Psychosocial interventions for cocaine and psychostimulant amphetamines related disorders

Psychostimulants such as amphetamines and cocaine are used, at least in part, because of their effects on mood, cognition and behaviour. People who abuse or are dependent on them often have a long history of repeated periods of intoxication and of withdrawal and after long-term use they can develop a stereotyped behaviour, paranoia, and aggressive behaviour. Substance use disorders are a major public health problem with high costs for society including related health and relationship problems, absenteeism, loss of productivity and the costs of treatment. Yet knowledge about treatment interventions that impact on maintenance of abstinence remains a challenge. Trials on drug treatments for psychostimulants dependence have high levels of dropouts from the trials and psychosocial interventions may be promising treatments as long as they can help to keep patients in treatment and reduce the use of the psychostimulants. In this review, several comparisons were made of psychosocial treatments but most of them did not show statistically significant differences between interventions, so that the evidence currently available does not have data supporting a single psychosocial treatment approach. The review authors identified 27 randomised controlled studies involving 3663 participants who were dependent on cocaine (crack or intravenous) in all but one Australian trial where oral amphetamine was the psychostimulant used. The other trials took place in the US. The trials lasted from 12 weeks to 9 months and the mean age of participants was 33 years old (range 18 to 65 years). Overall, 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). A multimodal intensive intervention was more effective than non-intensive delivery and cognitive behavioural treatments with some form of contingency management (involving the incentive of vouchers that are exchangeable for retail items) also showed benefits. Many of the results come from single studies, which limits their generalizability. The interventions used were variable and different types of cognitive behavioural treatments had overlapping but distinct therapeutic approaches. Simple reduction in the
amount of drug used or retention in treatment is not a measure of meaningful changes in lifestyle.

Authors' conclusions: 

Overall this review reports little significant behavioural changes with reductions in rates of drug consumption following an intervention. Moreover, with the evidence currently available, there are no data supporting a single treatment approach that is able to comprise the multidimensional facets of addiction patterns and to significantly yield better outcomes to resolve the chronic, relapsing nature of addiction, with all its correlates and consequences.

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Background: 

The consumption of psychostimulants for non-medical reasons probably occurs because of their euphoriant and psychomotor-stimulating properties. Chronic consumption of these agents results in development of stereotyped behaviour, paranoia, and possibly aggressive behaviour. Psychosocial treatments for psychostimulant use disorder are supposed to improve compliance, and to promote abstinence. Evidence from randomised controlled trials in this subject needs to be summarised.

Objectives: 

To conduct a systematic review of all RCTs on psychosocial interventions for treating psychostimulant use disorder.

Search strategy: 

Electronic searches of Cochrane Library, EMBASE, MEDLINE, and LILACS (to may 2006); reference searching; personal communication; conference abstracts; unpublished trials from pharmaceutical industry; book chapters on treatment of psychostimulants abuse/ dependence.

Selection criteria: 

All randomised-controlled trials focusing on psychosocial interventions for treating psychostimulants abuse/ dependence.

Data collection and analysis: 

Three authors extracted the data independently and Relative Risks, weighted mean difference and number needed to treat were estimated, when possible. The reviewers assumed that people who died or dropped out had no improvement (intention to treat analysis) and tested the sensitivity of the final results to this assumption.

Main results: 

Twenty-seven randomised controlled studies (3663 participants) fulfilled inclusion criteria and had data that could be used for at least one of the main comparisons. There was a wide heterogeneity in the interventions evaluated: this did not allow to provide a summary estimate of effect and results cannot be summarised in a clear cut way. The comparisons between different type of Behavioural Interventions showed results in favour of treatments with some form of Contingency management in respect to both reducing drop outs and lowering cocaine use.
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