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Cited by 161Substance Abuse Treatment and OutcomesOpioid Use Disorder TreatmentYouth, Drugs, and Violence

Comparison of Treatments for Cocaine Use Disorder Among Adults: A Systematic Review and Meta-analysis

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Bentzley, Brandon S., Han, Summer S., Neuner, Sophie, Humphreys, Keith, Kampman, Kyle M., Halpern, Casey H.·2021·JAMA Network Open
DOI 10.1001/jamanetworkopen.2021.8049PMC PMC8105751
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Abstract

Importance: 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. Objective: To compare treatments for active cocaine use among adults. Data Sources: PubMed and the Cochrane Database of Systematic Reviews were searched for clinical trials published between December 31, 1995, and December 31, 2017. Study Selection: 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. Data Extraction and Synthesis: 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. Main Outcomes and Measures: 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. Results: 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. Conclusions and Relevance: 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.

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  • Contingency management has shown the greatest effectiveness among studied interventions for stimulant use disorder and is the current standard of care.

    “Contingency management (CM) has demonstrated the best effectiveness in the treatment of stimulant use disorders (StUDs) compared to any other intervention studied and represents the current standard of care.”

    From The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder (2024) · cites this paper as [44]

    The Discussion (page not provided) reports that contingency management was the only treatment category consistently associated with a significant reduction in objectively measured cocaine use. The study concerns cocaine use disorder, not stimulant use disorders generally. It also does not establish contingency management as the current standard of care: the Introduction says there is an absence of a standard treatment for cocaine use disorder, and the Discussion calls for considering broader implementation. (LLM, conf=0.91)

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  • Multiple systematic reviews report positive effects of contingency management on methamphetamine use.

    “Multiple systematic reviews have shown positive effects of CM on methamphetamine use, 44,45”

    From The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder (2024) · cites this paper as [44]

    The Discussion (page unavailable) reports that this meta-analysis found a positive association between contingency management and reduced cocaine use, and says earlier meta-analyses suggested benefits for cocaine use. It does not report positive effects on methamphetamine use, the drug specified in the citing sentence. (LLM, conf=0.82)

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  • Strong evidence indicates that contingency management effectively increases treatment engagement and reduces stimulant use.

    “There is strong evidence that CM is an effective intervention for increasing treatment engagement and reducing stimulant use.”

    From The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder (2024) · cites this paper as [44]

    The Results and Discussion report that contingency management was consistently associated with reduced urinalysis-confirmed cocaine use. The paper does not establish that it increases treatment engagement, and its finding concerns cocaine rather than stimulant use generally. Its Conclusions also caution that the broad analysis limited the strength of its conclusions. (LLM, conf=0.86)

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Authors
Bentzley, B. S., Han, S. S., Neuner, S., Humphreys, K., Kampman, K. M., & Halpern, C. H.
Affiliations
  • Stanford Medicine (US)
  • VA Palo Alto Health Care System (US)
  • University of Pennsylvania (US)
Corresponding author
Bentzley, Brandon S.
ORCID
Venue
JAMA Network Open
Publisher
American Medical Association (AMA)
Published
2021-05-07
Volume
4
Issue
5
Pages
e218049
ISSN
2574-3805 (ISSN-L)
DOI
10.1001/jamanetworkopen.2021.8049
PMC
PMC8105751
OpenAlex
W3157239742
Cited by
161
References
222
Citations by year
2026: 32 · 2025: 39 · 2024: 41 · 2023: 29 · 2022: 15 · 2021: 5
FWCI
16.21
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • JAMA Network Open (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
  • Social Sciences › Demography › Youth, Drugs, and Violence
Keywords
cocaine dependence, cocaine treatment, psychosocial interventions, pharmacotherapy, contingency management, psychostimulants, dopamine agonists, antidepressants, antipsychotic drugs, antiepileptic drugs, treatment retention, treatment effectiveness comparison, outpatients
MeSH terms
Clinical Trials as Topic, Humans, Psychotherapy, Cocaine-Related Disorders

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