Treatment of cocaine and alcohol dependence with psychotherapy and disulfiram

Psychosocial interventions for stimulant use disorder

BACKGROUND

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.

OBJECTIVES

To assess the efficacy and safety of psychosocial interventions for stimulant use disorder in adults.

SEARCH METHODS

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.

SELECTION CRITERIA

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.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

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.

AUTHORS' CONCLUSIONS

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.

Disulfiram for the treatment of cocaine dependence

BACKGROUND

Cocaine is a psychostimulant used by approximately 0.4% of the general population worldwide. Cocaine dependence is a chronic mental disorder characterised by the inability to control cocaine use and a host of severe medical and psychosocial complications. There is current no approved pharmacological treatment for cocaine dependence. Some researchers have proposed disulfiram, a medication approved to treat alcohol use disorder. This is an update of a Cochrane review first published in 2010.

OBJECTIVES

To evaluate the efficacy and safety of disulfiram for the treatment of cocaine dependence.

SEARCH METHODS

We updated our searches of the following databases to August 2022: the Cochrane Drugs and Alcohol Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and PsycINFO. We also searched for ongoing and unpublished studies via two trials registries. We handsearched the references of topic-related systematic reviews and included studies. The searches had no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials that evaluated disulfiram alone or associated with psychosocial interventions versus placebo, no intervention, other pharmacological interventions, or any psychosocial intervention for the treatment of cocaine dependence.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Thirteen studies (1191 participants) met our inclusion criteria. Disulfiram versus placebo or no treatment Disulfiram compared to placebo may increase the number of people who are abstinent at the end of treatment (point abstinence; risk ratio (RR) 1.58, 95% confidence interval (CI) 1.05 to 2.36; 3 datasets, 142 participants; low-certainty evidence). However, compared to placebo or no pharmacological treatment, disulfiram may have little or no effect on frequency of cocaine use (standardised mean difference (SMD) -0.11 standard deviations (SDs), 95% CI -0.39 to 0.17; 13 datasets, 818 participants), amount of cocaine use (SMD -0.00 SDs, 95% CI -0.30 to 0.30; 7 datasets, 376 participants), continuous abstinence (RR 1.23, 95% CI 0.80 to 1.91; 6 datasets, 386 participants), and dropout for any reason (RR 1.20, 95% CI 0.92 to 1.55; 14 datasets, 841 participants). The certainty of the evidence was low for all these outcomes. We are unsure about the effects of disulfiram versus placebo on dropout due to adverse events (RR 12.97, 95% CI 0.77 to 218.37; 1 study, 67 participants) and on the occurrence of adverse events (RR 3.00, 95% CI 0.35 to 25.98), because the certainty of the evidence was very low for these outcomes. Disulfiram versus naltrexone Disulfiram compared with naltrexone may reduce the frequency of cocaine use (mean difference (MD) -1.90 days, 95% CI -3.37 to -0.43; 2 datasets, 123 participants; low-certainty evidence) and may have little or no effect on amount of cocaine use (SMD 0.12 SDs, 95% CI -0.27 to 0.51, 2 datasets, 123 participants; low-certainty evidence). We are unsure about the effect of disulfiram versus naltrexone on dropout for any reason (RR 0.86, 95% CI 0.56 to 1.32, 3 datasets, 131 participants) and dropout due to adverse events (RR 0.50, 95% CI 0.07 to 3.55; 1 dataset, 8 participants), because the certainty of the evidence was very low for these outcomes.

AUTHORS' CONCLUSIONS

Our results show that disulfiram compared to placebo may increase point abstinence. However, disulfiram compared to placebo or no pharmacological treatment may have little or no effect on frequency of cocaine use, amount of cocaine use, continued abstinence, and dropout for any reason. We are unsure if disulfiram has any adverse effects in this population. Caution is required when transferring our results to clinical practice.

Percentage of negative urine drug screens as a clinically meaningful endpoint for RCTs evaluating treatment for cocaine use

BACKGROUND

This study examined a threshold based on the percentage of cocaine-negative (CN) urine drug screens (UDS) collected during treatment as a potential meaningful endpoint for clinical trials. We hypothesized that individuals providing at least 75% CN UDS would have better long-term outcomes than those providing less than 75% CN UDS.

METHODS

Two separate pooled datasets of randomized clinical trials conducted at different institutions were used for analyses: one composed of eight trials (N = 760) and the other composed of three trials (N = 416), all evaluating behavioral and/or pharmacological treatments for cocaine use. UDS were collected at least once per week (up to three times per week) during the 8- or 12-week treatment period across all trials, with substance use and psychosocial functioning measured up to 12 months following treatment. Chi-squares and ANOVAs compared within-treatment and follow-up outcomes between the groups.

RESULTS

Compared to those who did not achieve the threshold, participants who achieved the 75%-CN threshold were retained in treatment longer and had a longer period of continuous abstinence, and were more likely to report problem-free functioning. Additionally, participants who achieved the 75%-CN threshold were more likely to report sustained abstinence and better psychosocial functioning throughout a follow-up period up to 12 months than those who did not achieve the threshold.

CONCLUSIONS

A threshold of 75%-CN UDS is associated with short- and long-term clinical benefits. Future clinical trials may consider this a meaningful threshold for defining treatment responders.

Cocaine use disorder patients develop distinct patterns of regulation of acth secretion by a vasopressin agonist and oxytocin: Report on a laboratory study

Background

: Oxytocin and Vasopressin systems in the brain sustain adaptation to stressors. Cocaine being a stressor, it may alter brain homeostatic function. This dysregulation may entrench cocaine use disorder.

Method

: This is a human laboratory study of the effects of intranasal desmopressin (a Vasopressin 1b receptor agonist) and oxytocin on ACTH secretion in cocaine use disorder patients versus a control group. It consisted of two endocrine challenges performed on consecutive days. On day 1, the effect of intranasal desmopressin (80 IU) on ACTH secretion was measured. On day 2, a pre-treatment with intranasal oxytocin (24 IU) preceded intranasal desmopressin to monitor its effect on desmopressin-induced ACTH secretion. We hypothesized that the effect of intranasal oxytocin in controls would differ from the effect in cocaine use disorder patients.

Results

: Forty-three patients were included in this study: 14 controls and 29 cocaine use disorder patients. Significant differences were noted in the direction of change of ACTH secretion between the two groups. In cocaine use disorder patients, overall ACTH secretion was on average 2.7 pg/ml/min higher after intranasal desmopressin than after intranasal oxytocin/desmopressin (t₂₉₂ = 2.91, p = 0.004). The opposite was observed in controls: overall ACTH secretion averaged 3.3 pg/ml/min less after intranasal desmopressin than after intranasal oxytocin/desmopressin (t₂₉₂ = -2.35, p = 0.02).

Conclusion

: Intranasal oxytocin and desmopressin revealed a pattern of ACTH secretion in cocaine use disorder patients that is distinct from a non-addicted control group. (ClinicalTrial.gov00255357, 10/2014).

The Added Value of Pharmacotherapy to Cognitive Behavior Therapy And Vice Versa in the Treatment of Alcohol Use Disorders: A Systematic Review

AIM

To explore whether combined interventions i.e. psychotherapeutic plus psychosocial interventions are more effective than monotherapies in the treatment of alcohol use disorders.

METHODS

Systematic review of the results of randomized controlled trials that compared combined therapies with monotherapies (either pharmacotherapy or psychotherapy).

RESULTS

The search resulted in 28 eligible studies. Data from these RCTs showed that 10 out of 19 RCTs (53%) demonstrated an added value of combined therapy (psychotherapy + pharmacotherapy) compared to psychotherapy only, whereas only three out of nine RCTs (33%) comparing combined therapy with pharmacotherapy showed a possible added value for combined therapy.

CONCLUSIONS

Pharmacotherapy is effective to treat AUD with or without psychotherapy and that psychotherapy can best be offered in combination with pharmacotherapy.

Cocaine Use Disorder (CUD): Current Clinical Perspectives

Cocaine use disorder (CUD) is a devastating disorder, impacting both individuals and society. Individuals with CUD face many barriers in accessing treatment for CUD, and most individuals with CUD never receive treatment. In this review, we provide an overview of CUD, including risk factors for CUD, common co-occurring disorders, acute and chronic effects of cocaine use, and currently available pharmacological and behavioral treatments. There are no FDA-approved pharmacological treatments for CUD. Future studies with larger sample sizes and testing treatment combinations are warranted. However, individuals with CUD and co-occurring disorders (eg, a mood or anxiety disorder) may benefit from medication treatments. There are behavioral interventions that have demonstrated efficacy in treating CUD – contingency management (CM) and cognitive-behavioral therapy for substance use disorders (CBT-SUD) in particular – however many barriers remain in delivering these treatments to patients. Following the discussion of current treatments, we highlight some promising emerging treatments, as well as offer a framework that can be used in building a treatment plan for individuals with CUD.

