Rassegna
Psychosocial interventions in stimulant use disorders: a systematic
review and qualitative synthesis of randomized controlled trials
Interventi psicosociali nei disturbi da uso di psicostimolanti: una revisione
sistematica e sintesi qualitativa di studi clinici randomizzati
RICCARDO DE GIORGI1,2, CAROLINA CASSAR3**, GIAN LORETO D’ALÒ4, MARCO CIABATTINI4, SILVIA MINOZZI5, ALEXIS ECONOMOU2, RENATA TAMBELLI3, FRANCO LUCCHESE3,
ROSELLA SAULLE5, LAURA AMATO5, LUIGI JANIRI6, FRANCO DE CRESCENZO1,6* *E-mail: decrescenzo.franco@gmail.com; **carolinacassar@hotmail.it
1Department of Psychiatry, University of Oxford, Oxford, UK
2Oxford Health NHS Foundation Trust, Oxford, UK
3Department of Dynamic and Clinical Psychology, Sapienza University, Rome, Italy
4School of Hygiene and Preventive Medicine, University Tor Vergata, Rome, Italy
5Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
6Institute of Psychiatry and Psychology, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
INTRODUCTION
Stimulants are a class of psychoactive substances that ex-cite the nervous system through complex interactions with monoamine transporters and neurotransmitters1. Cocaine
and amphetamines are the most commonly abused
stimu-lants, with an annual prevalence of 0.38% and 1.20% respec-tively in those aged 15-64 years2. Stimulant use disorders are
characterized by the sustained use of these substances lead-ing to substantial impairment and distress3. Common
symp-toms include craving for stimulants, failure to control use, continued use despite interference with major obligations or
SUMMARY. Stimulant use disorders are highly prevalent with a large burden of disease. Most clinical guidelines recommend psychosocial
in-terventions, but there are no clear hierarchies or indications. Moreover, these interventions have been reported unevenly in the literature. Identifying the most suitable treatment for each patient therefore represents a major challenge. In this review, we describe all psychosocial interventions for stimulant use disorders investigated in randomized controlled trials – including contingency management, cognitive behav-ioral interventions, community reinforcement approach, 12-step program, meditation-based interventions and physical exercise, supportive expressive psychodynamic therapy, interpersonal psychotherapy, family therapy, motivational interviewing, drug counseling –, and we syn-thesize the main findings of these studies. Similarities and differences between treatments are highlighted, suggesting that distinct psychoso-cial interventions can be relevant for certain patients’ groups but not for others. Conversely, several interventions can be equally effective in similar clinical contexts, suggesting that a shared element such as therapeutic alliance is key. Finally, combined approaches emerge as a viable option for people with complex needs. Future studies will need to benchmark psychosocial interventions in stimulant use disorders and as-certain markers of response with a view to individualized treatment.
KEY WORDS: Stimulant use disorders, psychosocial interventions, cocaine, systematic review, amphetamine.
RIASSUNTO. I disturbi da uso di stimolanti sono altamente prevalenti e hanno gravi ripercussioni nei pazienti a livello medico, psicologico
e sociale. La maggior parte delle linee-guida cliniche raccomanda l’uso di interventi psicosociali per il trattamento, ma le indicazioni sono ge-neriche e non si riferiscono a quali interventi psicosociali si debbano preferire. Inoltre, gli interventi sono stati riportati in modo non uniforme in letteratura. Identificare il trattamento più adatto da offrire per un singolo paziente rappresenta una grande sfida. In questa revisione sis-tematica, descriviamo tutti gli interventi psicosociali che sono stati studiati in studi clinici randomizzati per i disturbi da uso di psicostimolanti e sintetizziamo i principali risultati di questi studi. Evidenziamo anche le somiglianze e le differenze tra i trattamenti, suggerendo che distin-ti intervendistin-ti psicosociali possono essere rilevandistin-ti per alcuni gruppi di paziendistin-ti ma non per altri. Al contrario, diversi intervendistin-ti possono essere ugualmente efficaci in contesti clinici simili. Infine, gli approcci combinati emergono come un’opzione praticabile, soprattutto in caso di dia-gnosi doppia. Gli studi futuri dovranno valutare i marcatori di risposta in vista di un trattamento individualizzato.
social functioning, use of greater amount over time, develop-ment of tolerance, spending a great deal of time to obtain and use stimulants, and withdrawal symptoms that occur af-ter stopping or reducing use. These patients are at increased mortality risk and suffer from several comorbidities includ-ing psychosis and other mental illnesses, neurological disor-ders, cardiovascular dysfunctions, sexually-transmitted dis-eases, and blood-borne viral infections4. Moreover, the
im-pact on society is large because of the association between stimulants use and offending5.
Recent data suggest that people affected by stimulant use disorders are increasingly seeking out treatment2. Usually
these patients do not require inpatient care because with-drawal syndromes are not severe or complex, and most can be safely treated in outpatient programs. Psychiatric and psy-chological management is advocated as the best evidence-based option for these patients and aims to:
• motivate the patient to change;
• establish and maintain a therapeutic alliance with the pa-tient;
• assess the patient’s safety and clinical status;
• manage the patient’s intoxication and withdrawal state; • develop and facilitate the patient’s adherence to a
treat-ment plan;
• prevent the patient’s relapse;
• educate the patient about substance use disorders; • reduce the morbidity and sequelae of substance use
dis-orders.
Clinical guidelines recommend psychosocial interven-tions as the treatments of choice for all stimulant use disor-ders6-9, and there is no evidence of differential effect for any
psychosocial intervention in the management of patients us-ing distinct stimulants10. The development and assessment of
psychosocial interventions for substance use disorders has been a priority of the National Institute on Drug Abuse for over 20 years11. However, a key limitation of studies
investi-gating psychosocial interventions is that even well designed randomized controlled trials are subject to biases that can falsely increase the likelihood of a positive outcome12-14. A
recent systematic review and meta-analysis provided encour-aging results on the efficacy and acceptability of all types of psychosocial interventions for stimulant use disorders15;
however, this study did not compare qualitatively the various treatments.
In this paper, we performed a systematic review and qual-itative synthesis of all psychosocial interventions assessed in randomized controlled trials. Our aim is to provide clinicians with a comprehensive description of all the available psy-chosocial interventions for stimulant use disorders and re-port the most recent evidence-base for them.
METHODS Literature search
We performed an extensive computer literature search of peer-reviewed articles about psychosocial interventions in stimulant use disorders on the following databases: Cochrane Drugs and Alcohol Group Register of Trials, Med-line, Embase, CINAHL, ISI Web of Science, PsycINFO. The
search strategy is available as appendix 1 in the supplemen-tary material. We added a hand-search of the reference list of retrieved articles. All searches included non-english litera-ture.
Study selection
We included all randomized controlled trials comparing psychosocial interventions, either alone or in combination with pharmacological therapy, against no-treatment, waiting list, or any other psychosocial treatment. We only accepted studies performed in adults (>18 years old) with a diagnosis of stimulant use disorder according to the Diagnostic and Sta-tistical Manual of Mental Disorders (DSM) -III, -IV or -5 or the International Classification of Diseases (ICD) -9 or -10.
We excluded review articles, editorials, letters, comments, conference proceedings, case reports, and case series; studies dated before 1990 if the system used for the diagnosis did not use operationalized criteria, but only disease names with no diagnostic criteria (i.e. ICD-9); trials lacking a control group. Three authors (FDC, GLDA, MC) independently re-viewed the titles and abstracts of the articles retrieved, ap-plying the inclusion and exclusion criteria; then, they exam-ined the full-texts to confirm the studies’ eligibility for inclu-sion. Disagreements were resolved by consensus.
Data extraction
We designed and used a structured template to ensure consistency and we systematically appraised each study. Da-ta extracted embraced characteristics of the studies (i.e. first author, publication year, journal), of the participants (i.e. mean age, diagnosis), and of the interventions (i.e. types of treatment, comparisons, duration of treatment, duration of follow-up).
Qualitative synthesis
Two authors (CC, RDG) retrieved the manuals for each psychosocial intervention included and summarized the key principles. Then, they integrated these data with the main findings from all the randomized controlled trials previously selected. Risks of bias in the included studies were assessed using the tool described in the Cochrane Collaboration Handbook as a reference guide, which pays particular atten-tion to random sequence generaatten-tion, allocaatten-tion concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data and selective report-ing16. This tool allows a rating of “low”, “unclear” or “high”
risk of bias.
RESULTS
Our computer-based search retrieved 6 728 records. After removing 2 660 duplicates, further 4 068 articles were ex-cluded because they did not meet the required criteria, leav-ing 108 full-text articles included. Further six studies were added from trial registries and one additional article was re-trieved from hand-search. A total of 115 articles
correspon-ding to 91 randomized controlled trials (RCTs) were finally included in this review (see figure 1 in the supplementary material).
