A Metaanalytic Review of Psychological Interventions for Substance Use Idsorders
In the last 30 years, there has been pregnant progress in the development and validation of psychosocial treatments for substance abuse and dependence, with a predominant focus on the validation of cerebral behavioral treatments (1) . Prominent amid these approaches accept been contingency direction interventions and interventions emphasizing functional analyses and strategies for irresolute higher-risk situations for drug use in either relapse prevention or other cognitive behavioral formats.
Based on principles of operant conditioning, contingency management interventions offering incentives or rewards to encourage specific behavioral goals. In the instance of treatments for substance dependence, monetary and nonmonetary rewards typically have been made contingent on negative toxicology screens, indicating abstinence from drug use. The approaches take shown consequent success, with drug employ disorders ranging from opiate and cocaine dependence to nicotine dependence (2 – 7) . An alternative approach, relapse prevention, focuses on identifying and intervening with higher-chance situations or events for drug utilize past helping individuals either avoid or manage these situations by rehearsing alternative (nondrug) responses. Similar to contingency management, relapse prevention approaches have shown benefit in a wide range of trials for illicit drug and alcohol use disorders (eight , 9) . A similar focus on completing a functional analysis of cues for utilize and rehearsing behavioral and cerebral nondrug responses characterizes a variety of other cognitive behavioral approaches (10) .
Although a number of smaller meta-analyses have been conducted for pharmacologic interventions for substance employ disorders (11 – 14) , few intervention-specific (fifteen) and, to our cognition, no comprehensive meta-analyses have been conducted for psychosocial treatments for illicit substance utilize disorders. Indeed, footling is known nigh how the wide range of psychosocial treatments compare to one some other across dissimilar outcome variables (east.grand., abstinence, dropout rate, etc.), and fifty-fifty less is known about the overall forcefulness of psychosocial treatments across unlike drugs of abuse (ane) .
The electric current study uses a meta-analysis to systematically investigate the efficacy of psychosocial treatments for substance use disorders and provides indices of the force of findings for specific interventions and specific drug apply disorders. Because meta-analyses have been conducted for psychosocial treatments of alcohol and nicotine use disorders (16 – 20) , we focused only on illicit substance utilize disorders. Every bit existing meta-analyses have focused on motivational interviewing interventions (21 – 24) , which tend to be employed in single-session formats, nosotros chose to target more than comprehensive interventions. Additionally, considering 12-step interventions are distinct from traditional psychotherapies, these interventions were used as control conditions only. Nosotros provide a comprehensive business relationship of the strength of cerebral behavioral treatments for cocaine, opiates, cannabis, and polysubstance abuse and dependence. In add-on, nosotros provide an assay of various effect variables (including abstinence, handling retentiveness, and treatment dropout). Finally, we provide bear witness for potential moderating factors in treatment outcome across studies.
Method
Study Option
We selected randomized, controlled clinical trials for inclusion in this meta-assay by performing a comprehensive search strategy. First, we conducted a calculator-based PsycINFO search of bachelor articles published between 1840 and March of 2005 using the following key terms to behave title searches (asterisks denote that whatsoever characters/letters can follow the last graphic symbol in the terms): cocaine, crevice, opi*, heroin, amphetamine*, methamphetamine*, MDMA, ecstasy, methylenedioxymethamphetamine, cannabis, marijuana, psychedelic, mushroom, glue, inhalant, poly*, substance* abuse, substance* utilize, aficionado*, and dependen* singularly and in combination with the following secondary descriptors: treatment*, trial*, consequence*, therapy, random*, intervention*, medication*, psychopharm*, pharm*, buprenorphine, beliefs*, counseling, cognitive, meta analys*, contingency, and voucher*. Second, we performed a reckoner-based MEDLINE search of articles available between 1966 and March 2005, combined with a Cochrane Cardinal Register of Controlled Trials search for the offset quarter of 2005 with the following search terms: substance abuse and randomized, or drug abuse and randomized, or drug dependence and randomized, or cocaine and randomized, or heroin and randomized, or opioid and randomized, or opiates and randomized, or methamphetamine and randomized, or amphetamine and randomized, or marijuana and randomized, or polydrug and randomized. These terms were searched as key, title, abstract, name of substance, and MeSH subject heading terms. This search was combined with a MeSH field of study heading search in the same database with the following terms: amphetamine-related disorders, cocaine-related disorders, marijuana abuse, opioid-related disorders, phencyclidine abuse, substance corruption, and intravenous. We limited both the PsycINFO and the MEDLINE searches to studies conducted with human participants and published in the English language language. All titles or abstracts for the citations produced were screened, and manufactures were nerveless for whatever citation that appeared to see inclusion criteria.