Examining alcohol interventions across the lifespan among the African diaspora: A systematic review

AIMS

Racial/ethnic and cultural identity influences alcohol use consumption and help-seeking behaviors. The purpose of this systematic review was to assess alcohol prevention programs and interventions targeting African Americans/Blacks among the African Diaspora across the lifespan.

METHODS

According to PRISMA guidelines, literature searches were conducted via electronic databases, grey literature, and hand searches of relevant journal articles evaluating primary outcome data to reduce alcohol use. To be included in this systematic review, intervention and prevention studies required a population of more than 50% African descent and provided information about statistical significance (p < .05) indicating changes in alcohol as a primary outcome.

RESULTS

Search strategy identified 5691 citations and the full-text of 148 studies were screened. A total of 23 articles met the inclusion criteria. Studies were geographically located in the United States and African countries. Interventions were implemented in community, patient-care, school, and workplace settings. Adult studies evaluated pharmacological and/or behavioral interventions while utilizing validated instruments and procedures to assess alcohol outcomes. Strategies to change alcohol behavior included psychotherapy, brief motivational interviewing (BMI), and counseling. Adolescent studies utilized family-based, computer-assisted technology, and career development interventions to reduce alcohol use.

CONCLUSIONS

The systematic review identified a range of intervention articles addressing the reduction of alcohol use for African Americans/Blacks that may be used in various settings and by different age groups. Best practices and strategies designed to address socio-cultural factors by promoting protective and risk-reducing factors of alcohol use and successful alcohol interventions are needed.

Depression and/or PTSD Comorbidity Affects Response to Antidepressants in Those With Alcohol Use Disorder

Objective: Depression and post-traumatic stress disorder (PTSD) highly co-occur with alcohol use disorder (AUD). The comparative effects of noradrenergic vs. serotonergic antidepressants on drinking and depressive outcomes for those with AUD and co-occurring depression and/or PTSD are not well known. Methods: This study was an analysis of a randomized control trial of 128 patients with AUD who had co-occurring depression and/or PTSD. They were randomized to treatment with paroxetine vs. desipramine and naltrexone vs. placebo leading to four groups: paroxetine plus naltrexone, paroxetine plus placebo, desipramine plus naltrexone, and desipramine plus placebo. Outcomes were percent of drinking days, percent heavy drinking days, drinks per drinking day (Time Line Follow-back Method), and depressive symptoms (Hamilton Depression Scale). Groups compared were (1) depression without PTSD (depression group; n = 35), (2) PTSD without depression (PTSD group; n = 33), and (3) both depression and PTSD (comorbid group; n = 60). Results: There were no overall significant differences in drinking outcomes by medication in the entire sample, and no significant interaction when diagnostic groups were not considered. However, when diagnostic groups were included in the model, the interactions between time, diagnostic group, and medication (desipramine vs. paroxetine) were significant for percent drinking days (p = 0.042), and percent heavy drinking days (p = 0.036); paroxetine showed better drinking outcomes within the depression group, whereas desipramine showed better drinking outcomes in the PTSD and comorbid groups. Regarding depressive symptoms, paroxetine was statistically superior to desipramine in the total sample (p = 0.007), but there was no significant interaction of diagnostic group and medication. Naltrexone led to a decrease in craving but no change in drinking outcomes. Conclusions: The results of this study suggest that drinking outcomes may respond differently to desipramine and paroxetine depending on comorbid MDD and/or PTSD.

Pharmacogenetics of Addiction Therapy

Drug addiction is a serious relapsing disease that has high costs to society and to the individual addicts. Treatment of these addictions is still in its nascency, with only a few examples of successful therapies. Therapeutic response depends upon genetic, biological, social, and environmental components. A role for genetic makeup in the response to treatment has been shown for several addiction pharmacotherapies with response to treatment based on individual genetic makeup. In this chapter, we will discuss the role of genetics in pharmacotherapies, specifically for cocaine, alcohol, and opioid dependences. The continued elucidation of the role of genetics should aid in the development of new treatments and increase the efficacy of existing treatments.

New Drugs, Old Targets: Tweaking the Dopamine System to Treat Psychostimulant Use Disorders

The abuse of illicit psychostimulants such as cocaine and methamphetamine continues to pose significant health and societal challenges. Despite considerable efforts to develop medications to treat psychostimulant use disorders, none have proven effective, leaving an underserved patient population and unanswered questions about what mechanism(s) of action should be targeted for developing pharmacotherapies. As both cocaine and methamphetamine rapidly increase dopamine (DA) levels in mesolimbic brain regions, leading to euphoria that in some can lead to addiction, targets in which this increased dopaminergic tone may be mitigated have been explored. Further, understanding and targeting mechanisms underlying relapse are fundamental to the success of discovering medications that reduce the reinforcing effects of the drug of abuse, decrease the negative reinforcement or withdrawal/negative affect that occurs during abstinence, or both. Atypical inhibitors of the DA transporter and partial agonists/antagonists at DA D3 receptors are described as two promising targets for future drug development.

Alcohol and Cocaine Combined Substance Use on Adult Hypothalamic Neural Stem Cells and Neurogenesis

Many advancements have been made over the years looking at the individual and combined effects of drugs of abuse on the brain, with one key area of research focusing on the effects on neurogenesis. An integral part of fetal brain development and, later, maintenance in the adult brain, neurogenesis occurs in three main regions: subventricularzone of the lateral ventricles (SVZ), subgranularzone of the dentate gyrus (SGZ), and the tanycyte layer in the hypothalamus (TL). We will review current literature on combined drugs of abuse and their effect on adult neurogenesis. More specifically, this review will focus on the effect of combining cocaine and alcohol. Additionally, the tanycyte layer will be explored in more depth and probed to look at the neurogenic properties of tanycytes and their role in neurogenesis.

Psychological interventions for antisocial personality disorder

BACKGROUND

Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties. This review updates Gibbon 2010 (previous version of the review).

OBJECTIVES

To evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. We also searched reference lists and contacted study authors to identify studies.

SELECTION CRITERIA

Randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment-as-usual (TAU), waiting list or no treatment. The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called 'standard Maintenance'(SM) in some studies). Eight of the 18 psychological interventions reported data on our primary outcomes. Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD. Data were available from only 10 studies involving 605 participants. Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands. Study duration ranged from 4 to 156 weeks (median = 26 weeks). Most participants (75%) were male; the mean age was 35.5 years. Eleven studies (58%) were funded by research councils. Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%. Cognitive behaviour therapy (CBT) + TAU versus TAU One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low-certainty evidence) for outpatients at 12 months post-intervention. One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) -1.60 points, 95% CI -5.21 to 2.01; very low-certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0-24), for outpatients at 12 months post-intervention. Impulsive lifestyle counselling (ILC) + TAU versus TAU One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss-Perry Aggression Questionnaire-Short Form) for outpatients at nine months (MD 0.07, CI -0.35 to 0.49; very low-certainty evidence). One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low-certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low-certainty evidence) for outpatients between three and nine months follow-up. Contingency management (CM) + SM versus SM One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD -0.08, 95% CI -0.14 to -0.02; low-certainty evidence) for outpatients at six months. 'Driving whilst intoxicated' programme (DWI) + incarceration versus incarceration One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI -0.19 to 1.31; very low-certainty evidence) for prisoner participants at 24 months. Schema therapy (ST) versus TAU One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years. The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD -137.33, 95% CI -271.31 to -3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three-year period (OR 0.42, 95% CI 0.08 to 2.19). The certainty of the evidence for all outcomes was very low. Social problem-solving (SPS) + psychoeducation (PE) versus TAU One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants' level of social functioning (MD -1.60 points, 95% CI -5.43 to 2.23; very low-certainty evidence) assessed with the SFQ at six months post-intervention. Dialectical behaviour therapy versus TAU One study (skewed data, 14 participants) provided very low-certainty, narrative evidence that DBT may reduce the number of self-harm days for outpatients at two months post-intervention compared to TAU. Psychosocial risk management (PSRM; 'Resettle') versus TAU One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison. It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low-certainty evidence).

AUTHORS' CONCLUSIONS

There is very limited evidence available on psychological interventions for adults with AsPD. Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition. No intervention reported compelling evidence of change in antisocial behaviour. Overall, the certainty of the evidence was low or very low, meaning that we have little confidence in the effect estimates reported. The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies. This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.

