A Perfect Platform: Combining Contingency Management with Medications for Drug Abuse

Abstract

Contingency management (CM) procedures, which provide concrete reinforcers or rewards contingent on verification of discrete targeted behaviors, such as drug-free urines, have been demonstrated to be effective in a number of clinical trials. However, to date there have been only a few that have capitalized on the unique strengths and capabilities of CM as an ideal platform to improve response to or address weaknesses of many pharmacotherapies used in the treatment of drug abuse. In this review, we describe the multiple potential uses of CM as a platform for pharmacotherapy, including reducing illicit drug use in the context of agonist therapies; fostering medication compliance with antagonists, aversive agents and HIV medications; fostering a period of abstinence prior to initiation of agents used to treat comorbid psychiatric conditions or in the context of vaccines to foster adequate periods of abstinence while titer levels are building; and to enhance the effectiveness of anticraving agents through additive or synergistic effects. Although its multiple strengths render it an almost perfect platform, CM does have some weaknesses that have limited its use to date, including cost, the short-term nature of its effects, and need for training. Future treatment development of CM as a medication platform needs to counter these issues by focusing on CM applications with large potential benefit, developing simple or automated methods for CM delivery and placing greater emphasis on the process of transitioning away from formal CM treatment. KeywordsContingency management; medication compliance; medication trials; study design There has been enormous progress in recent years in the identification of empirically-supported behavioral (1) and pharmacological (2,3) treatments for a range of drug use disorders. However, despite growing consensus that combined treatments are often the more effective than monotherapies (4,5), the bulk of the literature is based on trials in which a single treatment is systematically varied, and simultaneous testing of combined treatments is comparatively rare (6). There remains much room for improvement, however, as even for our most effective therapies response is often only partial or transient for many patients, while others fail to respond at all. Furthermore, the potential effectiveness of many behavioral and pharmacologic

Current Expectations and Existing Deficits among Addiction Specialists

“…It is only natural that any profession should continue to evolve and develop its primary focus or product, and in this manner, the field of addiction treatment is no different from any other. However, because of the various factors that influence addiction treatment, primarily motivated by legislation, ongoing research, spending, and outcomes, updates in addiction treatment technology have occurred regularly but have not been widely disseminated and adopted in the field (Carroll & Rounsaville, 2007;Hoge et al, 2002). Moreover, changes in treatment interventions often reflect our expanding knowledge of addiction.…”

A New Frontier: Integrating Behavioral and Digital Technology to Promote Health Behavior

“…CM interventions targeting substance abuse, for example, use technology-based methods to detect drug metabolites and research assistants or counselors to deliver monetary consequences based on evidence of abstinence (for a review, see Silverman 2004). In addition to targeting substance use, technology can be used with CM interventions to promote medication adherence (Carroll and Rounsaville 2007). Several randomized clinical trials have demonstrated that CM can promote adherence to HAART based on MEMS cap openings in HIV-infected drug users (Rigsby et al 2000; Rosen et al 2007; Sorensen et al 2007).…”

Achieving Cannabis Cessation — Evaluating N-acetylcysteine Treatment (ACCENT): Design and implementation of a multi-site, randomized controlled study in the National Institute on Drug Abuse Clinical Trials Network

“…Cash rewards are provided to study participants for (a) cannabis abstinence, and (b) visit attendance (i.e., attending scheduled study visits). This CM intervention is based on prior use of CM in the treatment of cannabis use disorders previously reported in the literature [9, 15, 59–62]. This “two-tiered” CM approach was used with significant effect on both study retention and cannabis abstinence in a prior young adult CM study [59].…”

“…A recent meta-analysis showed modest benefit with behavioral treatments targeting CUDs (i.e., contingency management, relapse prevention, motivational interviewing, cognitive behavioral therapy, and combinations) compared to control conditions [6], yet there remains substantial room for improvement, as the majority of patients fail to achieve sustained periods of abstinence [7–9]. The development of pharmacological interventions to complement behavioral treatments represents a potential avenue to improve outcomes [10–14], and contingency management (CM) has specifically been identified as a preferred evidence-based behavioral platform to conduct pharmacotherapeutic efficacy trials [15]. Several promising agents to treat CUDs exist [16, 17], but to date, an effective medication targeting cannabis dependence in adults has not been established [12, 14, 18, 19], leaving clinicians and patients with limited options.…”