Psychosocial interventions for cocaine and psychostimulant amphetamines related disorders

 

Abstract

Background

The consumption of psychostimulants for non-medical reasons probably occurs because of their euphoriant and psychomotor-stimulating properties. Chronic consumption of these agents results in development of stereotyped behaviour, paranoia, and possibly aggressive behaviour. Psychosocial treatments for psychostimulant use disorder are supposed to improve compliance, and to promote abstinence. Evidence from randomised controlled trials in this subject needs to be summarised.

Objectives

To conduct a systematic review of all RCTs on psychosocial interventions for treating psychostimulant use disorder.

Search methods

Electronic searches of Cochrane Library, EMBASE, MEDLINE, and LILACS (to may 2006); reference searching; personal communication; conference abstracts; unpublished trials from pharmaceutical industry; book chapters on treatment of psychostimulants abuse/ dependence.

Selection criteria

All randomised-controlled trials focusing on psychosocial interventions for treating psychostimulants abuse/ dependence.

Data collection and analysis

Three authors extracted the data independently and Relative Risks, weighted mean difference and number needed to treat were estimated, when possible. The reviewers assumed that people who died or dropped out had no improvement (intention to treat analysis) and tested the sensitivity of the final results to this assumption.

Main results

Twenty-seven randomised controlled studies (3663 participants) fulfilled inclusion criteria and had data that could be used for at least one of the main comparisons. There was a wide heterogeneity in the interventions evaluated: this did not allow to provide a summary estimate of effect and results cannot be summarised in a clear cut way. The comparisons between different type of Behavioural Interventions showed results in favour of treatments with some form of Contingency management in respect to both reducing drop outs and lowering cocaine use.
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Authors' conclusions

Overall this review reports little significant behavioural changes with reductions in rates of drug consumption following an intervention. Moreover, with the evidence currently available, there are no data supporting a single treatment approach that is able to comprise the multidimensional facets of addiction patterns and to significantly yield better outcomes to resolve the chronic, relapsing nature of addiction, with all its correlates and consequences.

 

Plain language summary

Psychosocial interventions for cocaine and psychostimulant amphetamines related disorders

Psychostimulants such as amphetamines and cocaine are used, at least in part, because of their effects on mood, cognition and behaviour. People who abuse or are dependent on them often have a long history of repeated periods of intoxication and of withdrawal and after long-term use they can develop a stereotyped behaviour, paranoia, and aggressive behaviour. Substance use disorders are a major public health problem with high costs for society including related health and relationship problems, absenteeism, loss of productivity and the costs of treatment. Yet knowledge about treatment interventions that impact on maintenance of abstinence remains a challenge. Trials on drug treatments for psychostimulants dependence have high levels of dropouts from the trials and psychosocial interventions may be promising treatments as long as they can help to keep patients in treatment and reduce the use of the psychostimulants. In this review, several comparisons were made of psychosocial treatments but most of them did not show statistically significant differences between interventions, so that the evidence currently available does not have data supporting a single psychosocial treatment approach. The review authors identified 27 randomised controlled studies involving 3663 participants who were dependent on cocaine (crack or intravenous) in all but one Australian trial where oral amphetamine was the psychostimulant used. The other trials took place in the US. The trials lasted from 12 weeks to 9 months and the mean age of participants was 33 years old (range 18 to 65 years). Overall, cognitive behavioural interventions reduced dropouts from treatment and use of cocaine when compared with drug counseling. Behavioural interventions also clearly performed better than clinical management (psychotherapy sessions attended), usual care (lower rates of cocaine users at 1 and 3 months), information and referral (non-attendance). A multimodal intensive intervention was more effective than non-intensive delivery and cognitive behavioural treatments with some form of contingency management (involving the incentive of vouchers that are exchangeable for retail items) also showed benefits. Many of the results come from single studies, which limits their generalizability. The interventions used were variable and different types of cognitive behavioural treatments had overlapping but distinct therapeutic approaches. Simple reduction in the
amount of drug used or retention in treatment is not a measure of meaningful changes in lifestyle.

