Mobile telephone-delivered contingency management interventions promoting behaviour change in individuals with substance use disorders: a meta-analysis

Evolution of the substance use landscape: Implications for contingency management

Contingency management (CM), which involves the delivery of incentives upon meeting behavioral goals, has the potential to improve substance use treatment outcomes. The intervention allows for flexibility through numerous modifiable components including changes to incentive magnitude and schedule, target behavior, and intervention structure. Unfortunately, numerous changes in the substance use landscape have occurred in the past 10 to 15 years: Substances are more potent, overdose risk has increased, new substances and methods of use have been introduced, and substance classes are increasingly being intentionally and unintentionally mixed. These developments potentially undermine CM outcomes. We explored recent substance use changes due to legislative, regulatory, social, and economic factors for four substance classes: stimulants, opioids, tobacco, and cannabis. We discuss potential adjustments to the modifiable components of CM for future research in response to these changes. By continually adapting to the shifting substance use landscape, CM can maintain optimal efficacy.

Contingency management for substance use disorders in the U.S. Veterans Health Administration: 2018-2022

INTRODUCTION

Contingency management (CM) is one of the most effective interventions for substance use disorders (SUDs), including stimulant use disorder. In the United States, the Veterans Health Administration (VHA) led the largest-scale rollout of CM in the US to date, but little is known about characteristics of patients treated and CM clinical practices.

METHODS

In this retrospective cohort study, we used VHA electronic health records data to descriptively examine CM treatment course (e.g., number of visits, time between visits, duration of treatment episode) and characteristics of patients receiving CM for SUDs from 2018 to 2022.

RESULTS

From January 2018 to September 2022, 2844 patients received CM at 90 VA Health Systems (including 98 VA Medical Center, 7 community-based outpatient clinics, and 15 other sites). The median number of CM visits was 8 (mean = 10.17, SD = 8.12) visits over the course of 1.5 months (median = 45 days, mean = 57.46 days, SD = 62.65). The target substance was stimulants in 86.42 % of visits. Average age of patients was 52.29 years (SD = 12.10), with 55.06 % of patients experiencing homelessness or housing instability, and 97.50 % of patients diagnosed with more than one SUD. Compared to the year prior to the COVID-19 pandemic (03/2019-02/2020; mean = 957.33, SD = 157.71 visits/month), CM visits declined by 83.20 % in the year following the pandemic (03/2020-02/2021; mean = 160.83, SD = 164.14), and have yet to return to pre-pandemic levels.

CONCLUSIONS

The CM rollout has been markedly successful in the VHA, with adoption across multiple VHA sites within a complex patient population, indicating the potential for effective, more widespread CM implementation. At the same time, there was a considerable reduction in CM care during the COVID-19 pandemic and CM has not yet returned to pre-pandemic levels. Moreover, only a small minority of VA patients with stimulant use disorder have received CM. Given increasing rates of overdose, including stimulant-involved overdose, it is important to increase CM provision in VHA and non-VHA settings.

Contingency Management for Drug Use Disorders: Meta-Analysis and Application of Tolin's Criteria

Several professional organizations and federal agencies recommend contingency management (CM) as an empirically supported treatment for drug use disorder. However, the release of the "Tolin criteria" warrants an updated recommendation. Using this methodology, five meta-analyses (84 studies, 11,000 participants) were reviewed. Two meta-analyses were rated moderate quality, and three were rated low or critically low quality. Comparator conditions included active treatment, placebo, treatment as usual, and no treatment. The primary outcome was abstinence. Considering only the moderate quality meta-analyses, the effect of CM versus control on posttreatment abstinence was d = 0.54 [0.43, 0.64] and follow-up abstinence was d=0.08 [0.00, 0.16]. A "strong" recommendation was provided for CM as an empirically supported treatment for drug use disorder.

Therapeutic Content of Mobile Phone Applications for Substance Use Disorders: An Umbrella Review

Mobile phone applications (MPAs) for substance use disorder (SUD) treatment are increasingly used by patients. Although pilot studies have shown promising results, multiple previous systematic reviews noted insufficient evidence for MPA use in SUD treatment-many of the previously published reviews evaluated different trials. Subsequently, we aimed to conduct an umbrella review of previously published reviews investigating the efficacy of MPAs for SUD treatment, excluding nicotine/tobacco because umbrella reviews have been done in this population and the nicotine/tobacco MPA approach often differs from SUD-focused MPAs. No previous reviews have included a statistical meta-analysis of clinical trials to quantify an estimated overall effect. Seven reviews met inclusion criteria, and 17 unique studies with available data were taken from those reviews for the meta-analysis. Overall, reviews reported a lack of evidence for recommending MPAs for SUD treatment. However, MPA-delivered recovery support services, cognitive behavioral therapy, and contingency management were identified across multiple reviews as having promising evidence for SUD treatment. Hedges g effect size for an MPA reduction in substance use-related outcomes relative to the control arm was insignificant (0.137; 95% CI, -0.056 to 0.330; P=.16). In subgroup analysis, contingency management (1.29; 95% CI, 1.088-1.482; τ 2=0; k=2) and cognitive behavioral therapy (0.02; 95% CI, 0.001-0.030; τ 2=0; k=2) were significant. Although contingency management's effect was large, both trials were small (samples of 40 and 30). This review includes an adapted framework for the American Psychiatric Association's MPA guidelines that clinicians can implement to review MPAs critically with patients.

Effectiveness of Contingency Management in Tobacco Smokers with Depressive Symptoms: A Systematic Review

Background: Effective interventions are required to address tobacco smoking in people with depressive symptomatology. In this context, contingency management could be one useful therapeutic strategy. Objectives: This study is a systematic review of tobacco cessation interventions for smokers with depressive symptomatology including a contingency management component, evaluating their efficacy with regards to tobacco abstinence, depressive symptomatology, adherence to treatment and other variables related to tobacco use. For this purpose, a search was carried out in Pubmed, PsycINFO, Cochrane, Web of Science and ClinicalTrials.gov in September 2022. The quality of the studies was assessed using the Cochrane Risk of Bias tool. Results: Of the 208 articles identified, six were included in this review. Results: For the most part, the research included suggests that contingency management is an effective strategy for improving abstinence outcomes, adherence, and other smoking-related variables such as delay discounting and intensity of cigarette demand in smokers with depressive symptomatology. Conclusions: Although contingency management could be a promising intervention in tobacco smokers with depressive symptomatology, further research in this area is still required.

