Evaluating comparative effectiveness of psychosocial interventions adjunctive to opioid agonist therapy for opioid use disorder: A systematic review with network meta-analyses

Abstract

Background Guidelines recommend that individuals with opioid use disorder (OUD) receive pharmacological and psychosocial interventions; however, the most appropriate psychosocial intervention is not known. In collaboration with people with lived experience, clinicians, and policy makers, we sought to assess the relative benefits of psychosocial interventions as an adjunct to opioid agonist therapy (OAT) among persons with OUD. Methods A review protocol was registered a priori (CRD42018090761), and a comprehensive search for randomized controlled trials (RCT) was conducted from database inception to June 2020 in MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials. Established methods for study selection and data extraction were used. Primary outcomes were treatment retention and opioid use (measured by urinalysis for opioid use and opioid abstinence outcomes). Odds ratios were estimated using network meta-analyses (NMA) as appropriate based on available evidence, and in remaining cases alternative approaches to synthesis were used. Results Seventy-two RCTs met the inclusion criteria. Risk of bias evaluations commonly identified study limitations and poor reporting with regard to methods used for allocation concealment and selective outcome reporting. Due to inconsistency in reporting of outcome measures, only 48 RCTs (20 unique interventions, 5,404 participants) were included for NMA of treatment retention, where statistically significant differences were found when psychosocial interventions were used as an adjunct to OAT as compared to OAT-only. The addition of rewards-based interventions such as contingency management (alone or with community reinforcement approach) to OAT was superior to OAT-only. Few statistically significant differences between psychosocial interventions were identified among any other pairwise comparisons. Heterogeneity in reporting formats precluded an NMA for opioid use. A structured synthesis was undertaken for the remaining outcomes which included opioid use (n = 18 studies) and opioid abstinence (n = 35 studies), where the majority of studies found no significant difference between OAT plus psychosocial interventions as compared to OAT-only. Conclusions This systematic review offers a comprehensive synthesis of the available evidence and the limitations of current trials of psychosocial interventions applied as an adjunct to OAT for OUD. Clinicians and health services may wish to consider integrating contingency management in addition to OAT for OUD in their settings to improve treatment retention. Aside from treatment retention, few differences were consistently found between psychosocial interventions adjunctive to OAT and OAT-only. There is a need for high-quality RCTs to establish more definitive conclusions. Trial registration PROSPERO registration CRD42018090761.

Evaluating how has care been affected by the Ontario COVID-19 Opioid Agonist Treatment Guidance: Patients’ and prescribers’ experiences with changes in unsupervised dosing

“…As with many studies related to OAT, our sample was predominantly white. However, we did have similar rates of participation among male and female individuals, which is unusual for research on OUD ( Rice et al, 2020 ). Future research should include more diversity in their sample of participants to ensure a range of perspectives are expressed.…”

Relative effectiveness of medications for opioid-related disorders: A systematic review and network meta-analysis of randomized controlled trials

“…For the multi-arm trials, we took the following analytic approach to evidence synthesis. First, in studies with three or more treatment arms, we extracted all intervention information but included only the eligible arms for evidence synthesis, following the approach taken by Rice et al 2020 [ 27 ]. Second, in studies with two or more treatment arms with the same intervention (e.g., two arms with buprenorphine and two arms with methadone), we categorized each arm as ‘low dose’, ‘moderate dose’, or ‘high dose’ and treated two intervention arms with different medications that have the same categorization as a separate study.…”

Jail-based treatment for opioid use disorder in the era of bail reform: a qualitative study of barriers and facilitators to implementation of a state-wide medication treatment initiative

“…Stigma and misconceptions around OUD care [ 32 , 33 ] persisted, which often led to clinically inappropriate care. This was exemplified by some jails’ endorsement of extended-release naltrexone as a withdrawal medication despite this medication not being clinically indicated as such, certain providers’ preference for naltrexone over opioid agonists despite their stronger evidence-base [ 34 ], strict regimens for withdrawal management prior to MOUD initiation, mandates around counselling, and the belief that MOUD was not effective without added behavioral therapies despite evidence to the contrary [ 35 , 36 ], concerns about allowing individuals to leave the jail with buprenorphine prescriptions, and limited provision of naloxone at jail release. These practices underscore the need to establish a set of regularly updated clinical standards for all jails to follow, and processes by which jails could be held accountable to these standards.…”