Randomized controlled trial of contingency management for stimulant use in community mental health patients with serious mental illness

Psychosocial Interventions for Individuals With Comorbid Psychosis and Substance Use Disorders: Systematic Review and Meta-analysis of Randomized Studies

BACKGROUND AND HYPOTHESIS

Substance use is highly prevalent among people with schizophrenia (SCZ) and related disorders, however, there is no broad-spectrum pharmacotherapy that concurrently addresses both addiction and psychotic symptoms. Psychosocial (PS) interventions, which have yielded promising results in treating psychosis and substance dependence separately, demonstrate potential but have not been systematically evaluated when combined.

STUDY DESIGN

Systematic review and random-effects meta-analyses of randomized controlled trials (RCTs) investigating PS interventions for individuals with comorbid substance use and psychotic disorders, encompassing SCZ and schizophrenia spectrum disorders (SSD). We included relevant studies published from MEDLINE, PsycINFO, and Google Scholar through May 2023.

STUDY RESULTS

We included 35 RCTs (5176 participants total; approximately 2840 with SSD). Intervention durations ranged from 30 min to 3 years. Meta-analysis did not identify a statistically significant pooled PS intervention effect on the main primary outcome, substance use (18 studies; 803 intervention, 733 control participants; standardized mean difference, -0.05 standard deviation [SD]; 95% CI, -0.16, 0.07 SD; I2 = 18%). PS intervention effects on other outcomes were also not statistically significant. Overall GRADE certainty of evidence was low.

CONCLUSIONS

At present, the literature lacks sufficient evidence supporting the use of PS interventions as opposed to alternative therapeutic approaches for significantly improving substance use, symptomatology, or functioning in people with SCZ and related disorders. However, firm conclusions were precluded by low certainty of evidence. Further RCTs are needed to determine the efficacy of PS treatments for people with dual-diagnoses (DD), either alone or in combination with pharmacotherapy.

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.

Budget Impact Tool for Implementing Contingency Management for Co-occurring Alcohol Use Disorders and Serious Mental Illness

OBJECTIVE

Contingency management (CM) is a behavioral intervention in which tangible incentives are provided to patients when they achieve a desired behavior (e.g., reducing or abstaining from alcohol use). The authors sought to describe the resource requirements and associated costs of various CM versions (usual, high magnitude, and shaping) tailored to a high-risk population with co-occurring serious mental illness and severe alcohol use disorder.

METHODS

A microcosting analysis was conducted to identify the resource requirements of the different CM versions. This approach included semistructured interviews with site investigators, who also staffed the intervention. The resource costing method-multiplying the number of units of each resource utilized by its respective unit cost-was used to value the resources from a provider's perspective. All cost estimates were calculated in 2021 U.S. dollars.

RESULTS

The cost of setting up a CM program was $6,038 per site. Assuming full capacity and 56% of urine samples meeting the requirement for receipt of the CM incentive, the average cost of 16 weeks of usual and shaping CM treatments was $1,119-$1,136 and of high-magnitude CM was $1,848-$1,865 per participant.

CONCLUSIONS

A customizable tool was created to estimate the costs associated with various levels of treatment success and CM design features. After the trial, the tool will be updated and used to finalize per-participant cost for incorporation into a comprehensive economic evaluation. This costing tool will help a growing number of treatment providers who are interested in implementing CM with budgeting for and sustaining CM in their practices.

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.

Cluster analysis in gambling disorder based on sociodemographic, neuropsychological, and neuroendocrine features regulating energy homeostasis

BACKGROUND

The heterogeneity of gambling disorder (GD) has led to the identification of different subtypes, mostly including phenotypic features, with distinctive implications on the GD severity and treatment outcome. However, clustering analyses based on potential endophenotypic features, such as neuropsychological and neuroendocrine factors, are scarce so far.

AIMS

This study firstly aimed to identify empirical clusters in individuals with GD based on sociodemographic (i.e., age and sex), neuropsychological (i.e., cognitive flexibility, inhibitory control, decision making, working memory, attention, and set-shifting), and neuroendocrine factors regulating energy homeostasis (i.e., leptin, ghrelin, adiponectin, and liver-expressed antimicrobial peptide 2, LEAP-2). The second objective was to compare the profiles between clusters, considering the variables used for the clustering procedure and other different sociodemographic, clinical, and psychological features.

METHODS

297 seeking-treatment adult outpatients with GD (93.6% males, mean age of 39.58 years old) were evaluated through a semi-structured clinical interview, self-reported psychometric assessments, and a protocolized neuropsychological battery. Plasma concentrations of neuroendocrine factors were assessed in peripheral blood after an overnight fast. Agglomerative hierarchical clustering was applied using sociodemographic, neuropsychological, and neuroendocrine variables as indicators for the grouping procedure. Comparisons between the empirical groups were performed using Chi-square tests (χ2) for categorical variables, and analysis of variance (ANOVA) for quantitative measures.

RESULTS

Three-mutually-exclusive groups were obtained, being neuropsychological features those with the greatest weight in differentiating groups. The largest cluster (Cluster 1, 65.3%) was composed by younger males with strategic and online gambling preferences, scoring higher on self-reported impulsivity traits, but with a lower cognitive impairment. Cluster 2 (18.2%) and 3 (16.5%) were characterized by a significantly higher proportion of females and older patients with non-strategic gambling preferences and a worse neuropsychological performance. Particularly, Cluster 3 had the poorest neuropsychological performance, especially in cognitive flexibility, while Cluster 2 reported the poorest inhibitory control. This latter cluster was also distinguished by a poorer self-reported emotion regulation, the highest prevalence of food addiction, as well as a metabolic profile characterized by the highest mean concentrations of leptin, adiponectin, and LEAP-2.

CONCLUSIONS

To the best of our knowledge, this is the first study to identify well-differentiated GD clusters using neuropsychological and neuroendocrine features. Our findings reinforce the heterogeneous nature of the disorder and emphasize a role of potential endophenotypic features in GD subtyping. This more comprehensive characterization of GD profiles could contribute to optimize therapeutic interventions based on a medicine of precision.

The urgent need for contingency management among Tribal communities in the United States: Considerations for implementation, policy, and sovereignty

In two randomized controlled trials, culturally adapted contingency management (i.e., incentives provided for substance-negative urine samples) was associated with reduced alcohol and drug use among geographically diverse American Indian and Alaska Native (AI/AN) adults. In response to interest in contingency management from other Tribal and AI/AN communities, our research team in collaboration with AI/AN behavioral health experts, translated the research into practice with new AI/AN community partners. Tenets of community-based participatory research were applied to develop, pilot, and refine contingency management training and implementation tools, and identify implementation challenges. In partnership with the AI/AN communities, four members of the university team developed tools and identified implementation and policy strategies to increase the successful uptake of contingency management in each location. Through our collaborative work, we identified policy barriers including inadequate federal funding of contingency management incentives and a need for further clarity regarding federal anti-kickback regulations. Adoption of contingency management is feasible and can strengthen Tribal communities' capacity to deliver evidence-based substance use disorder treatments to AI/AN people. Unfortunately, non-evidence-based limits to the use of federal funding for contingency management incentives discriminate against AI/AN communities. We recommend specific federal policy reforms, as well as other practical solutions for Tribal communities interested in contingency management.

Lessons learned from statewide contingency management rollouts addressing stimulant use in the Northwestern United States

Increases in stimulant drug use (such as methamphetamine) and related deaths creates an imperative for community settings to adopt evidence-based practices to help people who use stimulants. Contingency management (CM) is a behavioral intervention with decades of research demonstrating efficacy for the treatment of stimulant use disorder, but real-world adoption has been slow, due to well-known implementation barriers, including difficulty funding reinforcers, and stigma. This paper describes the training and technical assistance (TTA) efforts and lessons learned for two state-wide stimulant-focused CM implementation projects in the Northwestern United States (Montana and Washington). A total of 154 providers from 35 community-based service sites received didactic training in CM beginning in 2021. Seventeen of these sites, ten of eleven in Montana (90.9%) and seven of 24 in Washington (29.2%), went on to implement contingency management programs adherent to their state's established CM protocol and received ongoing TTA in the form of implementation coaching calls. These findings illustrate that site-specific barriers such as logistical fit precluded implementation in more than 50% of the trained sites; however, strategies for site-specific tailoring within the required protocol aided implementation, resulting in successful CM program launch in a diverse cross-section of service sites across the states. The lessons learned add to the body of literature describing CM implementation barriers and solutions.

Effective, but underused: lessons learned implementing contingency management in real-world practice settings in the United States

Despite being one of the most effective adjunctive behavioral interventions in combination with medication for opioid use disorder, contingency management (CM) is one of the least available interventions in opioid treatment programs. This paradoxical state of affairs is perhaps the greatest example of the research-to-practice gap in the behavioral health field. Implementation science, a discipline that aims to identify replicable methods that can be used across settings and populations to bridge the gap between research and practice, can potentially help. Based on our team's experience implementing CM in opioid treatment programs, we detail five key lessons for researchers, clinicians, policy makers, and others seeking to implement and sustain CM in real-world settings. First, multiple barriers to CM implementation exist at both the counselor- and organization-levels, requiring multi-level solutions. Second, one-shot CM training alone is not sufficient for successful implementation: ongoing support is essential to achieve levels of intervention fidelity that will benefit patients. Third, assessing an organization's capacity for implementation prior to support provision can prevent costly mistakes. Fourth, implementors should plan for high staff turnover rates and expect the unexpected by developing detailed contingency plans. Finally, implementors should remember that the goal is to implement evidence-based CM and not simply incentives. We encourage colleagues to consider these lessons to increase the likelihood that CM can be implemented and sustained in a manner that improves the quality of care in opioid treatment programs.

