Q5: Is Psychosocial Support Effective for the Management of Psychostimulant Use Disorders in Non‐Specialist Settings?

Psychosocial support for the management of psychostimulant use disorders

Q5: Is psychosocial support effective for the management of psychostimulant use disorders in non‐specialist settings?

Background

Substance use disorders constitute a major public health problem with high costs for society, including the costs of the treatment, related health problems, absenteeism, lost of productivity among others. The motivation for using psychoactive substances is, in part, related to effects of these on mood, cognition and behaviour and patients with substance use disorders frequently present a long history of repeated episodes of intoxication and withdrawal, with a chronic course of disease.

There have been recent advances in substance abuse research, but to translate this knowledge into treatment interventions that significantly impact long‐term maintenance of abstinence remains a challenge. Regarding psychosocial approaches, authors suggest some specific techniques are superior to supportive therapy for substance abusers, including cognitive‐behavioural therapy (CBT).

Population/Intervention(s)/ Comparison/Outcome(s) (PICO)

• Population: adults and young people

• Interventions: psychosocial and case management

• Comparisons: basic supportive counseling or treatment as usual

• Outcomes:

o drug use

o abstinence

List of the systematic reviews identified by the search process

Systematic reviews included in narrative review:

1 Psychosocial support for the management of psychostimulant use disorders

NICE (2008). Drug Misuse: Psychosocial Interventions. National Clinical Practice Guideline 51.

Knapp WP et al (2007). Psychosocial interventions for cocaine and psychostimulant amphetamines related disorders. Cochrane Database of Systematic Reviews, (3):CD003023.

Narrative description of the studies that went into the analysis

In the NICE 2008 guideline, for the review of standard CBT, two trials met the eligibility criteria, providing data on 370 participants. Both trials were for cocaine dependence and were published in peer‐reviewed journals. In the review of relapse‐prevention CBT, nine trials met the eligibility criteria, providing data on 1,314 participants. Of these trials, six were on cocaine dependence and three were on cannabis dependence. All trials were published in peer‐reviewed journals. For contingency management, 14 trials met the eligibility criteria, providing data on 1,498 participants. Of these trials, six were for cocaine dependence, one for cocaine and/or heroin dependence, three for methamphetamine dependence and three for cannabis dependence. All trials were published in peer‐reviewed journals. Electronic MEDLINE, EMBASE, CINAHL, HMIC, PsycINFO, databases Cochrane Library Date searched Database inception to May 2006; table of contents December 2005 to November 2006 Study design RCT All trials were published in peer‐reviewed journals and were for people who were cocaine dependent or heroin dependent (all participants in these trials underwent detoxification, if required, before receiving the intervention). For family‐based and social‐systems interventions for young people, six trials met the eligibility criteria, providing data on 708 participants. All trials were published in peer reviewed publications. For psychodynamic interventions, one trial met the eligibility criteria, providing data on 247 participants. This trial was published in a peer‐reviewed journal and as for cocaine dependence. For interpersonal therapy, one trial met the eligibility criteria, providing data on 42 participants. This trial was published in a peer‐reviewed journal and was for cocaine dependence.

The Knapp et al, 2007 Cochrane review included 3663 subjects in 27 randomized trials assessing the value of psychosocial interventions for treating psychostimulant use disorders. 25/27 included studies considered as treatment intervention Cognitive Behavioural Interventions: 5/25 Relapse Prevention Intervention alone (Baker et al, 2001; Carroll et al, 1991b; Carroll et al, 1994; Hoffman et al, 1994; Schmitz et al, 1997), 2/25 considered Relapse Prevention plus Coping skill training (Carroll et al, 1998) or Cognitive Therapy (Kirby et al, 1998b); 5/25 Cognitive Therapy alone, (Crits‐Christoph et al, 1999; Magura et al, 1994; Maude‐Griffin et al, 1998; McKay et al, 1997; Rawson et al, 2002), 3/25 considered Cognitive Therapy plus Contingency Management (Kirby et al, 1998a; Silverman et al, 1996; Silverman et al, 1998) and 1/25 a particular form of Cognitive Therapy named Service Outreach And Recovery (plus Inform and referral (Rosenblum et al, 2005); 4/25 Community reinforcement Approach plus Contingency Management (Higgins et al, 1993; Higgins et al, 1994; Higgins et al, 2000; Higgins et al, 2003); 2/25 considered Contingency Management alone (Petry et al, 2005b ; Silverman et al, 2001); the other 3/25 studies considering Contingency management plus Counseling (Petry et al, 2005 a), Reinforcement‐Based Therapy (Jones et al, 2005) and Coping Skills Training (Monti et al, 1997).

