Psychosocial interventions for pregnant women in outpatient illicit drug treatment programs compared to other interventions

 

Abstract

Background

Illicit drug use in pregnancy is a complex social and public health problem. It is important to develop and evaluate effective treatments. There is evidence for the effectiveness of psychosocial in this population; however, to our knowledge, no systematic review on the subject has been undertaken.

Objectives

To evaluate the effectiveness of psychosocial interventions in pregnant women enrolled in illicit drug treatment programs on birth and neonatal outcomes, on attendance and retention in treatment, as well as on maternal and neonatal drug abstinence. In short, do psychosocial interventions translate into less illicit drug use, greater abstinence, better birth outcomes, or greater clinic attendance.?

Search methods

We searched the Cochrane Drugs and Alcohol Group's trial register (May 2006), the Cochrane Central Register of Trials (Central- The Cochrane Library, Issue 3, 2005); MEDLINE (1.1996-8.2006); EMBASE (1.1996-8.2006); CINAHL (1.1982-8.2006), and reference lists of articles.

Selection criteria

Randomised studies comparing any psychosocial intervention versus pharmacological interventions or placebo or non-intervention or another psychosocial intervention for treating illicit drug use in pregnancy.

Data collection and analysis

Two reviewers independently assessed trial quality and extracted data.

Main results

Nine trials involving 546 pregnant women were included. Five studies considered contingency management (CM), and four studies considered manual based interventions such as motivational interviewing (MI).
The main finding was that contingency management led to better study retention. There was only minimal effect of CM on illicit drug abstinence. In contrast, motivational interviewing led towards poorer study retention, although this did not approach statistical significance. For both, no difference in birth or neonatal outcomes was found, but this was an outcome rarely captured in the studies.

Authors' conclusions

The present evidence suggests that CM strategies are effective in improving retention of pregnant women in illicit drug treatment programs as well as in transiently reducing illicit drug use. There is insufficient evidence to support the use of MI. Overall the available evidence has low numbers and, therefore, it is impossible to accurately assess the effect of psychosocial interventions on obstetrical and neonatal outcomes.
It is important to develop a better evidence base to evaluate psychosocial modalities of treatment in this important population.

 

Plain language summary

Psychosocial interventions for pregnant women in outpatient illicit drug treatment programs compared to other interventions

The effectiveness of psychosocial interventions in pregnant women enrolled in illicit drug treatment programs.Women who use illicit drugs while pregnant are more likely to give birth early and have low weight infants that are at risk of neonatal abstinence syndrome and requiring intensive care. A pregnant woman reduces the risk of these complications by undergoing prenatal drug treatment. Maternal concern for the infant can also motivate her. The length of time on treatment is important. Psychosocial interventions may help to overcome the many barriers to staying in a treatment program and reduce the use of illicit drugs.Contingency management uses positive, supportive reinforcement with, for example, monetary vouchers or giving work and a salary only when abstaining from drug use or attending treatment to change behaviour. Manual based interventions include motivational interviewing with a
directive, counselling style.
This systematic review found that contingency management is effective in improving retention of pregnant women in illicit drug treatment programs but with minimal effects on their abstaining from illicit drugs. Motivational interviewing over three to six sessions may, if anything, lead to poorer retention in treatment. These findings are based on nine controlled trials over 14 days to 24 weeks, five studies used contingency management (346 women) and four studies (266 women) that considered motivational interviewing.All but one took place in the United States. Many of the young women were African American, single, never married or divorced, and unemployed. They were receiving methadone maintenance, using cocaine, or opiate dependent and marijuana and alcohol use was also involved in six studies. In two trials, almost all women were nicotine dependent. No difference in birth outcomes or length of hospital detoxification for the newborns was found, from two studies.None of the included studies stated how the women were referred to treatment. Manual based interventions are less likely to be effective among coerced individuals. it is also unlikely to be used on their own in clinical practice.

