Review question
We reviewed the evidence about the effect of psychosocial interventions, such as contingency management (CM) and motivational interviewing based (MIB) techniques vs. usual care for pregnant women in outpatient illicit drug treatment programmes.
Background
Women who use illicit drugs while pregnant are more likely to give birth early and have low birthweight infants. A pregnant woman can reduce the risk of these complications by undergoing drug treatment during pregnancy.
Psychosocial interventions, such as CM and MIB techniques, may help them to overcome the many barriers to staying in a drug treatment programme and reduce illicit drug use. CM uses positive supportive reinforcement with incentives, such as monetary vouchers, awarded based on pre-determined endpoints such as treatment attendance or drug abstinence. MIB is a form of patient-centred counselling used to resolve uncertainty in their drug use, treatment, or cessation.
Study characteristics
Researchers from the Cochrane Collaboration examined the evidence published up to January 2015 and included 14 studies with 1298 pregnant women in this Cochrane review. The 1298 pregnant women received either CM or MIB techniques in adjunct to other comprehensive care options; women in the control group received usual care that included pharmacological treatment such as methadone maintenance, counselling, prenatal care, STD counselling and testing, transportation, and/or childcare. Nine studies used CM techniques vs. usual care, while five studies involved MIB techniques vs. usual care.
All of the studies were completed in the United States of America and most participants were African American. Most studies used the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-R) criteria to determine drug dependence.
Key results
There were no differences in retention or abstinence between CM or MIB techniques and usual care. There were also no differences in birth outcomes between the groups.
Overall, there is low to moderate quality of evidence from the included studies. Allocation methods were often described in very limited manner. Furthermore, many studies lacked attrition information which could have impacted results. While further information related to these methods could be helpful, future randomized trials using psychosocial interventions are unlikely to show a benefit. In addition, there was significant heterogeneity in terms of methods for measuring outcomes.
The present evidence suggests that there is no difference in treatment outcomes to address drug use in pregnant women with use of psychosocial interventions, when taken in the presence of other comprehensive care options. However, few studies evaluated obstetrical or neonatal outcomes and rarely did so in a systematic way, making it difficult to assess the effect of psychosocial interventions on these clinically important outcomes. It is important to develop a better evidence base to evaluate psychosocial modalities of treatment in this important population.
Illicit drug use in pregnancy is a complex social and public health problem. The consequences of drug use in pregnancy are high for both the woman and her child. Therefore, it is important to develop and evaluate effective treatments. There is evidence for the effectiveness of psychosocial interventions in drug treatment but it is unclear whether they are effective in pregnant women. This is an update of a Cochrane review originally published in 2007.
To evaluate the effectiveness of psychosocial interventions in pregnant women enrolled in illicit drug treatment programmes 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?
We conducted the original literature search in May 2006 and performed the search update up to January 2015. For both review stages (original and update), we searched the Cochrane Drugs and Alcohol Group Trial's register (May 2006 and January 2015); the Cochrane Central Register of Trials (CENTRAL; the Cochrane Library 2015, Issue 1); PubMed (1996 to January 2015); EMBASE (1996 to January 2015); and CINAHL (1982 to January 2015).
We included randomized controlled trials comparing any psychosocial intervention vs. a control intervention that could include pharmacological treatment, such as methadone maintenance, a different psychosocial intervention, counselling, prenatal care, STD counselling and testing, transportation, or childcare.
We used standard methodological procedures expected by the Cochrane Collaboration. We performed analyses based on three comparisons: any psychosocial intervention vs. control, contingency management (CM) interventions vs. control, and motivational interviewing based (MIB) interventions vs. control.
In total, we included 14 studies with 1298 participants: nine studies (704 participants) compared CM vs. control, and five studies (594 participants) compared MIB interventions vs. control. We did not find any studies that assessed other types of psychosocial interventions. For the most part, it was unclear if included studies adequately controlled for biases within their studies as such information was not often reported. We assessed risk of bias in the included studies relating to participant selection, allocation concealment, personnel and outcome assessor blinding, and attrition.
The included trials rarely captured maternal and neonatal outcomes. For studies that did measure such outcomes, no difference was observed in pre-term birth rates (RR 0.71, 95% confidence interval (CI) 0.34 to 1.51; three trials, 264 participants, moderate quality evidence), maternal toxicity at delivery (RR 1.18, 95% CI 0.52 to 2.65; two trials, 217 participants, moderate quality evidence), or low birth weight (RR 0.72, 95% CI 0.36 to 1.43; one trial, 160 participants, moderate quality evidence). However, the results did show that neonates remained in hospital for fewer days after delivery in CM intervention groups (RR -1.27, 95% CI -2.52 to -0.03; two trials, 103 participants, moderate quality evidence). There were no differences observed at the end of studies in retention or abstinence (as assessed by positive drug test at the end of treatment) in any psychosocial intervention group compared to control (Retention: RR 0.99, 95% CI 0.93 to 1.06, nine trials, 743 participants, low quality evidence; and Abstinence: RR 1.14, 95% CI 0.75 to 1.73, three trials, 367 participants, low quality evidence). These results held for both CM and MIB combined. Overall, the quality of the evidence was low to moderate.