Beyond the 12 steps: Integrating chaplaincy services into Veteran Affairs substance use specialty care

Background: Interprofessional training is increasing in focus within medical education. Although substance use treatment has long been interprofessional in nature, chaplaincy has been relatively absent in outpatient settings. Since 2013, the Veterans Health Administration has supported an Interprofessional Advanced Fellowship in Addiction Treatment (IAFAT), with 7 sites nationally recruiting across multiple health care disciplines. In the fall of 2017, Veteran Affairs Connecticut Healthcare System (VACHS) became the first such fellowship to expand its recruitment to include chaplain fellows. We seek to share rationale for recruiting chaplains, current curriculum and curricular needs, and the potential roles of chaplains in outpatient addiction treatment. Methods: Collaborating with the office of chaplaincy education, we describe the process of chaplain recruitment, incorporation into a new treatment setting, and supervision, and we report on the feasibility of this innovative training initiative. Results: During the first year, the chaplain fellow has developed and maintained a new clinical service in an outpatient substance use disorder (SUD) specialty care setting, delivering over 150 hours of group and individual treatment to veterans. He has provided 12 presentations to staff on the role of a chaplain and other related topics, as well as written an article on the topic of addiction for a clergy audience. Anecdotally, staff satisfaction has been high, and the current chaplain is helping to recruit for his replacement. Limitations: As a feasibility pilot project, there is no outcome and very limited quantitative data. Conclusions: Chaplain fellows can be successfully incorporated into outpatient SUD clinics with a noticeable degree of fellow, staff, and patient satisfaction.

Combined Pharmacotherapy and Cognitive Behavioral Therapy for Adults With Alcohol or Substance Use Disorders: A Systematic Review and Meta-analysis

IMPORTANCE

Substance use disorders (SUDs) represent a pressing public health concern. Combined behavioral and pharmacological interventions are considered best practices for addiction. Cognitive behavioral therapy (CBT) is a first-line intervention, yet the superiority of CBT compared with other behavioral treatments when combined with pharmacotherapy remains unclear. An understanding of the effects of combined CBT and pharmacotherapy will inform best-practice guidelines for treatment of SUD.

OBJECTIVE

To conduct a meta-analysis of the published literature on combined CBT and pharmacotherapy for adult alcohol use disorder (AUD) or other SUDs.

DATA SOURCES

PubMed, Cochrane Register, MEDLINE, PsychINFO, and Embase databases from January 1, 1990, through July 31, 2019, were searched. Keywords were specified in 3 categories: treatment type, outcome type, and study design. Collected data were analyzed through September 30, 2019.

STUDY SELECTION

Two independent raters reviewed abstracts and full-text articles. English language articles describing randomized clinical trials examining CBT in combination with pharmacotherapy for AUD and SUD were included.

DATA EXTRACTION AND SYNTHESIS

Inverse-variance weighted, random-effects estimates of effect size were pooled into 3 clinically informative subgroups: (1) CBT plus pharmacotherapy compared with usual care plus pharmacotherapy, (2) CBT plus pharmacotherapy compared with another specific therapy plus pharmacotherapy, and (3) CBT added to usual care and pharmacotherapy compared with usual care and pharmacotherapy alone. Sensitivity analyses included assessment of study quality, pooled effect size heterogeneity, publication bias, and primary substance moderator effects.

MAIN OUTCOMES AND MEASURES

Substance use frequency and quantity outcomes after treatment and during follow-up were examined.

RESULTS

The sample included 62 effect sizes from 30 unique randomized clinical trials that examined CBT in combination with some form of pharmacotherapy for AUD and SUD. The primary substances targeted in the clinical trial sample were alcohol (15 [50%]), followed by cocaine (7 [23%]) and opioids (6 [20%]). The mean (SD) age of the patient sample was 39 (6) years, with a mean (SD) of 28% (12%) female participants per study. The following pharmacotherapies were used: naltrexone hydrochloride and/or acamprosate calcium (26 of 62 effect sizes [42%]), methadone hydrochloride or combined buprenorphine hydrochloride and naltrexone (11 of 62 [18%]), disulfiram (5 of 62 [8%]), and another pharmacotherapy or mixture of pharmacotherapies (20 of 62 [32%]). Random-effects pooled estimates showed a benefit associated with combined CBT and pharmacotherapy over usual care (g range, 0.18-0.28; k = 9). However, CBT did not perform better than another specific therapy, and evidence for the addition of CBT as an add-on to combined usual care and pharmacotherapy was mixed. Moderator analysis showed variability in effect direction and magnitude by primary drug target.

CONCLUSIONS AND RELEVANCE

The present study supports the efficacy of combined CBT and pharmacotherapy compared with usual care and pharmacotherapy. Cognitive behavioral therapy did not perform better than another evidence-based modality (eg, motivational enhancement therapy, contingency management) in this context or as an add-on to combined usual care and pharmacotherapy. These findings suggest that best practices in addiction treatment should include pharmacotherapy plus CBT or another evidence-based therapy, rather than usual clinical management or nonspecific counseling services.

Patterns of Cocaine Use During Treatment: Associations With Baseline Characteristics and Follow-Up Functioning

OBJECTIVE

Abstinence outcomes are typically prioritized in the treatment of cocaine use disorder while ignoring patterns of low-frequency cocaine use. This study examined patterns of cocaine use frequency during treatment and evaluated how these patterns related to baseline characteristics and functioning outcomes 6 and 12 months after treatment.

METHOD

We used a pooled dataset (N = 720) from seven randomized clinical trials for cocaine use disorder. The Addiction Severity Index (ASI) was used to assess functioning. Repeated-measures latent class analysis was used to derive patterns of cocaine use.

RESULTS

Three patterns were identified: abstinence (10.6%), low-frequency use (approximately 1 day/week; 66.3%), and persistent frequent use (approximately 4 days/week; 23.1%). The low-frequency group was associated with male gender, younger age, and a criminal justice referral. The abstinent group had the highest alcohol problem severity score at baseline. At Month 6, the low-frequency group reported lower problem severity than the persistent frequent use group across multiple ASI areas, including the cocaine use as well as psychological, family, employment, and legal domains. At Month 12, the low-frequency group did not differ from the abstinent group in problem severity on any ASI domain and, relative to the persistent frequent use group, had lower cocaine use and employment problem severity.

CONCLUSIONS

These findings highlight the importance of adopting a harm reduction approach and recognizing the potential clinical benefits associated with nonabstinent outcomes.

Clinical validation of reduction in cocaine frequency level as an endpoint in clinical trials for cocaine use disorder

BACKGROUND

Despite calls for non-abstinence endpoints in randomized clinical trials (RCTs) for cocaine use disorder, there is a lack of data validating non-abstinence endpoints. We conducted a clinical validation of reduction in cocaine frequency level as a non-abstinence endpoint in RCTs for cocaine use disorder (CUD).

METHODS

We utilized a pooled dataset (n = 716; 63.6 % male, 51.4 % non-Hispanic white) from seven RCTs for CUD. We specified three cocaine frequency levels at baseline and end of treatment (EOT): abstinence, low frequency (1-4 days/month), and high frequency (5+ days/month). Multiple regression analyses were conducted.

RESULTS

Among the sample, 38.3 % had at least a one-level reduction from baseline to EOT, whereas 61.7 % did not change/increased frequency level. At least a one-level reduction in cocaine frequency level from baseline to EOT versus no change/increase was significantly associated with better functioning up to one year following treatment on measures of cocaine use, as well as psychological, employment, legal, and other drug use problem severity domains of the Addiction Severity Index (ASI). We also conducted analyses only among those at the high frequency level at baseline and found those who reduced to low frequency use at EOT had similar outcomes at follow-up as those who reduced to abstinence.

CONCLUSIONS

At least a one-level reduction in cocaine frequency level from pretreatment to EOT can be a clinically meaningful endpoint given its relation to sustained clinical benefit up to one-year following treatment. These data parallel recent findings regarding reduction in drinking risk level among individuals with alcohol use disorder.

The efficacy of spiritual/religious interventions for substance use problems: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Spiritual/religious (S/R) interventions are commonly used to treat substance use problems, but this is the first systematic review and meta-analysis to examine their efficacy for these problems.

METHODS

Ten electronic databases were searched to identify eligible studies (i.e., randomized controlled trials) published between January 1990 and February 2018 that examined S/R interventions' efficacy for substance use or psycho-social-spiritual outcomes. Two reviewers independently screened studies, extracted data, and assessed risks of bias. Robust variance estimation in meta-regression was used to estimate effect sizes and conduct moderator analysis.

