inform patients, clinicians, and policy-makers.

A review of contingency management for the treatment of substance-use disorders: adaptation for underserved populations, use of experimental technologies, and personalized optimization strategies

This review of contingency management (CM; the behavior-modification method of providing reinforcement in exchange for objective evidence of a desired behavior) for the treatment of substance-use disorders (SUDs) begins by describing the origins of CM and how it has come to be most commonly used during the treatment of SUDs. Our core objective is to review, describe, and discuss three ongoing critical advancements in CM. We review key emerging areas wherein CM will likely have an impact. In total, we qualitatively reviewed 31 studies in a systematic fashion after searching PubMed and Google Scholar. We then describe and highlight CM investigations across three broad themes: adapting CM for underserved populations, CM with experimental technologies, and optimizing CM for personalized interventions. Technological innovations that allow for mobile delivery of reinforcers in exchange for objective evidence of a desired behavior will likely expand the possible applications of CM throughout the SUD-treatment domain and into therapeutically related areas (eg, serious mental illness). When this mobile technology is coupled with new, easy-to-utilize biomarkers, the adaptation for individual goal setting and delivery of CM-based SUD treatment in hard-to-reach places (eg, rural locations) can have a sustained impact on communities most affected by these disorders. In conclusion, there is still much to be done, not only technologically but also in convincing policy makers to adopt this well-established, cost-effective, and evidence-based method of behavior modification.

Development and evaluation of addiction treatment programs in Latin America

PURPOSE OF REVIEW

The aim of this article is to present a state-of-the-art review of the scientific studies that have evaluated healthcare systems, services and programs for addiction treatment in Latin America. As a secondary aim, this article presents a brief description and analysis of the addiction prevention and treatment resources and programs available in Latin America, based on information from the ATLAS on Substance Use (ATLAS-SU) project led by the WHO.

RECENT FINDINGS

Substance use disorders (SUDs) are among the main causes associated with global burden of disease. Around the world, many initiatives have been proposed to promote policies to reduce substance use and reduce the impact of SUD, including integrating treatments into healthcare systems, increasing access to treatment programs and impacting outcome measures. In Latin America, multiple efforts have been implemented to improve addiction services and programs, although little is known about the impact they have generated.

SUMMARY

International studies report the availability of strategies and public inicitatives on prevention and treatment of addiction in Latin America. These studies also report established networks of public and private services that include prevention and detoxification programs, outpatient and residential treatment, and also social reintegration initiatives. However, despite these advances, information on the evaluation of the progress, results and impact of these programs is limited.

Maternal, fetal and neonatal consequences associated with the use of crack cocaine during the gestational period: a systematic review and meta-analysis

OBJECTIVE

Crack cocaine consumption is one of the main public health challenges with a growing number of children intoxicated by crack cocaine during the gestational period. The primary goal is to evaluate the accumulating findings and to provide an updated perspective on this field of research.

METHODS

Meta-analyses were performed using the random effects model, odds ratio (OR) for categorical variables and mean difference for continuous variables. Statistical heterogeneity was assessed using the I-squared statistic and risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scale. Ten studies met eligibility criteria and were used for data extraction.

RESULTS

The crack cocaine use during pregnancy was associated with significantly higher odds of preterm delivery [odds ratio (OR), 2.22; 95% confidence interval (CI), 1.59-3.10], placental displacement (OR, 2.03; 95% CI 1.66-2.48), reduced head circumference (- 1.65 cm; 95% CI - 3.12 to - 0.19), small for gestational age (SGA) (OR, 4.00; 95% CI 1.74-9.18) and low birth weight (LBW) (OR, 2.80; 95% CI 2.39-3.27).

CONCLUSION

This analysis provides clear evidence that crack cocaine contributes to adverse perinatal outcomes. The exposure of maternal or prenatal crack cocaine is pointedly linked to LBW, preterm delivery, placental displacement and smaller head circumference.

Sociodemographic Characteristics, Patterns of Crack Use, Concomitant Substance Use Disorders, and Psychiatric Symptomatology in Treatment-Seeking Crack-Dependent Individuals in Brazil

Crack cocaine (crack) dependence is a severe disorder associated with considerable morbidity and mortality, constituting a major public health problem in Brazil. The aim of this study was to improve understanding of the profile of treatment-seeking crack-dependent individuals. We recruited 65 crack-dependent individuals from among those seeking treatment at an outpatient clinic for alcohol and drug treatment in the city of São Paulo, Brazil. Assessments, conducted between August 2012 and July 2014, focused on sociodemographic characteristics, the pattern/history of crack use, treatment history, concomitant substance use disorders, psychiatric symptomatology, and impulsivity. In the study sample, males predominated, as did unemployment, homelessness, and low levels of education. On average, the participants had smoked crack for 10 years. Most had previously been treated for crack dependence. Concomitant DSM-IV diagnoses of dependence on other substances were common, dependence on tobacco and alcohol being the most prevalent. Participants presented significant psychiatric symptomatology and impulsivity, with nearly half of the sample presenting psychotic symptoms, 90% presenting depressive symptoms, and 80% presenting anxiety symptoms. Most treatment-seeking crack-dependent individuals in Brazil are living in extremely poor social conditions and are struggling with the severe, chronic, and comorbid features of this disorder.

Crack cocaine users views regarding treatment with contingency management in Brazil

BACKGROUND

Contingency management (CM) has recently shown efficacy in promoting abstinence and retention in treatment among crack cocaine users in Brazil. However, partially because of unawareness and resistance among health care providers, CM has not been widely employed. The objective of this study was to conduct a secondary analysis in order to evaluate how CM participants perceive their treatment experience.