The characteristics of the studies included is reported in Table 1, while in Table 2 we summarized the main differen-tial elements of the psychosocial therapies included. A risk of bias summary is available as Table 3 in the supplementary material, while the references of all the included RCTs are listed in the Appendix 2 in the supplementary material.
Overall, contingency management (CM) was investigated in 45/91 studies (49%), cognitive behavioral interventions in 32/91 studies (35%), community reinforcement approach (CRA) in 9/91 studies (10%), 12-step program (12SP) in 8/91 studies (9%), meditation-based interventions (MbI) and physical exercise (PhE) in 6/91 studies (7%), supportive ex-pressive psychodynamic therapy (SEPT) in 3/91 studies (3%), interpersonal psychotherapy (IPT) in 3/91 studies (3%), family therapy (FT) in 3/91 studies (3%), motivational interviewing (MI) in 11/91 studies (12%), drug counselling (DC) in 10/91 studies (11%). It should be noted that some studies examined numerous or combined interventions at the same time (see Table 1).
Contingency management (CM)
Theoretical background
Contingency management (CM) is a behavioral interven-tion that emphasizes the positive reinforcement of healthy behaviors, whereby addicted patients are incentivized with rewards for providing drug-free urine samples17. It differs
from non-contingent reward where patients are remunerat-ed irrespective of the results of the urine drugs screening. Similarly to drugs, CM applies positive reinforcers to absti-nent behavior and immediately conveys relief and satisfac-tion. The purpose is to promote abstinence and improve the welfare of an often-deprived population.
Trials
A wealth of studies examined CM in stimulant use disor-ders.
a) Cash rewards
There is little research on CM using cash rewards, which showed that a cash-based CM combined with bupropion18
or topiramate19improved outcomes in cocaine users
com-pared to non-contingent rewards, regardless of the use of medication.
b) Voucher rewards
Since cash rewards may be spent on substances, most CM approaches offered vouchers instead. Voucher-CM was not inferior to cash-CM in improving cocaine abstinence and treatment attendance, regardless of the high or low value of the rewards20,21. Cocaine and crack cocaine users
responded to voucher-based CM with increased accept-ability and abstinence rates22and reduced craving23. The
use of CM coupons of escalating value was associated with sustained cocaine and opiate abstinence in a popula-tion of methadone-maintained patients24,25. Conversely,
Rawson et al.26and Menza et al.27reported an
improve-ment in short-term outcomes that was not maintained at follow-up, while Umbricht et al.28did not show any
differ-ence in abstindiffer-ence between voucher-based CM and non-contingent rewards.
c) Prize rewards
Stakeholders underlined that the cost of vouchers paid by the health system can be high on a large scale; therefore, another approach consisted of awarding prizes and lottery tickets attracting numerous low-value and limited high-value rewards. Petry et al.29 showed that voucher and
prize CM were equally effective in cocaine-using methadone patients, and prize-based incentives improved abstinence outcomes30and psychiatric comorbidities31,32.
Low-cost prizes can increase abstinence33-35, but
higher-magnitude prizes proved better on the long term36,37.
Longer periods of prize-CM promoted longer durations of abstinence38and increased post-exposure prophylaxis
in men who have sex with men using methamphetamine39.
However, some studies showed that prize-based CM did not significantly improved abstinence in stimulant use dis-orders, but it did in opioid40and alcohol use41.
d) Other rewards
Addicted patients may struggle with failing the lottery draw or can be inadvertently fed into a gambling addiction; hence some alternative CM strategies were devised. In case of stimulant- and opioid-use comorbidity, buprenorphine doses were provided as CM rewards, resulting in increased abstinence at follow-up compared to CM vouchers42,43used
an employment-based reinforcement that proved effective in long-term abstinence, but another study showed low en-gagement with a similar approach44.
Cognitive behavioral interventions
Theoretical background
Cognitive behavioral interventions are based on cogni-tivism and behaviorism paradigms. Cognicogni-tivism assumes that mental disorders are triggered by unhealthy beliefs45,46:
thoughts such as “I need to escape”, “I cannot deal with this unless I am high”, and “I deserve to get high considering what I am going through” are commonly noted to precede stimu-lants use47. Behaviorism maintains that most human traits and
actions are learned48, therefore stimulants use can be
consid-ered a learned behavior47. Cognitive behavioral interventions
aim to modify cognitions and behaviors that lead to substance misuse. Trials in stimulant use disorders included cognitive behavioral therapy (CBT), gay-specific cognitive behavioral therapy (G-CBT), and relapse prevention (RP).
a) Cognitive behavioural therapy (CBT) Theoretical background
CBT for stimulant use disorders is a short-term psy-chotherapy divided into functional analysis and coping-skills training47.
Functional analysis is based on the antecedents, behavior, and consequences model46. Initially, patient and therapist