Studies meeting all of the following inclusion criteria were included in the meta-analysis:
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Investigations of the efficacy of any individual psychosocial treatments for substance abuse/dependence, with the exception of alcohol abuse/dependence and nicotine abuse/dependence
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Randomized, controlled trials including a comparison group that could consist of inactive (e.g., waitlisted) or active (e.g., treatment as usual) treatments
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Studies including adult (18 years and older) participants only
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Studies including one or more of our posttreatment outcome measures (described below) to allow for comparable outcome data across studies
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Investigations of the efficacy of nonintensive outpatient treatments, which we defined as consisting of no more three two-hour handling sessions per calendar week
Studies with medication as a backdrop condition were included but if the medication dosage did non vary between the active handling and control conditions. Controlled trials comparing the efficacy of diverse treatment intensities (e.g., once per calendar week versus twice per calendar week individual therapy of the same therapy type) were excluded if a articulate control group (e.thou., 1 receiving inactive treatment or treatment as usual) was unavailable (7 studies). When multiple control conditions were included in these trials, nosotros employed the "most intensive" treatment status as the agile treatment to compare to the control condition, and whatsoever other weather of varying treatment intensity were excluded. Studies containing follow-up data beyond one calendar month posttreatment but not presenting data at posttreatment were excluded (4 studies). Likewise, we excluded studies employing control weather known to be efficacious for substance corruption treatment (e.thou., cognitive behavior therapy, five studies) and studies using trials of wrap-around service treatment (i report), therapeutic workplaces/work therapies (one study), hypnotherapy (ane study), telecommunications networking (one study), brief motivational enhancement (two studies), supportive/expressive therapy (one report), and acupuncture (seven studies). In full, 30 studies were excluded from consideration.
Procedure
When available, data on a number of descriptive variables were nerveless for each report, including the post-obit: sex (data from 91.2% of the studies available), ethnicity (76.five% available), employment status (64.seven% bachelor), marital status (61.eight% available), average length of substance use (55.nine% bachelor), comorbid booze abuse/dependence diagnoses (20.half dozen% available), numbers of weeks handling was administered (97.i% available), number of handling sessions per week (58.eight%), number of participants entered per condition (100% available), handling retention rates (47.1% available), and numerous consequence variables, equally described beneath.
Treatments were categorized into the post-obit handling condition "types": contingency management/vouchers (14 studies), general cerebral behavior therapy interventions (xiii studies), relapse prevention (five studies), and cerebral behavior therapy plus contingency management combined (two studies). Descriptions of handling conditions were used to categorize each condition into its best-fit handling type.
Given the lack of "gold standard" issue measures in the substance abuse treatment literature, nosotros reviewed all controlled trials meeting our inclusion criteria, as well as all available substance abuse treatment reviews and meta-analyses, to develop a set of variables that would sufficiently let for outcome comparison beyond studies. These variables included a combination of cocky-report information (data from 58.8% of the studies bachelor) and measures employing toxicology screening procedures (76.5% bachelor). Self-report event variables were the following:
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Mean maximum number of days or weeks abstinent throughout treatment
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Mean percent of days abstinent throughout treatment
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Percentage of sample abstinent for iii or more weeks throughout treatment
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Percent of sample demonstrating posttreatment and/or clinically significant abstinence
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Posttreatment scores on the drug calibration of the Addiction Severity Index (25)
Toxicology screen variables were ane) mean number of negative screens throughout treatment, 2) mean pct of negative screens throughout treatment, and three) pct of sample demonstrating clinically pregnant forbearance.
With respect to the percent of the sample demonstrating posttreatment and/or clinically pregnant abstinence, for both self-report and toxicology screen data, studies varied widely in defining this variable. These definitions of posttreatment and/or clinically meaning abstinence varied from 4 to 24 weeks of abstinence (or abstinence for the entire length of treatment), every bit measured by means of the participants' self-report or toxicology screen results. The 3-calendar week abstinence cutoff appeared to exist the most widely employed measure of clinically pregnant alter, equally these data were presented past 11 (30%) of the studies included in this meta-analysis. The Addiction Severity Index (used by 16 studies) (25) and the Time Line Follow-Back interview method (used by 4 studies) (26) were the most widely used interviews for collecting self-report information across studies.
