Contingency Management Program Research Articles

U.S. trends in methamphetamine-involved psychiatric hospitalizations in the United States, 2015–2019

BackgroundIn the U.S., overdose deaths and substance treatment admissions related to methamphetamine are rising. This study aims to measure and compare U.S. temporal trends in methamphetamine-involved psychiatric hospitalizations. MethodsWe conducted a population-based, trend analysis of U.S. psychiatric hospitalizations and calculated quarterly (Q) rates per 100,000 population of substance-involved psychiatric hospitalizations. We assessed U.S. regional quarterly percentage hospitalization rate changes using Joinpoint regression. ResultsFrom Q4 2015-Q4 2019, there were 963,202 psychiatric hospitalizations, 50,223 (5.2 %) involved methamphetamine and 102,877 (10.7 %) involved opioids and/or cocaine without methamphetamine. Methamphetamine-involved psychiatric hospitalization rates increased by 68.0 %, psychiatric hospitalizations rates involving opioid and/or cocaine without methamphetamine decreased by 22 %, while nonsubstance-involved psychiatric hospitalizations rates remained unchanged. The largest significant increases in methamphetamine-involved psychiatric hospitalization rates were among people >61 years old, males, and Midwesterners. Methamphetamine-involved psychiatric hospitalization rates doubled among Black patients. The largest average percent increase among methamphetamine-involved psychiatric hospitalizations was 10.2 % from Q4 2015-Q2 2017 in the Midwest. Conclusion and relevanceMost psychiatric hospitalizations did not involve substances. Methamphetamine-involved psychiatric hospitalizations greatly increased while opioid-involved psychiatric hospitalizations decreased, but involved more total encounters. Greater access to harm reduction services, contingency management programs, and mental health services is urgently needed.

The moderating role of sex in the relationship between cannabis use treatment admission profile and treatment processes and outcomes: A gender perspective

BackgroundGender-specific interventions are crucial in addressing substance use disorders —particularly cannabis use disorder — as they allow for tailored therapeutic approaches and increase the likelihood of successful outcomes. However, differences in therapeutic processes and outcomes between males and females are often not observed, making the prognosis and development of such interventions more difficult. ObjectiveThis study aimed to examine the moderating role of sex in the relationship between treatment admission profile characterized by indicators of cannabis use and sociodemographic sources of gender inequality (e.g., employment status) and adherence and outcome at discharge. MethodA multicentric retrospective observational study was conducted with a sample of 3,814 outpatients diagnosed with cannabis use disorder. Electronic health records were used for data analysis. ResultsThe interaction between sex and the number of children, as well as pre-treatment cannabis use, predicted lower treatment adherence, particularly among females. Additionally, the interaction between sex and the number of children predicted outcomes at discharge, with females showing a higher likelihood of dropout compared to males. Discussion and conclusionEnhanced comprehensive treatment with intensified contingency management programs should be prioritized for females (especially those with children) who have consumed cannabis in the month before treatment. Adopting a treatment policy framework incorporating sex/gender-sensitive therapist training and evaluative measures is essential for optimizing treatment outcomes for all patients.

A new approach to urinalysis: effectiveness of a contingency management program among adolescent offenders in Spain.

When addressing antisocial behaviour among adolescents, programs based on the paradigm of positive psychology through enhancing self-efficacy have demonstrated their effectiveness in furthering the positive development of young people with a history of antisocial behaviour. Nevertheless, there has been little research into the effectiveness of these type of programs in mitigating substance abuse among juvenile offenders. The aim of this paper is to analyse the effectiveness of a contingency management program in reducing the prevalence of relapses into drug consumption among adolescents who have committed serious crimes. The study consisted of a sample of 91 male adolescents, between 15 and 19 years, in juvenile detention, who were divided into two treatment groups. For both groups, biological testing was used to detect drug consumption upon their re-turn from leave permits from the Centre. The quasi-experimental group had significantly lower rates of relapse than the quasi-control group. Furthermore, being part of the quasi-experimental group was a significant predictor of reduced rates of relapses. The results suggest that the incorporation of treatment strategies which reinforce feelings of self-efficacy and adequate orientation towards the future, as a complement to disciplinary sanctions, are effective in reducing relapses in drug use among adolescent offenders.