ex-Ta bl e 1. T ab le o f i nc lu de d st ud ie s. S tu d y P a rt ic ip a n ts G e n d e r (m a le s% ) M e a n A g e (y rs ) D ia g n o si s In te rv e n ti o n s (n ) D u ra ti o n o f in te rv e n ti o n (w k s) F o ll o w -u p (w k s) G la sn er -E d w a rd s, 2 0 1 7 6 3 7 1 .4 % 4 5 .3 C o ca in e d e p e n d e n ce ( D S M -I V ) o r m e th a m p h e ta m in e d e p e n d e ce (D S M -I V ) 1 . V o u ch e r b a se d C M p lu s M b I (3 1 ) 2 . V o u ch e r b a se d C M p lu s T A U ( h e a lt h e d u ca ti o n c o n tr o l) ( 3 2 ) 8 1 2 P ir n ia , 2 0 1 7 1 0 0 1 0 0 % N A S e lf -r e p o rt e d c o ca in e d e p e n d e n ce ; a t le a st o n e m o n th h is to ry o f co ca in e a v o id a n ce 1 . C a sh b a se d C M ( 2 5 ) 2 . C a sh b a se d C M + T o p ir a m a te ( 2 5 ) 3 . T o p ir a m a te ( 2 5 ) 4 . P la ce b o c o n tr o l (2 5 ) 1 2 N A T ri v ed i, 2 0 1 7 3 0 2 6 0 % 3 9 .0 S ti m u la n ts a b u se o r d e p e n d e n ce (D S M -I V -T R ) 1 . E x e rc is e ( 1 5 2 ) 2 . H e a lt h e d u ca ti o n ( 1 5 0 ) 3 6 N A C a rr ic o , 2 0 1 6 1 3 8 0 % 2 7 (m e d ia n ; IQ R : 2 3 -1 3 ) A m p h e ta m in e -l ik e -u si n g f e m a le e n te rt a in m e n t a n d s e x w o rk e rs 1 . C B T ( N R ) 2 . C B T p lu s ca sh b a se d C M ( N R ) 1 2 N A C a rr o ll , 2 0 1 6 9 9 7 2 .7 % 3 9 .3 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . C B T w it h d is u lf ir a m ( 2 8 ) 2 . C B T w it h o u t d is u lf ir a m ( 2 6 ) 3 . C B T p lu s ca sh -b a se d C M w it h d is u lf ir a m (2 3 ) 4 . C B T p lu s ca sh -b a se d C M w it h o u t d is u lf ir a m ( 2 2 ) 1 2 4 8 D e L a G a rz a , 2 0 1 6 2 4 7 6 % 4 4 .7 C ig a re tt e s m o k e rs w it h c o n cu rr e n t co ca in e u se 1 . C B T p lu s R e w ( 7 ) 2 . C B T p lu s R e w p lu s P h y si ca l E x e rc is e (r u n n in g ) (1 0 ) 3 . C B T p lu s R e w p lu s P h y si ca l E x e rc is e (w a lk in g ) (7 ) 4 N A M ig u el , 2 0 1 6 5 5 8 5 .7 % 3 5 .3 C ra ck -c o ca in e d e p e n d e n ce ( D S M -IV ) 1 . T A U ( 3 2 ) 2 . V o u ch e r b a se d C M ( 3 3 ) 1 2 2 4 P ir n ia , 2 0 1 6 5 0 1 0 0 % N A S e lf -r e p o rt e d p h y si ca l d e p e n d e n cy to c o ca in e ; a t le a st t h re e m o n th s h is to ry o f co ca in e a v o id a n ce 1 . T A U ( 2 5 ) 2 . V o u ch e r b a se d C M ( 2 5 ) 1 2 N A Z h u , 2 0 1 6 6 0 1 0 0 % 4 0 S e d e n ta ry , s ti m u la n t a b u se rs 1 . T a i C h i (3 0 ) 2 . T A U ( re cr e a ti o n a l a ct iv it ie s) ( 3 0 ) 1 2 N A A g a rw a l, 2 0 1 5 2 4 7 6 % 4 8 .2 C ra ck -c o ca in e u se rs d ia g n o se d w it h H IV 1 . Y o g a m e d it a ti o n ( 1 2 ) 2 . N o i n te rv e n ti o n ( 1 2 ) 8 1 6 (c o n ti n u ed )
Ta bl e 1. T ab le o f i nc lu de d st ud ie s. S tu d y P a rt ic ip a n ts G e n d e r (m a le s% ) M e a n A g e (y rs ) D ia g n o si s In te rv e n ti o n s (n ) D u ra ti o n o f in te rv e n ti o n (w k s) F o ll o w -u p (w k s) L a n d o v it z , 2 0 1 5 1 4 0 1 0 .6 % 3 6 .8 S ti m u la n t-u si n g m e n w h o h a v e s e x w it h m e n ( M S M ) 1 . C M ( 7 0 ) 2 . R e w ( 7 0 ) 8 2 4 P et ry , 2 0 1 5 2 4 0 5 0 .4 % 4 0 .3 C o ca in e d e p e n d e n t (D S M -I V ) p a ti e n ts o n m e th a d o n e m a in te n a n ce 1 . T A U ( st a n d a rd m e th a d o n e m a in te n a n ce ) (5 7 ) 2 . C a sh -b a se d l o w m a g n it u d e p ri ze C M (5 8 ) 3 . C a sh -b a se d h ig h m a g n it u d e p ri ze C M (6 2 ) 4 . V o u ch e r-b a se d h ig h m a g n it u d e p ri ze C M ( 6 3 ) 1 2 2 4 R a w so n , 2 0 1 5 1 3 5 8 0 % 3 1 .7 M e th a m p h e ta m in e d e p e n d e n ce (D S M -I V ) 1 . T A U ( H e a lt h e d u ca ti o n ) (6 6 ) 2 . P h y si ca l e x e rc is e ( 6 9 ) 8 3 2 T a it , 2 0 1 5 1 6 0 1 6 0 7 5 .6 % 2 2 .3 M e th a m p h e ta m in e a b u se rs 1 . B ri e f C B T p lu s M I (8 1 ) 2 . T A U ( w a it li st ) (7 9 ) B I 2 4 C a rr o ll , 2 0 1 4 1 0 1 4 0 % 4 2 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . T A U ( st a n d a rd m e th a d o n e m a in te n a n ce ) (5 4 ) 2 . C B T ( co m p u te r-b a se d t ra in in g f o r C B T , C B T 4 C B T ) p lu s m e th a d o n e m a in te n a n ce ( 4 7 ) 8 5 2 F es ti n g er , 2 0 1 4 2 2 2 6 9 % 3 7 .2 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . V o u ch e r-b a se d C M ( 7 1 ) 2 . C a sh -b a se d C M ( 7 3 ) 3 . R e w ( 7 8 ) 1 2 N A G o n c¸ a lv es , 2 0 1 4 4 6 8 4 .1 % 3 1 .8 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . M o ti v a ti o n a l C h e ss ( 2 6 ) 2 . T A U ( a ct iv e c o n tr o l) ( 2 0 ) 4 N A N o rb er g , 2 0 1 4 1 7 4 6 5 % 2 3 .6 E cs ta sy u se rs 1 . M I (E C h e ck -u p ) (8 9 ) 2 . T A U ( E d u ca ti o n c o n tr o l g ro u p ) (8 5 ) B I 2 4 P et it je a n , 2 0 1 4 6 0 8 0 .1 % 3 4 .5 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . C B T p lu s p ri ze b a se d C M ( 2 9 ) 2 . C B T ( 3 1 ) 2 4 5 2 P o lc in , 2 0 1 4 2 1 7 5 0 .6 9 % 3 8 .4 M e th a m p h e ta m in e d e p e n d e n ce (D S M -I V ) 1 . 9 -s e ss io n I n te n si v e m o ti v a ti o n a l in te r-v ie w in g ) (I M I) ( 1 1 1 ) 2 . S in g le s ta n d a rd s e ss io n o f M I (S M I) + 8 n u tr it io n e d u ca ti o n s e ss io n s (1 0 6 ) 9 5 2 (c o n ti n u ed )
(c o n ti n u ed ) Ta bl e 1. T ab le o f i nc lu de d st ud ie s. S tu d y P a rt ic ip a n ts G e n d e r (m a le s% ) M e a n A g e (y rs ) D ia g n o si s In te rv e n ti o n s (n ) D u ra ti o n o f in te rv e n ti o n (w k s) F o ll o w -u p (w k s) U m b ri ch t, 2 0 1 4 1 7 1 5 2 % 4 1 .5 C o ca in e d e p e n d e n t (D S M -I V -T R ) in m e th a d o n e m a in ta in e d p a ti e n ts 1 . V o u ch e r-b a se d C M p lu s to p ir a m a te a n d m e th a d o n e m a in te n a n ce ( 4 0 ) 2 . V o u ch e r-b a se d R e w p lu s to p ir a m a te a n d m e th a d o n e m a in te n a n ce ( 4 5 ) 3 . V o u ch e r-b a se d C M p lu s p la ce b o a n d m e th a d o n e m a in te n a n ce ( 3 9 ) 4 . V o u ch e r-b a se d R e w p lu s p la ce b o a n d m e th a d o n e m a in te n a n ce ( 4 7 ) 1 2 N A C h en , 2 0 1 3 5 6 5 6 .1 % 4 5 .2 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . T A U ( in te n si v e o u tp a ti e n t p ro g ra m , IO P ) (3 7 ) 2 . T A U p lu s IM E A ( e a r a cu p u n ct u re a n d in te g ra ti v e m e d it a ti o n ) (3 5 ) 1 2 N A D o n o v a n , 2 0 1 3 4 7 1 4 1 .2 % 4 7 .1 S ti m u la n ts u se o r d e p e n d e n ce (D S M -I V ) 1 . T A U ( 2 3 7 ) 2 . 