RESULTS

Twenty studies comprising 3700 participants met inclusion criteria. Four studies used inactive controls, 14 used active controls, and two used both inactive and active controls and were therefore included in estimating both absolute and relative effect sizes. The absolute effect of S/R interventions (compared with inactive controls such as no treatment) was moderate but non-significant (six studies, d = .537, 95% confidence interval [CI] = -.316, 1.390), possibly due to low power. The relative effect of S/R interventions (compared with other interventions) was statistically significant (16 studies, d = .176, 95% CI = .001, .358). Because only 12-step-oriented interventions were compared with other interventions, this finding does not apply to the relative effect of non-12-step-oriented S/R interventions. Moderator analysis showed that relative effect sizes differ significantly by country.

CONCLUSION

We found evidence of S/R interventions' efficacy in helping people with substance use problems. More high-quality efficacy studies of non-12-step-oriented S/R interventions for substance use problems are needed.

Sociodemographic and clinical outcome differences among individuals seeking treatment for cocaine use disorders. The intersection of gender and race

BACKGROUND

Most published treatment trials for cocaine use disorders (CUD) have been conducted with samples composed predominantly of White men and underrepresent women and racial/ethnic minorities. Because of the high prevalence of men and White individuals in CUD treatment trials, results from studies that have compared treatment outcomes by gender and race or ethnicity separately may not be representative of women or racial/ethnic minorities.

METHODS

With a sample pooled from seven randomized clinical trials of treatment for CUD (n = 629), baseline characteristics and treatment outcome responses were compared with 4 subgroups of individuals created based on the intersection of gender and race (White men, Black men, White women and Black women).

RESULTS

At baseline, sociodemographic status, pattern, frequency and severity of cocaine use, psychiatric comorbidities, employment and legal problems significantly differed across groups. Treatment outcome indicators collected during treatment and through follow-up, consistently indicated poorer outcomes among the sample of White women, but were similar for the other groups.

CONCLUSIONS

Men and women with CUD from both racial groups enter treatment with different psychosocial issues (e.g., history of violence/trauma, financial problems, co-occurring psychiatric disorders) and substance use problems (e.g. types of substances) that may impact treatment outcomes and indicate a need for culturally-informed care to deliver more effective treatment for CUD. Poorer overall outcomes among White women may reflect the need for a more focused treatment approach for this group; and highlight the importance of evaluating gender and race in treatment trials to better address health disparities.

Stellungnahme Dachgesellschaft Sucht:

Zusammenfassung. Hintergrund: Unterschiede in der Therapiezielfindung bei der Behandlung von Alkoholkonsumstörungen, die sich zwischen völliger Abstinenz, vermindertem Konsum (Schadensvermeidung) und „kontrolliertem Konsum“ aufspannen, werden seit vielen Jahren z. T. kontrovers diskutiert. Ziel: Ziel der Stellungnahme der Dachgesellschaft Sucht ist es, vorhandene empirische Erkenntnisse zu diesem Themenbereich zusammenzutragen und daraus Empfehlungen für den praktischen Umgang mit verschiedenen Therapiezielen wie Trinkmengenreduktion oder Abstinenz für die Patienten oder Klienten abzuleiten. An der Erstellung des Positionspapiers haben sich Vertreter verschiedener Fachgesellschaften (DG Suchtmedizin, der DG Suchtforschung und Suchttherapie sowie die Deutsche Gesellschaft für Suchtpsychologie) beteiligt. Eine Reihe von Forschungsdesideraten wird benannt.

Pharmacogenetic role of dopamine transporter (SLC6A3) variation on response to disulfiram treatment for cocaine addiction

BACKGROUND AND OBJECTIVES

Disulfiram has been beneficial in treating cocaine addiction in several studies. Patients with two SLC6A3 (DAT1) rs28363170 10-repeat alleles who have with genetically high dopamine transporter (DAT) levels may benefit from increased dopamine levels resulting from disulfiram treatment.

METHODS

After stabilization for 2 weeks on methadone, 70 cocaine and opioid codependent patients were randomized into disulfiram and placebo groups for 12 weeks of treatment. We genotyped the SLC6A3 (DAT1) 40 bp 3'-untranslated region variable number tandem repeat variant and evaluated its role in moderating disulfiram efficacy for cocaine dependence.

RESULTS

Among the 10,10-repeat genotype group, cocaine-positive urines dropped from 78% to 48% and from 80% to 75% among the 9-repeat carrier group in the disulfiram group (P = 0.0001, with an effect size of 0.09). No difference was observed in cocaine-positive urines in the placebo group between the 10,10-repeat genotype and the 9-allele carrier patients.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

We found that patients with genetically higher DAT levels had better treatment outcomes with disulfiram pharmacotherapy of cocaine dependence than those with lower DAT levels. (Am J Addict 2019;28:311-317).

Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users

BACKGROUND

Problem alcohol use is common among people who use illicit drugs (PWID) and is associated with adverse health outcomes. It is also an important factor contributing to a poor prognosis among drug users with hepatitis C virus (HCV) as it impacts on progression to hepatic cirrhosis or opioid overdose in PWID.

OBJECTIVES

To assess the effectiveness of psychosocial interventions to reduce alcohol consumption in PWID (users of opioids and stimulants).

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and PsycINFO, from inception up to August 2017, and the reference lists of eligible articles. We also searched: 1) conference proceedings (online archives only) of the Society for the Study of Addiction, International Harm Reduction Association, International Conference on Alcohol Harm Reduction and American Association for the Treatment of Opioid Dependence; and 2) online registers of clinical trials: Current Controlled Trials, ClinicalTrials.gov, Center Watch and the World Health Organization International Clinical Trials Registry Platform.

SELECTION CRITERIA

We included randomised controlled trials comparing psychosocial interventions with other psychosocial treatment, or treatment as usual, in adult PWIDs (aged at least 18 years) with concurrent problem alcohol use.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included seven trials (825 participants). We judged the majority of the trials to have a high or unclear risk of bias.The psychosocial interventions considered in the studies were: cognitive-behavioural coping skills training (one study), twelve-step programme (one study), brief intervention (three studies), motivational interviewing (two studies), and brief motivational interviewing (one study). Two studies were considered in two comparisons. There were no data for the secondary outcome, alcohol-related harm. The results were as follows.Comparison 1: cognitive-behavioural coping skills training versus twelve-step programme (one study, 41 participants)There was no significant difference between groups for either of the primary outcomes (alcohol abstinence assessed with Substance Abuse Calendar and breathalyser at one year: risk ratio (RR) 2.38 (95% confidence interval [CI] 0.10 to 55.06); and retention in treatment, measured at end of treatment: RR 0.89 (95% CI 0.62 to 1.29), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was very low.Comparison 2: brief intervention versus treatment as usual (three studies, 197 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured as scores on the Alcohol Use Disorders Identification Test (AUDIT) or Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) at three months: standardised mean difference (SMD) 0.07 (95% CI -0.24 to 0.37); and retention in treatment, measured at three months: RR 0.94 (95% CI 0.78 to 1.13), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.Comparison 3: motivational interviewing versus treatment as usual or educational intervention only (three studies, 462 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured as scores on the AUDIT or ASSIST at three months: SMD 0.04 (95% CI -0.29 to 0.37); and retention in treatment, measured at three months: RR 0.93 (95% CI 0.60 to 1.43), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.Comparison 4: brief motivational intervention (BMI) versus assessment only (one study, 187 participants)More people reduced alcohol use (by seven or more days in the past month, measured at six months) in the BMI group than in the control group (RR 1.67; 95% CI 1.08 to 2.60). There was no difference between groups for the other primary outcome, retention in treatment, measured at end of treatment: RR 0.98 (95% CI 0.94 to 1.02), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was moderate.Comparison 5: motivational interviewing (intensive) versus motivational interviewing (one study, 163 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured using the Addiction Severity Index-alcohol score (ASI) at two months: MD 0.03 (95% CI 0.02 to 0.08); and retention in treatment, measured at end of treatment: RR 17.63 (95% CI 1.03 to 300.48), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.

AUTHORS' CONCLUSIONS

We found low to very low-quality evidence to suggest that there is no difference in effectiveness between different types of psychosocial interventions to reduce alcohol consumption among people who use illicit drugs, and that brief interventions are not superior to assessment-only or to treatment as usual. No firm conclusions can be made because of the paucity of the data and the low quality of the retrieved studies.