Integrated Care Models: HIV and Substance Use

PURPOSE OF REVIEW

Behaviors and practices associated with substance use contribute to lack of HIV virologic suppression and onward transmission. In the USA, many recent HIV outbreaks have been connected with substance use. Evidence-based strategies for integrating care of those at risk for and living with HIV and who use substances continue to evolve. This review, based on scientific and medical literature through March 2023, provides an overview and evaluation of initiatives for integrated care aimed to serve patients at risk for and with HIV and a substance use disorder.

RECENT FINDINGS

Integrated care services can improve health outcomes for patients at risk for and with HIV and a substance use disorder; for instance, treatment for an opioid use disorder can help improve HIV viral suppression. Brick-and-mortar facilities can provide successful care integration with appropriate clinic leadership to support multidisciplinary care teams, up-to-date provider training, and sufficient pharmacy stock for substance use treatment. Delivering healthcare services to communities (e.g., mobile healthcare clinics and pharmacies, telehealth) may prove to be an effective way to provide integrated services for those with or at risk of HIV and substance use disorders. Incorporating technology (e.g., mobile phone applications) may facilitate integrated care. Other venues, including harm reduction programs and carceral settings, should be targets for integrated services. Venues providing healthcare should invest in integrated care and support legislation that increases access to services related to HIV and substance use.

"That Line Just Kept Moving": Motivations and Experiences of People Who Use Methamphetamine

INTRODUCTION

Methamphetamine use is on the rise with increasing emergency department (ED) visits, behavioral health crises, and deaths associated with use and overdose. Emergency clinicians describe methamphetamine use as a significant problem with high resource utilization and violence against staff, but little is known about the patient's perspective. In this study our objective was to identify the motivations for initiation and continued methamphetamine use among people who use methamphetamine and their experiences in the ED to guide future ED-based approaches.

METHODS

This was a qualitative study of adults residing in the state of Washington in 2020, who used methamphetamine in the prior 30 days, met criteria for moderate- to high-risk use, reported recently receiving care in the ED, and had phone access. Twenty individuals were recruited to complete a brief survey and semi-structured interview, which was recorded and transcribed prior to being coded. Modified grounded theory guided the analysis, and the interview guide and codebook were iteratively refined. Three investigators coded the interviews until consensus was reached. Data was collected until thematic saturation.

RESULTS

Participants described a shifting line that separates the positive attributes from the negative consequences of using methamphetamine. Many initially used methamphetamine to enhance social interactions, combat boredom, and escape difficult circumstances by numbing the senses. However, continued use regularly led to isolation, ED visits for the medical and psychological sequelae of methamphetamine use, and engagement in increasingly risky behaviors. Because of their overwhelmingly frustrating experiences in the past, interviewees anticipated difficult interactions with healthcare clinicians, leading to combativeness in the ED, avoidance of the ED at all costs, and downstream medical complications. Participants desired a non-judgmental conversation and linkage to outpatient social resources and addiction treatment.

CONCLUSION

Methamphetamine use can lead patients to seek care in the ED, where they often feel stigmatized and are provided little assistance. Emergency clinicians should acknowledge addiction as a chronic condition, address acute medical and psychiatric symptoms adequately, and provide positive connections to addiction and medical resources. Future work should incorporate the perspectives of people who use methamphetamine into ED-based programs and interventions.

Acceptability and feasibility of using contingency management for cannabis reduction in specialist mental health services for psychosis: A qualitative study of staff views

AIM

There is increasing evidence linking cannabis use to onset, continuation, and relapse of psychosis. Contingency Management (CM) is discussed as a candidate intervention to reduce cannabis use. Our study aimed to explore staff views on the feasibility and acceptability of using CM for cannabis reduction in early intervention services for psychosis (EIS), in order to inform wider learning about implementation of such approaches in mental health services.

SETTING

EIS teams in England.

METHOD

Semi-structured interviews and focus groups analysed thematically.

PARTICIPANTS

Forty managers and staff members working in mental health services where a CM intervention was delivered as part of a trial, four staff who delivered CM in these settings, and three key informants (academic experts in relevant fields).

INTERVENTION

A complex intervention comprising CM with incremental financial incentives (vouchers) for reducing or stopping cannabis use, and psychoeducation about the risks of cannabis use.

FINDINGS

Acceptability appeared to depend on how well the intervention was seen to fit with the service setting and ethos. Concerns included who should deliver CM; potential impacts on the therapeutic relationship; the ethics of using incentives to reduce socially objectionable behaviours; and how CM fits with the work of mental health practitioners. Feasibility concerns centred on resource limitations including time, cost, training, and national guidance and commissioning.

CONCLUSIONS

Staff attitudes are likely to be a crucial influence on successful implementation of contingency management for cannabis reduction in specialist mental health settings. Several contextual barriers would need to be overcome to increase the acceptability of the intervention for use in early intervention services for psychosis.

Can we enhance the clinical efficacy of cognitive and psychological approaches to treat substance use disorders through understanding their neurobiological mechanisms?

Despite decades of research in the field of addiction, relapse rates for substance use disorders remain high. Consequently, there has been growing focus on providing evidence-based treatments for substance use disorders, resulting in the increased development and use of cognitive and psychological interventions. Such treatment approaches, including contingency management, community-reinforcement approach, and cognitive bias modification, have shown promising clinical efficacy in reducing substance use and promoting abstinence during treatment. However, these interventions are still somewhat limited in achieving sustained periods of abstinence post-treatment. The neurobiological mechanisms underpinning these treatment approaches remain largely unknown and under-studied, in part, due to a lack of translational animal models. The adoption of a reverse translational approach may assist in development of more representative models that can facilitate elucidation of the mechanisms behind these clinically relevant interventions. This review examines our current understanding of addiction neurobiology from clinical, preclinical research and existing animal models, and considers how the efficacy of such behavioral-oriented interventions alone, or in combination with pharmacotherapy, may be enhanced to improve treatment outcomes.

Sensitivity analyses for data missing at random versus missing not at random using latent growth modelling: a practical guide for randomised controlled trials

BACKGROUND

Missing data are ubiquitous in randomised controlled trials. Although sensitivity analyses for different missing data mechanisms (missing at random vs. missing not at random) are widely recommended, they are rarely conducted in practice. The aim of the present study was to demonstrate sensitivity analyses for different assumptions regarding the missing data mechanism for randomised controlled trials using latent growth modelling (LGM).

METHODS

Data from a randomised controlled brief alcohol intervention trial was used. The sample included 1646 adults (56% female; mean age = 31.0 years) from the general population who had received up to three individualized alcohol feedback letters or assessment-only. Follow-up interviews were conducted after 12 and 36 months via telephone. The main outcome for the analysis was change in alcohol use over time. A three-step LGM approach was used. First, evidence about the process that generated the missing data was accumulated by analysing the extent of missing values in both study conditions, missing data patterns, and baseline variables that predicted participation in the two follow-up assessments using logistic regression. Second, growth models were calculated to analyse intervention effects over time. These models assumed that data were missing at random and applied full-information maximum likelihood estimation. Third, the findings were safeguarded by incorporating model components to account for the possibility that data were missing not at random. For that purpose, Diggle-Kenward selection, Wu-Carroll shared parameter and pattern mixture models were implemented.

RESULTS

Although the true data generating process remained unknown, the evidence was unequivocal: both the intervention and control group reduced their alcohol use over time, but no significant group differences emerged. There was no clear evidence for intervention efficacy, neither in the growth models that assumed the missing data to be at random nor those that assumed the missing data to be not at random.

CONCLUSION

The illustrated approach allows the assessment of how sensitive conclusions about the efficacy of an intervention are to different assumptions regarding the missing data mechanism. For researchers familiar with LGM, it is a valuable statistical supplement to safeguard their findings against the possibility of nonignorable missingness.

TRIAL REGISTRATION

The PRINT trial was prospectively registered at the German Clinical Trials Register (DRKS00014274, date of registration: 12th March 2018).

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.

Dropout Rates in Psychosocial Interventions for People With Both Severe Mental Illness and Substance Misuse: A Systematic Review and Meta-Analysis

INTRODUCTION

Over the years, many psychosocial interventions for individual having both a psychotic spectrum disorder and a substance use disorder diagnoses have been developed and studied. However, there is a high dropout rate among this clinical population.

OBJECTIVES

This meta-analysis aims to replicate a previous meta-analysis on the effects of psychosocial treatment for dual disorders, while including and determining the dropout rates in those type of interventions.

METHOD

Based on a Cochrane systematic review conducted in 2019, we conducted a meta-analysis including 40 randomized clinical trials on psychosocial treatment among persons suffering from schizophrenia spectrum disorder and substance use disorder.