Quantitative or qualitative analyses

No quantitative analysis was possible and a narrative review was done instead. 2 Psychosocial support for the management of psychostimulant use disorders

Results of analyses, including statistical summaries (as appropriate)

People presenting to treatment with stimulant misuse (including cocaine and amphetamines') receiving contingency management were more likely to be abstinent for longer periods of time during treatment than people in the control group. Both prize‐ and voucher‐based reinforcement were found to be effective. Psychodynamic therapy was ineffective during treatment and at follow‐up in significantly reducing cocaine use. Direct comparisons of relapse‐ prevention CBT and contingency management for stimulant misuse demonstrated the superior effectiveness of contingency management during treatment but not at follow‐up. It is unclear whether the lack of difference between contingency management and relapse‐prevention CBT at follow‐up is due to a delay in the benefits of CBT, being observable only at follow‐up, and/or a weakening of the effects of contingency management after treatment has ended.

Case management did not have a significantly advantageous effect on abstinence compared to standard care for out of treatment drug users (RR 1.16, (0.59, 2.31).

Methodological limitations Studies lack standardized interventions, appropriate comparators, and standardized outcome measures. There is rarely masking of outcome assessment.

Directness (in terms of population, outcome, intervention and comparator)

Directness is compromised as studies were from high income countries and interventions were not always compared to basic drug counseling.

Narrative conclusion

Cognitive‐behavioural interventions reduced dropouts from treatment and use of cocaine when compared with drug counseling. Behavioural interventions also clearly performed better than clinical management (psychotherapy sessions attended), usual care (lower rates of cocaine users at 1 and 3 months), information and referral (non‐attendance). Contingency management was shown to be more effective than basic supportive counselling and CBT.

Any additional information (safety and tolerability issues, cost, resource use, other feasibility issues, as appropriate)

Despite the lack of evidence of the impact of basic psychosocial support compared to no treatment, it is likely some elements of basic psychosocial support (listening in a non judgemental way, providing information, inquiring about coping strategies, problem solving, making links to social supports when available) will not be harmful, and it would be difficult to justifiably deny them to patients when the capacity to provide them is there. Specific psychosocial therapies require more extensive training of health care providers than basic counselling and clinical management. There may also be more stigma attached to undertaking psychosocial therapies compared to more informal drug counselling.

3 Psychosocial support for the management of psychostimulant use disorders

References

Baker A, Boggs TG, Lewin TJ (2001). Randomized controlled trial of brief cognitive‐behavioural interventions among regular users of amphetamine. Addiction, 96:1279–87.

Carroll KM, Rounsaville BJ, Gawin FH (1991). A comparative trial of psychotherapies for ambulatory cocaine abusers: relapse prevention and interpersonal psychotherapy. American Journal of Drug and Alcohol Abuse, 17:229–47.

Carroll KM et al (1994b).Psychotherapy and pharmacotherapy for ambulatory cocaine abusers. Archives of General Psychiatry, 51:177–87.

Carroll KM et al (1998). Treatment of cocaine and alcohol dependence with psychotherapy and disulphiram. Addiction, 93:713–28.

Crits‐Christoph P et al (1999). Psychosocial treatments for cocaine dependence: National Institute of Drug Abuse Collaborative Cocaine Treatment Study. Archives of General Psychiatry, 56:493–502.

Higgins ST et al (1993). Achieving Cocaine Abstinence With a Behavioral Approach.. American Journal of Psychiatry, 150:763–9.

Higgins ST et al (1994). Incentives Improve Outcome in Outpatient Behavioral treatment of Cocaine Dependence. Archives of General Psychiatry, 51:568–76.

Higgins ST et al (2000). Contingent Reinforcement Increases Cocaine Abstinence During Outpatient Treatment and 1 Year of Follow‐Up. Journal of Consulting and Clinical Psychology, 68:64–72.

Higgins ST et al (2003).Community reinforcement therapy for cocaine‐dependent outpatients. Archives of General Psychiatry, 60:1043–52.

Hoffman JA et al (1994). Comparative Cocaine Abuse Treatment Strategies: Enhancing Client Retention and Treatment Exposure. Journal of Addictive Diseases, 13:115–28.

