Contingency Management for Stimulant-Opioid Co-Use: A Systematic Review and Meta-Analysis.

Abstract

We conducted a meta-analysis (PROSPERO CRD420251000204) examining treatment outcomes associated with contingency management for individuals with stimulant-opioid co-use. We searched Cochrane Library, Embase, PubMed, PsycINFO, and Web of Science through March 2026. Randomized controlled trials evaluating contingency management among individuals with past-year stimulant-opioid co-use were eligible. Outcomes included the longest duration of continuous, simultaneous abstinence from stimulants and opioids during treatment, the percentage of combined stimulant-opioid-negative urine toxicology samples, and treatment retention. Data were extracted following PRISMA guidelines, and random-effects meta-analyses were performed. Twenty-six trials (N=2356) were included. Across studies, cocaine was the stimulant of interest and heroin the primary opioid; fentanyl exposure was not reported in any trial. Contingency management significantly increased the longest duration of continuous abstinence from concurrent stimulant and opioid use compared with control conditions (mean difference=1.42 wk, 95% CI: 0.77-2.08; I²=50%). Participants receiving contingency management were more likely to submit combined stimulant-opioid-negative urine samples (odds ratio=2.46, 95% CI: 1.96-3.10; I2=0%). Overall treatment retention did not differ between groups, though subgroup analyses suggested improved retention among participants not receiving medication for opioid use disorder. Contingency management improves abstinence outcomes among individuals with stimulant-opioid co-use across treatment settings. The absence of fentanyl-specific data highlights an urgent need for research addressing treatment strategies in the context of the evolving synthetic opioid epidemic.