Toward an era of impact of digital contingency management in the treatment of substance use disorders

Digital contingency management entails remote methods to obtain biochemical confirmation of drug status and provide desirable, tangible consequences contingent on abstinence. Advances in digital CM suggest that it may be on the cusp of making a public health impact. Specific advances include technological capabilities and affordability, companies that specialize in digital CM, policies and reimbursement models, and the increasing availability of resources related to CM. Digital CM has expanded from cigarette smoking to alcohol and illicit substance misuse, and to include a diverse range of underserved and high-risk groups (e.g., pregnant and postpartum women, socioeconomically disadvantaged individuals, adolescents, and rural populations). Although the digital divide continues to narrow, culturally responsive methods may increase uptake and engagement with digital CM. The promise of digital CM is widescale access to an evidence-based treatment with low staff burden, no side effects, high fidelity engagement, acceptability, and effectiveness, and greater equity. We may be close to realizing this promise.

Voluntary Self-Exclusion and Contingency Management for the Treatment of Problematic and Harmful Gambling in the UK: An Exploratory Study

Research into self-directed methods for reducing problematic and harmful gambling is still in its infancy. One strategy that individuals use to prevent gambling involves voluntary self-exclusion (VSE) programs. For example, VSE programs can make it challenging to access betting sites or enable banks to block gambling-related transactions. Although individual VSEs can be helpful when used alone, it is unclear whether their efficacy is enhanced when combined. Furthermore, it is unknown how VSE compliance can be improved. We propose that contingency management (CM), an evidence-based strategy to incentivise abstinence, could encourage continued VSE use, promoting long-lasting recovery from problematic or harmful gambling. Here, we conducted exploratory analyses on VSE use and CM for gambling in two populations (members of the UK general population recruited and students). Participants responded favourably regarding combined VSE use. They felt that providing vouchers exchangeable for goods/services could incentivise gambling abstinence during VSE. However, some were concerned about people potentially "gaming" the system. Participants believed supplementing VSE and CM with social support could encourage abstinence. These attitudes, and recent research on treatment providers' opinions on CM for gambling, suggest that experimental evidence should be sought to determine the efficacy of combined VSE use and CM for gambling.

Mobile health contingency management for smoking cessation among veterans experiencing homelessness: A comparative effectiveness trial

Tobacco cessation is reduced in U.S. military veterans experiencing homelessness. Mobile contingency management (mCM) is a promising treatment for tobacco use among populations experiencing homelessness, but past CM studies have largely been small, have relied on in-person follow-up, and/or lacked long-term biochemically verified abstinence measures. Veterans who smoked and were experiencing homelessness (N = 127) were randomly assigned to mCM treatment (4 weeks of mCM, 5 weeks of telehealth counseling, and the option of 12 weeks of pharmacotherapy) or VA standard care (3 biweekly group sessions and clinically appropriate pharmacotherapy), and all participants were randomly assigned to a $100 longer-term financial incentive for abstinence at 3-month follow-up. Participants were followed at 3-, 6-, and 12-months post-randomization, with the a priori main outcome designated as biochemically verified prolonged abstinence (with lapses) at 6-month follow-up. At 6-months, participants in the mCM group were significantly more likely to meet criteria for prolonged abstinence (OR = 3.1). Across time points, veterans in the mCM group had twice the odds of prolonged abstinence as those in the standard care group. However, by the 12-month follow-up, there was no statistically significant group difference in abstinence. Cost-effectiveness analysis indicated a modest increase in cost ($1,133) associated with an increase of one quality-adjusted life year saved for the intervention compared to standard care. mCM is a cost-effective approach to smoking cessation among veterans experiencing homelessness. Considering waning potency of this and other tobacco cessation interventions at 12-month follow-up, it is crucial to implement strategies to sustain abstinence for individuals experiencing homelessness.

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.

Use of Mobile Applications in Smoking, Alcohol and Substance Use Disorders

Currently, technology and mobile health applications are developing and being applied in different fields every day. Especially the use of mobile technology in many health fields offers various opportunities for the use of mobile applications in smoking, alcohol and substance use disorders, which is an important public mental health problem. The aim of this review study was to examine 16 mobile applications designed for the treatment and monitoring of smoking, alcohol and substance use. It was concluded that self-monitoring, notification and warning systems, location services, peer and expert support services were frequently used in the analyzed mobile applications. As a result of the studies, the use of mobile applications as a preventive intervention in the prevention of addiction and as an additional treatment option in addiction treatment is promising. However, this situation brings along various harms, risks and obstacles. This review of the relevant literature provides a critical update of mobile applications used in smoking, alcohol and substance use disorders. This review is expected to be an important guide for mental health professionals and mobile application designers working on addiction.

Effective Behavior Change Techniques in Digital Health Interventions for the Prevention or Management of Noncommunicable Diseases: An Umbrella Review

BACKGROUND

Despite an abundance of digital health interventions (DHIs) targeting the prevention and management of noncommunicable diseases (NCDs), it is unclear what specific components make a DHI effective.

PURPOSE

This narrative umbrella review aimed to identify the most effective behavior change techniques (BCTs) in DHIs that address the prevention or management of NCDs.

METHODS

Five electronic databases were searched for articles published in English between January 2007 and December 2022. Studies were included if they were systematic reviews or meta-analyses of DHIs targeting the modification of one or more NCD-related risk factors in adults. BCTs were coded using the Behavior Change Technique Taxonomy v1. Study quality was assessed using AMSTAR 2.

RESULTS

Eighty-five articles, spanning 12 health domains and comprising over 865,000 individual participants, were included in the review. We found evidence that DHIs are effective in improving health outcomes for patients with cardiovascular disease, cancer, type 2 diabetes, and asthma, and health-related behaviors including physical activity, sedentary behavior, diet, weight management, medication adherence, and abstinence from substance use. There was strong evidence to suggest that credible source, social support, prompts and cues, graded tasks, goals and planning, feedback and monitoring, human coaching and personalization components increase the effectiveness of DHIs targeting the prevention and management of NCDs.