RESULTS

A dropout rate of 27,2% was obtained. Stimulants use significantly affected dropout rates. Age, gender, diagnosis, alcohol and cannabis abuse, and duration of treatment did not affect dropout rates.

CONCLUSION

The 27,2% rate of dropout from psychosocial treatment highlights the need to engage participants having a dual diagnosis from the start by focusing on therapeutic alliance and motivation for treatment.

What are the ethical implications of using prize-based contingency management in substance use? A scoping review

BACKGROUND

The area of substance use is notable for its early uptake of incentives and wealth of research on the topic. This is particularly true for prize-based contingency management (PB-CM), a particular type of incentive that uses a fishbowl prize-draw design. Given that PB-CM interventions are gaining momentum to address the dual public health crises of opiate and stimulant use in North America and beyond, it is imperative that we better understand and critically analyze their implications.

PURPOSE

The purpose of this scoping review paper is to identify the characteristics of PB-CM interventions for people who use substances and explore ethical implications documented in the literature as well as emerging ethical implications that merit further consideration.

METHODS

The PRISMA-ScR checklist was used in conjunction with Arksey and O'Malley's methodological framework to guide this scoping review. We completed a two-pronged analysis of 52 research articles retrieved through a comprehensive search across three key scholarly databases. After extracting descriptive data from each article, we used 9 key domains to identify characteristics of the interventions followed by an analysis of ethical implications.

RESULTS

We analyzed the characteristics of PB-CM interventions which were predominantly quantitative studies aimed at studying the efficacy of PB-CM interventions. All of the interventions used a prize-draw format with a classic magnitude of 50%. Most of the interventions combined both negative and positive direction to reward processes, behaviors, and/or outcomes. One ethical implication was identified in the literature: the risk of gambling relapse. We also found three emerging ethical implications by further analyzing participant characteristics, intervention designs, and potential impact on the patient-provider relationship. These implications include the potential deceptive nature of PB-CM, the emphasis placed on the individual behaviors to the detriment of social and structural determinants of health, and failures to address vulnerability and power dynamics.

CONCLUSIONS

This scoping review offers important insights into the ethics on PB-CM and its implications for research ethics, clinical ethics, and public health ethics. Additionally, it raises important questions that can inform future research and dialogues to further tease out the ethical issues associated with PB-CM.

Voucher Reinforcement Decreases Psychiatric Symptoms in Young People in Treatment for Drug Use Disorders - A Post Hoc Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

This multicenter, parallel randomized, open study examined the effect of using vouchers and session reminders as an added element to outpatient treatment for drug use disorders in youth. It was hypothesized that being randomly assigned to a contingency management condition would lead to a reduction of psychiatric symptoms, and that this reduction would be mediated through abstinence and treatment completion.

METHODS

A total of 460 participants aged 15 to 25 years from nine outpatient sites were randomized to one of four treatment conditions (standard treatment alone [STD], i.e., 12 sessions using motivational interviewing and cognitive behavioral therapy, STD plus vouchers for attendance [VOU], STD plus text reminders [REM], or STD plus vouchers and text reminders [REM + VOU]). Participants' symptoms of psychological distress were assessed using the YouthMap 12 instrument at intake, and at 3, 6, and 9 months post-treatment initiation. Interviewers were blinded to interventions.

RESULTS

114 participants were randomized to STD, 112 to REM, 113 to VOU, and 121 to VOU + REM. 69 clients were never interviewed for follow-up, leaving 391 for analysis (n = 90, n = 94, n = 99, n = 108). The mean age was 20.5 years (SD = 2.6), 23% were female, and 34% reported having a psychiatric diagnosis. Random effects regression showed that participants randomized to one of the two voucher-based conditions experienced significantly steeper declines in symptoms compared with STD (p < .01). Structural equation modeling results indicated that the effects of contingency management on symptoms were mediated through abstinence, but not sessions attended.

CONCLUSIONS

Adding contingency management to interventions for drug use disorders can reduce symptoms of psychological and emotional distress among populations of treatment-seeking youth, in part due to indirect effects through abstinence at follow-up. The data is collected from a clinical trial registered as ISRCTN27473213, at https://www.isrctn.com/.

Effect of Incentives for Alcohol Abstinence in Partnership With 3 American Indian and Alaska Native Communities: A Randomized Clinical Trial

Importance

Many American Indian and Alaska Native communities are disproportionately affected by problems with alcohol use and seek culturally appropriate and effective interventions for individuals with alcohol use disorders.

Objective

To determine whether a culturally tailored contingency management intervention, in which incentives were offered for biologically verified alcohol abstinence, resulted in increased abstinence among American Indian and Alaska Native adults. This study hypothesized that adults assigned to receive a contingency management intervention would have higher levels of alcohol abstinence than those assigned to the control condition.

Design, Setting, and Participants

This multisite randomized clinical trial, the Helping Our Native Ongoing Recovery (HONOR) study, included a 1-month observation period before randomization and a 3-month intervention period. The study was conducted at 3 American Indian and Alaska Native health care organizations located in Alaska, the Pacific Northwest, and the Northern Plains from October 10, 2014, to September 2, 2019. Recruitment occurred between October 10, 2014, and February 20, 2019. Eligible participants were American Indian or Alaska Native adults who had 1 or more days of high alcohol-use episodes within the last 30 days and a current diagnosis of alcohol dependence. Data were analyzed from February 1 to April 29, 2020.

Interventions

Participants received treatment as usual and were randomized to either the contingency management group, in which individuals received 12 weeks of incentives for submitting a urine sample indicating alcohol abstinence, or the control group, in which individuals received 12 weeks of incentives for submitting a urine sample without the requirement of alcohol abstinence. Regression models fit with generalized estimating equations were used to assess differences in abstinence during the intervention period.

Main Outcomes and Measures

Alcohol-negative ethyl glucuronide (EtG) urine test result (defined as EtG<150 ng/mL).

Results

Among 1003 adults screened for eligibility, 400 individuals met the initial criteria. Of those, 158 individuals (39.5%; mean [SD] age, 42.1 [11.4] years; 83 men [52.5%]) met the criteria for randomization, which required submission of 4 or more urine samples and 1 alcohol-positive urine test result during the observation period before randomization. A total of 75 participants (47.5%) were randomized to the contingency management group, and 83 participants (52.5%) were randomized to the control group. At 16 weeks, the number who submitted an alcohol-negative urine sample was 19 (59.4%) in the intervention group vs 18 (38.3%) in the control group. Participants randomized to the contingency management group had a higher likelihood of submitting an alcohol-negative urine sample (averaged over time) compared with those randomized to the control group (odds ratio, 1.70; 95% CI, 1.05-2.76; P = .03).

Conclusions and Relevance

The study's findings indicate that contingency management may be an effective strategy for increasing alcohol abstinence and a tool that can be used by American Indian and Alaska Native communities for the treatment of individuals with alcohol use disorders.

Trial Registration

ClinicalTrials.gov Identifier: NCT02174315.

Long-term efficacy of contingency management treatment based on objective indicators of abstinence from illicit substance use up to 1 year following treatment: A meta-analysis

OBJECTIVE

Contingency management (CM) is often criticized for limited long-term impact. This meta-analysis focused on objective indices of drug use (i.e., urine toxicology) to examine the effects of CM on illicit substance use up to 1 year following treatment.

METHOD

Analyses included randomized trials (k = 23) of CM for stimulant, opioid, or polysubstance use disorders that reported outcomes up to 1 year after the incentive delivery had ended. Using random effects models, odds ratios (OR) were calculated for the likelihood of abstinence. Metaregressions and subgroup analyses explored how parameters of CM treatment, namely escalation, frequency, immediacy, and magnitude of reinforcers, moderated outcomes.

RESULTS

The overall likelihood of abstinence at the long-term follow-up among participants who received CM versus a comparison treatment (nearly half of which were community-based comprehensive therapies or protocol-based specific therapies) was OR = 1.22, 95% confidence interval [1.01, 1.44], with low to moderate heterogeneity (I² = 36.68). Among 18 moderators, longer length of active treatment was found to significantly improve long-term abstinence.

CONCLUSIONS

CM showed long-term benefit in reducing objective indices of drug use, above and beyond other active, evidence-based treatments (e.g., cognitive-behavioral therapy, 12-step facilitation) and community-based intensive outpatient treatment. These data suggest that policymakers and insurers should support and cover costs for CM, which is the focus of hundreds of studies demonstrating its short-term efficacy and, now, additional data supporting its long-term efficacy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Mixed-methods trial of a phosphatidylethanol-based contingency management intervention to initiate and maintain alcohol abstinence in formerly homeless adults with alcohol use disorders

Background

Contingency management (CM) is an intervention where incentives are provided in exchange for biochemically confirmed alcohol abstinence. CM is effective at initiating alcohol abstinence, but it is less effective at maintaining long-term abstinence. Phosphatidylethanol (PEth), collected via a finger-stick, can detect alcohol use for 14–28 days. PEth allows for the development of a CM model that includes increasingly less frequent monitoring of abstinence to assist high risk groups, such as formerly homeless individuals, maintain long-term abstinence.

Aims

Investigate whether PEth-based CM intervention targeting alcohol abstinence in formerly homeless, currently housed individuals with alcohol use disorders is: (1) acceptable and feasible for housing program tenants and personnel; and is associated with increased (2) alcohol abstinence and (3) housing tenure.