Jones HE et al (2005). Reinforcement‐based therapy: 12‐month evaluation of an outpatient drug‐free treatment for heroin abusers. Drug and Alcohol Dependence, 79:119–28.

Kirby KC et al (1998). Schedule of Voucher Delivery Influences Initiation of Cocaine Abstinence. Journal of Consulting and Clinical Psychology, 66:761–7.

Knapp WP et al (2007). Psychosocial interventions for cocaine and psychostimulant amphetamines related disorders. Cochrane Database of Systematic Reviews, (3):CD003023.

4 Psychosocial support for the management of psychostimulant use disorders

Magura S et al (1994). Neurobehavioral Treatment for Cocaine‐Using Methadone Patients: A Preliminary Report. Journal of Addictive Diseases, 13:143–60.

Maude‐Griffin PM et al (1998). Superior Efficacy of Cognitive‐Behavioral Therapy for Urban Crack Cocaine Abusers: Main and Matching Effects. Journal of Consulting and Clinical Psychology, 66:832–7.

McKay JR et al (1997). Group Counseling Versus Individualized Relapse Prevention Aftercare Following Intensive Outpatient Treatment for Cocaine Dependence: Initial Results. Journal of Consulting and Clinical Psychology, 65:778–88.

Monti PM et al (1997). Brief coping skills treatment for cocaine abuse: substance use outcomes at three months. Addiction, 99:1717–28.

NICE (2008). Drug Misuse: Psychosocial Interventions. National Clinical Practice Guideline 51.

Petry NM et al (2005a).Effect of prize‐based incentives on outcomes in stimulant abusers in outpatient psychosocial treatment programs: a national drug abuse treatment clinical trials network study. Archives of General Psychiatry, 62:1148–56.

Petry NM, Martin B, Simcic F (2005b). Prize reinforcement contingency management for cocaine dependence: integration with group therapy in a methadone clinic. Journal of Consulting and Clinical Psychology, 73: 354–9.

Rawson RA et al (2002).A comparison of contingency management and cognitivebehavioral approaches during methadone maintenance treatment for cocaine dependence. Archives of General Psychiatry, 59:817–24.

Rosenblum A et al (2005). Motivationally enhanced group counselling for substance users in a soup kitchen: a randomized clinical trial. Drug and Alcohol Dependence, 80:91–103.

Schmitz JM et al (1997). Relapse Prevention Treatment for Cocaine Dependence: Group Vs Individual Format. Addictive Behaviors, 22:405–18.

Silverman K et al (1996).Sustained Cocaine Abstinence in Methadone Maintenance patients Through Voucher‐Based Reinforcement Therapy. Archives of General Psychiatry, 53:409–15.

Silverman K et al (1998). Broad Beneficial Effects of Cocaine Abstinence Reinforcement Among Methadone Patients. Journal of Consulting and Clinical Psychology, 66:811–24.

Silverman K et al (2001). A Reinforcement‐Based Therapeutic Workplace for the Treatment of Drug Abuse. Six‐Month Abstinence Outcomes. Experimental and Clinical Psychopharmacology, 9:14–23.

5 Psychosocial support for the management of psychostimulant use disorders

From evidence to recommendations

Factor Explanation

Narrative summary of the In total there have been 25 studies, in over 3000 participants on this topic. Despite this, there is evidence base no evidence to compare the effectiveness of basic psychosocial support to no treatment. There is some evidence that CBT and contingency management (CM) techniques offer advantages over basic psychosocial support and that CM is more effective than CBT based approaches, although whether this effect persists after the contingency is removed is unclear. Methodological difficulties make more exact comparisons difficult.

Summary of the quality of Despite the many studies, the overall quality of the evidence that addresses the question of evidence interest is low.

Balance of benefits versus There is unlikely to be harm from the provision of basic psychosocial support. harms

Define the values and Access to basic psychosocial support through the health system may be seen as a human right, preferences including any despite the lack of evidence of its effectiveness. variability and human rights issues†

Define the costs and resource use and any other relevant feasibility issues*†

Recommendation(s)

Brief interventions, based on motivational principles, should be offered for the treatment of stimulant use disorders in non‐ 6 Psychosocial support for the management of psychostimulant use disorders

specialist settings.

Strength of recommendation: STANDARD

Patients with stimulant use disorders who do not respond to short duration psychological treatment may be referred for treatment in a specialist setting, when available.

Strength of recommendation: STANDARD