METHODS

Twenty-seven crack cocaine users, previously assigned to 12 weeks of CM treatment, were assessed with a structured questionnaire designed to assess their personal opinion of, difficulty in understanding, and acceptance of the CM intervention, as well as their opinion regarding its impact on their treatment responses.

RESULTS

Descriptive analyses showed that 92.6% of the participants found it very easy to understand the CM protocol. All participants reported liking their CM experience quite a bit. For the perceived effects of CM on their treatment response, 81.5% of the participants stated that CM helped them considerably, the mean score for the impact of CM on treatment response (out of a maximum of 10) being 9 (SD = 1.5). When asked if they believed CM could help other people with crack cocaine dependence, 92.6% of the participants stated that CM could help such people a lot and 7.4% stated that it could help them a little.

CONCLUSIONS

From the perspective of the patients, CM was easily assimilated, easily accepted, and had a direct positive effect on treatment response. These findings provide additional support for the incorporation of CM into substance abuse treatment services in Brazil.

Contingency management treatment for substance use disorders: How far has it come, and where does it need to go?

Contingency management (CM) interventions consistently improve substance abuse treatment outcomes, yet CM remains a highly controversial intervention and is rarely implemented in practice settings. This article briefly outlines the evidence base of CM and then describes 4 of the most often-cited concerns about it: philosophical, motivational, durability, and economic. Data supporting and refuting each of these issues are reviewed. The article concludes with suggestions to address these matters and other important areas for CM research and implementation, with the aims of improving uptake of this efficacious intervention in practice settings and outcomes of patients with substance use disorders. (PsycINFO Database Record

Contingency management targeting abstinence is effective in reducing depressive and anxiety symptoms among crack cocaine-dependent individuals

Although contingency management (CM) is effective in promoting abstinence and treatment retention among crack cocaine users who meet the criteria for cocaine dependence, less is known about its off-target effects. In this secondary analysis, we evaluated the impact of CM on depressive and anxiety symptoms in a sample of cocaine-dependent individuals under treatment. Sixty-five crack cocaine users who met the criteria for cocaine dependence were randomly assigned to receive 12 weeks of standard treatment alone (STA; n = 32) or 12 weeks of standard treatment plus CM (STCM; n = 33). The outcome measures of the secondary analysis were depressive and anxiety symptoms assessed with the Beck Depression Inventory-II (BDI-II) and the Beck Anxiety Inventory (BAI). At baseline, 59 (90.8%) of the participants reported at least mild depressive symptoms and 47 (72.5%) reported at least mild anxiety symptoms. The mean BDI-II (24.5 ± 12.1) and BAI (20.7 ± 13.5) scores in the sample as a whole was moderate. After treatment, the reported levels of depressive symptoms (β = -9.6, p < .05) and anxiety symptoms (β = -9.9, p < .05) were lower among the individuals receiving STCM than among those receiving STA. This study provides evidence that an STCM intervention targeting crack cocaine abstinence also produces significant reductions in depressive and anxiety symptoms. This low cost intervention also demonstrated significant promise and optimization potential for crack cocaine users in a setting of scarce resources and high mental health comorbidity. Relevance Statement: We found that the prevalence of depressive and anxiety symptoms were extremely high among crack cocaine users, and that, among such individuals, contingency management (CM) reduced depressive and anxiety symptomatology to a greater degree than did standard treatment. Our results suggest that CM targeting crack cocaine abuse can have off-target effects on psychiatric symptomatology. (PsycINFO Database Record

Psychosocial interventions in stimulant use disorders: a focus on women

PURPOSE OF REVIEW

Stimulant use disorders are significant contributors to the global burden of disease, with a growing impact on women. Psychosocial interventions are the gold standard for treating this condition, but several barriers may prevent women from accessing appropriate treatment. Therefore, we systematically reviewed the most recent findings about psychosocial interventions for stimulant use disorders, focussing on results relevant to women.

RECENT FINDINGS

Twenty-two eligible studies were identified. Psychosocial interventions in stimulant use disorders were examined in 17 recent studies, but no analyses for sex-related differences were performed. These aspects were investigated in further five studies, either through secondary analyses on the female subgroup or specifically examining a female-only sample. Contingency management, either alone or in combination with other interventions, provided the most positive results on several outcome measures. Only one pilot study showed good potential for an alternative approach of systemic family therapy, warranting further research in this direction.

SUMMARY

Research in stimulant use disorders shows an increasing interest in exploring interventions capable of addressing sex-specific issues. Combined therapy including contingency management and other treatments appears the most promising option, but larger secondary studies are needed to rank the efficacy of different psychosocial interventions while considering their feasibility and acceptability in specific subpopulations, including women.

Cocaine-using substance abuse treatment patients with and without HIV respond well to contingency management treatment

HIV is common among individuals with substance use disorders, but relatively few studies have examined the impact of HIV status on response to substance abuse treatment. This secondary analysis compared patients seeking treatment for cocaine use with and without HIV in terms of substance use treatment outcomes. Primary treatment outcomes included treatment retention, longest duration of abstinence, and percent of negative samples; both substance use outcomes reflect abstinence from cocaine, alcohol and opioids concurrently. Participants (N=432) were enrolled in randomized clinical trials comparing contingency management (CM) to standard care, and 32 (7%) reported being positive for HIV. Overall, CM improved both treatment retention (average of 8.2weeks compared to 6.0weeks in the standard care condition) and longest duration of abstinence (average of 5.8weeks compared to 2.8weeks in the standard care condition). HIV status was not associated with treatment outcomes as a main effect, nor did it have an interaction effect with treatment condition. These results suggest a benefit of CM in substance abuse treatment irrespective of HIV status.