Methods

Acceptability and feasibility will be assessed using a QUAL+quant mixed-methods design using qualitative interviews and quantitative measures of satisfaction and attrition. Effectiveness will be evaluated through a randomized pilot trial of 50 study participants who will receive 6 months of either treatment as usual (TAU) including incentives (e.g., gift cards) for providing blood samples (Control Condition) or TAU and incentives for negative PEth results (PEth-CM Condition). Outcomes will be assessed during the intervention and at a three-month follow-up visit. The trial will be conducted via telehealth as a result of COVID-19.

Discussion

This protocol seeks to utilize a novel alcohol biomarker to evaluate the acceptability, feasibility, and initial effectiveness of a CM model that encourages long-term abstinence in a high-risk group.

Meta-Analysis on the Effect of Contingency Management for Patients with Both Psychotic Disorders and Substance Use Disorders

Background: Substance use disorders (SUD) are highly prevalent among psychotic patients and are associated with poorer clinical and functional outcomes. Effective interventions for this clinical population are scarce and challenging. Contingency management (CM) is one of the most evidence-based treatments for SUD’s, however, a meta-analysis of the effect of CM in patients with a dual diagnosis of psychotic disorder and SUD has not been performed. Methods: We searched PubMed and PsycINFO databases up to December 2020. Results: Five controlled trials involving 892 patients were included. CM is effective on abstinence rates, measured by the number of self-reported days of using after intervention (95% CI −0.98 to −0.06) and by the number of negative breath or urine samples after intervention (OR 2.13; 95% CI 0.97 to 4.69) and follow-up (OR 1.47; 95% CI 1.04 to 2.08). Conclusions: Our meta-analysis shows a potential effect of CM on abstinence for patients with SUD and (severe) psychotic disorders, although the number of studies is limited. Additional longitudinal studies are needed to confirm the sustained effectivity of CM and give support for a larger clinical implementation of CM within services targeting these vulnerable co-morbid patients.

Decision-making (in)flexibility in gambling disorder

BACKGROUND

Behavioral flexibility -the ability to dynamically readjust our behavior in response to reward contingency changes- is often investigated using probabilistic reversal learning tasks (PRLT). Poor PRLT performance has been proposed as a proxy for compulsivity, and theorized to be related to perseverative gambling. Previous attempts to measure inflexibility with the PRLT in patients with gambling disorder have, however, used a variety of indices that may conflate inflexibility with more general aspects of performance in the task.

METHODS

Trial-by-trial PRLT acquisition and reacquisition curves in 84 treatment-seeking patients with gambling disorder and 64 controls (non-gamblers and non-problem recreational gamblers) were analyzed to distinguish between (a) variability in acquisition learning, and (b) reacquisition learning in reversed contingency phases. Complementarily, stay/switch responses throughout the task were analyzed to identify (c) premature switching, and (d) sensitivity to accumulated negative feedback.

RESULTS AND INTERPRETATION

Even after controlling for differences in acquisition learning, patients were slower to readjust their behavior in reversed contingency phases, and were more prone to maintain their decisions despite accumulated negative feedback. Inflexibility in patients with gambling disorder is thus a robust phenomenon that could predate gambling escalation, or result from massive exposure to gambling activities.

The rewarding recovery study: a randomized controlled trial of incentives for alcohol and drug abstinence with a rural American Indian community

AIMS

To test if contingency management (CM) interventions for alcohol and drug abstinence were associated with increased alcohol and drug abstinence among American Indian adults with alcohol dependence who also use drugs.

DESIGN

In this 2 × 2 factorial randomized controlled trial, American Indian adults with alcohol dependence who also used drugs were randomized to four conditions: (1) incentives for submission of urine samples only (control condition), (2) CM incentives for alcohol abstinence, (3) CM incentives for drug abstinence or (4) CM incentives for abstinence from both alcohol and drugs.

SETTING

A Northern Plains Reservation in the United States.

PARTICIPANTS

A total of 114 American Indian adults aged 35.8 years (standard deviation = 10.4); 49.1% were male.

INTERVENTION AND COMPARATOR

Participants received incentives if they demonstrated abstinence from alcohol (CM for alcohol, n = 30), abstinence from their most frequently used drug (CM for drugs, n = 27) or abstinence from both alcohol and their most frequently used drug (CM for alcohol and drugs, n = 32) as assessed by urine tests. Controls (n = 25) received incentives for submitting urine samples only.

MEASUREMENTS

Primary outcomes were urine ethyl glucuronide (alcohol) and drug tests conducted three times per week during the 12-week intervention period. Data analyses included listwise deletion and multiple imputation to account for missing data.

FINDINGS

The three CM groups were significantly (P < 0.05) more likely to submit alcohol-abstinent urine samples compared with the control condition, with odds ratios ranging from 2.4 to 4.8. The CM for drugs (OR = 3.2) and CM for alcohol and drugs (OR = 2.5) were significantly more likely to submit urine samples that indicated drug abstinence, relative to the control condition (P < 0.05). However, these differences were not significant in multiple imputation analyses (P > 0.05).

CONCLUSIONS

Contingency management (CM) incentives for abstinence were associated with increased alcohol abstinence in American Indian adults diagnosed with alcohol dependence who also used drugs, living on a rural reservation. The effect of CM incentives on drug abstinence was inconclusive.

A contingency management intervention to reduce cannabis use and time to relapse in early psychosis: the CIRCLE RCT

BACKGROUND

Cannabis is the most prevalent illicit substance among people with psychosis, and its use is associated with poorer clinical and social outcomes. However, so far, there has been limited evidence that any treatment is effective for reducing use. Contingency management (CM) is an incentive-based intervention for substance misuse that has a substantial evidence base across a range of substances and cohorts. However, to date there have been no randomised controlled trials (RCTs) of CM as a treatment for cannabis use specifically in psychosis.

OBJECTIVE

To conduct a RCT investigating the clinical effectiveness and cost-effectiveness of CM in reducing cannabis use among Early Intervention in Psychosis (EIP) service users.

DESIGN

The CIRCLE (Contingency Intervention for Reduction of Cannabis in Early Psychosis) trial was a rater-blinded, multicentre RCT with two arms. Participants were randomised 1 : 1 to either an CM arm, in which participants received CM for cannabis use alongside an optimised treatment-as-usual programme including structured psychoeducation, or a control arm in which participants received the treatment as usual only.

SETTING

EIP services across the Midlands and the south-east of England.

PARTICIPANTS

The main eligibility criteria were EIP service users with a history of psychosis, aged 18-36 years, and having used cannabis at least once per week during 12 of the previous 24 weeks.

INTERVENTION

The CM intervention offered financial incentives (i.e. shopping vouchers) for cannabis abstinence over 12 once-weekly sessions, confirmed using urinalysis. The maximum value in vouchers that participants could receive was £240.

MAIN OUTCOME MEASURES

The main outcome was time to relapse, operationalised as admission to an acute mental health service or hospital. The primary outcome was assessed at 18 months post inclusion using electronic patient records. Secondary outcomes assessed the clinical effectiveness and cost-effectiveness of the intervention, for which data were collected at 3 and 18 months.

RESULTS

A total of 278 participants were randomised to the CM arm and 273 were randomised to the control arm. In total, 530 (96%) participants were followed up for the primary outcome. There was no significant difference in time to admission between trial arms by 18 months following consent (hazard ratio 1.03, 95% confidence interval 0.76 to 1.40). There were no statistically significant differences in most secondary outcomes, including cannabis use, at either follow-up assessment. There were 58 serious adverse events, comprising 52 inpatient episodes, five deaths and one arrest.

LIMITATIONS

Participant retention was low at 18 months, limiting the assessment of secondary outcomes. A different CM intervention design or reward level may have been effective.

CONCLUSIONS

The CM intervention did not appear to be effective in reducing cannabis use and acute relapse among people with early psychosis and problematic cannabis use.

FUTURE WORK

Cannabis use is still a significant clinical concern in this population. A pressing need remains to identify suitable treatments. A wider perspective on the social circumstances of young people with psychosis may be needed for a successful intervention to be found.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN33576045.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 45. See the NIHR Journals Library website for further project information.

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.

•

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.

The dissemination and implementation of contingency management for substance use disorders: A systematic review

Contingency management is one of the most effective behavioral interventions for substance use. However, the implementation of contingency management has not been as widespread as might be expected given its efficacy. This review summarizes literature that examines the dissemination and implementation of contingency management for substance use in community (e.g., specialized substance use treatment) and clinical (e.g., primary care) settings. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Databases including Google Scholar, World of Knowledge, PsycINFO, and PubMed were searched. Search results yielded 100 articles and after the screening of titles and abstracts 44 were identified. Full-text articles were examined for eligibility and yielded 24 articles that were included in this review. Of the 24 articles included in the review, the majority (n = 11) focused on implementing contingency management in methadone clinics and opioid treatment programs. Training methods, implementation strategies, fidelity assessments, and attitudes toward the implementation of contingency management are discussed in greater detail. These findings highlight the importance of organizational input and ongoing supervision and consultation, and the need for additional research that is guided by theoretical frameworks and use rigorous study designs. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Implementation of a contingency approach for people with co-occurring substance use and psychiatric disorders: Acceptability and feasibility pilot study

Introduction

The prevalence of co-occurrent substance use and psychiatric disorders is high. Contingency-based interventions have been shown to be effective in promoting adherence to treatment for people with substance use disorders but are among the least used evidence-based interventions for clients with comorbid psychiatric disorders, related to acceptability issues.