Frequent Use of Contingency Management and Opioid Treatment Programs that Provide Treatment for More than Only Opioid Use Disorder

Contingency management is an effective behavioral intervention for treating substance use disorders that provides patients with incentives for objective verification of completed targeted recovery behaviors including abstinence from substances, attending treatment, and medication adherence. Accredited/licensed opioid treatment programs provide effective, medications for opioid use disorder. This study evaluated the prevalence of frequent contingency management use among a national sample of opioid treatment programs in the U.S. ( N = 672). A binary logistic regression model examined factors associated with providing contingency management, including state-level fatal overdoses, number of pharmacotherapies, outpatient treatment, facility ownership, and residential treatment. Most evaluated facilities provided contingency management ( n = 440; 65.5%). Facilities that prescribed more pharmacotherapies, were located in states with high drug overdose death rates, and for-profit (compared to nonprofit) providers were more likely to offer contingency management. Because contingency management effectively treats substance use disorders, contingency management should be offered more broadly across opioid treatment programs.

Federal legal and regulatory aspects of contingency management incentives

ObjectiveIncentives are an integral part of Contingency Management (CM) Programs for substance use disorder treatment, primarily for the treatment stimulant use disorders, but because stimulant use often co-occurs with opioid use, the Substance Abuse and Mental Health Services Administration (SAMHSA) permits the use of CM incentives as a part of its State Opioid Response grant program. However, incentives implicate federal laws and could result in either financial penalties or criminal sanctions against programs that use them. MethodsThe U.S. Department of Health and Human Services Office of Inspector General (OIG) is tasked with enforcing key federal laws that address the issues of kick-backs, inducements, and false claims. By looking at these laws and regulations, this paper seeks to create a clearer understanding of the the barriers providers face when utilizing CM, as well as the guardrails that can be put in place to alleviate those barriers. ResultsThis paper distills key concerns raised by the OIG and suggests critical guardrails that militate against fraud, waste and abuse. Conclusion: Following the recommended guardrails should allow providers to employ CM strategies to help their patients by making clear that the intent is to help patients without engaging in kickbacks, illegal inducements or false claims.

History and current status of contingency management programs in the Department of Veterans Affairs

ObjectiveThis article describes the Department of Veterans Affairs (VA) national implementation of contingency management within VA substance use disorder (SUD) treatment programs. Methods: The rationale for implementing CM, role of VA leadership, and training and supervision procedures are detailed. The role of the Veterans Canteen Service (VCS) in sustaining the CM implementation through the donation of incentives is outlined. Updated outcomes from the primary program, CM to incentivize stimulant abstinence, are provided. Data presented were gathered from June 2011 to January 2023, from VA facilities across the country. ResultsMore than 6000 Veterans from 119 VA facilities have received CM in a 12-week program in which two urine samples are obtained per week, with 92% of the samples negative for the targeted substance. Two other CM pilot projects are described. The first incentivizes adherence to injectable medications for opioid and alcohol use disorders, with over 580 veterans from 27 VA sites participating to date. The second incentivized smoking cessation in 312 patients from four sites. A new initiative in which CM is implemented in smaller community-based VA facilities through use of onsite prize cabinets is presented and the possibility of providing CM remotely in VA is discussed. ConclusionsIt has proved feasible to implement abstinence CM and several other CM pilot programs at many VA facilities. Factors that contributed to the success of the VA CM rollout, challenges that were encountered along the way, and lessons learned that may facilitate wider use of CM outside VA are discussed.

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.

Feasibility, Engagement, and Usability of a Remote, Smartphone-Based Contingency Management Program as a Treatment Add-On for Patients Who Use Methamphetamine: Single-Arm Pilot Study.