CONCLUSIONS

This review identifies the most common and effective BCTs used in DHIs, which warrant prioritization for integration into future interventions. These findings are critical for the future development and upscaling of DHIs and should inform best practice guidelines.

Drive Time to Addiction Treatment Facilities Providing Contingency Management across Rural and Urban Census Tracts in 6 US States

OBJECTIVE

We examined drive times to outpatient substance use disorder treatment providers that provide contingency management (CM) and those that integrate CM with medication for opioid use disorder (MOUD) services in 6 US states.

METHODS

We completed cross-sectional geospatial analysis among census tracts in Delaware, Louisiana, Massachusetts, North Carolina, New York, and West Virginia. We excluded census tracts with a population of zero. Using data from the 2020 Shatterproof substance use treatment facility survey, our outcome was the minimum drive time in minutes from the census tract mean center of population to the nearest outpatient CM provider, outpatient CM provider with MOUD services, and federally qualified health centers (FQHC). We stratified census tracts by 2010 Rural-Urban Commuting Area codes and by state.

RESULTS

The population was greater than zero in 11,719 of 11,899 census tracts. The median drive time to the nearest CM provider was 12.2 [interquartile range (IQR), 7.0-23.5) minutes and the median drive time to the nearest CM provider increased from 9.7 (IQR, 6.0-15.0) minutes in urban census tracts to 38.8 (IQR, 25.4-53.0) minutes in rural ( H = 3683, P < 0.001). The median drive time increased to the nearest CM provider with MOUD services [14.2 (IQR, 7.9-29.5) minutes, W = 18,877, P < 0.001] and decreased to the nearest FQHC [7.9 (IQR, 4.3-13.6) minutes, W = 11,555,894, P < 0.001].

CONCLUSIONS

These results suggest limited availability of CM, particularly within rural communities and for patients needing concurrent CM and MOUD treatment. Our results suggest greater adoption of CM within FQHCs could reduce urban-rural disparities in CM availability.

A Preliminary Evaluation of the Effects of a Contingency Management + Deposit Contract Intervention on Problematic Smartphone Use With College Students

Problematic smartphone use (PSU) is smartphone usage that is, in some way, damaging to the user. PSU represents a growing public health concern that could be addressed via behavioral intervention. We recruited six college students who reported negative side effects of smartphone use and sought to decrease their PSU. The effects of a contingency management (CM) + deposit contract intervention on PSU was evaluated. During the CM + deposit contract condition, participants deposited $40 and had the opportunity to earn back their entire deposit by meeting daily smartphone usage goals. To promote adherence to study protocols, participants also had the opportunity to earn a $20 cooperation bonus. For all participants, lower levels of PSU were observed during intervention relative to baseline. The CM + deposit contract intervention produced consistent decreases in PSU for four participants (mean reduction percentages above 40% were obtained) and had inconsistent effects on PSU for two participants (mean reduction percentages below 20%). Maintenance of intervention effects was limited for all participants. Although preliminary, results suggest that CM + deposit contract interventions could be a viable, low-cost approach to addressing PSU. Potential explanations for our findings and avenues for future research are discussed.

A qualitative exploration of patients' experience of mobile telephone-delivered contingency management to promote adherence to supervised methadone

INTRODUCTION

Despite an increasing evidence base for mobile telephone-delivered contingency management (mCM), there had been no previous qualitative exploration of patients' experience of receiving mCM and the factors that might influence that experience and outcome in a UK setting. The aim of this study was to understand patients' views and experience of receiving mCM by exploring their beliefs, expectations and perceived benefits within the context of the UK's first mCM intervention.

METHODS

Qualitative interviews (N = 15) were conducted with patients undergoing opioid agonist treatment in a UK drug treatment service and receiving mCM to encourage adherence with supervised methadone as part of an existing study. Interviews were conducted at two time points and analysed using Framework to explore patients' expectations and beliefs during the early stage of the intervention (2 weeks) and their perceived benefits and experience at the end of the intervention (12 weeks).

RESULTS

The mCM was perceived as a motivator, providing validation of achievement, and involving discreet and positive interactions. Perceived benefits included enhanced methadone adherence, reduced drug use and the development of a supportive and non-judgemental connection that resembled a therapeutic alliance.

DISCUSSION AND CONCLUSIONS

The mechanisms underpinning contingency management appeared to operate in the absence of human interaction, and the mCM intervention was deemed to be meaningful, acceptable and well received by patients. These findings not only provide support for the application of mCM in this context but also offer insight into the factors that influence outcomes and should be considered in the development of future mCM interventions.

Increasing Use of Video Telehealth Among Veterans Experiencing Homelessness with Substance Use Disorder: Design of A Peer-Led Intervention

Telehealth offers promising opportunities, but also challenges, for veterans experiencing homelessness - during the COVID-19 pandemic and beyond. Recent research found low utilization of clinical video visits among homeless veterans receiving a VA tablet, and having a substance use disorder (SUD) further reduced visit likelihood. Hence, this study sought to identify unique barriers to telehealth use among veterans experiencing homelessness with a SUD and design an intervention to promote adoption. This qualitative study was guided by the Unified Theory of Acceptance and Use of Technology (UTAUT) model. The study's three phases included veteran interviews (N = 28) to identify barriers and facilitators to video telehealth use and propose intervention candidates, a provider expert panel to obtain feedback on interventions, and a focus group with veterans to complete the intervention. Finally, a prototype was designed using the intervention mapping approach. Veteran interviews revealed that barriers to video telehealth included complex physical and mental health issues, lack of digital literacy, and insufficient technical support. Together, veterans and experts proposed five intervention candidates. In the end, a veteran focus group combined two candidates, peer-led digital training and motivational interviewing. Intervention mapping was used to design a "stepped care" intervention that trains and activates veterans at all skill levels. This study demonstrates how inclusion of expert and veteran views led to development of a novel intervention to support and sustain video telehealth use among veterans experiencing homeless with SUD.