1 2 -s te p ( 2 3 4 ) 8 2 4 D u rs te le r-M a cF a rl a n d , 2 0 1 3 6 2 6 4 .5 % 3 6 C o ca in e, e ro in d e p e n d e n t (D S M -IV ) D ia ce ty lm o rp h in e ( D A M ) m a in ta in e d p a ti e n ts 1 . G ro u p C B T w it h m e th y lp h e n id a te ( 1 5 ) 2 . G ro u p C B T w it h p la ce b o ( 1 7 ) 3 . T A U w it h m e th y lp h e n id a te ( 1 5 ) 4 . T A U w it h p la ce b o ( 1 5 ) 1 2 N A H a g ed o rn , 2 0 1 3 1 3 9 9 8 .5 9 % 5 0 S ti m u la n t d e p e n d e n t v e te ra n s d ia g n o se d w it h a lc o h o l d e p e n d e n ce o n ly ( n = 1 9 1 ) o r st im u la n t d e p e n d e n ce ( n = 1 3 9 ). O n ly d a ta o f st im u la n t d e p e n d e n ts re p o rt e d 1 . V o u ch e r b a se d C M ( 7 1 ) 2 . T A U ( 6 8 ) 8 5 2 M cD o n el l, 2 0 1 3 1 7 6 3 4 .6 % 4 2 .7 S ti m u la n ts ( a m p h e ta m in e s, co ca in e ) d e p e n d e n ce ( M IN I) ; co n cu rr e n t sc h iz o p h re n ia o r sc h iz o a ff e ct iv e d is o rd e r o r b ip o la r d is o rd e r o r re cu rr e n t m a jo r d e p re ss iv e d is o rd e r 1 . P ri ze b a se d C M ( 9 1 ) 2 . R e w ( 8 5 ) 1 2 2 4 M cK a y, 2 0 1 3 a 3 2 1 7 6 % 4 3 .2 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . T A U ( 1 0 8 ) 2 . T M C ( 1 0 6 ) 3 . T M C p lu s R e w ( 1 0 7 ) 1 0 4 N A M cK a y, 2 0 1 3 b 1 5 2 7 7 % 4 2 .8 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . T A U ( 7 8 ) 2 . B ri e f co n ti n u in g c a re s e ss io n s (T M C o r in -p e rs o n s e ss io n s) ( 7 4 ) 5 2 N A P et ry , 2 0 1 3 1 9 5 8 % 4 1 .7 C o ca in e d e p e n d e n t (D S M -I V ) p a ti e n ts w it h s e v e re a n d p e rs is te n t m e n ta l h e a lt h d is o rd e r 1 . P ri ze B a se d C M (1 0 ) 2 . T A U ( 9 ) 8 N A
(c o n ti n u ed ) Ta bl e 1. T ab le o f i nc lu de d st ud ie s. S tu d y P a rt ic ip a n ts G e n d e r (m a le s% ) M e a n A g e (y rs ) D ia g n o si s In te rv e n ti o n s (n ) D u ra ti o n o f in te rv e n ti o n (w k s) F o ll o w -u p (w k s) R o ll , 2 0 1 3 1 1 8 5 5 % 3 2 M e th a m p h e ta m in e d e p e n d e n ce (D S M -I V ) 1 . M a tr ix M o d e l (n = 2 9 ) 2 . M a tr ix M o d e l p lu s 1 m o n th p ri ze C M (3 0 ) 3 . M a tr ix M o d e l p lu s 2 m o n th s p ri ze ( 3 0 ) 4 . M a tr ix M o d e l p lu s 4 m o n th s p ri ze ( 2 9 ) 1 6 5 2 S ec a d es V il la , 2 0 1 3 1 1 8 8 5 .5 % 3 1 .2 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . C R A p lu s v o u ch e r b a se d C M ( 5 0 ) 2 . C R A ( 6 8 ) 2 4 N A C a rr o ll , 2 0 1 2 1 1 2 5 9 % 3 8 .3 C o ca in e d e p e n d e n t (D S M -I V ) p a ti e n ts o n m e th a d o n e m a in te n a n ce , o r p a ti e n ts s e lf -re fe rr e d o r re fe rr e d b y c li n ic ia n a s co ca in e u se rs , n o t o n m e th a d o n e m a in te n a n ce 1 . T A U w it h d is u lf ir a m ( 3 0 ) 2 . T A U w it h p la ce b o ( 2 6 ) 3 . 1 2 -s te p w it h d is u lf ir a m ( 2 9 ) 4 . 1 2 -s te p w it h p la ce b o ( 2 7 ) 1 2 6 0 P et ry , 2 0 1 2 a 1 3 0 5 3 .4 % 3 6 .7 C o ca in e d e p e n d e n t (D S M -I V ) p a -ti e n ts o n m e th a d o n e m a in te n a n ce 1 . T A U ( 5 9 ) 2 . P ri ze b a se d C M ( 7 1 ) 1 2 3 6 P et ry , 2 0 1 2 b 4 4 2 4 4 .5 % 3 6 .8 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . T A U , c o ca in e n e g a ti v e p a ti e n ts a t b a se li n e ( 1 0 8 ) 2 . P ri ze b a se d C M , c o ca in e n e g a ti v e p a ti e n ts a t b a se li n e ( 1 1 8 ) 3 . R e w , c o ca in e n e g a ti v e p a ti e n ts a t b a se li n e ( 1 0 7 ) 4 . T A U , c o ca in e p o si ti v e p a ti e n ts a t b a se li n e ( 3 4 ) 5 . L o w m a g n it u d e p ri ze b a se d C M , c o ca in e p o si ti v e p a ti e n ts a t b a se li n e ( 3 5 ) 6 . H ig h m a g n it u d e p ri ze b a se d C M , co ca in e p o si ti v e p a ti e n ts a t b a se li n e ( 4 0 ) 1 2 3 6 S u v a n ch o t, 2 0 1 2 2 0 0 N R 2 5 A m p h e ta m in e u se ; c o -o cc u rr e n t p sy ch o lo g ic a l p ro b le m s 1 . M I p lu s B ri e f C B T ( 1 0 0 ) 2 . N o i n te rv e n ti o n ( 1 0 0 ) B I 2 4 G a rc ia -F er n a n d ez , 2 0 1 1 5 8 8 7 .9 % 3 0 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . C R A p lu s p ri ze b a se d C M ( 2 9 ) 2 . C R A ( 2 9 ) 2 4 4 8 In g er so ll , 2 0 1 1 5 4 4 6 .2 9 % 4 5 C ra ck c o ca in e u se a n d H IV w it h < 9 0 % h ig h ly a ct iv e a n ti re tr o v ir a l th e ra p y ( H A A R T ) a d h e re n ce 1 . M I p lu s fe e d b a ck a n d s k il ls b u il d in g (M I+ ) (2 8 ) 2 . V id e o i n fo rm a ti o n p lu s d e b ri e fi n g (V id e o + ) (2 8 ) 8 2 4 S ch o tt en fe ld , 2 0 1 1 1 4 5 0 % 3 1 .1 C o ca in e d e p e n d e n t (D S M -I V ) w o m e n w h o w e re e it h e r p re g n a n t o r h a d c u st o d y o f a y o u n g c h il d 1 . C R A p lu s v o u ch e r b a se d C M ( 3 6 ) 2 . T S F p lu s v o u ch e r b a se d C M ( 3 7 ) 3 . C R A p lu s R e w ( 3 5 ) 4 . T S F p lu s R e w ( 3 7 ) 2 4 5 2
(c o n ti n u ed ) Ta bl e 1. T ab le o f i nc lu de d st ud ie s. S tu d y P a rt ic ip a n ts G e n d e r (m a le s% ) M e a n A g e (y rs ) D ia g n o si s In te rv e n ti o n s (n ) D u ra ti o n o f in te rv e n ti o n (w k s) F o ll o w -u p (w k s) V a n H o rn , 2 0 1 1 1 9 5 7 5 % 4 3 .6 C o ca in e d e p e n d e n ce 1 . T M C ( 9 5 ) 2 . T M C p lu s R e w ( 1 0 0 ) 5 2 N A M cK a y, 2 0 1 0 1 0 0 4 2 % 4 1 .0 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . T A U ( In te n si v e O u tp a ti e n t P ro g ra m , IO P ) (2 5 ) 2 . T A U ( IO P ) p lu s R P ( 2 4 ) 3 . T A U ( IO P ) p lu s v o u ch e r b a se d C M ( 2 6 ) 4 . T A U ( IO P ) p lu s R P p lu s v o u ch e r b a se d C M ( 2 5 ) 2 0 7 6 M en z a , 2 0 1 0 1 2 7 3 4 .6 % 3 9 M e th a m p h e ta m in e u se r m e n w h o h a v e s e x w it h m e n ( M S M ) 1 . V o u ch e r b a se d C M ( 7 0 ) 2 . T A U ( 5 7 ) 1 2 2 4 S m o u t, 2 0 1 0 1 0 4 6 0 % 3 4 .9 M e th a m p h e ta m in e U se o r D e -p e n d e n ce ( M IN I) 1 . C B T ( 5 3 ) 2 . M b I (A cc e p ta n ce a n d C o m m it m e n t T h e ra p y, A C T ) (5 1 ) 1 2 2 4 D eF u li o , 2 0 0 9 5 1 3 3 % 4 3 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . E m p lo y m e n t o n ly ( 2 4 ) 2 . E m p lo y m e n t b a se d C M ( 2 7 ) 2 4 5 2 S te in , 2 0 0 9 1 9 8 6 1 .6 % 3 8 .1 C o ca in e u se o r d e p e n d e n ce 1 . M I (9 7 ) 2 . N o i n te rv e n ti o n ( 1 0 1 ) B I 2 4 M il b y, 2 0 0 8 2 0 6 7 4 .5 % 4 0 C o ca in e d e p e n d e n t (D S M -I V ), h o m e le ss p a ti e n ts 1 . V o ca ti o n a l tr a in in g , w o rk a n d c o n ti n g e n t h o u si n g b a se d C M ( 1 0 3 ) 2 . V o ca ti o n a l tr a in in g , w o rk a n d c o n ti n g e n t h o u si n g b a se d C M p lu s C B T d a y t re a t-m e n t (1 0 3 ) 2 4 7 6 P re st o n , 2 0 0 8 6 7 5 7 .7 5 % 3 9 .7 C o ca in e u se r, p h y si ca l o p ia te s d e -p e n d e n t p a ti e n ts 1 . P ri ze b a se d C M ( o p ia te -c o ca in e u se d e p e n d in g C M ) w it h m e th a d o n e ( 3 8 ) 2 . P ri ze b a se d C M ( co ca in e u se d e p e n d in g C M ) w it h m e th a d o n e ( 2 9 ) 1 7 2 5 S a n ch ez H er v a s, 2 0 0 8 8 2 8 6 .3 % 3 1 .4 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . C R A ( 4 7 ) 2 . T A U ( 3 5 ) 2 4 5 2 S h o p ta w , 2 0 0 8 1 2 8 1 0 0 % 3 7 G a y o r b is e x u a l m e n w it h st im u la n t a b u se 1 . G a y -s p e ci fi c C B T ( 6 4 ) 2 . T A U ( G a y s o ci a l su p p o rt t h e ra p y ) (6 4 ) 1 6 5 2 G a rc ia -R o d ri g u ez , 2 0 0 7 9 6 9 0 % 2 9 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . C R A p lu s lo w v o u ch e r b a se d C M ( 1 5 ) 2 . C R A p lu s h ig h v o u ch e r b a se d C M ( 2 9 ) 3 . T A U ( 5 2 ) 2 4 4 8 G h it z a , 2 0 0 7 1 1 6 5 6 % 3 7 H e ro in a n d c o ca in e u se rs o n m e th a d o n e m a in te n a n ce 1 . P ri ze b a se d C M ( 7 6 ) 2 . R e w ( 4 0 ) 1 2 2 4 M cK ee , 2 0 0 7 7 4 7 3 % 3 5 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . B ri e f C B T p lu s M I (3 8 ) 2 . B ri e f C B T ( 3 6 ) 7 1 6 M it ch es o n , 2 0 0 7 2 9 6 5 .5 % 4 0 C ra ck c o ca in e d e p e n d e n t p a ti e n ts o n m e th a d o n e m a in te n a n ce 1 . M I (1 7 ) 2 . I n fo rm a ti o n l e a fl e ts ( 1 2 ) B I 1 2
(c o n ti n u ed ) Ta bl e 1. T ab le o f i nc lu de d st ud ie s. S tu d y P a rt ic ip a n ts G e n d e r (m a le s% ) M e a n A g e (y rs ) D ia g n o si s In te rv e n ti o n s (n ) D u ra ti o n o f in te rv e n ti o n (w k s) F o ll o w -u p (w k s) P et ry , 2 0 0 7 7 4 4 3 .2 % 4 1 .6 C o ca in e d e p e n d e n t p a ti e n ts (D S M -I V ) o n m e th a d o n e m a in te n a n ce 1 . T A U w it h m e th a d o n e ( 1 9 ) 2 . V o u ch e r b a se d C M w it h m e th a d o n e ( 2 7 ) 3 . P ri ze a n d v o u ch e r b a se d C M w it h m e th a d o n e ( 3 0 ) 1 2 3 6 S ri su ra p a n o n t, 2 0 0 7 4 8 8 9 .5 % 1 6 .9 1 4 -1 9 y e a rs o ld , m e th a m p h e ta m in e d e p e n d e n t (D S M -I V ) p a ti e n ts 1 . T A U ( h e a lt h e d u ca ti o n ) (2 4 ) 2 . M I (2 4 ) B I 8 K n ea li n g , 2 0 0 6 4 7 1 0 .6 % 3 6 .6 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . E m p lo y m e n t b a se d C M ( 2 2 ) 2 . T A U ( 2 5 ) 3 6 6 4 M a rs d en , 2 0 0 6 3 4 2 6 6 .3 % 1 8 .4 S ti m u la n ts u se 1 . M I p lu s in fo rm a ti o n l e a fl e ts ( 1 6 6 ) 2 . I n fo rm a ti o n l e a fl e ts ( 1 7 6 ) B I 2 4 P ei rc e, 2 0 0 6 4 0 2 5 5 .8 % 4 2 S ti m u la n ts d e p e n d e n t p a ti e n ts o n m e th a d o n e m a in te n a n ce 1 . P ri ze b a se d C M ( 2 0 4 ) 2 . T A U ( 1 9 8 ) 1 2 2 4 P o li n g , 2 0 0 6 1 0 6 6 9 .8 % 3 4 .6 C o ca in e u se a n d o p ia te d e p e n d e n ce ( D S M -I V ) 1 . C B T p lu s ca sh b a se d C M w it h b u p o p ri o n ( 2 7 ) 2 . C B T p lu s ca sh b a se d C M w it h p la ce b o (2 5 ) 3 . C B T p lu s R e w w it h b u p o p ri o n ( 3 0 ) 4 . C B T p lu s R e w w it h p la ce b o ( 2 4 ) 2 5 N A R a w so n , 2 0 0 6 1 7 7 7 6 % N A S ti m u la n t d e p e n d e n ce ( D S M -I V ) 1 . C B T ( 5 8 ) 2 . C B T p lu s v o u ch e r-b a se d C M ( 5 9 ) 3 . V o u ch e r-b a se d C M ( 6 0 ) 1 6 5 2 B a k er , 2 0 0 5 2 1 4 6 2 .6 % 3 0 .2 R e g u la r u se rs o f a m p h e ta m in e s 1 . B ri e f C B T ( 2 s e ss io n s) ( 7 4 ) B I 2 4 P et ry , 2 0 0 5 a 4 1 5 4 4 .6 % 3 5 .8 S ti m u la n ts u se o r d e p e n d e n ce (D S M -I V ) 1 . P ri ze b a se d C M ( 2 2 3 ) 2 . T A U ( 2 2 2 ) 1 2 2 4 P et ry , 2 0 0 5 b 7 7 2 7 % 4 0 C o ca in e d e p e n d e n ce ( D S M -I V ) in m e th a d o n e m a in te n a n ce 1 . C M w it h m e th a d o n e ( 4 0 ) 2 . T A U w it h m e th a d o n e ( 3 7 ) 1 2 2 4 R a w so n , 2 0 0 5 9 7 8 4 5 % 3 2 .8 M e th a m p h e ta m in e d e p e n d e n ce (D S M -I V ) 1 . T A U ( N R ) 2 . M a tr ix M o d e l (N R ) 1 6 5 2
(c o n ti n u ed ) Ta bl e 1. T ab le o f i nc lu de d st ud ie s. S tu d y P a rt ic ip a n ts G e n d e r (m a le s% ) M e a n A g e (y rs ) D ia g n o si s In te rv e n ti o n s (n ) D u ra ti o n o f in te rv e n ti o n (w k s) F o ll o w -u p (w k s) S h o p ta w , 2 0 0 5 1 6 2 1 0 0 % 3 7 G a y a n d B is e x u a l w it h M e th a m p h e ta m in e d e p e n d e n ce (D S M -I V ) 1 . C B T ( 4 0 ) 2 . V o u ch e r b a se d C M ( 4 2 ) 3 . C B T p lu s v o u ch e r b a se d C M ( 4 0 ) 4 . G a y -s p e ci fi c C B T ( 4 0 ) 1 6 5 2 W ei ss , 2 0 0 5 4 8 7 7 6 .8 % 3 3 .9 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . T A U ( N R ) 2 . 1 2 -s te p ( N R ) 3 . S E P T ( N R ) 4 . C B T ( N R ) 2 4 N A C a rr o ll , 2 0 0 4 1 2 1 7 4 % 3 4 .6 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . C B T w it h d is u lf ir a m ( 3 0 ) 2 . C B T w it h p la ce b o ( 3 0 ) 3 . I P T w it h d is u lf ir a m ( 3 0 ) 4 . I P T w it h p la ce b o ( 3 1 ) 1 2 N A E p st ei n , 2 0 0 3 2 8 6 5 7 % 3 9 C o ca in e a b u se rs i n m e th a d o n e m a in te n a n ce 1 . C B T p lu s v o u ch e r b a se d R e w (m e th a d o n e m a in te n a n ce ) (4 8 ) 2 . C B T p lu s v o u ch e r b a se d C M (m e th a d o n e m a in te n a n ce ) (4 9 ) 3 . V o u ch e r b a se d C M ( m e th a d o n e m a in te n a n ce ) (4 7 ) 4 . V o u ch e r b a se d R e w ( m e th a d o n e m a in te n a n ce ) (4 9 ) 1 2 5 2 H ig g in s, 2 0 0 3 1 0 0 5 9 % 3 4 C o ca in e d e p e n d e n ce ( D S M -I II -R ) 1 . C R A p lu s v o u ch e r b a se d C M ( 4 9 ) 2 . V o u ch e r b a se d C M ( 5 1 ) 2 4 1 0 4 C o v i, 2 0 0 2 6 8 8 8 .2 % 3 4 C o ca in e a n d o th e r su b st a n ce s d e p e n d e n ce ( D S M -I II -R ) 1 . C B T ( o n ce e v e ry t w o w e e k s) ( 2 1 ) 2 . C B T ( o n ce a w e e k ) (2 1 ) 3 . C B T ( tw ic e a w e e k ) (2 6 ) 1 2 5 2 P et ry , 2 0 0 2 4 2 2 8 .6 % 3 8 .5 C o n cu rr e n t co ca in e a n d o p io id d e p e n d e n ce ( D S M -I V ) 1 . T A U ( 2 3 ) 2 . L o w p ri ze C M ( 1 9 ) 1 2 2 4 R a w so n , 2 0 0 2 1 0 8 5 5 % 4 3 .6 C o ca in e d e p e n d e n ce ( D S M -I V ) p a ti e n ts o n m e th a d o n e m a in te n a n ce 1 . T A U ( 2 7 ) 2 . C B T ( 2 8 ) 3 . V o u ch e r b a se d C M ( 2 7 ) 4 . C B T p lu s v o u ch e r b a se d C M ( 2 6 ) 1 6 1 0 4 B a k er , 2 0 0 1 6 4 6 2 % 3 2 R e g u la r u se o f a m p h e ta m in e s 1 . B ri e f C B T ( R P B ri e f) a n d s e lf -h e lp b o o k le t o n r e d u ci n g a m p h e ta m in e u se a n d r e la te d h a rm s (3 2 ) 2 . S e lf -h e lp b o o k le t o n ly ( 3 2 ) B I 2 4 H ig g in s, 2 0 0 0 7 0 7 3 % 3 0 .4 C o ca in e d e p e n d e n ce ( D S M -I II -R ) 1 . C R A p lu s v o u ch e r b a se d C M ( 3 6 ) 2 . C R A p lu s R e w ( 3 4 ) 2 4 5 2
