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Comparison of Treatments for Cocaine Use Disorder Among Adults: A Systematic Review and Meta-analysis
Open accessAbstract
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 (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]
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“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]
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“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]
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2 retracted
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Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement
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“…and meta-analytic work in CUD shows the strongest and most consistent benefits for contingency management, while phar-macotherapies yield mixed effects across endpoints and subgroups—reinforcing the value of the combined approach we used (NB plus weekly CBT and lifestyle counselling) [17].”
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InfluentialAdditional file 4 of Predictors of cocaine use disorder treatment outcomes: a systematic review
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Additional file 3 of Predictors of cocaine use disorder treatment outcomes: a systematic review
Palazón-Llecha, A., Caparrós, B., Trujols, J., Duran‐Sindreu, S., Batlle, F., Madre, M., & Mallorquí‐Bagué, N. (2024) · Figshare · doi:10.6084/m9.figshare.26717739
Additional file 1 of Predictors of cocaine use disorder treatment outcomes: a systematic review
Palazón-Llecha, A., Caparrós, B., Trujols, J., Duran‐Sindreu, S., Batlle, F., Madre, M., & Mallorquí‐Bagué, N. (2024) · Figshare · doi:10.6084/m9.figshare.26717733
Additional file 2 of Predictors of cocaine use disorder treatment outcomes: a systematic review
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“Contingency Management (CM) and specialized cognitive behavioral therapy (CBT) are often named as particularly effective (Kampman, 2019; Schwartz et al., 2022), with CM showing the most consistent evidence for reducing cocaine use (Bentzley et al., 2021).”
InfluentialContingency management for adherence to injectable medication for substance use disorders
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“Contingency management (CM), which provides tangible reinforcement contingent upon objective abstinence verification [23], demonstrates the most robust efficacy among behavioral modalities [24–26].”
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Editorial: Emerging treatment approaches for substance use disorders
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“Non-pharmacological interventions have also been employed to address SUDs, including cognitive behavioral therapy (CBT) (15), community reinforcement approach (16), motivational interviewing (17), and contingency management (18), with varying degrees of ef fi cacy.”
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Metadata
- 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)
- 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
- gold
- doi.org
- 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
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › 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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