Objective

The present implementation study aims to evaluate the acceptability and feasibility of a contingency approach in co-occurring disorders specialized treatment services.

Methodology

Focus groups were conducted with health professionals and service users recruited from a specialized co-occurring disorder program (COD). Pre-intervention focus groups were conducted to select preferred modalities to implement the program. Post-intervention focus groups were conducted to document the satisfaction and benefits of the intervention. Throughout the study, program monitoring was conducted systematically to determine the gaps between planned and actual interventions.

Results

Both health professionals consulted and service users agreed that the contingency approach could be integrated within usual co-occurring disorders treatment. In general, patients more readily accepted the contingency approach than health professionals. The higher functioning level group reported several benefits from the approach and implementation in its group sessions went as planned. Contingency approach was described by all participants as consistent with general treatment goals and led to patient's awareness about their group attendance.

Conclusion

This study highlights several challenges related to the implementation of a contingency approach. It also suggests that implementation of this approach could benefit from taking into account the needs and perspectives of service users.

Psychosocial interventions for people with both severe mental illness and substance misuse

BACKGROUND

Even low levels of substance misuse by people with a severe mental illness can have detrimental effects.

OBJECTIVES

To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care.

SEARCH METHODS

The Information Specialist of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (2 May 2018), which is based on regular searches of major medical and scientific databases.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. Where meta-analyses were possible, we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison.

MAIN RESULTS

Our review now includes 41 trials with a total of 4024 participants. We have identified nine comparisons within the included trials and present a summary of our main findings for seven of these below. We were unable to summarise many findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low- or very-low quality due to high or unclear risks of bias because of poor trial methods, or inadequately reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. 1. Integrated models of care versus standard care (36 months) No clear differences were found between treatment groups for loss to treatment (RR 1.09, 95% CI 0.82 to 1.45; participants = 603; studies = 3; low-quality evidence), death (RR 1.18, 95% CI 0.39 to 3.57; participants = 421; studies = 2; low-quality evidence), alcohol use (RR 1.15, 95% CI 0.84 to 1.56; participants = 143; studies = 1; low-quality evidence), substance use (drug) (RR 0.89, 95% CI 0.63 to 1.25; participants = 85; studies = 1; low-quality evidence), global assessment of functioning (GAF) scores (MD 0.40, 95% CI -2.47 to 3.27; participants = 170; studies = 1; low-quality evidence), or general life satisfaction (QOLI) scores (MD 0.10, 95% CI -0.18 to 0.38; participants = 373; studies = 2; moderate-quality evidence). 2. Non-integrated models of care versus standard care There was no clear difference between treatment groups for numbers lost to treatment at 12 months (RR 1.21, 95% CI 0.73 to 1.99; participants = 134; studies = 3; very low-quality evidence). 3. Cognitive behavioural therapy (CBT) versus standard care There was no clear difference between treatment groups for numbers lost to treatment at three months (RR 1.12, 95% CI 0.44 to 2.86; participants = 152; studies = 2; low-quality evidence), cannabis use at six months (RR 1.30, 95% CI 0.79 to 2.15; participants = 47; studies = 1; very low-quality evidence) or mental state insight (IS) scores by three months (MD 0.52, 95% CI -0.78 to 1.82; participants = 105; studies = 1; low-quality evidence). 4. Contingency management versus standard care We found no clear differences between treatment groups for numbers lost to treatment at three months (RR 1.55, 95% CI 1.13 to 2.11; participants = 255; studies = 2; moderate-quality evidence), number of stimulant positive urine tests at six months (RR 0.83, 95% CI 0.65 to 1.06; participants = 176; studies = 1) or hospitalisations (RR 0.21, 95% CI 0.05 to 0.93; participants = 176; studies = 1); both low-quality evidence. 5. Motivational interviewing (MI) versus standard care We found no clear differences between treatment groups for numbers lost to treatment at six months (RR 1.71, 95% CI 0.63 to 4.64; participants = 62; studies = 1). A clear difference, favouring MI, was observed for abstaining from alcohol (RR 0.36, 95% CI 0.17 to 0.75; participants = 28; studies = 1) but not other substances (MD -0.07, 95% CI -0.56 to 0.42; participants = 89; studies = 1), and no differences were observed in mental state general severity (SCL-90-R) scores (MD -0.19, 95% CI -0.59 to 0.21; participants = 30; studies = 1). All very low-quality evidence. 6. Skills training versus standard care At 12 months, there were no clear differences between treatment groups for numbers lost to treatment (RR 1.42, 95% CI 0.20 to 10.10; participants = 122; studies = 3) or death (RR 0.15, 95% CI 0.02 to 1.42; participants = 121; studies = 1). Very low-quality, and low-quality evidence, respectively. 7. CBT + MI versus standard care At 12 months, there was no clear difference between treatment groups for numbers lost to treatment (RR 0.99, 95% CI 0.62 to 1.59; participants = 327; studies = 1; low-quality evidence), number of deaths (RR 0.60, 95% CI 0.20 to 1.76; participants = 603; studies = 4; low-quality evidence), relapse (RR 0.50, 95% CI 0.24 to 1.04; participants = 36; studies = 1; very low-quality evidence), or GAF scores (MD 1.24, 95% CI -1.86 to 4.34; participants = 445; studies = 4; very low-quality evidence). There was also no clear difference in reduction of drug use by six months (MD 0.19, 95% CI -0.22 to 0.60; participants = 119; studies = 1; low-quality evidence).

AUTHORS' CONCLUSIONS

We included 41 RCTs but were unable to use much data for analyses. There is currently no high-quality evidence to support any one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high-quality trials are required which address these concerns and improve the evidence in this important area.

Psychological interventions for co-occurring depression and substance use disorders

BACKGROUND

Comorbid depression and substance use disorders are common and have poorer outcomes than either disorder alone. While effective psychological treatments for depression or substance use disorders are available, relatively few randomised controlled trials (RCTs) have examined the efficacy of these treatments in people with these comorbid disorders.

OBJECTIVES

To assess the efficacy of psychological interventions delivered alone or in combination with pharmacotherapy for people diagnosed with comorbid depression and substance use disorders.

SEARCH METHODS

We searched the following databases up to February 2019: Cochrane Central Register of Controlled Trials, PubMed, Embase, CINAHL, Google Scholar and clinical trials registers. All systematic reviews identified, were handsearched for relevant articles.

SELECTION CRITERIA

The review includes data from RCTs of psychological treatments for people diagnosed with comorbid depression and substance use disorders, using structured clinical interviews. Studies were included if some of the sample were experiencing another mental health disorder (e.g. anxiety); however, studies which required a third disorder as part of their inclusion criteria were not included. Studies were included if psychological interventions (with or without pharmacotherapy) were compared with no treatment, delayed treatment, treatment as usual or other psychological treatments.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Seven RCTs of psychological treatments with a total of 608 participants met inclusion criteria. All studies were published in the USA and predominately consisted of Caucasian samples. All studies compared different types of psychological treatments. Two studies compared Integrated Cognitive Behavioural Therapy (ICBT) with Twelve Step Facilitation (TSF), another two studies compared Interpersonal Psychotherapy for Depression (IPT-D) with other treatment (Brief Supportive Therapy (BST) or Psychoeducation). The other three studies compared different types or combinations of psychological treatments. No studies compared psychological interventions with no treatment or treatment as usual control conditions. The studies included a diverse range of participants (e.g. veterans, prisoners, community adults and adolescents). All studies were at high risk of performance bias, other main sources were selection, outcome detection and attrition bias. Due to heterogeneity between studies only two meta-analyses were conducted. The first meta-analysis focused on two studies (296 participants) comparing ICBT to TSF. Very low-quality evidence revealed that while the TSF group had lower depression scores than the ICBT group at post-treatment (mean difference (MD) 4.05, 95% confidence interval (CI) 1.43 to 6.66; 212 participants), there was no difference between groups in depression symptoms (MD 1.53, 95% CI -1.73 to 4.79; 181 participants) at six- to 12-month follow-up. At post-treatment there was no difference between groups in proportion of days abstinent (MD -2.84, 95% CI -8.04 to 2.35; 220 participants), however, the ICBT group had a greater proportion of days abstinent than the TSF group at the six- to 12-month follow-up (MD 10.76, 95% CI 3.10 to 18.42; 189 participants). There were no differences between the groups in treatment attendance (MD -1.27, 95% CI -6.10 to 3.56; 270 participants) or treatment retention (RR 0.95, 95% CI 0.72 to 1.25; 296 participants). The second meta-analysis was conducted with two studies (64 participants) comparing IPT-D with other treatment (Brief Supportive Psychotherapy/Psychoeducation). Very low-quality evidence indicated IPT-D resulted in significantly lower depressive symptoms at post-treatment (MD -0.54, 95% CI -1.04 to -0.04; 64 participants), but this effect was not maintained at three-month follow-up (MD 3.80, 95% CI -3.83 to 11.43) in the one study reporting follow-up outcomes (38 participants; IPT-D versus Psychoeducation). Substance use was examined separately in each study, due to heterogeneity in outcomes. Both studies found very low-quality evidence of no significant differences in substance use outcomes at post-treatment (percentage of days abstinent, IPD versus Brief Supportive Psychotherapy; MD -2.70, 95% CI -28.74 to 23.34; 26 participants) or at three-month follow-up (relative risk of relapse, IPT-D versus Psychoeducation; RR 0.67, 95% CI 0.30 to 1.50; 38 participants). There was also very low-quality evidence for no significant differences between groups in treatment retention (RR 1.00, 95% CI 0.81 to 1.23; 64 participants). No adverse events were reported in any study.