(c o n ti n u ed ) Ta bl e 1. T ab le o f i nc lu de d st ud ie s. S tu d y P a rt ic ip a n ts G e n d e r (m a le s% ) M e a n A g e (y rs ) D ia g n o si s In te rv e n ti o n s (n ) D u ra ti o n o f in te rv e n ti o n (w k s) F o ll o w -u p (w k s) C ri ts -C ri st o p h , 1 9 9 9 4 8 7 7 6 .8 % 3 3 .9 C o ca in e d e p e n d e n ce ( D S M -I V ) 1 . C B T ( 1 1 9 ) 2 . S E P T ( 1 2 4 ) 3 . 1 2 -s te p ( 1 2 1 ) 4 . T A U ( G ro u p D ru g C o u n se li n g ) (1 2 3 ) 3 6 4 8 C a rr o ll , 1 9 9 8 1 2 2 7 3 % 3 0 .8 C o ca in e d e p e n d e n ce w it h co m o rb id A lc o h o l d e p e n d e n ce o r a b u se ( D S M -I II -R ) 1 . C B T ( 1 9 ) 2 . C B T w it h d is u lf ir a m ( 2 7 ) 3 . 1 2 -s te p a lo n e ( n = 2 5 ) 4 . 1 2 -s te p w it h d is u lf ir a m ( 2 5 ) 5 . T A U w it h d is u lf ir a m ( 2 7 ) 1 2 N A G o tt h ei l, 1 9 9 8 4 4 7 N A N A C o ca in e d e p e n d e n ce ( D S M -I II -R ) 1 . I n te n si v e p ro g ra m ( 1 5 0 ) 2 . I n d iv id u a l co u n se li n g ( 1 4 6 ) 3 . I n d iv id u a l co u n se li n g p lu s g ro u p se ss io n s (1 5 1 ) 1 2 3 6 K ir b y, 1 9 9 8 9 0 6 7 % 3 1 .7 C o ca in e d e p e n d e n ce ( D S M -I II -R ) 1 . C B T p lu s v o u ch e r b a se d C M ( 4 4 ) 2 . C B T ( 4 6 ) 1 2 N A M a u d e-G ri ff in , 1 9 9 8 1 2 8 9 8 .4 % N A C o ca in e d e p e n d e n ce ( D S M -I II -R ) 1 . C B T ( 5 9 ) 2 . 1 2 -s te p ( 6 9 ) 1 2 2 6 S il v er m a n , 1 9 9 8 5 9 6 6 % 3 7 .8 C o ca in e u se ( D S M -I II ) 1 . V o u ch e r b a se d C M ( 2 0 ) 2 . V o u ch e r b a se d C M w it h S ta rt -u p b o n u s (2 0 ) 3 . R e w ( 1 9 ) 1 2 2 0 M cK a y, 1 9 9 7 9 8 1 0 0 % 4 0 C o ca in e d e p e n d e n ce ( D S M I II -R ) 1 . T A U ( 5 2 ) 2 . R P ( 4 6 ) 2 4 N A M o n ti , 1 9 9 7 1 2 8 6 9 % 2 8 .4 C o ca in e u se o r d e p e n d e n ce (D S M -I II -R ) 1 . C B T ( ru ra l si te ) (4 4 ) 2 . C B T ( u rb a n s it e ) (1 6 ) 3 . T A U ( ru ra l si te ) (5 1 ) 4 . T A U ( u rb a n s it e ) (1 7 ) 1 -3 1 2 S ch m it z , 1 9 9 7 3 2 5 0 % 3 4 .9 C o ca in e d e p e n d e n ce ( D S M -I II -R ) 1 . G ro u p C B T ( 1 6 ) 2 . I n d iv id u a l C B T ( 1 6 ) 8 2 4 W ei n st ei n , 1 9 9 7 4 2 3 N A N A C o ca in e d e p e n d e n ce ( D S M -I II -R ) 1 . I n te n si v e o u tp a ti e n t tr e a tm e n t (S E -IN T ) (1 3 7 ) 2 . O u tp a ti e n t in d iv id u a l th e ra p y ( S E -I N D ) (1 4 4 ) 3 . I n d iv id u a l th e ra p y + a w e e k ly g ro u p (S E -I N D -G R P ) (1 4 2 ) 1 2 3 6
L eg en d : B I: b ri ef in te rv en ti o n ; C B T : c o gn it iv e b eh av io u ra l t h er ap y; C M : c o n ti n ge n cy m an ag em en t; C R A : c o m m u n it y re in fo rc em en t ap p ro ac h ; F T : f am il y th er ap y; F U : f o ll o w -u p ; I P T : i n te rp er so n al th e ra p y ; M b I: m in d fu ln e ss b a se d i n te rv e n ti o n ; M I: m o ti v a ti o n a l in te rv ie w in g ; N A : n o t a ss e ss e d ; N R : n o t re p o rt e d ;R e w : n o n -c o n ti n g e n t re w a rd s; R P : r e la p se p re v e n ti o n ; S E P T : S u p p o rt iv e -E x p re ss iv e P sy ch o d y n a m ic T h e ra p y ; S U D : s ti m u la n t u se d is o rd e r; T A U : t re a tm e n t a s u su a l; T M C : t e le p h o n e m o n it o ri n g a n d c o u n se ll in g ; T S F : t w e lv e -s te p f a ci li ta ti o n . Ta bl e 1. T ab le o f i nc lu de d st ud ie s. S tu d y P a rt ic ip a n ts G e n d e r (m a le s% ) M e a n A g e (y rs ) D ia g n o si s In te rv e n ti o n s (n ) D u ra ti o n o f in te rv e n ti o n (w k s) F o ll o w -u p (w k s) S il v er m a n , 1 9 9 6 3 7 N A 3 6 .0 5 C o ca in e u se o r d e p e n d e n ce (D S M -I II -R ) 1 . V o u ch e r b a se d C M ( 1 9 ) 2 . R e w ( 1 8 ) 1 2 1 6 C a rr o ll , 1 9 9 4 1 1 0 6 3 % 2 8 .8 C o ca in e u se o r d e p e n d e n ce (D S M -I II -R ) 1 . C B T w it h d e si p ra m in e h y d ro ch lo ri d e (2 9 ) 2 . C B T w it h p la ce b o ( 2 9 ) 3 . T A U w it h d e si p ra m in e h y d ro ch lo ri d e (2 5 ) 4 . T A U w it h p la ce b o ( 2 7 ) 1 2 N A H ig g in s, 1 9 9 4 4 0 6 7 .5 % 3 1 .3 C o ca in e d e p e n d e n ce ( D S M -I II -R ) 1 . C R A p lu s v o u ch e r C M ( 2 0 ) 2 . C R A ( 2 0 ) F o r su b je ct s w h o m e t a ls o c ri te ri a f o r a lc o h o l d e p e n d e n ce /a b u se ( 4 1 % ) w a s o ff e re d D is u lf ir a m ( ~ 2 5 0 m g /d a y ). 2 4 5 2 H o ff m a n , 1 9 9 4 H o ff m a n , 1 9 9 6 3 0 3 6 8 % 3 2 C o ca in e u se rs f ro m a n o u tp a ti e n t tr e a tm e n t p ro g ra m 1 . T A U ( st a n d a rd g ro u p t h e ra p y ) (5 0 ) 2 . I P T p lu s st a n d a rd g ro u p t h e ra p y ( 5 3 ) 3 . I P T p lu s F T p lu s st a n d a rd g ro u p t h e ra p y (5 0 ) 4 . I n te n si v e G ro u p T h e ra p y ( 5 0 ) 5 . I P T p lu s In d iv id u a l P sy ch o - th e ra p y ( 5 1 ) 6 . I P T p lu s F T p lu s In d iv id u a l P sy ch o -th e ra p y ( 4 9 ) 1 6 5 2 W el ls , 1 9 9 4 1 1 0 6 4 % 2 9 .4 C o ca in e u se o r d e p e n d e n ce 1 . C B T ( R P ) (4 8 ) 2 . 1 2 -s te p ( 6 2 ) 1 2 2 4 H ig g in s, 1 9 9 3 3 8 8 9 % 2 9 .3 C o ca in e d e p e n d e n ce ( D S M -I II -R ) 1 . C R A p lu s v o u ch e r b a se d C M ( 1 9 ) 2 . 1 2 -s te p p lu s R e w ( 1 9 ) T o s u b je ct s w h o a ls o m e t cr it e ri a f o r a lc o h o l d e p e n d e n ce /a b u se i t w a s o ff e re d D is u lf ir a m ( ~ 2 5 0 m g /d a y ) 2 4 5 2 C a rr o ll , 1 9 9 1 4 2 7 4 % 2 7 C o ca in e u se o r d ep en d en ce ( D S M -II I) 1 . C B T ( R P ) (2 1 ) 2 . I P T ( 2 1 ) 1 2 N A K a n g , 1 9 9 1 1 6 8 8 6 % N A C o ca in e u se o r d e p e n d e n ce (D S M -I II -R ) 1 . F T ( n = N R ) 2 . T A U ( in d iv id u a l th e ra p y ) (n = N R ) 3. T A U ( gr o u p t h er ap y) ( n = N R ) 2 4 -5 2 N A
Table 2. Differential elements of psychosocial therapies included.