Client Views of Contingency Management in Gambling Treatment: A Thematic Analysis

Low levels of treatment access and poor retention among those with gambling problems suggests a need to improve treatment. Contingency management (CM) is a behavioural intervention involving the identification of target behaviours and the provision of incentives when targets are met. There exists a substantial evidence base for CM increasing abstinence and attendance in substance misuse treatment, but this has not been widely extended to gambling treatment setting. This study sought to explore the views of clients about CM for the treatment of problematic and disordered gambling. We conducted semi-structured interviews with 25 gambling treatment clients who were, or had previously been, engaged in treatment in Great Britain. Participants were provided with an explanation of CM, two hypothetical scenarios, and two structured questionnaires to facilitate discussion. Thematic analysis was used to interpret findings. Some participants felt that clients could manipulate CM while in treatment to obtain money to gamble, and that mechanisms of CM could trigger recovering clients into relapse. Participants also identified potential benefits of CM to achieve treatment goals, by enhancing motivation and engagement while in treatment, and helping bring people into treatment earlier. Gambling treatment clients broadly supported the use of incentives for treatment. CM is seen as a facilitator of extended engagement in treatment, and an encouragement for clients to make progress in the treatment process.

Practical Technology for Expanding and Improving Substance Use Disorder Treatment: Telehealth, Remote Monitoring, and Digital Health Interventions

The US opioid crisis and the COVID-19 pandemic have sparked innovation in substance use disorder (SUD) treatment such that telehealth, remote monitoring, and digital health interventions are increasingly feasible and effective. These technologies can increase SUD treatment access and acceptability, even for nontreatment seeking, remote, and underserved populations, and can be used to reduce health disparities. Overall, digital tools will likely overcome many barriers to delivery of evidence-based behavioral treatments such as cognitive behavioral therapy and contingency management, that, along with appropriate medications, constitute the foundation of treatment of SUDs.

Could COVID expand the future of addiction research? Long-term implications in the pandemic era

BACKGROUND/AIMS

The COVID-19 pandemic has significantly impacted face-to-face research. This has propelled ideas and plans for more remote styles of research and provided new perspectives on conducting research. This paper aimed to identify challenges specific to conducting remote forms of experimental addiction research, although some of these challenges apply to all types of addiction research.

ARGUMENT

The impact of the COVID-19 pandemic has led to important lessons for future addiction research. Although remote research has been conducted for decades, little experimental research has been performed remotely. To do so require a new perspective on what research questions we can ask and could also enable preferential capture of those who may be more reluctant to engage in research based in clinical settings. There may, however, be crucial factors that will compromise this process. We illustrate our argument with three real-world, ongoing case studies centred on gambling behaviour, opioid overdose, and cannabinoid psychopharmacology. We highlight the obstacles to overcome to enable more remote methods of study.

CONCLUSIONS

The future of experimental research and, more generally, addiction research, will be shaped by the pandemic and may result in advantages, such as reaching different populations and conducting addiction research in more naturalistic settings.

Homelessness and health-related outcomes: an umbrella review of observational studies and randomized controlled trials

BACKGROUND

Homelessness has been associated with multiple detrimental health outcomes across observational studies. However, relatively few randomized controlled trials (RCTs) have been conducted on people who experience homelessness (PEH). Thus, this umbrella review ranked the credibility of evidence derived from systematic reviews (SRs) and meta-analyses (MAs) of observational studies investigating the associations between homelessness and any health outcome as well as RCTs targeting health needs in this population.

METHODS

Several databases were systematically searched from inception through April 28, 2021. Any SR and/or MA reporting quantitative data and providing a control group were eligible for inclusion. The credibility of the evidence derived from observational studies was appraised by considering the significance level of the association and the largest study, the degree of heterogeneity, the presence of small-study effects as well as excess significance bias. The credibility of evidence was then ranked in five classes. For SRs and/or MAs of RCTs, we considered the level of significance and whether the prediction interval crossed the null. The AMSTAR-2 and AMSTAR-plus instruments were adopted to further assess the methodological quality of SRs and/or MAs. The Newcastle-Ottawa Scale (NOS) was employed to further appraise the methodological quality of prospective cohort studies only; a sensitivity analysis limited to higher quality studies was conducted.

RESULTS

Out of 1549 references, 8 MAs and 2 SRs were included. Among those considering observational studies, 23 unique associations were appraised. Twelve of them were statistically significant at the p≤0.005 level. Included cases had worst health-related outcomes than controls, but only two associations reached a priori-defined criteria for convincing (class I) evidence namely hospitalization due to any cause among PEH diagnosed with HIV infection, and the occurrence of falls within the past year among PEH. According to the AMSTAR-2 instrument, the methodological quality of all included SRs and/or MAs was "critically low." Interventional studies were scant.

CONCLUSION

While homelessness has been repeatedly associated with detrimental health outcomes, only two associations met the criteria for convincing evidence. Furthermore, few RCTs were appraised by SRs and/or MAs. Our umbrella review also highlights the need to standardize definitions of homelessness to be incorporated by forthcoming studies to improve the external validity of the findings in this vulnerable population.

Global, regional, and national cancer deaths and disability-adjusted life-years (DALYs) attributable to alcohol consumption in 204 countries and territories, 1990-2019

BACKGROUND

Alcohol consumption is a risk factor for a number of communicable and non-communicable diseases, including several types of cancer. This article reports the burden of cancers attributable to alcohol consumption by age, sex, location, sociodemographic index (SDI), and cancer type from 1990 to 2019.

METHODS

The Comparative Risk Assessment approach was used in the 2019 Global Burden of Disease study to report the burden of cancers attributable to alcohol consumption between 1990 and 2019.

RESULTS

In 2019, there were globally an estimated 494.7 thousand cancer deaths (95% uncertainty interval [UI], 439.7 to 554.1) and 13.0 million cancer disability-adjusted life-years (DALYs; 95% UI, 11.6 to 14.5) that were attributable to alcohol consumption. The alcohol-attributable DALYs were much higher in men (10.5 million; 95% UI, 9.2 to 11.8) than women (2.5 million; 95% UI, 2.2 to 2.9). The global age-standardized death and DALY rates of cancers attributable to alcohol decreased by 14.7% (95% UI, 6.4% to 23%) and 18.1% (95% UI, 9.2% to 26.5%), respectively, over the study period. Central Europe had the highest age-standardized death rates that were attributable to alcohol consumption(10.3; 95% UI, 8.7 to12.0). Moreover, there was an overall positive association between SDI and the regional age-standardized DALY rate for alcohol-attributable cancers.