In the United States, methamphetamine-related overdoses have tripled from 2015 to 2020 and continue to rise. However, efficacious treatments such as contingency management (CM) are often unavailable in health systems. We conducted a single-arm pilot study to evaluate the feasibility, engagement, and usability of a fully remotely delivered mobile health CM program offered to adult outpatients who used methamphetamine and were receiving health care within a large university health system. Participants were referred by primary care or behavioral health clinicians between September 2021 and July 2022. Eligibility criteria screening was conducted by telephone and included self-reported methamphetamine use on ≥5 out of the past 30 days and a goal of reducing or abstaining from methamphetamine use. Eligible participants who agreed to take part then completed an initial welcome phase that included 2 videoconference calls to register for and learn about the CM program and 2 "practice" saliva-based substance tests prompted by a smartphone app. Participants who completed these welcome phase activities could then receive the remotely delivered CM intervention for 12 consecutive weeks. The intervention included approximately 24 randomly scheduled smartphone alerts requesting a video recording of themselves taking a saliva-based substance test to verify recent methamphetamine abstinence, 12 weekly calls with a CM guide, 35 self-paced cognitive behavioral therapy modules, and multiple surveys. Financial incentives were disbursed via reloadable debit cards. An intervention usability questionnaire was completed at the midpoint. Overall, 37 patients completed telephone screenings, with 28 (76%) meeting the eligibility criteria and consenting to participate. Most participants who completed a baseline questionnaire (21/24, 88%) self-reported symptoms consistent with severe methamphetamine use disorder, and most had other co-occurring non-methamphetamine substance use disorders (22/28, 79%) and co-occurring mental health disorders (25/28, 89%) according to existing electronic health records. Overall, 54% (15/28) of participants successfully completed the welcome phase and were able to receive the CM intervention. Among these participants, engagement with substance testing, calls with CM guides, and cognitive behavioral therapy modules varied. Rates of verified methamphetamine abstinence in substance testing were generally low but varied considerably across participants. Participants reported positive opinions about the intervention's ease of use and satisfaction with the intervention. Fully remote CM can be feasibly delivered within health care settings lacking existing CM programs. Although remote delivery may help reduce barriers to treatment access, many patients who use methamphetamine may struggle to engage with initial onboarding. High rates of co-occurring psychiatric conditions in the patient population may also contribute to uptake and engagement challenges. Future efforts could leverage greater human-to-human connection, more streamlined onboarding procedures, larger incentives, longer durations, and the incentivization of non-abstinence-based recovery goals to increase uptake and engagement with fully remote mobile health-based CM.

Contingency Management in a Perinatal Substance Exposure Clinic

Project CARA, a perinatal substance exposure clinic, has implemented a contingency management program that targets appointment attendance for patients with any use disorder, regardless of substance or urine drug screen results.

Expanding access to treatment for stimulant use disorder in a frontier state: A qualitative study of contingency management and TRUST program implementation in Montana

BackgroundThe client population eligible for treatment services supported by State Opioid Response (SOR) grant funding, administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), was expanded to include individuals with a stimulant use disorder (stimUD) in 2020. Due to a significant need to improve services for individuals with stimUD in Montana, the Behavioral Health and Developmental Disabilities Division (BHDD) of the Montana Department of Public Health and Human Services used the grant opportunity to work with experts in the field of stimUD to pilot contingency management (CM) and the Treatment for Individuals who Use Stimulants (TRUST) treatment model. The CM protocol included twice weekly visits for twelve weeks, using an escalating schedule of gift card incentives contingent upon stimulant-negative urine samples. TRUST is a multi-component treatment program, incorporating exercise, group therapy, and individual therapy with content guided by cognitive behavioral therapy (CBT) and clinical research associate (CRA) materials. In addition to SOR dollars, BHDD used additional funding for CM reinforcers provided by state tax dollars to meet research-supported target incentive totals. MethodsIn this pilot project, TRUST/CM was implemented by four state-approved treatment providers and three Federally Qualified Health Centers (FQHCs), all of which had little prior experience with CM as a component of their treatment programs for stimUD. This article examines the processes of training staff, the experiences among staff with initial implementation of the treatment model, and the client characteristics of initial pilot treatment cohorts. Data for this study include primary qualitative data collected from providers, as well as client characteristics collected on the SAMHSA Government Performance and Results Act (GPRA) data collection form. ResultsSeven sites were trained in TRUST/CM, and these sites enrolled a total of 70 patients in the program. Qualitative data collected through interviews with site staff revealed the following themes: the value of intensive technical assistance being integrated in the program, concerns about staff retention and loss of expertise, adjustments of target client populations, and the importance of creative strategies for the provision of evidence-informed incentive totals. ConclusionsTRUST/CM was implemented throughout Montana, including rural and urban communities. Qualitative and quantitative data support that providers viewed the CM component as beneficial for treatment retention and improved outcomes for people with stimUD. These implementation study results provide insight into challenges and solutions for providers who are considering the implementation of CM within either a state-approved substance use treatment clinic or FQHC.

Implications of epidemic-pandemic convergence for routine care adoption of contingency management: A case study.

