Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Cagliari, Italy.
Cochrane Database Syst Rev. 2024 Feb 15;2(2):CD011866. doi: 10.1002/14651858.CD011866.pub3.
Stimulant use disorder is a continuously growing medical and social burden without approved medications available for its treatment. Psychosocial interventions could be a valid approach to help people reduce or cease stimulant consumption. This is an update of a Cochrane review first published in 2016.
To assess the efficacy and safety of psychosocial interventions for stimulant use disorder in adults.
We searched the Cochrane Drugs and Alcohol Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, three other databases, and two trials registers in September 2023. All searches included non-English language literature. We handsearched the references of topic-related systematic reviews and the included studies.
We included randomised controlled trials (RCTs) comparing any psychosocial intervention with no intervention, treatment as usual (TAU), or a different intervention in adults with stimulant use disorder.
We used the standard methodological procedures expected by Cochrane.
We included a total of 64 RCTs (8241 participants). Seventy-three percent of studies included participants with cocaine or crack cocaine use disorder; 3.1% included participants with amphetamine use disorder; 10.9% included participants with methamphetamine use disorder; and 12.5% included participants with any stimulant use disorder. In 18 studies, all participants were in methadone maintenance treatment. In our primary comparison of any psychosocial treatment to no intervention, we included studies which compared a psychosocial intervention plus TAU to TAU alone. In this comparison, 12 studies evaluated cognitive behavioural therapy (CBT), 27 contingency management, three motivational interviewing, one study looked at psychodynamic therapy, and one study evaluated CBT plus contingency management. We also compared any psychosocial intervention to TAU. In this comparison, seven studies evaluated CBT, two contingency management, two motivational interviewing, and one evaluated a combination of CBT plus motivational interviewing. Seven studies compared contingency management reinforcement related to abstinence versus contingency management not related to abstinence. Finally, seven studies compared two different psychosocial approaches. We judged 65.6% of the studies to be at low risk of bias for random sequence generation and 19% at low risk for allocation concealment. Blinding of personnel and participants was not possible for the type of intervention, so we judged all the studies to be at high risk of performance bias for subjective outcomes but at low risk for objective outcomes. We judged 22% of the studies to be at low risk of detection bias for subjective outcomes. We judged most of the studies (69%) to be at low risk of attrition bias. When compared to no intervention, we found that psychosocial treatments: reduce the dropout rate (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.74 to 0.91; 30 studies, 4078 participants; high-certainty evidence); make little to no difference to point abstinence at the end of treatment (RR 1.15, 95% CI 0.94 to 1.41; 12 studies, 1293 participants; high-certainty evidence); make little to no difference to point abstinence at the longest follow-up (RR 1.22, 95% CI 0.91 to 1.62; 9 studies, 1187 participants; high-certainty evidence); probably increase continuous abstinence at the end of treatment (RR 1.89, 95% CI 1.20 to 2.97; 12 studies, 1770 participants; moderate-certainty evidence); may make little to no difference in continuous abstinence at the longest follow-up (RR 1.14, 95% CI 0.89 to 1.46; 4 studies, 295 participants; low-certainty evidence); reduce the frequency of drug intake at the end of treatment (standardised mean difference (SMD) -0.35, 95% CI -0.50 to -0.19; 10 studies, 1215 participants; high-certainty evidence); and increase the longest period of abstinence (SMD 0.54, 95% CI 0.41 to 0.68; 17 studies, 2118 participants; high-certainty evidence). When compared to TAU, we found that psychosocial treatments reduce the dropout rate (RR 0.79, 95% CI 0.65 to 0.97; 9 studies, 735 participants; high-certainty evidence) and may make little to no difference in point abstinence at the end of treatment (RR 1.67, 95% CI 0.64 to 4.31; 1 study, 128 participants; low-certainty evidence). We are uncertain whether they make any difference in point abstinence at the longest follow-up (RR 1.31, 95% CI 0.86 to 1.99; 2 studies, 124 participants; very low-certainty evidence). Compared to TAU, psychosocial treatments may make little to no difference in continuous abstinence at the end of treatment (RR 1.18, 95% CI 0.92 to 1.53; 1 study, 128 participants; low-certainty evidence); probably make little to no difference in the frequency of drug intake at the end of treatment (SMD -1.17, 95% CI -2.81 to 0.47, 4 studies, 479 participants, moderate-certainty evidence); and may make little to no difference in the longest period of abstinence (SMD -0.16, 95% CI -0.54 to 0.21; 1 study, 110 participants; low-certainty evidence). None of the studies for this comparison assessed continuous abstinence at the longest follow-up. Only five studies reported harms related to psychosocial interventions; four of them stated that no adverse events occurred.
AUTHORS' CONCLUSIONS: This review's findings indicate that psychosocial treatments can help people with stimulant use disorder by reducing dropout rates. This conclusion is based on high-certainty evidence from comparisons of psychosocial interventions with both no treatment and TAU. This is an important finding because many people with stimulant use disorders leave treatment prematurely. Stimulant use disorders are chronic, lifelong, relapsing mental disorders, which require substantial therapeutic efforts to achieve abstinence. For those who are not yet able to achieve complete abstinence, retention in treatment may help to reduce the risks associated with stimulant use. In addition, psychosocial interventions reduce stimulant use compared to no treatment, but they may make little to no difference to stimulant use when compared to TAU. The most studied and promising psychosocial approach is contingency management. Relatively few studies explored the other approaches, so we cannot rule out the possibility that the results were imprecise due to small sample sizes.