These eight outcome variables were used for the purposes of computing handling versus control condition effect size estimates. Effect size was calculated using Cohen'due south d (27) . Owing to inconsistency in the outcome variables employed by each study, when studies presented data on two or more consequence variables, we aggregated (averaged) across these variables to yield an aggregate mean effect size for each written report. In addition, to decide the differential effect of cocky-written report versus toxicology screen outcome data, nosotros aggregated outcome variables within each study to yield 1) an aggregate mean overall effect size, 2) an amass mean self-report event size, and 3) an aggregate mean toxicology screen upshot size. Finally, every bit a general mensurate of abstinence rates, we provide the per centum of the sample demonstrating posttreatment and/or clinically significant abstinence variable (these data were reported by sixteen of the 37 studies), or, if this variable was not reported for a particular study, we calculated this data from the information provided (information calculated for six studies).
Results
Report and Sample Characteristics
Effect sizes were calculated for a full of 34 studies. Across all studies, 2,340 entered the handling and identified command weather condition. The mean age of the participants across all studies was 34.9 years (range of means=20.half dozen to 43.0, SD=4.5). On boilerplate, samples were 62.ii% male and 61.0% Caucasian. The majority of the participants were single/unmarried (67.seven%), and less than half were employed part-time or full-fourth dimension (42.5%). The participants reported an average of 10.ane years of substance utilise (SD=five.1). Of the seven studies reporting specific diagnostic criteria, approximately 50.seven% of the participants met criteria for comorbid alcohol corruption or dependence, although booze was not the targeted substance in the handling report.
Table one presents a detailed overview of these treatments, including 14 identified equally contingency management, two as cognitive behavior therapy/contingency direction combination weather condition, xiii as full general cognitive behavior therapy interventions, and 5 as relapse prevention. Of these, 13 of the treatments were for polysubstance apply, nine for cocaine utilize, seven for opiate use, and five for cannabis utilize disorders. Treatment types were not significantly associated with (confounded with) the targeted drug use disorders according to chi-foursquare analyses (contingency management versus all other treatments).
Overall, 43.6% of the studies included samples in which the participants received medication maintenance (due east.one thousand., methadone maintenance) in conjunction with both the experimental handling and control conditions. The mean length of treatment across all conditions was 21 weeks (range=4–52 weeks, SD=fourteen), and the average number of sessions per week averaged 1.8 sessions (range=one–iii, SD=0.8). The mean intent-to-treat sample size per treatment condition was 38.23 (SD=32.00), ranging from v to 135 participants across all atmospheric condition.
Treatment Retention
Approximately one-third of the participants across all weather condition dropped out before handling completion (35.4%). Mean dropout among control conditions was 44.6%. Across all substance use groups, cocaine and opiate patients tended to have college mean dropout rates (42.0% and 37.0%, respectively) than patients treated for cannabis and polysubstance use (27.viii% and 31.3%, respectively). Contingency management demonstrated the everyman dropout rates (29.4%), followed by full general cognitive behavior therapy (35.3%) and cognitive behavior therapy plus contingency management (44.v%). But two studies provided relapse prevention dropout rates (57.0%), and these studies were specific to cocaine treatment.
Aggregate Effect Sizes
Table 1 presents aggregate effect sizes beyond all studies. The aggregate issue size across all conditions and all substances was in the moderate range (d=0.45), with a 95% confidence interval (CI) of 0.27 to 0.63. Although there was an credible difference in effect sizes depending on the outcome measure used, with self-report yielding a high-moderate effect size (d=0.61, 95% CI=0.35 to 1.20) and toxicology screen outcomes yielding a depression-moderate consequence size (d=0.33, 95% CI=0.17 to 0.49), this divergence did non reach significance according to a within-sample t test, which included simply the 12 studies that provided both measures (t=1.16, df=11, p<0.28). Urine analysis detection time differs across drugs of corruption. Whereas cocaine and opiates have an guess window of detection of ane–iii days, the window of detection fourth dimension for marijuana (cannabis) can extend to weeks to months for individuals who are chronic heavy users. In the current meta-analysis, only 1 study of marijuana used urine assay as an consequence variable ( Table 1 ).
Effect Sizes Across Substance Type
Figure 1 represents overall effect sizes for psychosocial treatments (complanate across treatment blazon) in terms of the substance use being targeted. Independent-sample t tests revealed that psychosocial treatments had their lowest efficacy for polysubstance employ, with a significant difference between outcomes for polysubstance use (d=0.24, 95% CI=0.03 to 0.44) and cannabis use (d=0.81, 95% CI=0.25 to ane.36) disorders (t=two.42, df=17, p<0.03). Treatments targeting cocaine apply yielded medium to large upshot sizes (d=0.62, 95% CI=0.xvi to one.08), and treatments targeting opiate employ yielded pocket-size to medium effect sizes (d=0.39, 95% CI=0.18 to 0.60). At that place were no other significant differences between the substance utilise disorders treated.