Therapy Elements of therapy Duration Target population
Cognitive behavioural coping skill treatment (CBT)
– Functional analysis of substance use: history, when it occurs, triggers, frequency, intensity, motivation and resources about change
– Coping skills training: role play to adopt new different strategies (positive modelling), systematic analysis of the short and long term consequences of substance use (operant conditioning), to increase awareness, avoidance of high-risk situations (classical conditioning) 12 to 16 sessions, usually over 12 weeks Individuals with psychostimulant addiction Gay specific cognitive behavioural therapy (GCBT)
– Functional analysis of substance use and coping skills training – Specific HIV prevention
48 sessions in 16 weeks or 24 sessions in 8 weeks Individuals homosexual or bisexual with methamphetamine use Relapse prevention (RP)
– Specific interventions: to identify and cope with high-risk situations, enhance self-efficacy, to eliminate positive myths and placebo effect assumptions about the drug, lapse management – Global interventions: to reduce stressful lifestyle, promote
“positive addictions”, to cope with craving
12 weeks Individuals who have received,
or are receiving, treatment for addictive behavior problems. RP can be used to foster initial abstinence or as a maintenance strategy
Community reinforcement approach (CRA)
– To identify and address causes of drug abuse to more complex relational and psychiatric problems
– Functional analysis – Coping skill training
– Eventually vouchers with urinalysis monitoring two-three times a week
– Eventually meetings outside the office
24 weeks, twice weekly counselling sessions for the first 12 weeks, then once weekly
Cocaine use, 18 years or older, living within a reasonable distance of the clinic, due to the intensive nature of the intervention
Contingency management
– Positive reinforcement of positive behaviours and attitudes – Using objective measures such as urinalysis
– Giving prizes: vouchers, lottery tickets, methadone doses (in case of comorbidity with opioid addiction)
– No relationship with a therapist
Not specified Individuals with
psychostimulants addiction. May not be appropriate for people with problematic gambling.
Supportive-expressive psychodynamic therapy
– To develop awareness of personal hopes or needs from a relationship (wish), personal expectations and experiences from others (Response from Others - RO), and personal reaction to this response (Response from Self - RS)
– To be aware of how repetitive patterns are related to past relationship with the caregivers, and to the present as triggers for craving
– To work with transference and countertransference
6-month active phase and 3-month booster phase, During the first 3 months sessions are held twice per week, during the next 3 months sessions are held weekly, during the booster phase 1 session is held each month
Individuals with
psychostimulants addiction, who can achieve initial abstinence
Interpersonal psychotherapy
– To develop the need to stop using cocaine and to abandon the ambivalence about the substance
– Comparison between the negative and positive effects of drug abuse
– To recreate the thoughts and emotions that precede the use of cocaine
– To manage the impulsiveness
– Analysis of interpersonal problems that have caused and maintained drug abuse and
– Identify new functional solutions in preference of cocaine use
12-16 sessions Individuals with
psychostimulants addiction, who feel the abuse is secondary to interpersonal problems
Family therapy – To focus on relationships in the family system rather than the drug and the patient themselves
– To redefine the addiction and its functions at the family life cycle actual stage
– To restructure the system to maximise the potential in each member
– To work on family’s boundaries – To work on present and past – To identify repetitive family patterns
5 months Individuals with
psychostimulants addiction who feel the addiction stems from and is maintained by family patterns
The 12-step program
– Based on self-help group
– Spiritual and pragmatic vision embraced in twelve steps: acceptance of being addicted and surrender to a “higher Power”
Not specified Individuals who desire to stop
using cocaine and all other mind-altering substances
plore the features of historical drug use. They move next at analyzing maladaptive behavioral patterns including timing, frequency, and intensity of misuse, as well as any environ-mental, psychological, or somatic trigger for craving. Finally, emerging personal and interpersonal resources, motivation for change, and future goals are discussed.
Coping-skills training works on basic learning mecha-nisms that led to stimulants use in the first place, such as modeling49,50, classical conditioning51, and operant
condition-ing52. Modeling theory suggests that people learn new
be-haviors by watching and then imitating others, so patients ex-posed to negative models of drug use within their family or peer group will shape their behavior accordingly and devel-op an addiction. On this basis, CBT aims to replace that neg-ative model with a positive one conveyed by the therapist; al-so, new skills such as rejecting an offer of drugs and manag-ing relationships with peer users are presented through role-play in a therapeutic setting and then routinely practiced by patients. Classical conditioning occurs when an uncondi-tioned stimulus is paired with another condiuncondi-tioned stimulus, producing a conditioned response; thus, the recurrent use of stimulants (i.e. the unconditioned stimulus) can be associat-ed with places, times, money, and other triggers (i.e. the con-ditioned stimuli) that will elicit craving for substances (i.e. the conditioned response). Here, CBT is used for increasing awareness of these unhelpful mechanisms and facilitate the avoidance of high-risk situations. Operant conditioning re-quires active involvement of the subject because future be-havior relies on the consequences of past bebe-havior; in
stimu-lant use disorders, the intake of cocaine and amphetamines is reinforced by its most desired consequences such as in-creased energy and efficiency, euphoria, grandiosity, and dis-inhibition. A CBT approach encourages patients to examine the short- and long-term outcomes of stimulant use, which turn out to be negative in most cases (i.e. a negative rein-forcement); moreover, the therapist can redirect patient’s behavior to other pleasant endeavors such as hobbies, work, and relationships (i.e. positive reinforcement).
Trials
Many trials assessed CBT in stimulant use disorders. CBT was associated with improved outcomes in cocaine53, crack
cocaine54, and methadone-maintained cocaine users26 with
lasting effects. Even non-intensive CBT delivered fortnight-ly over 12 weeks was effective in cocaine use55, and Baker et
al.56,57obtained comparable results with a brief CBT
inter-vention plus psychoeducation via self-help booklets in am-phetamine users. A CBT strategy focusing on the negative effects of misuse significantly reduced craving for the sub-stance in methamphetamine58and cocaine users59. Carroll47
and Carroll et al.11showed that combined CBT and
disulfi-ram was effective in cocaine use disorder irrespective of con-current alcohol misuse. In contrast, one study reported that CBT was less effective than counseling in reducing days of cocaine use and drug-related problems60, whilst another
compared CBT with other interventions, but no abstinence outcomes were reported for it61. As CBT can be
resource-consuming, some researchers attempted strategies for
in-(continued) - Table 2.
Therapy Elements of therapy Duration Target Population
Mindfulness based stress reduction (MBSR)
– Body scan, sitting meditation and hatha yoga practice – To develop greater attention to internal and external
experiences as they occur moment by moment – To adopt non-judgement of, and openness to, current
experience, instead of trying to modify or suppress it
– Promote detachment and lower reactivity to stimuli that lead to relapse, as opposed to complete avoidance of them
8 weeks program comprised of weekly two and a half hour sessions, a one day retreat and daily homework (about 45 minutes)
Individuals with
psychostimulant addiction who can renounce to traditional talking based therapy
Mindfulness based relapse prevention (MBRP)
– Integration of relapse prevention and mindfulness practice – To develop awareness and acceptance of thoughts, feelings, and
sensations
– To utilize these mindfulness skills as an effective coping strategy in the face of high-risk situations
8 weeks program Individuals with
psychostimulant addiction who can renounce to traditional talking based therapy
Motivational interviewing
– Manage the patient’s ambivalence about change – Reflective listening, understanding and empathy
– Highlight discrepancies between the client’s current situation and their hopes for the future,
– To allow them to identify their own motivation – Enhancing motivation
2-4 sessions Initial tool in individuals with
psychostimulant use who feel poorly motivated
Individual counselling
– Focuses on the present, with short-term and behavioural goals related to the symptoms of substance abuse
– Support to achieve and maintain abstinence – Recognising and avoiding triggers, – Enhancing motivation,
– Developing new and more effective coping strategies – Using objective measures such as urinalysis
36 sessions over 6 months
Cocaine addicts with the exception of opiates if methadone maintenance is to be used
Group drug counselling
– Phase one: psycho-educational group of 12 standard sessions to improve knowledge about addiction and the recovery process. – Phase two: problem solving
34 sessions (once a week)
Early and middle stages of recovery from addiction, preferred in combination with an individual treatment
creasing availability. Group CBT failed to show any differ-ence against usual treatment62. A preliminary study by
Ke-oleian et al.63used a CBT-based text-messaging intervention
for methamphetamine users that showed high feasibility and acceptability. Carroll et al.64, delivered a computer-based
CBT to cocaine users on methadone, reporting easy accessi-bility and increased abstinence with lasting effects. Finally, another study used a self-guided web-based intervention based on CBT and motivational interviewing principles over 6 months via a free-to-access site for amphetamine users, but this failed to show improvement in drug use and engagement remained low65.