The significant increase in opioid-related drug overdoses during the coronavirus disease (COVID-19) pandemic has put an unprecedented burden on hospital emergency departments, who saw as high as an approximate 150% increase in emergency department (ED) admission rates in the initial months of the pandemic. Although overdose is a clear sign of problem drug use, only a small proportion of nonfatal overdose patients enroll in treatment within 30 days of their overdose. To bridge the gap between opioid overdoses and treatment entry, a smartphone-smart debit card contingency management program was developed to promote entry into medication-assisted treatment by out-of-treatment opioid users who have recently received care in a hospital emergency department. The case study described in this article highlights a successful implementation of this intervention despite numerous disruptions related to COVID-19 that would have made engagement difficult without the remote access to contingency management provided by this technology. Patient status over time is presented in conjunction with contingency management earnings. Technology-based contingency management may provide improved scalability, rigorous outcomes metrics, and lower costs than prior onsite, manual contingency management (CM) approaches. The COVID-19 pandemic, in combination with the opioid epidemic has created a context in which historical obstacles to the adoption of contingency management may be overcome. This case study demonstrates the potential utility of smartphone-based contingency management when in-person care is difficult to access or disrupted. The requirement for further research demonstrating the efficacy of these approaches is discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Transcranial Stimulation for the Treatment of Stimulant Use Disorder

The increasing prevalence of stimulant use disorder (StUD) involving methamphetamine and cocaine has been a growing healthcare concern in the United States. Cocaine usage is associated with atherosclerosis, systolic and diastolic dysfunction, and arrhythmias. Furthermore, approximately one of every four MIs is cocaine-induced among patients aged 18 to 45. Methamphetamine use has been associated with nerve terminal damage in the dopaminergic system resulting in impaired motor function, cognitive decline, and co-morbid psychiatric disorders. Current treatment options for StUD are extremely limited, and there are currently no FDA-approved pharmacotherapies. Behavioral interventions are considered first-line treatment; however, in a recent meta-analysis comparing behavioral treatment options for cocaine, contingency management programs provided the only significant reduction in use. Current evidence points to the potential of various neuromodulation techniques as the next best modality in treating StUD. The most promising evidence thus far has been transcranial magnetic stimulation which several studies have shown to reduce risk factors associated with relapse. Another more invasive neuromodulation technique being studied is deep-brain stimulation, which has shown promising results in its ability to modulate reward circuits to treat addiction. Results showing the impact of transcranial magnetic stimulation (TMS) in the treatment of StUD are limited by the lack of studies conducted and the limited understanding of the neurological involvement driving addiction-based diseases such as StUD. Future studies should seek to provide data on consumption-reducing effects rather than craving evaluations.

Promoting vegetable acceptance in toddlers using a contingency management program: A cluster randomised trial

Children learn to accept novel foods by repeated exposure to these foods. In the current study, we investigated in toddlers whether a contingency management program (The Vegetable Box), comprising repeated vegetable taste exposure with contingent non-food rewards, is particularly potent at increasing recognition of and willingness to try vegetables. A total of 598 children (1–4 years old) recruited at 26 different day-care centres in the Netherlands took part. The day-care centres were randomly assigned to one of three conditions (‘exposure/reward’, ‘exposure/no reward’, or ‘no exposure/no reward’). At the start and directly after the 3-month intervention period, all children were asked to identify various vegetables (recognition test; max score = 14) and whether they would like to taste and consume 1 or 2 bite-size pieces of tomato, cucumber, carrot, bell pepper, radish, and cauliflower (willingness to try test). Data were analysed with linear mixed-effects regression analyses (for recognition and willingness to try separately) with condition and time as independent variables, and adjusting for day-care centre clustering. Vegetable recognition significantly increased in both the ‘exposure/reward’ and the ‘exposure/no reward’ group, relative to the ‘no exposure/no reward’ control group. The willingness to try vegetables only increased significantly in the ‘exposure/reward’ group. Offering vegetables to children at day-care centres significantly increased toddlers' ability to identify various vegetables, but rewards contingent upon tasting vegetables appear particularly effective to also increase children's willingness to try (i.e., taste and consume) different vegetables. This result corroborates and strengthens previous findings demonstrating the efficacy of similar reward-based programs.

