As this remains a public health crisis in the U.S., it’s more important than ever to take stock of what works in treating substance use issues. A recent systematic review and meta-analysis found that contingency management, a specific type of therapy that rewards patients for positive behavior, can improve outcomes of opioid use disorder.
The Research
Research has shown that contingency management effectively treats substance use and related disorders. It is a type of behavioral therapy in which individuals are rewarded for evidence of positive behavioral change. Most often, the reward is monetary. Despite its rates of success, contingency management is a seldom-used therapy modality due to a lack of familiarity among psychiatrists and other mental health professionals. To review the efficacy of contingency management for treating opioid use disorder, researchers consulted three databases to identify studies examining contingency management for medical treatment for opioid use disorder. After narrowing down the reports for eligibility, researchers were left with 74 studies that met full inclusion criteria. This included data from 10,444 patients. The findings, published in JAMA Psychiatry, revealed that contingency management using financial incentives improved outcomes in six common clinical problems that come up during medication for opioid use disorder: illicit-opioid use, psychomotor stimulant use, polysubstance use, cigarette smoking, therapy attendance, and medication adherence. Decreasing psychomotor stimulant use is important because, as the researchers note in a press release, the use of psychomotor stimulants, such as cocaine or methamphetamine, is a “major driver” behind the increase in overdose rates because these drugs are often cut with black-market synthetic opioids, such as fentanyl. The findings also revealed that treatment effects often dissolved after contingency management ends. Researchers state that this isn’t surprising and is consistent with other maintenance therapy modalities.
Other Methods of Treating Addiction
While researchers urge policymakers to “make concerted efforts to support broad dissemination of contingency management to the many community clinics throughout the U.S.,” other methods are also being used to fight the opioid crisis. Addiction psychiatrist Allen Masry, MD, points to the successes of the biospsychosocial model, which is used at the addiction treatment and recovery clinic at which he serves as head psychiatrist, All in Solutions. “This means that we treat the biology, psychology and social issues,” Masry says. “So, a program that incorporates medications, helps a person deal with their thinking and offer social supports is a program that is successful.” At Masry’s clinic, this model works as a sort of holistic healing method, enabling patients to work through life tasks together, attend therapy to process psychological aspects of addiction and get medication-assisted treatment to treat what can be attributed to biology. “Good care coupled with enhancing patients’ self-esteem and self-efficacy is the core of treatment, in my opinion,” Masry says. In addition to other common methods of treatment like detoxification and 12-step facilitation, prevention is also an important part of fighting the opioid crisis. Adam Ackerman, MD, physician lead and co-director of the Opioid Stewardship Program at Yale New Haven Health, mentions the importance of aiming for “right-size” opioid prescriptions to help patients still manage pain while eliminating the potential for abuse or addiction.
Addressing the Root Issue
The opioid epidemic is a crossroad of crises, from a historic lack of FDA oversight on the prescription of pain medications, to lack of access to proper medical care and addiction treatment services, to the incredible impact of addiction on social and economic welfare. To address this, the Department of Health and Human Services has announced plans to improves access to treatment, promote use of overdose-reversing drugs, improve public health surveillance and research, advance improved practices for pain management and holding pharmaceutical companies accountable. But in a crisis as life-threatening as this, the need for change is urgent, especially when it comes to mental health professionals’ ability to provide adequate care to their patients. While the treatment paradigms are there, Masry says, the resources to use them aren’t available for a number of reasons. If it were easier for addiction treatment centers and providers to get paid for their work, they could spend more time treating opioid use. “It is my belief that the areas that should be addressed are the stigma of opioid addiction, increasing funding towards opioid addiction through redistribution of government spending from the law enforcement side to the treatment side and making it easier for physicians to treat patient suffering from addictions with regards to insurance payments,” Masry says. Moving toward a less stigmatized and criminalized perception of opioid addiction could increase resources available to patients and make sobriety a much easier goal to reach.