AUTHORS' CONCLUSIONS

The conclusions of this review are limited due to the low number and very poor quality of included studies. No conclusions can be made about the efficacy of psychological interventions (delivered alone or in combination with pharmacotherapy) for the treatment of comorbid depression and substance use disorders, as they are yet to be compared with no treatment or treatment as usual in this population. In terms of differences between psychotherapies, although some significant effects were found, the effects were too inconsistent and small, and the evidence of too poor quality, to be of relevance to practice.

Psychological treatment for methamphetamine use and associated psychiatric symptom outcomes: A systematic review

BACKGROUND

Regular methamphetamine use is associated with increased rates of psychiatric symptoms. Although there has been a substantial body of research reporting on the effectiveness of psychological treatments for reducing methamphetamine use, there is a paucity of research examining the effects of these treatments on co-occurring psychiatric symptoms. We addressed this gap by undertaking a systematic review of the evidence of the effectiveness of psychological treatments for methamphetamine use on psychiatric symptom outcomes in randomized controlled trials.

METHODS

A narrative synthesis of studies was conducted following the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement to inform methodology. Eight electronic peer-reviewed databases were searched. Ten eligible studies were assessed.

RESULTS

Most studies found an overall reduction in levels of methamphetamine use and psychiatric symptoms among samples as a whole. Although brief interventions were effective, there is evidence that more intensive interventions have greater impact on methamphetamine use and/or psychiatric symptomatology. Intervention attendance was variable.

CONCLUSIONS

The evidence suggests that a variety of psychological treatments are effective in reducing levels of methamphetamine use and improving psychiatric symptoms. Future research should consider how psychological treatments could maximize outcomes in the co-occurring domains of methamphetamine use and psychiatric symptoms, with increasing treatment attendance as a focus. PROSPERO registration number: CRD42016043657.

An initial randomized controlled trial of behavioral activation for treatment of concurrent crystal methamphetamine dependence and sexual risk for HIV acquisition among men who have sex with men

Men who have sex with men (MSM) continue to be the largest risk group for HIV infections in the U.S., where crystal methamphetamine abuse heightens risk for HIV infection through greater engagement in condomless anal sex (CAS). Existing treatments lack attention to replacement activities or the role of depressed mood. Behavioral activation (BA) is an evidence-based approach for depression that involves identifying and participating in pleasurable, goal-directed activities. We hypothesize, for MSM abusing crystal methamphetamine, re-learning how to engage in non-drug-using aspects of life would facilitate their ability to benefit from sexual risk reduction (SRR) counseling. Project IMPACT was a pilot randomized-controlled-trial. Forty-six MSM at sexual risk of acquiring HIV who met DSM-IV criteria for crystal methamphetamine dependence were enrolled. Of those MSM, 41 were randomized: 21 were assigned to the intervention, two sessions of SRR, ten sessions of BA with SRR, and one session of relapse prevention; 20 participants were assigned to a control condition (two sessions of SRR). At the acute post-intervention visit, intervention participants reported an average of 3.2 CAS acts with men who were HIV-infected or whose status they did not know, compared to 4.5 among control participants (β = -0.36; 95% CI: -0.69, -0.02; p = 0.035). At the 6-month post-intervention visit, intervention participants reported 1.1 CAS acts with men who were HIV-infected or whose status they did not know compared to 2.8 among control participants (β = -0.95; 95% CI: -1.44, -0.46; p < 0.0001). Similarly, intervention participants reported 1.0 CAS acts under the influence of crystal methamphetamine with men who were HIV-infected or whose status they did not know compared to 2.5 among control participants (β = -0.87; 95% CI: -1.38, -0.36; p = 0.0005). Lastly, intervention participants reported more continuous days abstaining from crystal methamphetamine compared to control (50.1 vs. 39.0, respectively) (β = 0.25; 95% CI: 0.16, 0.34; p < 0.0001). Findings are encouraging, provide evidence of feasibility and acceptability, and demonstrate initial efficacy for reducing sexual risk for HIV and crystal methamphetamine use.

Clinical and cost-effectiveness of contingency management for cannabis use in early psychosis: the CIRCLE randomised clinical trial

BACKGROUND

Cannabis is the most commonly used illicit substance amongst people with psychosis. Continued cannabis use following the onset of psychosis is associated with poorer functional and clinical outcomes. However, finding effective ways of intervening has been very challenging. We examined the clinical and cost-effectiveness of adjunctive contingency management (CM), which involves incentives for abstinence from cannabis use, in people with a recent diagnosis of psychosis.

METHODS

CIRCLE was a pragmatic multi-centre randomised controlled trial. Participants were recruited via Early Intervention in Psychosis (EIP) services across the Midlands and South East of England. They had had at least one episode of clinically diagnosed psychosis (affective or non-affective); were aged 18 to 36; reported cannabis use in at least 12 out of the previous 24 weeks; and were not currently receiving treatment for cannabis misuse, or subject to a legal requirement for cannabis testing. Participants were randomised via a secure web-based service 1:1 to either an experimental arm, involving 12 weeks of CM plus a six-session psychoeducation package, or a control arm receiving the psychoeducation package only. The total potential voucher reward in the CM intervention was £240. The primary outcome was time to acute psychiatric care, operationalised as admission to an acute mental health service (including community alternatives to admission). Primary outcome data were collected from patient records at 18 months post-consent by assessors masked to allocation. The trial was registered with the ISRCTN registry, number ISRCTN33576045.

RESULTS

Five hundred fifty-one participants were recruited between June 2012 and April 2016. Primary outcome data were obtained for 272 (98%) in the CM (experimental) group and 259 (95%) in the control group. There was no statistically significant difference in time to acute psychiatric care (the primary outcome) (HR 1.03, 95% CI 0.76, 1.40) between groups. By 18 months, 90 (33%) of participants in the CM group, and 85 (30%) of the control groups had been admitted at least once to an acute psychiatric service. Amongst those who had experienced an acute psychiatric admission, the median time to admission was 196 days (IQR 82, 364) in the CM group and 245 days (IQR 99, 382) in the control group. Cost-effectiveness analyses suggest that there is an 81% likelihood that the intervention was cost-effective, mainly resulting from higher mean inpatient costs for the control group compared with the CM group; however, the cost difference between groups was not statistically significant. There were 58 adverse events, 27 in the CM group and 31 in the control group.

CONCLUSIONS

Overall, these results suggest that CM is not an effective intervention for improving the time to acute psychiatric admission or reducing cannabis use in psychosis, at least at the level of voucher reward offered.

Drug Use Mediates the Relationship Between Depressive Symptoms and Adherence to ART Among Recently Incarcerated People Living with HIV

Depression is a known risk factor for antiretroviral therapy (ART) non-adherence, but little is known about the mechanisms explaining this relationship. Identifying these mechanisms among people living with HIV (PLHIV) after release from prison is particularly important, as individuals during this critical period are at high risk for both depression and poor ART adherence. 347 PLHIV recently released from prison in North Carolina and Texas were included in analyses to assess mediation of the relationship between depressive symptoms at 2 weeks post-release and ART adherence (assessed by unannounced telephone pill counts) at weeks 9-21 post-release by the hypothesized explanatory mechanisms of alcohol use, drug use, adherence self-efficacy, and adherence motivation (measured at weeks 6 and 14 post-release). Indirect effects were estimated using structural equation models with maximum likelihood estimation and bootstrapped confidence intervals. On average, participants achieved 79% ART adherence. The indirect effect of depression on adherence through drug use was statistically significant; greater symptoms of depression were associated with greater drug use, which was in turn associated with lower adherence. Lower adherence self-efficacy was associated with depressive symptoms, but not with adherence. Depression screening and targeted mental health and substance use services for depressed individuals at risk of substance use constitute important steps to promote adherence to ART after prison release.

Incentives for smoking cessation

BACKGROUND

Financial incentives, monetary or vouchers, are widely used in an attempt to precipitate, reinforce and sustain behaviour change, including smoking cessation. They have been used in workplaces, in clinics and hospitals, and within community programmes.

OBJECTIVES

To determine the long-term effect of incentives and contingency management programmes for smoking cessation.

SEARCH METHODS

For this update, we searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The most recent searches were conducted in July 2018.