Promising Effects of Socioemotional Skills Training in Bilingual Children With Attention and Behavioral Concerns

<h3>Research Objectives</h3> Bilingualism is present in every country of the world, class of society, and age group. Yet, monolingual-focused health practices, policies, and research dominate delivery of care, contributing to health disparities. To investigate the role of language in treatment delivery, the present study examined the effect of second language use on socioemotional skills in bilingual children with attention and behavioral concerns. <h3>Design</h3> A two-level (students, schools) cluster randomized controlled design accounted for treatment [Collaborative Life Skills (CLS) versus control] across 23 elementary schools. In addition, four schools received treatment in Spanish (parent group) and combination of Spanish and English (child skills training, classroom intervention). <h3>Setting</h3> The CLS program integrates empirically-supported treatments (parent training, classroom intervention, and child skills training) in school settings to encourage accessibility and sustainability. <h3>Participants</h3> Students were referred to the program by school staff for substantial inattention, hyperactivity/impulsivity, and/or related academic/social problems. We conducted secondary data analyses on 120 monolingual and 37 bilingual children (Grades 2-5, Mage=8.32, SDage = 1.08, 28% girls, 35% Latinx, 23% White, 18% Asian, 17% multiracial, 8% Black). <h3>Interventions</h3> Mental health professionals led nine 40-minute child group sessions during school hours. Modules targeted social functioning (e.g., self-control, friendship making, assertion) and independence (e.g., homework skills, routines). Socioemotional skills were taught through didactic instruction, behavioral rehearsal, and in-vivo practice. A reward-based contingency management program was used to manage behaviors and reinforce new skills. <h3>Main Outcome Measures</h3> ADHD symptoms, ADHD impairment. <h3>Results</h3> A mixed effects model revealed a treatment (CLS, control) by language status (bilingual, monolingual) interaction. A greater reduction in parent-reported impairment was found for bilingual children compared to monolingual children. <h3>Conclusions</h3> Socioemotional skills appear to especially benefit bilingual children with attentional and behavioral concerns. Future studies to understand mechanisms are warranted. Receiving socioemotional skills training in second language may help to down-regulate negative emotions, which may be conducive to learning socioemotional skills in clinical settings. <h3>Author(s) Disclosures</h3> No conflicts of interest to disclose.

Promoting vegetable acceptance in toddlers using a contingency management program: a cluster randomised trial

Promoting vegetable acceptance in toddlers using a contingency management program: a cluster randomised trial

Addressing stimulant use disorder through state opioid response grants from the substance abuse and mental health services administration: Missouri’s initial approach

ABSTRACT Background: The alarming growth of stimulant-involved deaths underscores the urgent need for states to expand existing opioid-specific approaches to intentionally reach and serve people who use stimulants. Recent permission from federal agencies has allowed states to spend grant funding that was previously restricted to opioid-related activities on approaches addressing stimulant use. Objectives: This manuscript describes the rationale, methods, and initial results supporting the implementation of Missouri’s recent stimulant-focused efforts – including previously-prohibited activities such as Contingency Management and fentanyl test strip distribution. Methods: Missouri’s State Opioid Response team facilitated the design and implementation of Contingency Management pilot programming abiding by federal spending limits of no more than $75 of incentives per client, mass distribution of fentanyl test strips, and publicly accessible harm reduction trainings and materials specific to stimulant use. Data sources used for initial evaluations included state-level treatment claims, fentanyl test strip distribution counts by type and region of organizations receiving them, and qualitative feedback from stakeholders. Results: Six substance use treatment agencies developed Contingency Management programs, serving 29 individuals in the first nine months. Over 20,000 fentanyl test strips were distributed using a prioritization system designed to reach those most likely to benefit from their use. Conclusions: Recent federally funded efforts to better address stimulant use in Missouri have increased access to evidence-based treatment and harm reduction resources. Lessons learned from early implementation, especially those regarding time allowed for program development and how best to ensure equitable resource distribution, will inform future stimulant-focused program efforts.

California is first state to establish Medicaid waiver for CM

Last week, California's Department of Health Care Services (DHCS) issued the request for applications (RFA) for counties to implement a $58.5 million pilot contingency management (CM) program for Medicaid patients in the state.