Upshot Sizes Across Treatment Type
Figure 2 presents consequence sizes for treatment outcome in terms of treatment type beyond all substances. The results indicate that treatments incorporating both cerebral behavior therapy and contingency direction had the highest upshot sizes (d=1.02); however, this issue must exist interpreted cautiously equally there were few studies in this category (N=2; 95% CI=–0.05 to 2.09). Treatments using contingency management lone produced moderate-high issue sizes (d=0.58, 95% CI=0.25 to 0.xc). Cognitive behavior therapy alone and relapse prevention evidenced depression moderate upshot sizes: d=0.28 (95% CI=0.06 to 0.51) and d=0.32 (95% CI=0.06 to 0.56), respectively.
Abstinence Rates
Across all active treatment weather condition, nigh one-third of the participants (31%) accomplished posttreatment and/or clinically significant abstinence. Alternately, only 13% of all participants in command conditions achieved abstinence. Across drug utilise groups, rates were similar, with 36.2% of opiate users, 31.vii% of cocaine users, and 26.0% of cannabis users achieving abstinence during the written report period.
Although the combination of cognitive behavior therapy and contingency direction evidenced the largest result size, this reward was non evident for the percent of abstinence posttreatment (26.v%). Treatment involving relapse prevention evidenced the largest posttreatment forbearance rates, with 39.0% abstemious. Posttreatment pct abstinent for general cognitive behavior therapy alone was 27.ane%, and for contingency management alone, information technology was 31.0%.
Moderators
In an attempt to better sympathize our issue findings, we examined variables that may potentially moderate the association betwixt aggregate result size estimates and treatment dropout rates. In terms of sample demographics, we used Pearson's fractional correlations to appraise the human relationship between age, sex (percent male in each written report), ethnicity (percent white), marital status (percentage unmarried/single), employment status (percent employed), and boilerplate years of substance utilise in relation to outcome variables (due east.thousand., treatment retention, overall upshot size).
A significant negative correlation was constitute between age and effect size (r=–0.37, p<0.05), suggesting that younger samples were more probable to have larger effect sizes. A pregnant negative correlation was also found betwixt boilerplate years of substance use and handling dropout rate (r=–0.68, p<0.05), indicating that participants with longer histories of substance use were less probable to driblet out of treatment than those with shorter histories of use. No other demographic variables were significantly associated with treatment outcome.
In addition, nosotros also examined a number of treatment variables in relation to key issue variables. Treatment variables included the number of weeks treatment was administered, the number of treatment sessions per week, and whether or not medication maintenance was employed. The results indicated a significant negative correlation between the number of treatment weeks and effect size (r=–0.34, p<0.05). Number of treatment sessions per week, however, was not significantly related to handling issue or treatment memory. Receipt of medication maintenance was negatively associated with dropout rates (r=–0.51, p<0.05); patients in studies in which medication maintenance provided a backdrop to the psychosocial atmospheric condition under study were less likely to drib out of treatment than patients in handling that did not employ medication.
Agonist Versus Other/No Drug Therapies
An additional event that may influence the size of treatment effects is the background drug treatment condition. Agonist therapies, stimulating the relevant drug receptor, attenuate withdrawal and drug craving and may provide either a amend or worse backdrop for other treatments. In a controlled effect size assay, this drug status affects changes in both the experimental and command handling weather, and hence, for there to be differential effects evident for comparisons between the psychosocial treatment weather, the drug must lead to interaction effects. For instance, if cravings are attenuated, a subsequent psychosocial handling may have a differential "foothold" for changing drug use behaviors. Alternatively, the drug benefits applied to both the experimental treatment group and the control condition may brand information technology more difficult to show additive effects by providing all patients in the trial with initial changes in drug use that may approach ceiling furnishings for short-term treatment.
