Importance Medication treatment for opioid use disorder (MOUD) is efficacious, but comorbid stimulant use and other behavioral health problems often undermine efficacy. Objective To examine the association of contingency management, a behavioral intervention wherein patients receive material incentives contingent on objectively verified behavior change, with end-of-treatment outcomes for these comorbid behavioral problems. Data Sources A systematic search of PubMed, Cochrane CENTRAL, Web of Science, and reference sections of articles from inception through May 5, 2020. The following search terms were used: vouchers OR contingency management OR financial incentives. Study Selection Prospective experimental studies of monetary-based contingency management among participants receiving MOUD. Data Extraction and Synthesis Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline, 3 independent investigators extracted data from included studies for a random-effects meta-analysis. Main Outcomes and Measures Primary outcome was the association of contingency management at end-of-treatment assessments with 6 clinical problems: stimulant use, polysubstance use, illicit opioid use, cigarette smoking, therapy attendance, and medication adherence. Random-effects meta-analysis models were used to compute weighted mean effect size estimates (Cohen d) and corresponding 95% CIs separately for each clinical problem and collapsing across the 3 categories assessing abstinence and the 2 assessing treatment adherence outcomes. Results The search identified 1443 reports of which 74 reports involving 10 444 unique adult participants met inclusion criteria for narrative review and 60 for inclusion in meta-analyses. Contingency management was associated with end-of-treatment outcomes for all 6 problems examined separately, with mean effect sizes for 4 of 6 in the medium-large range (stimulants, Cohen d = 0.70 [95% CI, 0.49-0.92]; cigarette use, Cohen d = 0.78 [95% CI, 0.43-1.14]; illicit opioid use, Cohen d = 0.58 [95% CI, 0.30-0.86]; medication adherence, Cohen d = 0.75 [95% CI, 0.30-1.21]), and 2 in the small-medium range (polysubstance use, Cohen d = 0.46 [95% CI, 0.30-0.62]; therapy attendance, d = 0.43 [95% CI, 0.22-0.65]). Collapsing across abstinence and adherence categories, contingency management was associated with medium effect sizes for abstinence (Cohen d = 0.58; 95% CI, 0.47-0.69) and treatment adherence (Cohen d = 0.62; 95% CI, 0.40-0.84) compared with controls. Conclusions and Relevance These results provide evidence supporting the use of contingency management in addressing key clinical problems among patients receiving MOUD, including the ongoing epidemic of comorbid psychomotor stimulant misuse. Policies facilitating integration of contingency management into community MOUD services are sorely needed.

中文翻译：

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接受阿片类药物使用障碍药物治疗的患者的应急管理：系统评价和荟萃分析。

重要性 阿片类药物使用障碍 (MOUD) 的药物治疗是有效的，但共病兴奋剂的使用和其他行为健康问题往往会降低疗效。目的 研究应急管理（一种行为干预措施，其中患者根据客观验证的行为变化接受物质激励）与这些共病行为问题的治疗结束结果之间的关联。数据来源 对 PubMed、Cochrane CENTRAL、Web of Science 以及从开始到 2020 年 5 月 5 日的文章参考部分进行系统检索。使用以下检索词：优惠券或应急管理或财务激励。研究选择 接受 MOUD 的参与者中基于货币的应急管理的前瞻性实验研究。数据提取和综合按照系统评价和荟萃分析的首选报告项目 (PRISMA) 报告指南，3 名独立研究人员从纳入的研究中提取数据进行随机效应荟萃分析。主要结果和措施 主要结果是治疗结束评估时的应急管理与 6 个临床问题的关联：兴奋剂使用、多物质使用、非法阿片类药物使用、吸烟、治疗出勤和药物依从性。使用随机效应荟萃分析模型分别计算每个临床问题的加权平均效应大小估计值 (Cohen d) 和相应的 95% CI，并在评估戒断的 3 个类别和评估治疗依从性结果的 2 个类别中进行折叠。结果 搜索确定了 1443 份报告，其中 74 份报告涉及 10 444 名独特的成人参与者，符合叙述性审查的纳入标准，60 份报告符合荟萃分析的纳入标准。应急管理与单独检查的所有 6 个问题的治疗结束结果相关，6 个问题中的 4 个的平均效应大小处于中大范围内（兴奋剂，Cohen d = 0.70 [95% CI，0.49-0.92]；香烟使用，Cohen d = 0.78 [95% CI，0.43-1.14]；非法阿片类药物使用，Cohen d = 0.58 [95% CI，0.30-0.86]；用药依从性，Cohen d = 0.75 [95% CI，0.30-1.21] ），2 个处于中小范围（多物质使用，Cohen d = 0.46 [95% CI，0.30-0.62]；治疗出勤率，d = 0.43 [95% CI，0.22-0.65]）。与戒断和依从性类别相比，应急管理与戒断（Cohen d = 0.58；95% CI，0.47-0.69）和治疗依从性（Cohen d = 0.62；95% CI，0.40-0.84）的中等效应大小相关。控制。结论和相关性这些结果提供了证据支持使用应急管理来解决接受 MOUD 的患者的关键临床问题，包括持续流行的共病精神运动兴奋剂滥用。迫切需要制定政策促进将应急管理纳入社区 MOUD 服务。