SELECTION CRITERIA

We considered only randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to smoking cessation incentive schemes or control conditions. We included studies in a mixed-population setting (e.g. community, work-, clinic- or institution-based), and also studies in pregnant smokers.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. The primary outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up (at least six months from the start of the intervention). In the trials of pregnant women we used abstinence measured at the longest follow-up, and at least to the end of the pregnancy. Where available, we pooled outcome data using a Mantel-Haenzel random-effects model, with results reported as risk ratios (RRs) and 95% confidence intervals (CIs), using adjusted estimates for cluster-randomised trials. We analysed studies carried out in mixed populations separately from those carried out in pregnant populations.

MAIN RESULTS

Thirty-three mixed-population studies met our inclusion criteria, covering more than 21,600 participants; 16 of these are new to this version of the review. Studies were set in varying locations, including community settings, clinics or health centres, workplaces, and outpatient drug clinics. We judged eight studies to be at low risk of bias, and 10 to be at high risk of bias, with the rest at unclear risk. Twenty-four of the trials were run in the USA, two in Thailand and one in the Phillipines. The rest were European. Incentives offered included cash payments or vouchers for goods and groceries, offered directly or collected and redeemable online. The pooled RR for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.49 (95% CI 1.28 to 1.73; 31 RCTs, adjusted N = 20,097; I² = 33%). Results were not sensitive to the exclusion of six studies where an incentive for cessation was offered at long-term follow up (result excluding those studies: RR 1.40, 95% CI 1.16 to 1.69; 25 RCTs; adjusted N = 17,058; I² = 36%), suggesting the impact of incentives continues for at least some time after incentives cease.Although not always clearly reported, the total financial amount of incentives varied considerably between trials, from zero (self-deposits), to a range of between USD 45 and USD 1185. There was no clear direction of effect between trials offering low or high total value of incentives, nor those encouraging redeemable self-deposits.We included 10 studies of 2571 pregnant women. We judged two studies to be at low risk of bias, one at high risk of bias, and seven at unclear risk. When pooled, the nine trials with usable data (eight conducted in the USA and one in the UK), delivered an RR at longest follow-up (up to 24 weeks post-partum) of 2.38 (95% CI 1.54 to 3.69; N = 2273; I² = 41%), in favour of incentives.

AUTHORS' CONCLUSIONS

Overall there is high-certainty evidence that incentives improve smoking cessation rates at long-term follow-up in mixed population studies. The effectiveness of incentives appears to be sustained even when the last follow-up occurs after the withdrawal of incentives. There is also moderate-certainty evidence, limited by some concerns about risks of bias, that incentive schemes conducted among pregnant smokers improve smoking cessation rates, both at the end of pregnancy and post-partum. Current and future research might explore more precisely differences between trials offering low or high cash incentives and self-incentives (deposits), within a variety of smoking populations.

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.

Cognitive-behavioural treatment for amphetamine-type stimulants (ATS)-use disorders

Background

Amphetamine-type stimulants (ATS) refer to a group of synthetic stimulants including amphetamine, methamphetamine, 3,4-methylenedioxy-methamphetamine (MDMA) and related substances. ATS are highly addictive and prolonged use may result in a series of mental and physical symptoms including anxiety, confusion, insomnia, mood disturbances, cognitive impairments, paranoia, hallucinations and delusion.Currently there is no widely accepted treatment for ATS-use disorder. However, cognitive-behavioural treatment (CBT) is the first-choice treatment. The effectiveness of CBT for other substance-use disorders (e.g. alcohol-, opioid- and cocaine-use disorders) has been well documented and as such this basic treatment approach has been applied to the ATS-use disorder.

Objectives

To investigate the efficacy of cognitive-behavioural treatment for people with ATS-use disorder for reducing ATS use compared to other types of psychotherapy, pharmacotherapy, 12-step facilitation, no intervention or treatment as usual.

Search methods

We identified randomised controlled trials (RCT) and quasi-RCTs comparing CBT for ATS-use disorders with other types of psychotherapy, pharmacotherapy, 12 step facilitation or no intervention. We searched the Cochrane Drugs and Alcohol Group Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE via PubMed, Embase and five other databases up to July 2018. In addition, we examined reference lists of eligible studies and other systematic reviews. We contacted experts in the field.

Selection criteria

Eligibility criteria consisted of RCTs and quasi-RCTs comparing CBT versus other types of interventions with adult ATS users (aged 18 years or older) diagnosed by any explicit diagnostic system. Primary outcomes included abstinence rate and other indicators of drug-using behaviours.

Data collection and analysis

We used standard methodological procedures expected by Cochrane.

Main results

Only two studies met the eligibility criteria. Both studies were at low risk of selection bias and reporting bias. In one study, almost half of participants in the intervention group dropped out and this study was at high risk of attrition bias. The studies compared a single session of brief CBT or a web-based CBT to a waiting-list control (total sample size across studies of 129). Results were mixed across the studies. For the single-session brief CBT study, two out of five measures of drug use produced significant results, percentage of abstinent days in 90 days (odds ratio (OR) 0.22, 95% confidence interval (CI) 0.02 to 2.11) and dependence symptoms (standardised mean difference (SMD) -0.59, 95% CI-1.16 to-0.02). Little confidence could be placed in the results from this study give the small sample size (25 participants per group) and corresponding large CIs around the observed effects. For the web-based CBT, there was no significant difference across different outcomes. Neither study reported adverse effects. The meta-analytic mean across these two trials for drug use was not significant (SMD -0.28, 95% CI-0.69 to 0.14). In summary, overall quality of evidence was low and there was insufficient evidence to conclude that CBT is effective, or ineffective, at treating ATS use.

Authors' conclusions

Currently, there is not enough evidence to establish the efficacy of CBT for ATS-use disorders because of a paucity of high-quality research in this area.

Decreases in smoking during treatment for methamphetamine-use disorders: preliminary evidence

Despite high rates of smoking (70-90%) and the severely negative impact of smoking on physical and mental health, only 12% of individuals receiving stimulant-use disorder treatment also receive smoking-cessation treatment. The aim of this investigation was to examine the effect of a contingency management (CM) intervention targeting methamphetamine (MA) use on cigarette smoking. Sixty-one adults with MA-use disorders who were smokers were assigned to CM or standard psychosocial treatment. Rates of smoking-negative breath samples (carbon monoxide <3 ppm) were compared between the two groups while controlling for baseline carbon monoxide level, marijuana use, MA use, and time. This subgroup of mostly male (59%) participants included 44 participants in the CM group and 17 participants in the standard psychosocial treatment. Tobacco smoking participants who received CM targeting MA use were 140% (odds ratio: 2.395; 95% confidence interval: 1.073-5.346) more likely to submit a smoking-negative breath sample relative to standard psychosocial treatment during the treatment period, holding constant several other prespecified covariates. This study provides evidence that a behavioral treatment for MA use results in reductions in cigarette smoking in adults with MA-use disorder.

"I's" on the prize: A systematic review of individual differences in Contingency Management treatment response

Contingency Management is an evidence-based treatment for substance use disorders with strong potential for measurement-based customization. Previous work has examined individual difference factors in Contingency Management treatment response of potential relevance to treatment targeting and adaptive implementation; however, a systematic review of such factors has not yet been conducted. Here, we summarize and evaluate the existing literature on patient-level predictors, mediators, and moderators of Contingency Management treatment response in stimulant and/or opioid using outpatients - clinical populations most frequently targeted in Contingency Management research and clinical practice. Our search strategy identified 648 unique, peer-reviewed publications, of which 39 met full inclusion criteria for the current review. These publications considered a variety of individual difference factors, including (1) motivation to change and substance use before and during treatment (8/39 publications), (2) substance use comorbidity and chronicity (8/39 publications), (3) psychiatric comorbidity and severity (8/39 publications), (4) medical, legal, and sociodemographic considerations (15/39 publications), and (5) cognitive-behavioral variables (1/39 publications). Contingency Management was generally associated with improved treatment outcomes (e.g., longer periods of continuous abstinence, better retention), regardless of individual difference factors; however, specific patient-level characteristics were associated with either an enhanced (e.g., more previous treatment attempts, history of sexual abuse, diagnosis of antisocial personality disorder) or diminished (e.g., complex post-traumatic stress symptoms, pretreatment benzodiazepine use) response to Contingency Management. Overall, the current literature is limited but existing evidence generally supports greater benefits of Contingency Management in patients who would otherwise have a poorer prognosis in standard outpatient care. It was also identified that the majority of previous work represents a posteriori analysis of pre-existing clinical samples and has therefore rarely considered pre-specified, hypothesis-driven individual difference factors. We therefore additionally highlight patient-level factors that are currently understudied, as well as promising future directions for measurement-based treatment adaptations that may directly respond to patient traits and states to improve Contingency Management effectiveness across individuals and over time.

Cognitive-behavioural treatment for amphetamine-type stimulants (ATS)-use disorders

BACKGROUND

Amphetamine-type stimulants (ATS) refer to a group of synthetic stimulants including amphetamine, methamphetamine, 3,4-methylenedioxy-methamphetamine (MDMA) and related substances. ATS are highly addictive and prolonged use may result in a series of mental and physical symptoms including anxiety, confusion, insomnia, mood disturbances, cognitive impairments, paranoia, hallucinations and delusion.Currently there is no widely accepted treatment for ATS-use disorder. However, cognitive-behavioural treatment (CBT) is the first-choice treatment. The effectiveness of CBT for other substance-use disorders (e.g. alcohol-, opioid- and cocaine-use disorders) has been well documented and as such this basic treatment approach has been applied to the ATS-use disorder.