To appraise the potential influence of agonist therapies, we compared studies using this arroyo (N=13, including both methadone and buprenorphine handling) to those that offered no drug treatment (N=xviii) or antagonist therapy (N=iii, naltrexone treatment). Agonist treatment was used in seven of 13 polysubstance use studies, three of nine cocaine studies, and three of vii opiate studies. No agonist treatment was offered in studies of cannabis treatment; hence, these studies (Northward=5) were not considered in the post-obit analysis. Overall, we found no significant difference or tendency in effect sizes for the combined drug groups, excluding marijuana (agonist overall: mean d=0.38, not agonists: d=0.forty; t=0.1, df=27, p<0.xc). Variability in effects was high, with agonist therapies showing both the highest and lowest event sizes in the unabridged sample of studies included in this meta-analysis. No differences betwixt agonist apply and the remainder of the sample were significant when they were examined separately in the polysubstance, cocaine, and opiate employ groups (all p values >0.14).
Publication Bias and Associations With Sample Size and Publication Year
Investigators take recognized the potential discrepancy betwixt the number of trials completed and the number of trials published. If studies are not published considering the findings are not significant, a meta-analysis of published studies may overestimate effect sizes. This problem has been labeled "the file drawer problem" (62) .
Using a bourgeois method of addressing this problem, one must assume that the outcome sizes of all electric current or future unpublished studies are equal to 0 and compute the number of studies it would require to reduce the overall issue size to a minimally informative level, in this case, a small effect size (d=0.ii). With the guidelines of Orwin (63) , more than than 42 "file drawer studies" with null results would be required to reduce the overall effect size to a pocket-size level, co-ordinate to Cohen'south standards (27) , a effect indicating that the findings to engagement (based on 34 studies) are adequately robust. Moreover, we institute no meaning relationship betwixt sample size and effect size (r=0.02, p>0.90), and at that place was no significant association between publication twelvemonth and effect size (r=–0.09, p>0.50).
Discussion
Overall, our meta-analytic review of cognitive behavioral treatment trials published through March of 2005 provided consistent show for do good from a variety of psychosocial interventions. Effect sizes were in the low-moderate to high-moderate range, depending on the substance disorder and handling type. Given the long-term social, emotional, and cognitive difficulties associated with substance corruption and dependence, these effect sizes and abstinence rates are noteworthy and comparable to those of interventions for other psychiatric disorders. Specifically, they are in the same range every bit those obtained in meta-analytic reviews using similar methods to examine the benefits of pharmacotherapy for anxiety disorders (64 , 65) .
Among the disorders under treatment, interventions for cannabis and cocaine yielded the largest result sizes. Nonetheless, cocaine treatments likewise yielded the largest dropout rates, and this dichotomous finding may propose that rather than pursuing stepwise gains, many patients make an early conclusion between targeting forbearance or dropping out of treatment. Not surprisingly, handling targeting polysubstance use yielded the everyman upshot size and the lowest per centum posttreatment abstinence. Polysubstance users, every bit a group, tend to accept the highest rates of comorbid psychiatric and medical weather, which may enhance dysfunctional coping motives while also interfering with treatment participation (1) .
Overall, the highest effect size estimates were obtained for contingency management approaches, followed past relapse prevention and other cerebral behavioral therapy approaches. The combination of cognitive behavioral therapy and contingency direction had particularly high effect sizes, but confidence in these estimates was express by having only ii studies for evaluation. Contingency management therapies often involve monetary incentives and frequent drug testing, which may challenge some treatment networks, although at that place has been some promise with the development of more cost-constructive incentives (66) .
Our meta-analysis was express by the small number of studies for the combination of contingency direction and cerebral behavioral therapy also equally for studies of relapse prevention. Likewise, fewer studies were completed for cannabis and opiate utilise disorders; hence, conviction in our effect size estimates is most limited for these disorders. Likewise, it is noteworthy that none of the relapse prevention studies analyzed included polysubstance users, the group with the lowest effect size estimates.
Although the backdrop condition of medication utilise (e.chiliad., the use of agonist therapies) may have an effect on the overall responsivity of the handling samples, this treatment effect should be applied equally to the experimental handling and the comparing treatment conditions unless there is an interaction issue. For instance, agonist therapy may make it easier for patients to respond to other treatment resources if peckish is reduced; still, information technology is non clear whether this will differentially advantage the experimental versus the comparing treatment. In our meta-assay, we found no reliable evidence of differential do good in terms of the controlled effect sizes showing the effects of cognitive behavioral treatment over the control condition.
Overall, meta-analytic review of the psychosocial handling literature for illicit drug utilise revealed promising findings. Given the aggregate effect size for active treatment, the current prove suggests that the average patient undergoing psychosocial interventions achieves acute outcomes better than approximately 67% of the patients in command conditions. Directions for future research include studies aimed at improving retentivity rates for all substance use groups, besides as at improving treatment efficacy for polysubstance users.
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Source: https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2007.06111851
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