CM for stimulant use disorder: No limit imposed by OIG

The oft‐stated assumption that the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) bans any gifts of $75 or more as a contingency in the treatment of stimulant use disorder is incorrect. From the Federal Register announcement: “Gifts that implicate the Beneficiary Inducements CMP that exceed these dollar limits are not prohibited but are analyzed on a case‐by‐case basis for compliance under the statute,” according to the OIG December 2020 Federal Register final rule (https://www.federalregister.gov/documents/2020/12/02/2020‐26072/medicare‐and‐state‐health‐care‐programs‐fraud‐and‐abuse‐revisions‐to‐safe‐harbors‐under‐the). “We highlight, however, that this nominal value guidance applies to the value of in‐kind items and services, not to the value of incentive payments in the form of cash or cash equivalents. In other words, cash and cash‐equivalent payments under $75 would not be covered by this guidance. Moreover, this guidance applies only with respect to the Beneficiary Inducements CMP and not to the Federal anti‐kickback statute. Furthermore, we are aware that some industry stakeholders may be under a misimpression that OIG prohibits contingency management program incentives above $75. There is no OIG‐imposed $75 limitation on contingency management program incentives. Rather, the Federal anti‐kickback statute may constrain the ability of individuals or entities to offer contingency management program incentives of any value to Federal health care program beneficiaries, depending on the facts of the arrangement. Moreover, in‐kind incentives above the $75 annual, aggregate limit, and all cash or cash‐equivalent incentives regardless of the amount, must be analyzed on the basis of their specific facts for compliance with the Beneficiary Inducements CMP.”

Comparison of Treatments for Cocaine Use Disorder Among Adults

In the US and the United Kingdom, cocaine use is the second leading cause of illicit drug overdose death. Psychosocial treatments for cocaine use disorder are limited, and no pharmacotherapy is approved for use in the US or Europe. To compare treatments for active cocaine use among adults. PubMed and the Cochrane Database of Systematic Reviews were searched for clinical trials published between December 31, 1995, and December 31, 2017. This meta-analysis was registered on Covidence.org (study 8731) on December 31, 2015. Clinical trials were included if they (1) had the term cocaine in the article title; (2) were published between December 31, 1995, and December 31, 2017; (3) were written in English; (4) enrolled outpatients 18 years or older with active cocaine use at baseline; and (5) reported treatment group size, treatment duration, retention rates, and urinalysis results for the presence of cocaine metabolites. A study was excluded if (1) more than 25% of participants were not active cocaine users or more than 80% of participants had negative test results for the presence of cocaine metabolites at baseline and (2) it reported only pooled urinalysis results indicating the presence of multiple substances and did not report the specific proportion of positive test results for cocaine metabolites. Multiple reviewers reached criteria consensus. Of 831 records screened, 157 studies (18.9%) met selection criteria and were included in the analysis. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. Search results were imported from PubMed XML into Covidence.org then Microsoft Excel. Data extraction was completed in 2 iterations to ensure fidelity. Analyses included a multilevel random-effects model, a multilevel mixed-effects meta-regression model, and sensitivity analyses. Treatments were clustered into 11 categories (psychotherapy, contingency management programs, placebo, opioids, psychostimulants, anticonvulsants, dopamine agonists, antidepressants, antipsychotics, miscellaneous medications, and other therapies). Missing data were imputed using multiple imputation by chained equations. The significance threshold for all analyses was P = .05. Data were analyzed using the metafor and mice packages in R software, version 3.3.2 (R Foundation for Statistical Computing). Data were analyzed from January 1, 2018, to February 28, 2021. The primary outcome was the intention-to-treat logarithm of the odds ratio (OR) of having a negative urinalysis result for the presence of cocaine metabolites at the end of each treatment period compared with baseline. The hypothesis, which was formulated after data collection, was that no treatment category would have a significant association with objective reductions in cocaine use. A total of 157 studies comprising 402 treatment groups and 15 842 participants were included. Excluding other therapies, the largest treatment groups across all studies were psychotherapy (mean [SD] number of participants, 40.04 [36.88]) and contingency management programs (mean [SD] number of participants, 37.51 [25.51]). Only contingency management programs were significantly associated with an increased likelihood of having a negative test result for the presence of cocaine (OR, 2.13; 95% CI, 1.62-2.80), and this association remained significant in all sensitivity analyses. In this meta-analysis, contingency management programs were associated with reductions in cocaine use among adults. Research efforts and policies that align with this treatment modality may benefit those who actively use cocaine and attenuate societal burdens.

Treatment for kratom abuse in a contingency-management-based MAT setting: A case series.

Kratom (Mitragyna speciosa) is a plant extract that exhibits opioid agonistic activity at the µ-opioid receptor. The use of this substance has increased recently due to widespread local availability across the United States, primarily at gas stations. Repeated kratom use has been shown to have major adverse effects leading to physiological dependence and addiction similar to other opioids. We used a novel contingency management (CM) program utilizing nonmonetary reinforcers along with medication-assisted treatment (MAT) using buprenorphine in an office-based setting to treat kratom use disorder in two cases. MAT with buprenorphine in a CM-based setting was found to be an effective strategy for treating kratom use disorder.