Key messages
• Psychosocial treatments reduce the number of participants with stimulant use disorder who leave treatment prematurely and probably increase the length of time they abstain from stimulants, compared to no treatment.
• Compared to usual care, psychosocial treatments help people stay in treatment longer, but probably make little to no difference in the frequency of drug intake.
• More studies are needed comparing different psychosocial approaches to increase our understanding of what treatments are best for whom, when, and in what context.
What is stimulant use disorder?
Stimulant use disorder is a mental disorder characterised by a strong urge to use psychostimulants and the inability to control their use. Cocaine, amphetamines, crack, and MDMA are psychostimulants. Psychostimulants are the second-most commonly used illicit drug worldwide, after cannabis. Stimulant use disorder is associated with serious medical consequences, including delusions and hallucinations, cardiovascular diseases, AIDS, viral hepatitis, and sexually transmitted infections. People with stimulant use disorder are at high risk of being involved in car accidents, crime, sexual abuse, and interpersonal violence.
How is stimulant use disorder treated?
Currently, no medicines are approved for treating stimulant use disorder. Consequently, psychosocial treatments are regarded as suitable alternatives. Psychosocial treatments act on people's memory and learning, and aim to help them develop the skills to deal with stimulant use disorder. Many types of psychosocial therapy exist, and each has a theory to explain how it helps people change. The most widely-used psychosocial treatments for stimulant use disorder are the following.
• Cognitive behavioural therapy tries to help people recognise and alter their dysfunctional beliefs, negative thoughts, and unwanted behaviours, through behavioural tasks and coping skills.
• Contingency management rewards or 'reinforces' people for positive behavioural change, giving them money, vouchers, or other rewards when they abstain from using stimulants.
• Motivational interviewing aims to resolve people's contradictory feelings about their drug use and increase their readiness to change.
• Psychodynamic therapy uses the therapeutic relationship between a psychotherapist and a client to solve unconscious conflicts and develop insight.
• Twelve-step facilitation are treatments that have adapted the methodology and concepts of Alcoholics Anonymous.
What did we want to find out?
We wanted to find out whether psychosocial treatments help people with stimulant use disorder to reduce or stop using psychostimulants.
What did we do?
We searched for studies where people were allocated at random to one of two or more treatment groups that compared any psychosocial treatment with no treatment or usual care (counselling, education, or information about stimulant use). We summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and precision of the results.
What did we find?
We found 64 studies involving a total of 8241 people with stimulant use disorder. Nearly three-quarters of the studies involved people who used cocaine or crack. Most studies were conducted in the USA, and there were 4 studies in Spain, 3 each in Australia and the UK, 2 each in Switzerland, Brazil, and Iran, and 1 each in the Netherlands and South Africa. Overall, the studies offered treatment for an average of 4 months, but the study programmes varied from a single session to a 12-month programme. The studies examined the different types of psychosocial treatments outlined above.
Most studies compared psychosocial treatment with no treatment. Twelve studies compared psychosocial treatment with usual care. Fourteen studies compared one type of psychosocial treatment to another type.
Main results
Compared to no treatment, psychosocial treatments reduce the number of people who leave the study prematurely and probably increase the length of time that they stay off stimulants (i.e. they increase abstinence). They also reduce the frequency of drug intake. They probably help people to have longer periods of abstinence during treatment but may make little to no difference in continuous abstinence in the long term.
Compared to usual care, psychosocial treatments reduce the number of people who leave treatment prematurely. They may have little to no effect on helping people have periods of continuous abstinence during treatment and in increasing the period of abstinence. They probably have little to no effect on the frequency of drug intake.
Five studies assessed whether psychosocial treatments had any negative effects. Of these, 4 studies stated that no negative effects occurred.
What are the limitations of the evidence?
Both the people delivering treatments and the participants knew which type of treatment they were receiving. Therefore, they could have modified their behaviours in a way that would influence the outcomes. However, in most studies, the drug use outcomes reported by participants were verified by urine analysis, so we believe that people's awareness did not influence the results substantially. We cannot be sure that the allocation of participants to groups was done appropriately, as most studies provided insufficient information about this process. Studies comparing psychosocial treatments with usual care were scarce and small, so we are uncertain about our results.
How up to date is this evidence?
The evidence is current to 26 September 2023.
This review's findings indicate that psychosocial treatments can help people with stimulant use disorder by reducing dropout rates. This conclusion is based on high-certainty evidence from comparisons of psychosocial interventions with both no treatment and TAU. This is an important finding because many people with stimulant use disorders leave treatment prematurely. Stimulant use disorders are chronic, lifelong, relapsing mental disorders, which require substantial therapeutic efforts to achieve abstinence. For those who are not yet able to achieve complete abstinence, retention in treatment may help to reduce the risks associated with stimulant use. In addition, psychosocial interventions reduce stimulant use compared to no treatment, but they may make little to no difference to stimulant use when compared to TAU.