Comparative efficacy and acceptability of psychosocial interventions for individuals with cocaine and amphetamine addiction: A systematic review and network meta-analysis

BACKGROUND

Clinical guidelines recommend psychosocial interventions for cocaine and/or amphetamine addiction as first-line treatment, but it is still unclear which intervention, if any, should be offered first. We aimed to estimate the comparative effectiveness of all available psychosocial interventions (alone or in combination) for the short- and long-term treatment of people with cocaine and/or amphetamine addiction.

METHODS AND FINDINGS

We searched published and unpublished randomised controlled trials (RCTs) comparing any structured psychosocial intervention against an active control or treatment as usual (TAU) for the treatment of cocaine and/or amphetamine addiction in adults. Primary outcome measures were efficacy (proportion of patients in abstinence, assessed by urinalysis) and acceptability (proportion of patients who dropped out due to any cause) at the end of treatment, but we also measured the acute (12 weeks) and long-term (longest duration of study follow-up) effects of the interventions and the longest duration of abstinence. Odds ratios (ORs) and standardised mean differences were estimated using pairwise and network meta-analysis with random effects. The risk of bias of the included studies was assessed with the Cochrane tool, and the strength of evidence with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We followed the PRISMA for Network Meta-Analyses (PRISMA-NMA) guidelines, and the protocol was registered in PROSPERO (CRD 42017042900). We included 50 RCTs evaluating 12 psychosocial interventions or TAU in 6,942 participants. The strength of evidence ranged from high to very low. Compared to TAU, contingency management (CM) plus community reinforcement approach was the only intervention that increased the number of abstinent patients at the end of treatment (OR 2.84, 95% CI 1.24-6.51, P = 0.013), and also 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). At the end of treatment, CM plus community reinforcement approach had the highest number of statistically significant results in head-to-head comparisons, being more efficacious than cognitive behavioural 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 programme plus non-contingent rewards (OR 4.07, 95% CI 1.13-14.69, P = 0.031). CM plus community reinforcement approach was also associated with fewer dropouts than TAU, both at 12 weeks and the end of treatment (OR 3.92, P < 0.001, and 3.63, P < 0.001, respectively). At the longest follow-up, community reinforcement approach was more effective than non-contingent rewards, supportive-expressive psychodynamic therapy, TAU, and 12-step programme (OR ranging between 2.71, P = 0.026, and 4.58, P = 0.001), but the combination of community reinforcement approach with CM was superior also to CBT alone, CM alone, CM plus CBT, and 12-step programme plus non-contingent rewards (ORs between 2.50, P = 0.039, and 5.22, P < 0.001). The main limitations of our study were the quality of included studies and the lack of blinding, which may have increased the risk of performance bias. However, our analyses were based on objective outcomes, which are less likely to be biased.

CONCLUSIONS

To our knowledge, this network meta-analysis is the most comprehensive synthesis of data for psychosocial interventions in individuals with cocaine and/or amphetamine addiction. Our findings provide the best evidence base currently available to guide decision-making about psychosocial interventions for individuals with cocaine and/or amphetamine addiction and should inform patients, clinicians, and policy-makers.

Tobacco use during a clinical trial of mecamylamine for alcohol dependence: Medication effects on smoking and associations with reductions in drinking

Mecamylamine is a nicotinic acetylcholine receptor (nAChR) antagonist that was recently used in a clinical trial to treat alcohol use disorder (AUD) in both smokers and non-smokers. The current manuscript reports a reanalysis of data from this clinical trial in which we examine changes in smoking that occurred over the course of the trial. We focused on examining the effects of mecamylamine on smoking and the association between reductions in alcohol use and smoking. Participants were the subgroup of smokers who participated in the clinical trial of mecamylamine (10 mg/day) to treat their AUD (n = 76). Smoking was assessed prior to randomization and tracked throughout the course of the 12-week medication treatment phase. Participants were categorized as treatment responders or non-responders based on their changes in drinking over the course of the clinical trial. Participants showed a reduction in smoking over the course of the clinical trial, but there were no significant differences in smoking outcomes between the mecamylamine and placebo groups. Among moderate/high dependence smokers, those who successfully reduced drinking showed a significant reduction in cigarettes smoked per day over the clinical trial. Mecamylamine had no detectable effect on smoking outcomes. Reductions in alcohol use predicted more favorable smoking outcomes among moderate/high tobacco dependence smokers irrespective of medication condition. The reduction in smoking among patients who decreased their alcohol use responders highlights an opportunity for patients being treated for AUD to reduce their smoking.

Mecamylamine treatment for alcohol dependence: a randomized controlled trial

BACKGROUND AND AIMS

The nicotinic acetylcholine receptor antagonist, mecamylamine, is a potential novel pharmacotherapy for alcohol use disorder. The aims were to compare alcohol consumption between mecamylamine and placebo and test if smoking status modified treatment effects.

DESIGN

Out-patient, randomized, double-blind clinical trial for 12 weeks of treatment with mecamylamine (10 mg) (n = 65) versus placebo (n = 63).

SETTING

Connecticut, USA.

PARTICIPANTS

Individuals had current alcohol dependence (n = 128), had an average age of 48.5 [standard deviation (SD) = 9.4], 110 (85.9%) were men, and included 74 smokers (57.8%) and 54 non-smokers (42.2%). Participants were randomized to mecamylamine 10 mg per day or placebo. All subjects also received medical management therapy administered by trained research personnel.

MEASUREMENTS

Primary outcome was percentage of heavy drinking days during the last month of treatment; other outcomes included drinking days, drinks per drinking days, alcohol craving, smoking, symptoms of nicotine withdrawal and side effects.

FINDINGS

There were no significant differences in the percentage of heavy drinking days at 3 months between the mecamylamine (mean = 18.4, SD = 29.0) and placebo treatment groups (mean = 20.4, SD = 29.2) [F1, 100  = 1.3, P = 0.25; effect size d = 0.07; mean difference = 2.06, 95% confidence interval (CI) = -8.96 to 13.08]. There were no significant differences in percentage of drinking days or in drinks per drinking day at month 3 between the mecamylamine and placebo groups; there were no significant interactions.

CONCLUSIONS

Mecamylamine 10 mg per day did not reduce alcohol consumption significantly in treatment-seeking smokers and non-smokers with alcohol use disorder.

Initial validation of a proxy indicator of functioning as a potential tool for establishing a clinically meaningful cocaine use outcome

BACKGROUND

Establishing a non-abstinence cocaine use outcome as clinically meaningful has been elusive, in part due to the lack of association between cocaine use outcomes and meaningful indicators of long-term functioning.

METHODS

Using data pooled across 7 clinical trials evaluating treatments for cocaine (N=718), a dichotomous indicator of functioning was created to represent a meaningful outcome ('problem-free functioning' - PFF), defined as the absence of problems across non-substance-related domains on the Addiction Severity Index. Its validity was evaluated at multiple time points (baseline, end-of-treatment, terminal follow-up) and used to explore associations with cocaine use.

RESULTS

The percentage of participants meeting PFF criteria increased over time (baseline=18%; end-of-treatment=32%; terminal follow-up=37%). At each time point, ANOVAs indicated those who met PFF criteria reported significantly less distress on the Brief Symptom Inventory and less perceived stress on the Perceived Stress Scale. Generalized linear models indicated categorical indices of self-reported cocaine use at the end of treatment were predictive of the probability of meeting PFF criteria during follow-up (β=-0.01, p<0.01; 95% CI: -0.008 to -0.003), with those reporting 0days or 1-4days ('occasional' use) in the final month of treatment showing an increased likelihood of achieving PFF.

CONCLUSIONS

Initial validation of a proxy indicator of problem-free functioning demonstrated criterion validity and sensitivity to change over time. Frequency of cocaine use in the final month of treatment was associated with PFF during follow-up, with strongest associations between PFF and abstinence or 'occasional' use.

