Comparative efficacy and acceptability of psychosocial interventions for individuals with cocaine and amphetamine addiction: A systematic review and network meta-analysis

Abstract

BackgroundClinical guidelines recommend psychosocial interventions for cocaine and/or amphetamine addiction as first-line treatment, but it is still unclear which intervention, if any, should be offered first. We aimed to estimate the comparative effectiveness of all available psychosocial interventions (alone or in combination) for the short- and long-term treatment of people with cocaine and/or amphetamine addiction.Methods and findingsWe searched published and unpublished randomised controlled trials (RCTs) comparing any structured psychosocial intervention against an active control or treatment as usual (TAU) for the treatment of cocaine and/or amphetamine addiction in adults. Primary outcome measures were efficacy (proportion of patients in abstinence, assessed by urinalysis) and acceptability (proportion of patients who dropped out due to any cause) at the end of treatment, but we also measured the acute (12 weeks) and long-term (longest duration of study follow-up) effects of the interventions and the longest duration of abstinence. Odds ratios (ORs) and standardised mean differences were estimated using pairwise and network meta-analysis with random effects. The risk of bias of the included studies was assessed with the Cochrane tool, and the strength of evidence with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We followed the PRISMA for Network Meta-Analyses (PRISMA-NMA) guidelines, and the protocol was registered in PROSPERO (CRD 42017042900). We included 50 RCTs evaluating 12 psychosocial interventions or TAU in 6,942 participants. The strength of evidence ranged from high to very low. Compared to TAU, contingency management (CM) plus community reinforcement approach was the only intervention that increased the number of abstinent patients at the end of treatment (OR 2.84, 95% CI 1.24–6.51, P = 0.013), and also at 12 weeks (OR 7.60, 95% CI 2.03–28.37, P = 0.002) and at longest follow-up (OR 3.08, 95% CI 1.33–7.17, P = 0.008). At the end of treatment, CM plus community reinforcement approach had the highest number of statistically significant results in head-to-head comparisons, being more efficacious than cognitive behavioural therapy (CBT) (OR 2.44, 95% CI 1.02–5.88, P = 0.045), non-contingent rewards (OR 3.31, 95% CI 1.32–8.28, P = 0.010), and 12-step programme plus non-contingent rewards (OR 4.07, 95% CI 1.13–14.69, P = 0.031). CM plus community reinforcement approach was also associated with fewer dropouts than TAU, both at 12 weeks and the end of treatment (OR 3.92, P < 0.001, and 3.63, P < 0.001, respectively). At the longest follow-up, community reinforcement approach was more effective than non-contingent rewards, supportive-expressive psychodynamic therapy, TAU, and 12-step programme (OR ranging between 2.71, P = 0.026, and 4.58, P = 0.001), but the combination of community reinforcement approach with CM was superior also to CBT alone, CM alone, CM plus CBT, and 12-step programme plus non-contingent rewards (ORs between 2.50, P = 0.039, and 5.22, P < ...

Long-Term Outcome of Repetitive Transcranial Magnetic Stimulation in a Large Cohort of Patients With Cocaine-Use Disorder: An Observational Study

“…Therefore, rTMS for CocUD may find its place as an additional tool in settings where psychotherapeutic or behavioral treatments are administered. Meta-analyses have repeatedly shown that the most effective known treatments for CocUD are behavioral ones incorporating both tangible incentives for abstinence and social reinforcement of abstinence (25). rTMS could readily be integrated into those behavioral approaches, to be given as needed.…”

Increases in methamphetamine use among heroin treatment admissions in the United States, 2008–17

“…Together, these findings highlight the critical need to ensure that individuals are provided with appropriately tailored evidence‐based services. In particular, medications for OUD combined with a contingency management and community reinforcement approach may be an effective clinical strategy for this population. In addition, given the high prevalence of methamphetamine injection and the increased odds of reporting methamphetamine injection among treatment admissions reporting heroin injection, expansion of interventions aimed at reducing injection drug use‐related harms such as implementation of comprehensive syringe services programs (needle and syringe exchange programs) are needed to mitigate additional spread of infectious diseases such as viral hepatitis and HIV and injection drug‐use associated morbidity and mortality.…”

Pharmacological Treatment of Methamphetamine/Amphetamine Dependence: A Systematic Review

“…Even short periods of intervention with CBT (1-2 sessions) demonstrate a reduction in MA use in people who are dependent on MA [14]. CM has demonstrated significant reduction in stimulant use [16] alone, or in combination with CBT [16] or a community reinforcement approach [17]. However, the effects of psychosocial therapies are often not sustained following their cessation [14,18], and are less effective for severe disorder (long duration, frequent use) [19].…”