The most studied and promising psychosocial approach is contingency management. Relatively few studies explored the other approaches, so we cannot rule out the possibility that the results were imprecise due to small sample sizes.
Stimulant use disorder is a continuously growing medical and social burden without approved medications available for its treatment. Psychosocial interventions could be a valid approach to help people reduce or cease stimulant consumption. This is an update of a Cochrane review first published in 2016.
To assess the efficacy and safety of psychosocial interventions for stimulant use disorder in adults.
We searched the Cochrane Drugs and Alcohol Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, three other databases, and two trials registers in September 2023. All searches included non-English language literature. We handsearched the references of topic-related systematic reviews and the included studies.
We included randomised controlled trials (RCTs) comparing any psychosocial intervention with no intervention, treatment as usual (TAU), or a different intervention in adults with stimulant use disorder.
We used the standard methodological procedures expected by Cochrane.
We included a total of 64 RCTs (8241 participants). Seventy-three percent of studies included participants with cocaine or crack cocaine use disorder; 3.1% included participants with amphetamine use disorder; 10.9% included participants with methamphetamine use disorder; and 12.5% included participants with any stimulant use disorder. In 18 studies, all participants were in methadone maintenance treatment.
In our primary comparison of any psychosocial treatment to no intervention, we included studies which compared a psychosocial intervention plus TAU to TAU alone. In this comparison, 12 studies evaluated cognitive behavioural therapy (CBT), 27 contingency management, three motivational interviewing, one study looked at psychodynamic therapy, and one study evaluated CBT plus contingency management. We also compared any psychosocial intervention to TAU. In this comparison, seven studies evaluated CBT, two contingency management, two motivational interviewing, and one evaluated a combination of CBT plus motivational interviewing. Seven studies compared contingency management reinforcement related to abstinence versus contingency management not related to abstinence. Finally, seven studies compared two different psychosocial approaches.
We judged 65.6% of the studies to be at low risk of bias for random sequence generation and 19% at low risk for allocation concealment. Blinding of personnel and participants was not possible for the type of intervention, so we judged all the studies to be at high risk of performance bias for subjective outcomes but at low risk for objective outcomes. We judged 22% of the studies to be at low risk of detection bias for subjective outcomes. We judged most of the studies (69%) to be at low risk of attrition bias.
When compared to no intervention, we found that psychosocial treatments: reduce the dropout rate (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.74 to 0.91; 30 studies, 4078 participants; high-certainty evidence); make little to no difference to point abstinence at the end of treatment (RR 1.15, 95% CI 0.94 to 1.41; 12 studies, 1293 participants; high-certainty evidence); make little to no difference to point abstinence at the longest follow-up (RR 1.22, 95% CI 0.91 to 1.62; 9 studies, 1187 participants; high-certainty evidence); probably increase continuous abstinence at the end of treatment (RR 1.89, 95% CI 1.20 to 2.97; 12 studies, 1770 participants; moderate-certainty evidence); may make little to no difference in continuous abstinence at the longest follow-up (RR 1.14, 95% CI 0.89 to 1.46; 4 studies, 295 participants; low-certainty evidence); reduce the frequency of drug intake at the end of treatment (standardised mean difference (SMD) −0.35, 95% CI −0.50 to −0.19; 10 studies, 1215 participants; high-certainty evidence); and increase the longest period of abstinence (SMD 0.54, 95% CI 0.41 to 0.68; 17 studies, 2118 participants; high-certainty evidence).
When compared to TAU, we found that psychosocial treatments reduce the dropout rate (RR 0.79, 95% CI 0.65 to 0.97; 9 studies, 735 participants; high-certainty evidence) and may make little to no difference in point abstinence at the end of treatment (RR 1.67, 95% CI 0.64 to 4.31; 1 study, 128 participants; low-certainty evidence). We are uncertain whether they make any difference in point abstinence at the longest follow-up (RR 1.31, 95% CI 0.86 to 1.99; 2 studies, 124 participants; very low-certainty evidence). Compared to TAU, psychosocial treatments may make little to no difference in continuous abstinence at the end of treatment (RR 1.18, 95% CI 0.92 to 1.53; 1 study, 128 participants; low-certainty evidence); probably make little to no difference in the frequency of drug intake at the end of treatment (SMD −1.17, 95% CI −2.81 to 0.47, 4 studies, 479 participants, moderate-certainty evidence); and may make little to no difference in the longest period of abstinence (SMD −0.16, 95% CI −0.54 to 0.21; 1 study, 110 participants; low-certainty evidence). None of the studies for this comparison assessed continuous abstinence at the longest follow-up.
Only five studies reported harms related to psychosocial interventions; four of them stated that no adverse events occurred.