兴奋剂使用障碍是一种不断增长的医学和社会负担，但其治疗方法尚无获得批准的药物。心理社会干预可能是帮助人们减少或停止兴奋剂消费的有效方法。这是一篇对 2016 年首次发表的 Cochrane 综述的更新。
评估针对成人兴奋剂使用障碍的心理社会干预措施的疗效和安全性。
我们于 2023 年 9 月检索了 Cochrane 药物和酒精组专业注册库、Cochrane 对照试验中心注册库（CENTRAL）、医学文献分析与检索系统（MEDLINE）、Embase、其他三个数据库以及两个试验注册库。所有检索均包括非英语文献。我们还手工检索了与专题系统评价相关的参考文献和纳入的研究。
我们纳入了比较任何心理社会干预与无干预、常规治疗（TAU）或成人兴奋剂使用障碍患者不同干预措施的随机对照试验（RCTs）。
我们使用了 Cochrane 预期的标准方法学程序。
我们共纳入了 64 项 RCT（8241 名参与者）。73%的研究纳入了可卡因或快克可卡因使用障碍的参与者；3.1%的研究纳入了安非他命使用障碍的参与者；10.9%的研究纳入了甲基苯丙胺使用障碍的参与者；12.5%的研究纳入了任何兴奋剂使用障碍的参与者。在 18 项研究中，所有参与者均接受美沙酮维持治疗。在我们对任何心理社会治疗与无干预的主要比较中，我们纳入了将心理社会干预加 TAU 与 TAU 单独比较的研究。在这一比较中，12 项研究评估了认知行为疗法（CBT），27 项研究评估了行为契约管理，3 项研究评估了动机访谈，1 项研究评估了心理动力学疗法，1 项研究评估了 CBT 加行为契约管理。我们还比较了任何心理社会干预与 TAU。在这一比较中，7 项研究评估了 CBT，2 项研究评估了行为契约管理，2 项研究评估了动机访谈，1 项研究评估了 CBT 加动机访谈。7 项研究比较了与戒断相关的行为契约管理强化与与戒断无关的行为契约管理强化。最后，7 项研究比较了两种不同的心理社会方法。我们判断 65.6%的研究在随机序列生成方面存在低偏倚风险，19%的研究在分配隐匿方面存在低偏倚风险。由于干预的类型，我们无法对人员和参与者进行盲法，因此我们认为所有研究在主观结局的表现偏倚方面都存在高风险，但在客观结局方面则存在低风险。我们判断 22%的研究在主观结局的检测偏倚方面存在低偏倚风险。我们判断大多数研究（69%）在脱落偏倚方面存在低风险。与无干预相比，我们发现心理社会治疗：降低脱落率（风险比（RR）0.82，95%置信区间（CI）0.74 至 0.91；30 项研究，4078 名参与者；高确定性证据）；对治疗结束时的点戒断率影响不大（RR 1.15，95%CI 0.94 至 1.41；12 项研究，1293 名参与者；高确定性证据）；对最长随访时的点戒断率影响不大（RR 1.22，95%CI 0.91 至 1.62；9 项研究，1187 名参与者；高确定性证据）；可能增加治疗结束时的连续戒断率（RR 1.89，95%CI 1.20 至 2.97；12 项研究，1770 名参与者；中等确定性证据）；对最长随访时的连续戒断率影响不大（RR 1.14，95%CI 0.89 至 1.46；4 项研究，295 名参与者；低确定性证据）；减少治疗结束时的药物摄入量频率（标准化均数差（SMD）-0.35，95%CI -0.50 至 -0.19；10 项研究，1215 名参与者；高确定性证据）；并增加最长的戒断期（SMD 0.54，95%CI 0.41 至 0.68；17 项研究，2118 名参与者；高确定性证据）。与 TAU 相比，我们发现心理社会治疗降低了脱落率（RR 0.79，95%CI 0.65 至 0.97；9 项研究，735 名参与者；高确定性证据），并可能对治疗结束时的点戒断率影响不大（RR 1.67，95%CI 0.64 至 4.31；1 项研究，128 名参与者；低确定性证据）。我们不确定它们是否对最长随访时的点戒断率有任何影响（RR 1.31，95%CI 0.86 至 1.99；2 项研究，124 名参与者；极低确定性证据）。与 TAU 相比，心理社会治疗可能对治疗结束时的连续戒断率影响不大（RR 1.18，95%CI 0.92 至 1.53；1 项研究，128 名参与者；低确定性证据）；可能对治疗结束时的药物摄入量频率影响不大（SMD -1.17，95%CI -2.81 至 0.47，4 项研究，479 名参与者，中等确定性证据）；并可能对最长的戒断期影响不大（SMD -0.16，95%CI -0.54 至 0.21；1 项研究，110 名参与者；低确定性证据）。这一比较中没有研究评估最长随访时的连续戒断率。仅有 5 项研究报告了与心理社会干预相关的不良事件；其中 4 项报告未发生不良事件。
本综述的研究结果表明，心理社会治疗可通过降低脱落率帮助患有兴奋剂使用障碍的人。这一结论基于与无治疗和 TAU 相比，心理社会干预的高确定性证据。这是一个重要的发现，因为许多患有兴奋剂使用障碍的人过早地离开治疗。兴奋剂使用障碍是一种慢性、终身、复发性的精神障碍，需要大量的治疗努力才能实现戒断。对于那些尚未能够完全戒断的人来说，保留治疗可能有助于降低兴奋剂使用带来的风险。此外，心理社会干预与无治疗相比可减少兴奋剂使用，但与 TAU 相比，可能对兴奋剂使用影响不大。最受研究和最有前途的心理社会方法是行为契约管理。相对较少的研究探索了其他方法，因此我们不能排除由于样本量小而导致结果不准确的可能性。
