Psychosocial interventions for psychostimulant misuse

Silvia Minozzi; Rosella Saulle; Franco De Crescenzo; Laura Amato

doi:10.1002/14651858.CD011866.pub2

Psychosocial interventions for psychostimulant misuse

Authors' declarations of interest

Version published: 29 September 2016 Version history

https://doi.org/10.1002/14651858.CD011866.pub2

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Abstract

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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 We also searched for ongoing and unpublished studies via ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP)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.

PICOs

Population

Intervention

Comparison

Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

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Psychosocial interventions for cocaine and amphetamines abusers

Review question

We reviewed the evidence about the effect of psychosocial treatment, which encompasses a wide variety of strategies that aim to change behaviour and support adults who are affected by harmful use, abuse or dependence on cocaine or amphetamines, including MDMA (ecstasy).

Background

Globally, cocaine and amphetamines are the two main recreational psychostimulants. The latest estimates indicate that more than 0.35% of adults globally have used cocaine and 0.7% amphetamines at least once in the past year. In terms of prevalence, amphetamines were second only to cannabis as the most commonly used illicit drug type worldwide.

Both cocaine and amphetamine dependence have been associated with negative social, physical and psychological consequences. These include delusions and hallucinations, cardiovascular diseases, AIDS and viral hepatitis, and sexually transmitted infections. There is a close link between illicit drug use, including crack cocaine and amphetamines, and crime, sexual abuse and interpersonal violence.

Pharmacological treatments do not appear to be effective in addressing this condition, therefore it is crucial to find out whether psychosocial interventions increase adherence to treatment abstinence or reduce frequency of use.

Search date

The evidence was current to November 2015.

Study characteristics

We looked at 52 randomised controlled trials (studies where people were allocated at random to one of two or more treatment or control groups) in this review.

On average, the interventions lasted about 16 weeks, while investigators followed up participants for 6 to 12 months.

The studies examined different kinds of psychosocial interventions: cognitive behavioural therapy (19 studies), contingency management (25 studies), motivational interviewing (5 studies), interpersonal therapy (3 studies), psychodynamic therapy (1 study) and 12‐step facilitation (4 studies).

Forty‐one studies took place in the United States, four in Spain, three in Australia, two in Switzerland and two in the UK. We included a total of 6923 participants with an average age of 36 years. The proportion of males is 63%. The comparisons made were: any psychosocial versus no intervention (32 studies), any psychosocial versus treatment as usual (6 studies), and one psychosocial intervention versus an alternative psychosocial intervention (13 studies). Five of the included studies did not provide any useful data for inclusion in statistical synthesis.

Key results

We found that, compared to no intervention, any psychosocial intervention probably improves treatment adherence and may increase abstinence at the end of treatment; however, people may not be able to stay clean several months after the end of treatment. Finally, we found that people undergoing specific psychosocial interventions stay clean for a longer time without using stimulants. However, the vast majority of the studies we looked at assessed a specific psychosocial treatment added to treatment as usual or compared it to another specific psychosocial or pharmacological treatment. So, control groups were not really untreated. This could have led to an underestimation of the true effect of the psychosocial interventions.

We found that, when compared to TAU, any psychosocial treatment probably improves adherence but may not improve abstinence at the end of treatment nor help participants to stay clean for a longer time.

We could not draw any conclusions on which is the most effective psychosocial treatment based on direct comparisons. Most 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.

None of the studies reported harms related to psychosocial interventions.

Quality of evidence

The quality of evidence was moderate for adherence to treatment but low for abstinence.

Authors' conclusions

Implications for practice

The addition of any psychosocial treatment to treatment as usual (usually characterised by group counselling or case management) probably reduces dropout rate and increases the longest period of abstinence. It may also increase the number of subjects with continuous abstinence at the end of treatment, although people may not be able to maintain abstinence at longest follow‐up. The most studied and most promising psychosocial approach to be given in addition 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 probably improves adherence, but it may not improve abstinence at the end of treatment nor increase the longest period of abstinence. The results of our review do not answer to the most relevant clinical question regarding which is the most effective type of psychosocial approach. Moreover, the review does not rule out the potential effectiveness of other treatments, even if they currently do not have the evidence base to support their use.

Implications for research

The results of our review do not answer the most relevant clinical question regarding which is the most effective type of psychosocial approach. There were few studies directly comparing different types of psychosocial approaches, and the comparisons were very heterogeneous and the samples size small. The most studied psychosocial approach given in addition to another treatment or to treatment as usual was contingency management, but we cannot rule out that other types of treatment resulted in non‐significant results because of lack of statistical power in meta‐analysis. At the moment, we have collected more evidence on contingency management, but we do not consider our results to be conclusive. We urgently need adequately powered and methodologically sound studies making head‐to‐head comparisons between different psychosocial approaches in order to make reliable clinical recommendations. Future studies should also explore the effect of different psychosocial approaches in the following subgroups of participants: consumers of psychostimulant drugs alone, people with additional diagnosis of abuse/dependence on other substances and people with comorbid psychiatric disorders.