 

摘要

背景

心理社會介入對於可卡因(cocaine)和精神刺激劑安非他命(amphetamines)相關疾患之療效

對於非醫療目的使用精神興奮劑，可能是因為這些物質具有令人有欣快感和精神刺激的特性。長期消費這些物質，導致刻板的行為，妄想症，和可能侵略性行為的發展。對於精神刺激劑使用不當，心理社會的治療是為了改善順從性，並推動戒斷。需要總結有關討論這個主題的隨機對照試驗所提供的證據。

目標

執行所有關於治療因精神刺激劑使用不當的心理社會介入之隨機對照試驗的系統性回顧。

搜尋策略

Cochrane Library，EMBASE，MEDLINE和LILACS(直到2006年5月)的電子檢索參考文獻的搜索個人的通信會議的摘要製藥工廠未發表的試驗以及書籍有關治療精神刺激劑濫用或依賴的章節。

選擇標準

著重於治療精神刺激劑的濫用或依賴的心理社會介入之所有隨機對照試驗。

資料收集與分析

三位作者分別篩選數據，且在可能的情況下，計算相對風險，加權平均偏異和需要治療的數量。回顧者採取納入死亡或因治療沒有改善而退出者之計算分析(也就是意向治療分析)並測試這個分析最後結果的敏感度。

主要結論

27個隨機對照研究(共3663參與者)符合納入標準，且至少具備一個主要比較的數據。評估的介入有極大的異質性：不允許提供影響的摘要估算且結果無法以清楚的方法被摘錄。對比不同類型的行為介入，結果呈現在關於減少退出試驗和降低cocaine的使用，傾向某種形式的權變管理.

作者結論

整體回顧的報告指出在持續介入下減少藥物消費的比例，有些許顯著的行為改變。此外，在現有可用的證據下，沒有數據支持有可以包含多維層面的成癮模式並且對解決慢性、復發性成癮及其所有相關和後果有顯著更好成果的單一治療方法。

翻譯人

本摘要由高雄榮民總醫院洪碧蓮翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

精神刺激劑(如amphetamiones和cocaine)的使用，至少有一部分乃歸因於它們情緒，認知和行為的影響。濫用或依賴精神刺激劑的人，往往有長久反覆中毒和戒斷時期，在長期使用後，他們可能發展具刻板行為，妄想症，和攻擊行為。物質的不當使用，對社會而言，是一個重要的高成本公共健康問題，它包括與健康有關及其相關之問題、曠職，生產力損失和治療的花費。 然而，在治療介入對維持戒斷效果的知識上，仍然是一個質疑。 有關精神刺激劑依賴性的藥物治療試驗，具有高比例的退出試驗，而心理社會的介入，只要能幫助患者持續治療且減少精神刺激劑的使用，此介入可能是有希望的治療方法。 在這篇評論中，執行了幾個心理社會治療的比較，但這些介入中，大多數並沒有統計學上顯著的差異，所以目前的實證並沒有數據支持單一心理社會的治療方法。 這篇評論的作者確認了27個隨機對照研究，其中包含3663個對於cocaine具依賴性的參與者(包括吸入或靜脈注射使用)，但在澳大利亞的試驗中，其精神刺激劑為口服的amphetamine。 其他發生在美國的試驗。這些試驗歷時12個星期至9個月，平均參與者年齡為33歲(範圍為18至65歲)。整體而言，與藥物諮詢相較下，認知行為的介入減少治療退出率和cocaine的使用。 行為介入也清楚地表現優於臨床治療(參加心理輔導)，一般的照顧(cocaine使用者在1及3個月具較低使用比率) ，諮商及轉介(無照護)。 多模式密集性的介入，比非密集的交流和某種有顯現出其優點之權變管理(包括給予可交換零售項目憑據的激勵)形式的認知行為治療更有效。 許多的研究結果來自於個別的研究，這限制了它們的普遍性。 多種不同類型的認知行為治療的介入，是具重疊性的，但是有不同的治療方法。在治療上，藥物的減少使用或維持使用並不是生活方式上有意義改變的一種測量。