Date Published: December 26, 2018
Publisher: Public Library of Science
Author(s): Franco De Crescenzo, Marco Ciabattini, Gian Loreto D’Alò, Riccardo De Giorgi, Cinzia Del Giovane, Carolina Cassar, Luigi Janiri, Nicolas Clark, Michael Joshua Ostacher, Andrea Cipriani, Louisa Degenhardt
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long-term treatment of people with cocaine and/or amphetamine addiction.Methods and findingsWe searched published and unpublished randomised controlled trials (RCTs) comparing any structured psychosocial intervention against an active control or treatment as usual (TAU) for the treatment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 < 0.001). The main limitations of our study were the quality of included studies and the lack of blinding, which may have increased the risk of performance bias. However, our analyses were based on objective outcomes, which are less likely to be biased.ConclusionsTo our knowledge, this network meta-analysis is the most comprehensive synthesis of data for psychosocial interventions in individuals with cocaine and/or amphetamine addiction. Our findings provide the best evidence base currently available to guide decision-making about psychosocial interventions for individuals with cocaine and/or amphetamine addiction and should inform patients, clinicians, and policy-makers.
Partial Text: Drug use disorders are the 15th leading cause of disability-adjusted life years in high-income countries . Cocaine and amphetamines are the most commonly abused stimulants in people aged 15–64 years, with an annual prevalence of misuse of 0.38% and 1.20%, respectively . Patients addicted to stimulants experience a range of psychological and physical sequelae including psychosis and other mental illnesses, neurological disorders and cognitive deficits, cardiovascular dysfunctions, sexually transmitted diseases, and blood-borne viral infections such as HIV and hepatitis B and C , and are at increased risk of all-cause mortality . Moreover, the social burden of stimulant abuse is worsened by its association with crime, violence, and sexual abuse .
From the initially identified 7,261 citations, we retrieved 160 potentially eligible articles in full text (Fig 1). We excluded 88 reports, but then included 4 additional studies (3 from trial registers and 1 from screening the references), resulting in 76 publications (S3 Text) describing 50 RCTs (6,942 participants), published between 1993 and 2016 (Fig 2; Table 1), comparing 12 psychosocial interventions or TAU (listed and defined in S4 Text). Overall, 5,158 participants were randomly assigned to psychosocial treatments, and 1,784 to TAU. Full clinical and demographic characteristics are reported in Table 1. The mean study sample size was 139 participants, ranging between 19 and 487 participants. The median duration of treatment was 12 weeks (range 6–36). Dropout rates varied between 15.1% (CM + CBT) and 60.2% (meditation-based therapies) (S1 Table). A total of 37 studies were followed up after study completion, for a mean duration of 41.4 weeks (range 16–96). A total of 42 (84%) trials recruited patients from North America, 6 from Europe, 1 from Latin America, and 1 from Oceania. About a third of the population was women (35.9%), and the mean age was 36.8 years. A total of 76% of trials (38 of 50) enrolled participants with cocaine addiction, 8% of trials (4 of 50) with amphetamine addiction, and 16% (8 of 50) with both. About one-third of trials (18 of 50) enrolled participants on methadone maintenance. The mean addiction severity was moderate/high (S2 Table). In terms of risk of bias, 22 (44%) trials were rated low risk, 13 (26%) moderate, and 15 (30%) high (S3 Table; S1 Fig).
This network meta-analysis is based on 50 studies including 6,942 individuals randomly assigned to 12 different psychosocial interventions or TAU. To our knowledge, it is the most comprehensive synthesis of data for all available psychosocial interventions in individuals with cocaine and/or amphetamine addiction.