CONCLUSIONS

Despite decreases in age-standardized deaths and DALYs, substantial numbers of cancer deaths and DALYs are still attributable to alcohol consumption. Because there is a higher burden in males, the elderly, and developed regions (based on SDI), these groups and regions should be prioritized in any prevention programs.

Technology-based contingency management for walking to prevent prolonged periods of workday sitting

Sedentary behavior is an emerging public health issue. Frequent, brief bouts of walking are recommended by experts to reduce the health risks correlated with physical inactivity and prolonged sedentary periods. The purpose of the current study was to extend the literature by evaluating a remote, technology-based contingency management (CM) intervention that reinforced frequent, brief bouts of walking to decrease prolonged periods of sitting during the workday. A packaged intervention consisting of a contingency contract, monetary incentives, goal setting, textual prompts, and performance feedback was implemented with individuals with sedentary job responsibilities working from home during the COVID-19 pandemic. The intervention increased the number of physically active intervals to mastery for 4 participants, thereby disrupting prolonged periods of sedentary time. For 2 participants, the intervention did not meaningfully increase the number of physically active intervals. Results suggest that a remote, digital CM intervention can decrease sedentary behavior in home office environments.

A pilot feasibility study of a behavioral intervention for nicotine vaping cessation among young adults delivered via telehealth

BACKGROUND

Nicotine vaping among youth has increased, warranting concern from tobacco control proponents. Many youth who vape indicate interest in quitting; however, few empirically supported vaping cessation interventions exist. This pilot feasibility study adapted an established behavioral intervention, contingency management (CM), delivered via telehealth to promote vaping cessation among young adults.

METHODS

Participants (N = 27; ages 17-21) vaping nicotine regularly were recruited via social media and digital advertisements from across the US (June 2020-January 2021). Participants were randomized at approximately 4:1 to CM or Monitoring control (22:5). CM was delivered through DynamiCare Health's smartphone app for 4 weeks, in which financial incentives were delivered contingent on abstinent cotinine samples after the quit day until the end of treatment (EOT; Days 7-28; 10 expected submissions). Control participants earned incentives for submitting cotinine, regardless of abstinence. Feasibility, acceptability, and abstinence was collected throughout treatment, at EOT, and at 1-month follow-up.

RESULTS

The majority of enrolled participants completed treatment (Monitoring: 5/5; CM: 20/22), and intervention components were rated favorably overall (> 80%). CM participants submitted 112/220 (55%) abstinent cotinine samples throughout the quit attempt, while the Monitoring group submitted 4/50 (8%) negative samples. There were no differences in abstinence between groups at EOT or follow-up.

CONCLUSION

This pilot study of a telehealth-based youth vaping cessation intervention demonstrated preliminary feasibility and acceptability. These results suggest that CM for young adult vaping cessation, delivered remotely, is a promising direction for future work and fully powered trials are warranted to assess intervention efficacy.

New Directions for Motivational Incentive Interventions for Smoking Cessation

Background

Motivational incentive interventions are highly effective for smoking cessation. Yet, these interventions are not widely available to people who want to quit smoking, in part, due to barriers such as administrative burden, concern about the use of extrinsic reinforcement (i.e., incentives) to improve cessation outcomes, suboptimal intervention engagement, individual burden, and up-front costs.

Purpose

Technological advancements can mitigate some of these barriers. For example, mobile abstinence monitoring and digital, automated incentive delivery have the potential to lower the clinic burden associated with monitoring abstinence and administering incentives while also reducing the frequency of clinic visits. However, to fully realize the potential of digital technologies to deliver motivational incentives it is critical to develop strategies to mitigate longstanding concerns that reliance on extrinsic monetary reinforcement may hamper internal motivation for cessation, improve individual engagement with the intervention, and address scalability limitations due to the up-front cost of monetary incentives. Herein, we describe the state of digitally-delivered motivational incentives. We then build on existing principles for creating just-in-time adaptive interventions to highlight new directions in leveraging digital technology to improve the effectiveness and scalability of motivational incentive interventions.

Conclusions

Technological advancement in abstinence monitoring coupled with digital delivery of reinforcers has made the use of motivational incentives for smoking cessation increasingly feasible. We propose future directions for a new era of motivational incentive interventions that leverage technology to integrate monetary and non-monetary incentives in a way that addresses the changing needs of individuals as they unfold in real-time.

Volunteer Recovery Support for Adolescents: Using propensity score based methods to understand dosage effects within a randomized controlled trial

BACKGROUND

In a recently published randomized controlled trial (RCT) of Volunteer Recovery Support for Adolescents (VRSA), a secondary finding indicated that better adherence to planned VRSA telephone session frequency resulted in significantly higher remission rates relative to lower session adherence. However, interpretation of this dose-response relationship may have been confounded by participant characteristics such as baseline levels of substance use and mental health problems.

METHODS

The present study used statistical methods designed to approximate RCTs when comparing more than two nonequivalent groups that include an assessment of the potential impact of omitted variables. Classification and Regression Tree (CRT) analysis was used to establish the cut-point between high (H) and low (L) VRSA dosage groups. Because we were interested in generalizing to youth with poor attendance, the L-VRSA group served as the reference group. Balancing weights for H-VRSA and a services as usual (SAU) control group were calculated to ensure similarity of baseline pretreatment characteristics to the reference group, and sensitivity of findings to unobserved confounding variables was assessed.

RESULTS

Findings suggested that superior remission rates at the end of the intervention phase were the result of high adherence to planned VRSA session frequency. Recommendations to achieve high VRSA participation among a larger segment of youth and to test whether longer VRSA duration improves the stability of recovery outcomes are provided.

CONCLUSION

Few published dose-response studies have adequately controlled for selection confounds from both observed and unobserved confounding. As such, the present study aims to both assess the impact of different dosage levels of VRSA and provide a template for how to apply state-of-the-art statistical methods designed to approximate randomized controlled trials to such studies.