 

摘要

背景

懷孕婦女服用違禁藥品的門診治療計畫，心理層面的處置(介入)與其他處置(介入)的比較

懷孕婦女服用違禁藥品是一個複雜的社會及公共衛生問題。發展及評估一個有效的計畫是相當重要的。據我們所知，雖然有証據顯示心理層面的效果，但並沒有針對這個族群實施系統性的評估。

目標

懷孕婦女服用違禁藥品的治療計畫上，評估心理層面的干預，對分娩及胎兒的情況，對參與及留在計畫的情形，對母親及胎兒的藥物戒斷等干預成效。簡而言之，心理干預可以有：較少的違禁藥使用，較好的藥物戒斷，較佳的分娩結果，較好的臨床參與?

搜尋策略

搜索以下資料庫：Cochrane Drugs and Alcohol Group trial register (May 2006), the Cochrane Central Register of Trials (Central The Cochrane Library, Issue 3, 2005);MEDLINE (1.1996 – 8.2006); EMBASE (1.1996 – 8.2006); CINAHL (1.1982 – 8.2006)，以及參考文獻的文章。

選擇標準

懷孕婦女服用違禁藥的治療中選擇隨機實驗組，比較心理干預，或藥物干預，或placebo, 或沒有干預，或者其他心理干預，之間的差異。

資料收集與分析

兩位獨立審核者評估實驗的品質及拮取數據。

主要結論

9個臨床實驗包括546位懷孕婦女，5個研究是緊急應變處理contingency management (CM)，其他4個是人為操作的激勵訪談motivational interviewing (MI)。主要的發現是：CM有較好的計畫滯留人數，最少違禁藥的戒斷結果。相反地，MI有較差的滯留計畫人數，但這些並沒有統計上差異。兩者對分娩或胎兒的影響並沒有差異，這是較少出現在研究結果中的項目。

作者結論

現有的資料顯示用CM策略，對留住懷孕婦女在違禁藥治療的計畫是有效的，以及瞬時減少違禁藥的使用也有效。沒有充份的証據支持MI的使用，所有可用的証據顯示較低的數據，因此，不可能準確評估心理干預在產科及胎兒的結果。發展一個較好的証據基礎的研究，以評估心理情態在這個重要族群上的治療，是重要的事項。

翻譯人

本摘要由高雄榮民總醫院陳淑梅翻譯。

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

總結

心理干預對治療懷孕婦女服用違禁藥的成效。服用違禁藥的懷孕婦女，較容易早產，以及生出體重較輕的嬰兒，新生兒戒斷症狀的風險，以及需要特別照護。若進行藥物注射治療，懷孕婦女將減少併發症的風險。母親對嬰兒的顧慮可以激勵她，治療期間的長短也是重要的。心理干預可以幫助克服任何障礙，繼續留在治療計畫中，減少違禁藥的使用。緊急應變管理，使用正面、支持性的強化，例如：當戒藥時、或參加治療、或改變行為時，提供貨幣券、提供工作、提供薪水。人為基礎的干預，包括激勵訪談，使用直接或諮詢型式。這個系統化審核發現，緊急應變管理對改善懷孕婦女留在違禁藥治療的計畫上，是有效的。但對戒斷僅有較少的效果。若激勵訪談超過3∼6次時，將導致不好的計畫留滯人數。這些結論根據9個控制組的臨床實驗，超過14天到24週。5個研究屬於緊急應變管理(346個婦女)，4個研究(266個婦女)屬於激勵訪談。其中8個實驗在美國進行。許多年輕的婦女是非裔美國人，單身未結婚或者離婚，失業。6個研究包括：接受methadone維持治療，服用cocaine, 或者opiate依賴，marujuana及酒精成癮。在2個臨床研究，所有的婦女是nicotine依賴者。由2個研究發現：對分娩結果及新生兒戒毒住院長短沒有不同。沒有任何一個研究說明如何治療這些婦女。人為基礎的干預對於脅迫的個人較不可能有好的成效，同樣也不可能使用在自己的臨床執業上。