Functional neural changes following behavioral therapies and disulfiram for cocaine dependence

A growing literature exists on neural correlates of treatment outcome. However, different types-or components of-treatment have distinct theorized mechanisms of action. And it is not yet known how changes in neural activity across treatment relate to engagement in different treatment components. Participants with cocaine use disorders in a randomized clinical trial received cognitive-behavioral therapy (CBT) plus, in a 2 × 2 design, contingency management (CM) or no CM, and disulfiram or placebo. Participants performed a functional MRI Stroop task, a measure of cognitive control, at the beginning of and after the 12-week treatment. Analyses assessed changes in Stroop-related neural activity within the sample overall and assessed how changes in Stroop-related activity correlated with measures of treatment process specific to each form of treatment (i.e., participation in CBT sessions, receipt of CM prizes, administration of disulfiram pills). Within the sample overall, compared with beginning of treatment, posttreatment Stroop-related neural activity was diminished in the hippocampus, thalamus, cingulate, precentral, post- and precentral gyrus, and precuneus and culmen regions (pFWE < .05). In separate whole-brain correlation analyses, greater reductions in Stroop-related activity were associated with more treatment engagement-"CBT sessions" with the precentral gyrus, inferior parietal lobule, and middle and medial frontal gyrus; "CM prizes" with the postcentral frontal gyrus. Disulfiram "medication days" were not associated with changes in Stroop-related activity. Findings suggest that key process indicators of CBT and CM may be associated with functional changes in cognitive-control-related neurocircuitry. (PsycINFO Database Record

Comparable efficacy of behavioral and pharmacological treatments among African American and White cocaine users

Multiple randomized clinical trials (RCTs) have evaluated a range of treatments for cocaine dependence, but few of these have focused specifically on the racial diversity observed among cocaine-dependent patients. The present analyses evaluated racial variation in cocaine use and addiction-related psychosocial outcomes at baseline and follow-up among 388 African American and White adults participating in 1 of 5 RCTs evaluating a range of pharmacological and behavioral treatments for cocaine use disorders. General linear modeling (GLM) indicated significant racial variation in cocaine and psychosocial indicators at baseline. At baseline, there were significant racial differences in the number of days paid for work in the 30 days prior to the study, age, days of cocaine use in the past month, age of first cocaine use, psychosocial problems (i.e., employment, cocaine, legal, and family), public assistance status, and prevalence of lifetime anxiety disorders. There were no significant main or interaction effects of race and study on treatment outcomes at posttreatment. These findings suggest that despite significant racial differences at baseline, the pharmacological and behavioral treatments resulted in fairly comparable outcomes across racial groups in these 5 RCTs.

Similarities and Differences in Neurobiology

Substance addiction is a chronic, relapsing brain disease characterized by compulsive drug seeking and use despite harmful consequences. Non-substance addiction is defined recently that people may compulsively engage in an activity despite any negative consequences to their lives. Despite differences with respect to their addictive object, substance addiction and non-substance addiction may share similarities with respect to biological, epidemiological, clinical, genetic and other features. Here we review the similarities and differences in neurobiology between these two addictions with a focus on dopamine, serotonin, opioid, glutamate and norepinephrine systems. Studies suggest the involvement of all these systems in both substance addiction and non-substance addiction while differences may exist with respect to their contributions.

Alcohol use in opioid agonist treatment

Alcohol misuse among individuals receiving agonist treatment for an opioid use disorder is common and is associated with significant morbidity and mortality. At present, though substantial research highlights effective strategies for the screening, diagnosis and management of an alcohol or opioid use disorder individually, less is known about how best to care for those with a dual diagnosis especially since common treatments for opioid addiction may be contraindicated in a setting of alcohol use. This review summarizes existing research and characterizes the prevalence, clinical implications and management of alcohol misuse among individuals with opioid addiction. Furthermore, it highlights clinically relevant management strategies in need of future research to advance care for this unique, but important, patient population.

Treatment-refractory substance use disorder: Focus on alcohol, opioids, and cocaine

Substance use disorders are common, but only a small minority of patients receive adequate treatment. Although psychosocial therapies are effective, relapse is common. This review focusses on novel pharmacological and other treatments for patients with alcohol, opioid, or cocaine use disorders who do not respond to conventional treatments. Disulfiram, acamprosate, and the opioid antagonist naltrexone have been approved for the treatment of alcoholism. A novel, "as needed" approach is the use of the mu-opioid antagonist and partial kappa agonist nalmefene to reduce alcohol consumption. Other novel pharmacological approaches include the GABA-B receptor agonist baclofen, anticonvulsants such as topiramate and gabapentin, the partial nicotine receptor agonist varenicline, and other drugs. For opioid dependence, opioid agonist therapy with methadone or buprenorphine is the first-line treatment option. Other options include oral or depot naltrexone, morphine sulfate, depot or implant formulations, and heroin (diacetylmorphine) in treatment-refractory patients. To date, no pharmacological treatment has been approved for cocaine addiction; however, 3 potential pharmacological treatments are being studied, disulfiram, methylphenidate, and modafinil. Pharmacogenetic approaches may help to optimize treatment response in otherwise treatment-refractory patients and to identify which patients are more likely to respond to treatment, and neuromodulation techniques such as repeated transcranial magnetic stimulation and deep brain stimulation also may play a role in the treatment of substance use disorders. Although no magic bullet is in sight for treatment-refractory patients, some novel medications and brain stimulation techniques have the potential to enrich treatment options at least for some patients.

Interventions to reduce intimate partner violence perpetration among people with substance use disorders

The social and economic cost of intimate partner violence (IPV) is exorbitant and highlights the need for policy reform as it pertains to IPV interventions at a global level. There are multiple variables associated with the aetiology of IPV and, hence, multiple treatment needs must be considered. Substance use is one of several factors likely to influence the occurrence of IPV, but often goes unaddressed in standard treatment approaches. This review will discuss several treatment models for substance using offenders of IPV, including Psycho-educational Models, Cognitive Behavioural Therapy, Couples' Treatments, Parenting Programmes, Integration of Care Models, and Pharmacotherapies. Clinical recommendations will be discussed. Treatment outcomes among substance using offenders of IPV may be improved by implementing changes in protocol that increase diagnostic evaluations, integrate care with evidence-based models, require limits to the number of offenders in a group, and require qualifications for clinicians who treat offenders (licensed and trained psychologists, social workers, and/or psychiatrists).

Psychosocial interventions for psychostimulant misuse

BACKGROUND

Psychostimulant misuse is a continuously growing medical and social burden. There is no evidence proving the efficacy of pharmacotherapy. Psychosocial interventions could be a valid approach to help patients in reducing or ceasing drug consumption.

OBJECTIVES

To assess the effects of psychosocial interventions for psychostimulant misuse in adults.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Specialised Register (via CRSLive); Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science and PsycINFO, from inception to November 2015. We also searched for ongoing and unpublished studies via ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (apps.who.int/trialsearch/).All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials comparing any psychosocial intervention with no intervention, treatment as usual (TAU) or a different intervention in adults with psychostimulant misuse or dependence.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included a total of 52 trials (6923 participants).The psychosocial interventions considered in the studies were: cognitive behavioural therapy (19 studies), contingency management (25 studies), motivational interviewing (5 studies), interpersonal therapy (3 studies), psychodynamic therapy (1 study), 12-step facilitation (4 studies).We judged most of the studies to be at unclear risk of selection bias; blinding of personnel and participants was not possible for the type of intervention, so all the studies were at high risk of performance bias with regard to subjective outcomes; the majority of studies did not specify whether the outcome assessors were blind. We did not consider it likely that the objective outcomes were influenced by lack of blinding.The comparisons made were: any psychosocial intervention versus no intervention (32 studies), any psychosocial intervention versus TAU (6 studies), and one psychosocial intervention versus an alternative psychosocial intervention (13 studies). Five of included studies did not provide any useful data for inclusion in statistical synthesis.We found that, when compared to no intervention, any psychosocial treatment: reduced the dropout rate (risk ratio (RR): 0.83, 95% confidence interval (CI) 0.76 to -0.91, 24 studies, 3393 participants, moderate quality evidence); increased continuous abstinence at the end of treatment (RR: 2.14, 95% CI 1.27 to -3.59, 8 studies, 1241 participants, low quality evidence); did not significantly increase continuous abstinence at the longest follow-up (RR: 2.12, 95% CI 0.77 to -5.86, 4 studies, 324 participants, low quality evidence); significantly increased the longest period of abstinence: (standardised mean difference (SMD): 0.48, 95% CI 0.34 to 0.63, 10 studies, 1354 participants, high quality evidence). However, it should be noted that the in the vast majority of the studies in this comparison the specific psychosocial treatment assessed in the experimental arm was given in add on to treatment as usual or to another specific psychosocial or pharmacological treatment which was received by both groups. So, many of the control groups in this comparison were not really untreated. Receiving some amount of treatment is not the same as not receiving any intervention, so we could argue that the overall effect of the experimental psychosocial treatment could be smaller if given in add on to TAU or to another intervention than if given to participants not receiving any intervention; this could translate to a smaller magnitude of the effect of the psychosocial intervention when it is given in add on.When compared to TAU, any psychosocial treatment reduced dropout rate (RR: 0.72, 95% CI 0.59 to 0.89, 6 studies, 516 participants, moderate quality evidence), did not increase continuous abstinence at the end of treatment (RR: 1.27, 95% CI 0.94 to 1.72, 2 studies, 224 participants, low quality evidence), did not increase longest period of abstinence (MD -3.15 days, 95% CI -10.35 to 4.05, 1 study, 110 participants, low quality evidence). No studies in this comparison assessed the outcome of continuous abstinence at longest follow-up.There were few studies comparing two or more psychosocial interventions, with small sample sizes and considerable heterogeneity in terms of the types of interventions assessed. None reported significant results.None of the studies reported harms related to psychosocial interventions.