A Scoping Review of Opioid Use Disorder Treatment Barriers and Telehealth for African Americans with Disabilities in Rural Communities

This article provided a comprehensive overview of challenges that African Americans with disabilities residing in rural areas often face in the United States when accessing telehealth treatment to mitigate opioid misuse. A scoping literature review was conducted focusing on this target population, telehealth, disabilities, opioid treatment, and rural healthcare systems. Systematic searches on eight electronic databases were carried out in line with the study's aims. The results identified treatment benefits and advantages, expansion challenges, and multicultural considerations for telehealth delivery. There may be a need to increase rehabilitation research in this area to inform needed changes in policies and practice.

Pilot Cohorts for Development of Concurrent Mobile Treatment for Alcohol and Tobacco Use Disorders

Alcohol and tobacco are the 2 most frequently used drugs in the United States and represent the highest co-occurrence of polysubstance use. The objective of this study was to refine an intervention combining mobile contingency management with cognitive-behavioral telephone counseling for concurrent treatment of alcohol and tobacco use disorders. Two cohorts (n = 13 total, n = 5 women) of participants were enrolled, with 10/13 completing treatment and 7/13 completing the 6-month follow-up. At enrollment, participants were drinking a mean of 28.9 drinks per week (SD = 14.1), with a mean of 14.7 heavy drinking days in the past month (SD = 9.9), and a mean of 18.1 cigarettes per day (SD = 11.7). Treatment included a mobile application that participants used to record carbon monoxide and breath alcohol content readings to bioverify abstinence. Participants received up to 4 sessions of phone cognitive-behavioral therapy and monetary reinforcement contingent on abstinence. In cohort 1, 4/6 participants reported abstinent or low-risk drinking post-monitoring. Six weeks post quit-date, 2/6 participants were CO-bioverified abstinent from tobacco use, with 2/6 in dual remission. These results were maintained at 6-months. In cohort 2, 6/7 reported abstinent or low-risk drinking post-monitoring, 5 weeks post quit-date. At the post-monitoring visit, 5/7 were CO-bioverified abstinent from smoking, with 5/7 in dual remission. At 6-months, 3/7 reporting abstinent or low-risk drinking, 1/7 had bioverified abstinence from smoking, with 1/7 in dual remission. Observations suggest that it is possible to develop a concurrent mobile treatment for alcohol and tobacco use disorders.

Challenges to Conducting Contingency Management Treatment for Substance Use Disorders: Practice Recommendations for Clinicians

A growing empirical literature supports contingency management (CM) as an efficacious treatment for substance use disorders, especially when reinforcers are immediate, frequent, and of sufficient magnitude on escalating schedules. However, in real world-practice, CM is often conducted in ways that are inconsistent with research protocols. One reason for these inconsistencies may be due to pragmatic challenges inherent in conducting CM. In this article, we described an outpatient CM treatment program for drug use disorders and several specific challenges associated with adherence to CM parameters from research protocols. Finally, we propose possible solutions for these challenges and discuss implications for practice.

Remotely delivered incentives to promote buprenorphine treatment engagement in out-of-treatment adults with opioid use disorder

BACKGROUND

Opioid overdose remains a leading cause of death. Office-based buprenorphine could expand access to treatment to the many opioid users who are not in treatment and who are at risk for opioid overdose. However, many people in need of buprenorphine treatment do not enroll in treatment. This randomized pilot trial evaluated efficacy of a remotely delivered incentive intervention in promoting engagement in buprenorphine treatment in out-of-treatment adults with opioid use disorder.

METHODS

Participants (N = 41) were offered referrals to buprenorphine treatment and randomly assigned to Control or Incentive groups for 6 months. Incentive participants were offered incentives for enrolling in buprenorphine treatment, verified by providing documentation showing that they received a buprenorphine prescription, and providing videos taking daily buprenorphine doses. Participants used a smartphone application to record and submit a video of their buprenorphine prescription and daily buprenorphine administration. Incentive earnings were added remotely to reloadable credit cards.

RESULTS

Incentive participants were significantly more likely to enroll in treatment compared to control participants (71.4 % versus 30.0 % of participants; OR [95 % CI]: 6.24 [1.46-26.72], p = .014). Few participants in either group adhered to buprenorphine treatment, and the two groups continued to use opioids, including fentanyl at high and comparable rates. The two groups did not differ in the percentage of urine samples that were positive for buprenorphine, opiates, fentanyl, or methadone at monthly assessments conducted during the 6-month intervention.

CONCLUSIONS

Remotely delivered incentives can connect out-of-treatment adults with opioid use disorder to treatment, but additional supports are needed to promote buprenorphine adherence.

Digital delivery of a contingency management intervention for substance use disorder: A feasibility study with DynamiCare Health

Digital health tools can provide convenient delivery of evidence-based treatments. The DynamiCare Health smartphone app delivers a contingency management intervention for substance use disorder consisting of remote self-testing for alcohol (breath) and drugs (saliva) with remote test validation and delivery of financial incentives for negative test results. This study examined feasibility, engagement (duration and consistency of app utilization), and impact on usual care treatment participation when a community substance use treatment program implemented this digital therapy among its patients. The study randomly assigned patients with alcohol use disorder (N = 61) to receive either DynamiCare along with treatment-as-usual (TAU; N = 29) or TAU only (N = 32) during a 90-day evaluation period. Mean duration between first and last app use was 64 (±35) days, with mean earnings of $248 (±$209, out of $600 maximum). Among those with any app use (n = 25), compliance was 68% and 74%, respectively for requested breath and saliva samples. Overall, two thirds of patients (66%) assigned to the app used it for at least 57 days and with high rates of self-testing compliance. Those completing the assessment (n = 13; 45% of sample) endorsed high satisfaction ratings. DynamiCare versus TAU participants were more likely to be retained in usual care treatment at 90 days (24% vs 3%; (χ2 (1, 61) = 5.9, p < 0.05), but sustained app utilization was associated with a wide range of usual care treatment participation. These data suggest that DynamiCare Health is feasible and potentially beneficial as a complement to community substance use treatment programs.