b) Gay-specific cognitive behavioral therapy (G-CBT) Trials
Cognitive behavioral interventions can be targeted to spe-cific populations: G-CBT was adapted for men who have sex with men affected by methamphetamine dependence by Shoptaw et al.66,67. In addition to standard
cognitive-behav-ioral principles, G-CBT considered cultural aspects of methamphetamine use by men who have sex with men in-cluding triggers such as circuit parties and sex clubs, and ob-tained significant and susob-tained improvements in both drug use and prevention of HIV.
c) Relapse prevention (RP) Theoretical background
Once abstinence is achieved, cognitive behavioral inter-ventions aim to prevent further relapses. The RP model views relapse as secondary to difficulty in coping with imme-diate determinants (i.e. negative emotional states, relational problems, social pressures, lapses) and to covert antecedents (i.e. life-style, urges and craving)68. Through RP work,
pa-tients learn to identify high-risk situations such as lapses that are associated with guilt and other negative emotions, even-tually leading to relapses. Lapse management uses cognitive restructuring to recognize lapses and relapses not as failures but opportunities to learn from mistakes. RP interventions also focus on the antecedents and aim to reduce stressful life-style factors by eliminating all items associated with stimu-lants use and promoting “positive addictions” such as medi-tation, relaxation training, and other recreational activities. Trials
RP reduced cocaine and other drugs use post-treatment69,
and it was more effective in those whose drug use was the most severe70-72. Group and individual approaches showed
comparable results73. However, McKay et al.74stressed that
RP was useful only after abstinence was fully achieved. d) Cognitive behavioural interventions plus CM Trials
Cognitive behavioral interventions are often combined with CM with a view of increasing the engagement with ther-apy. CBT plus CM increased abstinence in cocaine users75,
es-pecially when rewards were arranged in conjunction with therapeutic progress76. Also, combining RP with CM
im-proved outcomes in cocaine users who had achieved initial abstinence77. Rawson et al.26,78reported superior short- and
long-term outcomes for CBT and CM respectively, but no ad-ditive effect was observed. On the contrary, combined CBT and CM obtained significantly better outcomes than CBT or CM alone in cocaine79,80and methamphetamine users67.
Mil-by et al.81studied a population of homeless cocaine users and
showed that the combination of a housing- and employment-based CM with cognitive behavioral interventions lead to more durable abstinence. A preliminary study by Carrico et al.82highlighted the feasibility of CBT plus CM in a high-risk
population of Cambodian female sex workers using amphet-amines who live in a resource-limited area.
Community reinforcement approach (CRA)
Theoretical background
The community reinforcement approach (CRA) is a multilayered intensive intervention delivered over 24 weeks and adapted to treat cocaine and amphetamines addiction83. It teaches drug avoidance
skills, encourages lifestyle changes, gives relationship counseling, and addresses comorbid substance use and psychiatric disorders. As in CBT, it involves functional analysis and coping-skills training. Social, fa-milial, recreational, and vocational reinforcers are largely used, pro-viding a comprehensive and supportive structure to treatment. a) CRA alone
Trials
Only one trial used CRA alone, showing better retention and abstinence rates, and improvements in addiction severi-ty scores after 24 weeks of treatment84.
b) CRA plus CM Trials
Incentives such as vouchers and out-of-treatment sessions (e.g. meetings outside the office hours) are frequently added to improve treatment compliance. Numerous studies by Hig-gins et al.17,85-87, García-Rodríguez et al.88, García-Fernández
et al.89,90showed that CRA plus CM was effective, had
in-creased retention rates, and improved psychosocial out-comes in cocaine users, although this was not demonstrated at follow-ups longer than 6-12 months after the end of treat-ment. These findings were confirmed in cocaine users of any socioeconomic status91. However, another study failed to
show any superiority of CRA when added to CM92.
12-step program (12-SP)
Theoretical background
The 12-step program (12-SP) was originally designed for alcoholism93 and then adjusted to several other substance
use disorders including cocaine and amphetamines. Contrar-ily to other treatments, it considers addiction as a chronic ill-ness that can be controlled, but never cured. It is largely based on spiritual and relational principles applied to a fel-lowship of peers associated by the willingness to fight
addic-tion. All members share a transcendent yet pragmatic vision embraced in twelve steps (see box 1 in the supplementary material), including the acceptance of being addicted and the surrender to a “higher Power”, often but not necessarily in-terpreted as God. The self-help group reduces social isola-tion and conveys support and empathy from people facing similar problems, all in complete anonymity. However, com-plex group dynamics pose frequent challenges, especially be-cause most members are not trained to work on this aspect. Moreover, group therapies normally do not allow enough time to address deeper individual experiences. A 12-step fa-cilitation therapy was therefore developed with the aim to improve participation and involvement in the 12-SP94. This is
a structured, individual, and time-limited intervention deliv-ered by a trained psychotherapist.
a) 12-SP alone Trials
Trials of 12-SP and 12-step facilitation in stimulant use disorders achieved modest95or mixed96results. Two studies
showed that 12-SP and cognitive behavioral interventions were equally effective in patients addicted to cocaine and alcohol69,97. Maude-Griffin et al.54obtained opposite results
but highlighted a potential benefit from 12-SP in the spe-cific subgroup of African American with strong religious beliefs.
b) 12-SP plus other interventions Trials
Few studies on combined interventions are reported in lit-erature. The effectiveness of 12-SP plus counseling in cocaine use disorder was supported by Weiss et al.61, who reported
that active participation predicted less cocaine use. Higgins et al.85 compared 12-SP plus non-contingent reward with
CRA plus CM, but the former resulted in worse outcomes. However, when CM was combined with either 12-SP or CRA, no difference between treatments was found92.
Meditation-based interventions (MbI) and physical exercise (PhE)
Meditation-based interventions (MbI) and physical exer-cise (PhE) share several theoretical underpinnings and therefore are reported together.
a) Meditation-based interventions (MbI) Theoretical background
Meditation refers to a broad variety of practices including body scan, yoga, and mindfulness meditation, whereby indi-viduals train their minds to pay greater attention to internal and external experiences as they occur98,99. It is not designed
to suppress dysfunctional behaviors, but encourages the adoption of a non-judgmental approach to stressful experi-ences, leading to detachment and lower reactivity to stimuli associated with relapse and reduced distress. It can be deliv-ered in group and then self-applied, so the overall cost is low. The engagement with MbI can vary as some patients may
have a positive attitude towards it, but others may be reluc-tant to abandon traditional talking-based therapies.
Trials
MbI for stimulant use disorders were examined in 3 trials. Smout et al.100devised a modified version of the acceptance
and commitment therapy101,102, integrating aspects of
mind-fulness training and behavioral therapy and consisting of weekly 60-minute individual sessions for 12 weeks. This was tested on a sample of methamphetamine users and showed results comparable to those of a CBT intervention of the same intensity. Chen et al.103used a different MbI to treat
co-caine addiction, which involved adjusting the breath to near-resonant frequency, regulating the mind with inward atten-tion and guided imagery, and ear acupressure. This treatment was confirmed to increase abstinence and to reduce craving and anxiety when compared to usual treatment. Yoga medi-tation was used on a population of crack cocaine users with comorbid HIV, showing high feasibility and acceptability as well as modest improvements in measures of quality of life104. Finally, a recent trial developed a Mindfulness Based
Relapse Prevention and used it in addition to CM for pa-tients with stimulant use disorders, showing declining stimu-lant use among those with comorbid depressive and anxiety disorders105.
b) Physical exercise (PhE) Theoretical background
PhE is an intervention that is thought to impact directly on stimulant use and mediates important health-related out-comes such as withdrawal symptoms, mood, sleep, cognitive function, and quality of life106.
Trials
A few studies recently assessed various PhE interventions in stimulant use disorders. Zhu et al.107used tai-chi, a
tradi-tional Chinese sport classified as a moderate exercise, on am-phetamine users, reporting significant improvements on all domains of a quality of life for drug addiction questionnaire. Rawson et al.108showed that a structured PhE program and
health education for methamphetamine users decreased sub-stance use among lower severity patients and significantly re-duced comorbid depressive symptoms. However, walking and running, in addition to a baseline intervention of CBT and rewards including cash and sport equipment, improved the fitness of cigarette-smoker patients with concurrent co-caine use disorder, but did not significantly improved absti-nence and craving from cocaine109. Likewise, a recent study
failed to show any significant difference in abstinence rates between PhE and health education110.
Supportive-expressive psychodynamic therapy (SEPT)
Theoretical background
All psychodynamic approaches derive from Freud’s psy-choanalytic model; amongst these, supportive-expressive psychodynamic therapy (SEPT) is the only evidence-based