AUTHORS' CONCLUSIONS

The addition of any psychosocial treatment to treatment as usual (usually characterised by group counselling or case management) probably reduces the dropout rate and increases the longest period of abstinence. It may increase the number of people achieving continuous abstinence at the end of treatment, although this might not be maintained at longest follow-up. The most studied and the most promising psychosocial approach to be added to treatment as usual is probably contingency management. However, the other approaches were only analysed in a few small studies, so we cannot rule out the possibility that the results were not significant because of imprecision. When compared to TAU, any psychosocial treatment may improve adherence, but it may not improve abstinence at the end of treatment or the longest period of abstinence.The majority of the studies took place in the United States, and this could limit the generalisability of the findings, because the effects of psychosocial treatments could be strongly influenced by the social context and ethnicity. The results of our review do not answer the most relevant clinical question, demonstrating which is the most effective type of psychosocial approach.Further studies should directly compare contingency management with the other psychosocial approaches.

Patient Pre-Treatment Expectations Do Not Predict Cocaine Use Outcomes: Data From Four Clinical Trials

BACKGROUND

There are very few data regarding the extent to which patients' initial expectations regarding treatment are associated with substance use treatment outcomes.

OBJECTIVE

This study sought to determine how patients' treatment expectations were associated with treatment outcomes.

METHODS

This study explored patient pre-treatment expectations and substance use treatment outcomes for 387 individuals participating in treatment for cocaine use within the United States (68.2% male, mean age 36 years old, 54.8% Caucasian).

RESULTS

Participants' expectations regarding abstinence were not strongly associated with post-treatment or follow-up cocaine use outcome measures. There was a significant association between the expected timeframe of receiving a positive treatment effect (i.e., outcome efficiency expectations) and days of cocaine use at the 1-month follow-up point (F = 3.45, p =.009). Post-hoc comparisons revealed that participants that expected positive effects of treatment within 0-1 week reported fewer days of cocaine use than those that expected results in 1-2 months. Also, those that expected positive effects of treatment in 1-2 months reported more cocaine use than those who expected positive results within two weeks to one month. Further, there was a significant effect of outcome efficiency expectations on a proxy measure of achieving a good treatment outcome at the three-month follow-up point (F = 11.13, p =.025).

CONCLUSIONS/IMPORTANCE

Results suggest that treatment outcomes are not associated with patients' treatment outcome expectations, but that some outcomes are associated with treatment outcome efficiency expectations.

Organizational Predictors of Pharmacological Innovation Adoption: The Case of Disulfiram

The research-to-practice gap in substance abuse treatment, particularly with regard to pharmacological innovations, necessitates the consideration of organizational characteristics that facilitate the adoption of innovations. Using data from a nationally representative sample of 394 privately funded substance abuse treatment centers, this study examines variation in the adoption of disulfiram in terms of organizational structure, workforce professionalism, and treatment philosophy. Logistic regression results indicated that hospital-based centers were significantly more likely to use disulfiram than freestanding treatment programs. In addition, the percentage of counselors with master's degrees and the percentage of certified/licensed counselors were positively associated with the likelihood of disulfiram utilization. Treatment centers that emphasized confrontational group therapy and spirituality were less likely to use disulfiram, while the adoption of disulfiram was more likely in centers that emphasized a medical model of addiction.

Predictors of 12-Step Attendance and Participation for Individuals With Stimulant Use Disorders

OBJECTIVE

Few studies have examined the effectiveness of 12-step peer recovery support programs with drug use disorders, especially stimulant use, and it is difficult to know how outcomes related to 12-step attendance and participation generalize to individuals with non-alcohol substance use disorders (SUDs).

METHOD

A clinical trial of 12-step facilitation (N=471) focusing on individuals with cocaine or methamphetamine use disorders allowed examination of four questions: Q1) To what extent do treatment-seeking stimulant users use 12-step programs and, which ones? Q2) Do factors previously found to predict 12-step participation among those with alcohol use disorders also predict participation among stimulant users? Q3) What specific baseline "12-step readiness" factors predict subsequent 12-step participation and attendance? And Q4) Does stimulant drug of choice differentially predict 12-step participation and attendance?

RESULTS

The four outcomes variables, attendance, speaking, duties at 12-step meetings, and other peer recovery support activities, were not related to baseline demographic or substance problem history or severity. Drug of choice was associated with differential days of Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) attendance among those who reported attending, and cocaine users reported more days of attending AA or NA at 1-, 3- and 6-month follow-ups than did methamphetamine users. Pre-randomization measures of perceived benefit of 12-step groups predicted 12-step attendance at 3- and 6-month follow-ups. Pre-randomization 12-step attendance significantly predicted number of other self-help activities at end-of-treatment, 3- and 6-month follow-ups. Pre-randomization perceived benefit and problem severity both predicted number of self-help activities at end-of-treatment and 3-month follow-up. Pre-randomization perceived barriers to 12-step groups were negatively associated with self-help activities at end-of-treatment and 3-month follow-up. Whether or not one participated in any duties was predicted at all time points by pre-randomization involvement in self-help activities.

CONCLUSIONS

The primary finding of this study is one of continuity: prior attendance and active involvement with 12-step programs were the main signs pointing to future involvement. Limitations and recommendations are discussed.

Coadministration of disulfiram and lorazepam in the treatment of alcohol dependence and co-occurring anxiety disorder: an open-label pilot study

BACKGROUND

Anxiety is common among persons with alcohol use disorder during early abstinence from alcohol. Although benzodiazepines are effective for short-term treatment of anxiety, they are rarely used beyond acute detoxification due to concerns about misuse or interactions with alcohol.

OBJECTIVES

We conducted an open-label trial to explore the effects of coadministering lorazepam and disulfiram to alcohol-dependent patients with anxiety disorder symptoms. The rationale for this model is to minimize the risks of the benzodiazepine, while also potentially enhancing adherence to disulfiram.

METHODS

Forty-one participants with DSM-IV alcohol dependence who also met syndromal criteria for anxiety disorder with or without co-occurring major depressive syndrome initiated treatment with lorazepam (starting dose 0.5 mg three times daily) and disulfiram (starting dose 500 mg three times weekly). Participants received 16 weeks of monitored pharmacotherapy with manualized medical management.

RESULTS

Adherence to treatment decreased steadily with time (85.4% at 4 weeks, 36.6% at 16 weeks). Participants showed significant increases in percent abstinent days during treatment and at 24 weeks follow-up. Large reductions in anxiety, depression, and craving were observed during treatment, and improvement remained significant at 24 weeks. Duration of adherence with disulfiram strongly predicted abstinence at 16 weeks. There was no evidence of misuse of lorazepam or dose escalation during the study.

CONCLUSION

Lorazepam can be safely used for short-term treatment of anxiety in combination with disulfiram treatment of alcohol use disorder. However, it is not clear that making lorazepam dispensing contingent on adherence to disulfiram enhances retention in disulfiram treatment.

A randomized factorial trial of disulfiram and contingency management to enhance cognitive behavioral therapy for cocaine dependence

BACKGROUND

This study evaluated the extent to which the addition of disulfiram and contingency management for adherence and abstinence (CM), alone and in combination, might enhance the effects of cognitive behavioral therapy (CBT) for cocaine use disorders.

METHODS

Factorial randomized double blind (for medication condition) clinical trial where CBT served as the platform and was delivered in weekly individual sessions in a community-based outpatient clinic. 99 outpatients who met DSM-IV criteria for current cocaine dependence were assigned to receive either disulfiram or placebo, and either CM or no CM. Cocaine and other substance use was assessed via a daily calendar with thrice weekly urine sample testing for 12 weeks with a one-year follow-up (80% interviewed at one year).

RESULTS

The primary hypothesis that CM and disulfiram would produce the best cocaine outcomes was not confirmed, nor was there a main effect for disulfiram. For the primary outcome (percent days of abstinence, self report), there was a significant interaction, with the best cocaine outcomes were seen for the combination of CM and placebo, with the two groups assigned to disulfiram associated with intermediate outcomes, and poorest cocaine outcome among those assigned to placebo and no CM. The secondary outcome (urinalysis) indicated a significant effect favoring CM over no CM but the interaction effect was not significant. One year follow-up data indicated sustained treatment effects across conditions.