Patients' beliefs towards contingency management: Target behaviours, incentives and the remote application of these interventions

INTRODUCTION

Contingency management interventions are among the most efficacious psychosocial interventions in promoting abstinence from smoking, alcohol and substance use. The aim of this study was to assess the beliefs and objections towards contingency management among patients in UK-based drug and alcohol services to help understand barriers to uptake and support the development and implementation of these interventions.

METHODS

The Service User Survey of Incentives was developed and implemented among patients (N = 181) at three UK-based drug and alcohol treatment services. Descriptive analyses were conducted to ascertain positive and negative beliefs about contingency management, acceptability of different target behaviours, incentives and delivery mechanisms including delivering incentives remotely using technology devices such as mobile telephones.

RESULTS

Overall, 81% of participants were in favour of incentive programs, with more than 70% of respondents agreeing with the majority of positive belief statements. With the exception of two survey items, less than a third of participants agreed with negative belief statements. The proportion of participants indicating a neutral response was higher for negative statements (27%) indicating greater levels of ambiguity towards objections and concerns regarding contingency management.

DISCUSSION AND CONCLUSIONS

Positive beliefs towards contingency management interventions were found, including high levels of acceptability towards a range of target behaviours, incentives and the use of technology devices to remotely monitor behaviour and deliver incentives. These findings have implications for the development and implementation of remote contingency management interventions within the UK drug treatment services.

Mobile telephone delivered contingency management for encouraging adherence to supervised methadone consumption: feasibility study for an RCT of clinical and cost-effectiveness (TIES)

BACKGROUND

Prescription methadone or buprenorphine enables people with opioid use disorder to stop heroin use safely while avoiding withdrawal. To ensure methadone is taken as prescribed and to prevent diversion onto the illicit market, people starting methadone take their daily dose under a pharmacist's supervision. Many patients miss their daily methadone dose risking withdrawal, craving for heroin and overdose due to loss of heroin tolerance. Contingency management (CM) can improve medication adherence, but remote delivery using technology may be resource-light and cost-effective. We developed an innovative way to deliver CM by mobile telephone. Software monitors patients' attendance and supervised methadone consumption through an internet self-login at the pharmacy and sends reinforcing text messages to patients' mobile telephones. A linked system sends medication adherence reports to prescribers and provides early warning alerts of missed doses. A pre-paid debit card system provides financial incentives.

METHODS

A cluster randomised controlled trial design was used to test the feasibility of conducting a future trial of mobile telephone CM to encourage adherence to supervised methadone in community pharmacies. Each cluster (drug service/3 allied pharmacies) was randomly allocated to provide patient's presenting for a new episode of opiate agonist treatment (OAT) with either (a) mobile telephone text message CM, (b) mobile telephone text message reminders, or (c) no text messages. We assessed acceptability of the interventions, recruitment, and follow-up procedures.

RESULTS

Four drug clinics were approached and three recruited. Thirty-three pharmacists were approached and 9 recruited. Over 3 months, 173 individuals were screened and 10 enrolled. Few patients presented for OAT and high numbers were excluded due to receiving buprenorphine or not attending participating pharmacies. There was 96% consistency in recording medication adherence by self-login vs. pharmacy records. In focus groups, CM participants were positive about using self-login, the text messages, and debit card. Prescribers found weekly reporting, time saving, and allowed closer monitoring of patients. Pharmacists reported that the tablet device was easy to host.

CONCLUSION

Mobile telephone CM worked well, but a planned future trial will use modified eligibility criteria (existing OAT patients who regularly miss their methadone/buprenorphine doses) and increase the number of participating pharmacies.

TRIAL REGISTRATION

The trial is retrospectively registered, ISRCTN 58958179 .

Adaptation of contingency management for stimulant use disorder during the COVID-19 pandemic

The current coronavirus disease (COVID-19) pandemic has rapidly spread across the world. Individuals with stimulant use disorder are a vulnerable population, who are particularly at risk of negative outcomes during this pandemic due to several risk factors, including mental and physical comorbidities, weakened immune responses, high-risk behaviors, and barriers to healthcare access. Engaging patients with stimulant use disorder in regular treatment has become even more difficult during this pandemic, which has resulted in many cuts to addiction treatment programs. The most effective treatment options for stimulant use disorder are psychosocial interventions, which rely heavily on in-person interactions, posing an added challenge during physical distancing. In particular, contingency management (CM) is a behavioral therapy that utilizes tangible reinforcements to incentivize targeted behavior changes, and is an effective treatment intervention used for stimulant use disorder. This paper highlights the treatment challenges for individuals with stimulant use disorder and the importance of adapting CM programs during COVID-19. We present strategies for how CM can be adapted and its role expanded in a safe way during the COVID-19 pandemic to help prevent infection spread, stimulant use relapse, and worsened psychosocial consequences.

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Stimulant users face increased risk of relapse and infection during a pandemic.

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Contingency management is an effective treatment for stimulant use disorder.

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Contingency management can be adapted to mitigate negative outcomes of COVID-19.

A randomized clinical trial of smartphone self-managed recovery support services

This study examines the effectiveness of smartphone-based ecological momentary interventions (EMI) and assessments (EMA), delivered separately and combined, to provide recovery support following substance use disorder (SUD) treatment engagement. We recruited adults (N = 401) from SUD treatment programs in Chicago and, after engagement for at least two sessions, nights, or medication dosages, we randomly assigned them to one of four conditions that lasted 6 months: (1) EMI only, (2) EMA only, (3) both EMI and EMA, and (4) control condition of neither EMI nor EMA. EMIs provided support for recovery through applications on the phone or links to other resources; EMAs were delivered randomly 5 times per day asking participants to indicate recent substance use and situational risk and protective factors. The primary dependent variable was days of abstinence in the 6 months following study intake. Rates of EMI and EMA utilization indicated high compliance, although EMI use decreased over time. There was a small direct effect of time across conditions (F_(2,734) = 4.33, p = .014, Cohen's f = 0.11) and a small direct effect of time-by-EMI use (F_(2,734) = 4.85, p = .009, f = 0.11) on days of abstinence. There was no significant direct effect of time-by-EMAs nor interaction effect of time-by-EMI-by-EMA. However, secondary path model analyses showed a small but significant indirect effect of EMA on abstinence via EMI use. Stepwise modeling identified a simplified model based on the proportion of weeks using ≥1 EMI and the EMI to listen to music, which predicted 7.2% of the variance in days of abstinence (F_(2,195,) = 7.56, p < .001). Combined delivery of EMI and EMA shows potential for increasing abstinence above and beyond the effect of SUD treatment engagement and for addressing the limited national capacity for recovery support.