OBJECTIVES

To investigate the efficacy of cognitive-behavioural treatment for people with ATS-use disorder for reducing ATS use compared to other types of psychotherapy, pharmacotherapy, 12-step facilitation, no intervention or treatment as usual.

SEARCH METHODS

We identified randomised controlled trials (RCT) and quasi-RCTs comparing CBT for ATS-use disorders with other types of psychotherapy, pharmacotherapy, 12 step facilitation or no intervention. We searched the Cochrane Drugs and Alcohol Group Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE via PubMed, Embase and five other databases up to July 2018. In addition, we examined reference lists of eligible studies and other systematic reviews. We contacted experts in the field.

SELECTION CRITERIA

Eligibility criteria consisted of RCTs and quasi-RCTs comparing CBT versus other types of interventions with adult ATS users (aged 18 years or older) diagnosed by any explicit diagnostic system. Primary outcomes included abstinence rate and other indicators of drug-using behaviours.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Only two studies met the eligibility criteria. Both studies were at low risk of selection bias and reporting bias. In one study, almost half of participants in the intervention group dropped out and this study was at high risk of attrition bias. The studies compared a single session of brief CBT or a web-based CBT to a waiting-list control (total sample size across studies of 129). Results were mixed across the studies. For the single-session brief CBT study, two out of five measures of drug use produced significant results, percentage of abstinent days in 90 days (odds ratio (OR) 0.22, 95% confidence interval (CI) 0.02 to 2.11) and dependence symptoms (standardised mean difference (SMD) -0.59, 95% CI -1.16 to -0.02). Little confidence could be placed in the results from this study give the small sample size (25 participants per group) and corresponding large CIs around the observed effects. For the web-based CBT, there was no significant difference across different outcomes. Neither study reported adverse effects. The meta-analytic mean across these two trials for drug use was not significant (SMD -0.28, 95% CI -0.69 to 0.14). In summary, overall quality of evidence was low and there was insufficient evidence to conclude that CBT is effective, or ineffective, at treating ATS use.

AUTHORS' CONCLUSIONS

Currently, there is not enough evidence to establish the efficacy of CBT for ATS-use disorders because of a paucity of high-quality research in this area.

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.

Racial-Ethnic Disparities in First-Episode Psychosis Treatment Outcomes From the RAISE-ETP Study

OBJECTIVE

This study examined racial and ethnic differences in treatment outcomes among participants in a randomized controlled trial of an intervention for first-episode psychosis called NAVIGATE.

METHODS

Secondary data analyses were conducted for participants randomly assigned to usual community care (N=181) and NAVIGATE (N=223). Generalized estimating equations assessed whether race and ethnicity were associated with psychiatric symptoms and service use (medication management, family psychoeducation, and individual therapy) over a 24-month treatment period, accounting for baseline symptoms, duration of untreated psychosis, and insurance status.

RESULTS

Among persons in usual community care, non-Hispanic blacks scored significantly higher throughout treatment on measures of positive symptoms (β=2.15, p=.010), disorganized thoughts (β=1.15, p=.033), and uncontrolled hostility (β=.74, p=.027), compared with non-Hispanic whites, and non-Hispanic blacks were less likely than non-Hispanic whites to receive individual therapy (OR=.45, p=.001). Families of Hispanic participants in usual community care were less likely than non-Hispanic white families to receive family psychoeducation (OR=.20, p=.01). For NAVIGATE participants, race and ethnicity were not associated with differences in psychiatric symptoms over time; families of non-Hispanic black participants were less likely than those of non-Hispanic white participants to receive family psychoeducation (OR=.53, p=.009). Hispanic participants in NAVIGATE were more likely than non-Hispanic white participants to receive medication management (OR=2.93, p=.001).

CONCLUSIONS

In usual community care, non-Hispanic blacks scored higher on measures of psychiatric symptoms and were less likely to receive important services, compared with non-Hispanic whites. In NAVIGATE, racial and ethnic differences in psychiatric symptoms were not evident, although non-Hispanic blacks were less likely than non-Hispanic whites to receive family psychoeducation.

Effectiveness of Integrated Dual Diagnosis Treatment (IDDT) in severe mental illness outpatients with a co-occurring substance use disorder

Integrating substance use disorder treatment with psychiatric treatment is considered more favourable then treating these disorders parallel or sequential, but the evidence base is inconclusive. We examined the effectiveness of Integrated Dual Diagnosis Treatment (IDDT) on substance use in severe mental illness outpatients with substance use disorders. IDDT is a collaborative, multidisciplinary team approach in which motivational interviewing is a key element. In addition, we also examined the effects of IDDT implementation on skills and knowledge of mental health care professionals. A randomized controlled stepped-wedge cluster trial was performed in 6 functional assertive cummunity treatment teams. We included 37 clinicians who were given a three-day IDDT training. Our primary outcome was days of substance use at follow up, 12 months after IDDT implementation. This was assessed in 154 included patients and was measured with the Measurement in the Addiction for Triage and Evaluation. After implementation of IDDT we found a reduction in the number of days patients used alcohol or drugs, but no improvements on other secondary outcomes such as psychopathology, functioning, therapeutic alliance or motivation to change. Also, IDDT training did not seem to improve clinicians' knowledge, attitudes and motivational interviewing skills. Effects on our secondary outcomes may have been limited by the absence of a training effect in our clinicians. Our study clearly underlines the complexity of disseminating IDDT and in particular motivational interviewing.

Contingency management intervention targeting co-addiction of alcohol and drugs among American Indian adults: Design, methodology, and baseline data

BACKGROUND/AIMS

American Indian adults have some of the highest alcohol abstinence rates compared to the overall US population. Despite this, many American Indian people are more likely to concurrently use alcohol and illicit drugs and are less likely to participate and remain in outpatient treatment for alcohol and other drug use compared to the general US population. There is limited knowledge about effective interventions targeting alcohol and drug co-addiction among American Indian adults. Contingency management is a behavioral intervention designed to increase drug abstinence by offering monetary incentives in exchange for drug and alcohol negative urine samples. We aim to evaluate and describe a culturally tailored contingency management intervention to increase alcohol and other drug abstinence among American Indian adults residing in a Northern Plains reservation.

METHODS

This 2 × 2 factorial, randomized controlled trial currently includes 114 American Indian adults with alcohol and/or drug dependence who are seeking treatment. Participants were randomized into one of four groups that received (1) contingency management for alcohol, (2) contingency management for other drug, (3) contingency management for both substances, or (4) no contingency management for either substance. We present descriptive, baseline data to characterize the sample and describe the modified contingency management approach that is specific to the community wherein this trial was being conducted.

RESULTS

The sample is 49.1% male, with an average age of 35.8 years (standard deviation = 10.4 years). At baseline, 43.0% of the sample tested positive for ethyl glucuronide, 50.9% of participants self-reported methamphetamine as their most used drug, 36.8% self-reported cannabis, and 12.3% self-reported prescription opiates as their most used drug. Among randomized participants, 47.4% tested positive for cannabis, 28.1% tested positive for methamphetamine, 16.7% tested positive for amphetamines, and 2.1% tested positive for opiates.

CONCLUSION

This is the first study to examine a culturally tailored contingency management intervention targeting co-addiction of two substances among American Indian adults. By establishing a tribal-university partnership to adapt, implement, and evaluate contingency management, we will increase the literature on evidence-based addiction treatments and research, while improving trust for addiction interventions among American Indian communities through ongoing collaboration. Moreover, results have implications for the use of contingency management as an intervention for co-addiction in any population.

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.

Pilot investigation: randomized-controlled analog trial for alcohol and tobacco smoking co-addiction using contingency management

Contingency management (CM) is associated with decreases in off-target drug and alcohol use during primary target treatment. The primary hypothesis for this trial was that targeting alcohol use or tobacco smoking would yield increased abstinence in the opposite, nontargeted drug. We used a 2 [CM vs. noncontingent control (NC) for alcohol]×2 (CM vs. NC for smoking tobacco) factorial design, with alcohol intake (through urinary ethyl glucuronide) and tobacco smoking (through urinary cotinine) as the primary outcomes. Thirty-four heavy-drinking smokers were randomized into one of four groups, wherein they received CM, or equivalent NC reinforcement, for alcohol abstinence, smoking abstinence, both drugs, or neither drug. The CM for alcohol and tobacco group had only two participants and therefore was not included in analysis. Compared with the NC for alcohol and tobacco smoking group, both the CM for the tobacco smoking group [odds ratio (OR)=12.03; 95% confidence interval (CI): 1.50-96.31] and the CM for the alcohol group (OR=37.55; 95% CI: 4.86-290.17) submitted significantly more tobacco-abstinent urinalyses. Similarly, compared with the NC for the alcohol and tobacco group, both the CM for smoking (OR=2.57; 95% CI: 1.00-6.60) and the CM for alcohol groups (OR=3.96; 95% CI: 1.47-10.62) submitted significantly more alcohol-abstinent urinalyses. These data indicate cross-over effects of CM on indirect treatment targets. Although this is a pilot investigation, it could help to inform the design of novel treatments for alcohol and tobacco co-addiction.