CONCLUSIONS

CM enhances outcomes for CBT treatment of cocaine dependence, but disulfiram provided no added benefit to the combination of CM and CBT.

Addiction pharmacogenetics: a systematic review of the genetic variation of the dopaminergic system

Substance use disorders have significant personal, familial, and societal consequences. Despite the serious consequences of substance use, only a few therapies are effective in treating substance use disorders, thus highlighting a need for improved treatment practices. Substance use treatment response depends on multiple factors such as genetic, biological, and social factors. It is essential that each component is represented in treatment plans. The dopaminergic system plays a critical role in the pharmacotherapy for addictions, and an understanding of the role of variation of genes involved in this system is essential for its success. This review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement guidelines. A computerized literature search was conducted using PubMed and Scopus (all databases). Articles published up to April 2015 that examined the role of dopaminergic gene variation in the pharmacotherapy of alcohol, opioid, and cocaine use disorders were reviewed. Search terms were dopamine, gene, polymorphism, substance abuse, treatment, and response. Polymorphisms of the DRD2, ANKK1, DAT1, DBH, and DRD4 genes have been found to moderate the effects of pharmacotherapy of alcohol, opioid, and cocaine use disorders. The integration of genetic information with clinical data will inform health professionals of the most efficacious pharmacotherapeutic intervention for substance use disorders. More studies are needed to confirm and extend these findings.

Serotonergic gene variation in substance use pharmacotherapy: a systematic review

Drug addiction is a serious disease with damaging effects on the brain and physical health. Despite the increase in the number of affected individuals, there are few effective pharmacological treatment options for substance use disorders. The study of the influence of an individual's genetic features on the treatment response may help to identify more efficacious treatment options. This systematic review focuses on the serotonergic system because of its relevant role in mood and impulse control disorders, and its contribution to the development and maintenance of drug use disorders. In particular, we examine the role of serotonergic genes in the response to pharmacotherapy for alcohol, cocaine and nicotine addiction. Current evidence suggests that genetic variability of the serotonergic biosynthesis enzyme tryptophan hydroxylase 2 (TPH2) and the serotonin transporter (SLC6A4) genes mediates the efficacy of several addiction treatments, such as ondansetron and disulfiram, and the antidepressants bupropion, nortriptyline and sertraline.

A review of pharmacogenetic studies of substance-related disorders

BACKGROUND

Substance-related disorders (SRDs) are a major cause of morbidity and mortality worldwide. Family, twin, and adoption studies have demonstrated the substantial heritability of SRDs. To determine the impact of genetic variation on risk for SRD and the response to treatment, researchers have conducted a number of secondary data analyses and quasi-experimental studies that target one or more candidate gene variants.

METHODS

This review examines studies in which candidate polymorphisms were examined as mediator variables to identify pharmacogenetic effects on subjective responses to drug administration or cues or outcomes of medication trials for SRDs. Efforts to use a meta-analytic approach to quantify these effects are premature because the number of available studies using similar methods and outcomes is limited, so the present review is qualitative.

RESULTS

Findings from these studies provide preliminary evidence of clinically relevant pharmacogenetic effects. However, independent replication of these findings has been sparse.

CONCLUSIONS

Although this growing body of literature has produced conflicting results, improved statistical controls may help to clarify the findings. Additionally, the use of empirically derived sub-phenotypes (i.e., which serve to differentiate distinct groups of affected individuals) may also help to identify genetic mediators of pharmacologic response in relation to SRDs. The identification of genetic mediators can inform clinical care both by identifying risk factors for SRDs and predicting adverse events and therapeutic outcomes associated with specific pharmacotherapies.

Evaluation of the dopamine β-hydroxylase (DβH) inhibitor nepicastat in participants who meet criteria for cocaine use disorder

In the present study, we tested the hypothesis that the potent and selective dopamine-β-hydroxylase (DβH) inhibitor nepicastat would have minimal effects on cardiovascular and pharmacokinetic parameters associated with cocaine administration and would reduce the positive subjective effects produced by cocaine. We conducted a double-blind, placebo-controlled, inpatient study of oral nepicastat (0, 80 and 160mg) concurrent with intravenous (IV) cocaine (0, 10, 20 and 40mg) in non-treatment seeking participants who metcriteria for cocaine use disorder. Safety analyses revealed that nepicastat was well-tolerated and there were no differences in adverse events observed after nepicastat plus cocaine vs. cocaine alone. In addition, the pharmacokinetic properties of cocaine administration were not altered by nepicastat treatment. Cocaine-induced cardiovascular and subjective effects were evaluated for completers in the cohort randomized to nepicastat (n=13) using a within-subjects statistical analysis strategy. Specifically, the cardiovascular and subjective effects of cocaine were assessed in the presence of placebo (0mg), 80mg of nepicastat or 160mg of nepicastat on study Days 4, 8 and 12, respectively. Analyses revealed a main effect of nepicastat to reduce several cocaine-induced positive subjective effects. Taken together, these data indicate that nepicastat is safe when co-administered with cocaine and may suppress its positive subjective effects, and may be viable as a pharmacotherapy for treatment of cocaine use disorder.

WITHDRAWN: Psychosocial interventions for cocaine and psychostimulant amphetamines related disorders

Review withdrawn as the Cochrane Funding Arbitration Panel found this review non‐compliant with the Cochrane’s commercial sponsorship policy. The new author team will update and replace this review.

The editorial group responsible for this previously published document have withdrawn it from publication.

Prompted to treatment by the criminal justice system: Relationships with treatment retention and outcome among cocaine users

BACKGROUND AND OBJECTIVES

A substantial portion of individuals entering treatment for substance use have been referred by the criminal justice system, yet there are conflicting reports regarding treatment engagement and outcome differences compared to those not referred. This study examined baseline characteristic and treatment outcome differences among cocaine-dependent individuals participating in cocaine treatment randomized trials.

METHODS

This secondary analysis pooled samples across five completed randomized controlled trials, resulting in 434 participants. Of these, 67 (15%) were prompted to treatment by the criminal justice system.

RESULTS

This subsample of criminal justice prompted (CJP) individuals did not differ from those not prompted by the criminal justice system in terms of gender, race/ethnicity, marital status, or age. However, the CJP group reported more years of regular cocaine use, more severe employment and legal problems, as well as less readiness to change prior to treatment. Treatment outcomes did not differ significantly from those without a criminal justice prompt, and on some measures the outcomes for CJP group were better (e.g., percentage of days cocaine abstinent, number of therapy sessions attended).

DISCUSSION AND CONCLUSIONS

These findings suggest that being prompted to treatment by the criminal justice system may not lead to poorer treatment engagement or substance use outcomes for individuals participating in randomized controlled treatment trials.

SCIENTIFIC SIGNIFICANCE

Despite some baseline indicators of poorer treatment prognosis, individuals who have been prompted to treatment by the criminal justice system have similar treatment outcomes as those presenting to treatment voluntarily.

Drug and alcohol addiction: do psychosocial treatments work?

Methodological issues such as social desirability bias, subjective outcome measures, therapist enthusiasm and fidelity to the intervention remain a major problem in assessing the effectiveness of psychosocial treatments for substance misuse. Alcoholics Anonymous and other 12-step programmes are still widely used, although it is difficult to formally assess their effectiveness. Motivational interviewing is perhaps the most commonly used professional psychosocial treatment for substance misuse, but brief interventions based on this technique report a disappointing effect size (∼0.2). Contingency management is perhaps the most effective reported modality, although it remains politically controversial. Cognitive—behavioural therapy and community reinforcement have been widely studied, but the results are often disappointing (effect sizes seldom exceed 0.5, despite very large trials). Residential rehabilitation remains an established treatment, but patient selection prevents formal cost-effectiveness studies.

Pharmacotherapy for alcohol use disorder: current and emerging therapies

Alcohol use disorder is a heterogeneous illness with a complex biology that is controlled by many genes and gene-by-environment interactions. Several efficacious, evidence-based treatments currently exist for treating and managing alcohol use disorder, including a number of pharmacotherapies that target specific aspects of biology that initiate and maintain dangerous alcohol misuse. This article reviews the neurobiological and neurobehavioral foundation of alcohol use disorder, the mechanisms of action and evidence for the efficacy of currently approved medications for treatment, and the literature on other emerging pharmacotherapies.