The application of digital health to the assessment and treatment of substance use disorders: The past, current, and future role of the National Drug Abuse Treatment Clinical Trials Network

The application of digital technologies to better assess, understand, and treat substance use disorders (SUDs) is a particularly promising and vibrant area of scientific research. The National Drug Abuse Treatment Clinical Trials Network (CTN), launched in 1999 by the U.S. National Institute on Drug Abuse, has supported a growing line of research that leverages digital technologies to glean new insights into SUDs and provide science-based therapeutic tools to a diverse array of persons with SUDs. This manuscript provides an overview of the breadth and impact of research conducted in the realm of digital health within the CTN. This work has included the CTN's efforts to systematically embed digital screeners for SUDs into general medical settings to impact care models across the nation. This work has also included a pivotal multi-site clinical trial conducted on the CTN platform, whose data led to the very first "prescription digital therapeutic" authorized by the U.S. Food and Drug Administration (FDA) for the treatment of SUDs. Further CTN research includes the study of telehealth to increase capacity for science-based SUD treatment in rural and under-resourced communities. In addition, the CTN has supported an assessment of the feasibility of detecting cocaine-taking behavior via smartwatch sensing. And, the CTN has supported the conduct of clinical trials entirely online (including the recruitment of national and hard-to-reach/under-served participant samples online, with remote intervention delivery and data collection). Further, the CTN is supporting innovative work focused on the use of digital health technologies and data analytics to identify digital biomarkers and understand the clinical trajectories of individuals receiving medications for opioid use disorder (OUD). This manuscript concludes by outlining the many potential future opportunities to leverage the unique national CTN research network to scale-up the science on digital health to examine optimal strategies to increase the reach of science-based SUD service delivery models both within and outside of healthcare.

Telephone delivered incentives for encouraging adherence to supervised methadone consumption (TIES): Study protocol for a feasibility study for an RCT of clinical and cost effectiveness

The majority of people receiving treatment for their heroin addiction, are prescribed methadone; for which there is an extensive evidence base. When treatment starts, people take their daily dose of methadone under supervision at a community pharmacy. Supervision guarantees methadone is taken as directed by the individual for whom it has been prescribed, helps to ensure individuals take their correct dose every day, and safeguards against diversion and overdose. However, individuals often fail to attend the pharmacy to take their methadone. Each missed dose is of concern. If a patient misses their daily dose of methadone, they will start to experience opiate withdrawal and cravings and are more likely to use heroin. If they miss three days dose, there are concerns that they may lose tolerance to the drug and may be at risk of overdose when the next dose is taken. Hence there is an urgent need to develop effective interventions for medication adherence. Research suggests that incentive-based medication adherence interventions may be very effective, but there are few controlled trials and the provision of incentives requires time and organisational systems which can be challenging in pharmacies. The investigators have developed the technology to deliver incentives by mobile telephone. This cluster randomised trial will test the feasibility of conducting a future trial evaluating the clinical and cost effectiveness of using telephone delivered incentives (praise and modest financial rewards via text messaging) to encourage adherence with supervised consumption of methadone in community pharmacies. Three drug services (each with two or three community pharmacies supervising methadone consumption that will enrol 20 individuals, a total of 60 participants) will be recruited and randomly allocated to deliver either i) telephone delivered incentives, ii) telephone delivered reminders or iii) no telephone system. Acceptability, recruitment, follow-up, and suitable measures of clinical and cost effectiveness will be assessed. Findings from this feasibility study will be assessed against stated progression criteria and used to inform a future confirmatory trial of the clinical and cost effectiveness of telephone delivered incentives to encourage medication adherence.

Trial registration

ISRCTN58958179 (retrospectively registered).

Mobile telephone-delivered contingency management interventions promoting behaviour change in individuals with substance use disorders: a meta-analysis

BACKGROUND/AIMS

Contingency management (CM) interventions have gained considerable interest due to their success in the treatment of addiction. However, their implementation can be resource-intensive for clinical staff. Mobile telephone-based systems might offer a low-cost alternative. This approach could facilitate remote monitoring of behaviour and delivery of the reinforcer and minimize issues of staffing and resources. This systematic review and meta-analysis assessed the evidence for the effectiveness of mobile telephone-delivered CM interventions to promote abstinence (from drugs, alcohol and tobacco), medication adherence and treatment engagement among individuals with substance use disorders.

DESIGN

A systematic search of databases (PsychINFO, CINAHL, MEDLINE PubMed, CENTRAL, Embase) for randomized controlled trials and within-subject design studies (1995-2019). The review was conducted in accordance with the PRISMA statement. The protocol was registered on PROSPERO.

SETTING

All included studies originated in the United states.

PARTICIPANTS

Seven studies were found, including 222 participants; two targeted alcohol abstinence among frequent drinkers and four targeted smoking cessation (in homeless veterans and those with post-traumatic stress disorder). One targeted medication adherence.

MEASURES

The efficacy of CM to increase alcohol and nicotine abstinence was compared with control using several outcomes; percentage of negative samples (PNS), quit rate (QR) and longest duration abstinent (LDA) at the end of the intervention.

FINDINGS

The random-effects meta-analyses produced pooled effect sizes of; PNS [d = 0.94, 95% confidence interval (CI) = 0.63-1.25], LDA (d = 1.08, 95% CI = 0.69-1.46) and QR (d = 0.46, 95% CI = 0.27-0.66), demonstrating better outcomes across the CM conditions. Most of the studies were rated as of moderate quality. 'Fail-safe N' computations for PNS indicated that 50 studies would be needed to produce a non-significant overall effect size. None could be calculated for QR and LDA due to insufficient number of studies.

CONCLUSION

Mobile telephone-delivered contingency management performs significantly better than control conditions in reducing tobacco and alcohol use among adults not in treatment for substance use disorders.