Comparative efficacy and acceptability of psychosocial interventions for individuals with cocaine and amphetamine addiction: A systematic review and network meta-analysis.
Level 1 - systematic review of randomized trials
Systematic review and network meta-analysis of randomized controlled trials
PubMed 30586362 · doi:10.1371/journal.pmed.1002715
What was done
Systematic review and network meta-analysis (PRISMA-NMA compliant, PROSPERO-registered) evaluating published and unpublished randomized controlled trials of structured psychosocial interventions versus active control or treatment as usual (TAU) in adults with cocaine and/or amphetamine addiction. Primary outcomes were efficacy (urinalysis-verified abstinence) and acceptability (all-cause dropout) at end of treatment, 12 weeks, and longest follow-up. Random-effects pairwise and network meta-analyses synthesized data from 50 RCTs evaluating 12 psychosocial interventions or TAU across 6,942 participants.
What was found
Contingency management (CM) combined with the community reinforcement approach was the only intervention superior to TAU for abstinence at end of treatment (OR 2.84, 95% CI 1.24-6.51, P = 0.013), at 12 weeks (OR 7.60, 95% CI 2.03-28.37, P = 0.002), and at longest follow-up (OR 3.08, 95% CI 1.33-7.17, P = 0.008). In head-to-head comparisons at treatment end, CM plus community reinforcement approach was superior to cognitive behavioral therapy (CBT; OR 2.44, 95% CI 1.02-5.88, P = 0.045), non-contingent rewards (OR 3.31, 95% CI 1.32-8.28, P = 0.010), and 12-step programs plus non-contingent rewards (OR 4.07, 95% CI 1.13-14.69, P = 0.031). It also reduced dropouts versus TAU at 12 weeks (OR 3.92, P < 0.001) and end of treatment (OR 3.63, P < 0.001). At longest follow-up, the combination remained superior to CBT alone, CM alone, CM plus CBT, and 12-step plus non-contingent rewards (ORs 2.50 to 5.22, P < 0.05 to P < 0.001). GRADE ratings across evidence comparisons ranged from high to very low.
Why it matters
This network meta-analysis provides comprehensive comparative evidence identifying contingency management combined with the community reinforcement approach as the most effective psychosocial regimen for both abstinence and retention in stimulant use disorders.
Limits
The quality of included primary RCTs was variable, and open-label designs with lack of blinding across psychosocial interventions created a risk of performance bias. Several node comparisons had wide confidence intervals indicating statistical imprecision.