Summary of findings

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Summary of findings for the main comparison. Any psychosocial treatment compared to no intervention for psychostimulant misuse

Any psychosocial treatment compared to no intervention for psychostimulant misuse
Patient or population: adults (18 years and older) with a diagnosis of psychostimulant misuse Settings: outpatients Intervention: any psychosocial treatment Comparison: no intervention
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)
	Assumed risk	Corresponding risk
	No intervention	Any treatment
Dropout Follow‐up: mean 9 months	382 per 1000	317 per 1000 (290 to 348)	RR 0.83 (0.76 to 0.91)	3393 (24 studies)	⊕⊕⊕⊝ Moderate^a
Continuous abstinence end of treatment Follow‐up: mean 11 months	108 per 1000	232 per 1000 (138 to 389)	RR 2.14 (1.27 to 3.59)	1241 (8 studies)	⊕⊕⊝⊝ Low^b,c
Continuous abstinence longest follow‐up Follow‐up: mean 12 months	311 per 1000	660 per 1000 (240 to 1000)	RR 2.12 (0.77 to 5.86)	224 (4 studies)	⊕⊕⊝⊝ Low^d,e
Longest period of abstinence Follow‐up: mean 8 months	—	The mean longest period of abstinence in the intervention groups was 0.48 standard deviations higher (0.34 to 0.63 higher)	SMD 0.48 (0.34 to 0.63)	1354 (10 studies)	⊕⊕⊕⊕ High
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio; SMD: standardised mean difference.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
^aHigh risk of selection bias in one study, unclear risk in the majority of the others. ^bDowngraded one level due to serious risk of bias (high risk for attrition bias for three studies). ^cDowngraded one level due to serious inconsistency (I2 = 70%, p=0.001. Confidence intervals not overlapping). ^dDowngraded one level due to serious risk of bias (unclear risk of selection bias in all but one study, which is at high risk; high risk of attrition bias in one study; high risk of detection bias in one study). ^eDowngraded one level due to serious imprecision (optimal information size (OIS) not met, wide confidence interval).

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Summary of findings 2. Any psychosocial treatment compared to TAU for psychostimulant misuse

Any psychosocial treatment compared to TAU for psychostimulant misuse
Patient or population: adults (18 years and older) with a diagnosis of psychostimulant misuse Settings: outpatients Intervention: any psychosocial treatment Comparison: TAU
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)
	Assumed risk	Corresponding risk
	TAU	Any treatment
Dropout N of participants not completing treatment Follow‐up: mean 10 months	575 per 1000	414 per 1000 (339 to 512)	RR 0.72 (0.59 to 0.89)	516 (6 studies)	⊕⊕⊕⊝ Moderate^a
Continuous abstinence end of treatment N of participants with continuous abstinence at the end of treatment Follow‐up: mean 12 months	395 per 1000	454 per 1000 (360 to 577)	RR 1.15 (0.91 to 1.46)	264 (3 studies)	⊕⊕⊝⊝ Low^b,c
Continuous abstinence longest follow‐up N of participants with continuous abstinence at longest follow‐up	—	—	Not estimable	0 (0)	—
Longest period of abstinence	The mean longest period of abstinence in the control groups was 22.4 days	The mean longest period of abstinence in the intervention groups was3.15 lower (10.35 lower to 4.05 higher)	—	110 (1 study)	⊕⊕⊝⊝ Low^d,e
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
^aDowngraded one level due to serious risk of bias (unclear risk of selection bias in all the studies, high risk of attrition bias in two studies). ^bDowngraded one level due to serious indirectness (only urban gay and bisexual men included). ^cDowngraded one level due to serious imprecision (optimal information size (OIS) not met). ^dDowngraded one level due to serious risk of bias (unclear risk of selection bias; high risk of attrition bias). ^eDowngraded one level due to serious imprecision (only one study with 110 participants).

Background

Description of the condition

Cocaine and amphetamine‐type stimulant use

Globally, cocaine and amphetamines are the two main recreational psychostimulants. The latest estimates from the United Nations Office on Drugs and Crime indicate that in 2013, approximately 17 million people used cocaine at least once in the previous year, equivalent to 0.35% of the global population aged 15 to 64, and there were 34 million amphetamine users worldwide, equivalent to 0.7% of the global population (UNODC 2015). Between 2008 and 2010, about 1.3% of adults worldwide reported use of amphetamine‐type stimulants, involving compounds that range from amphetamine to an array of amphetamine analogues, excluding MDMA (ecstasy). This means that more individuals are estimated to use amphetamine‐type stimulants than heroin or cocaine. In terms of prevalence, amphetamines were the second most commonly used illicit drug type worldwide, second only to cannabis (UNODC 2015).

For many countries, the problem of amphetamine‐type stimulants is relatively new but growing quickly. In others, where amphetamines have been an important component of the drug consumption picture for longer, recent data on increasing methamphetamine availability suggest that this substance is now displacing amphetamines in some markets. All in all, the number of new psychoactive substances and amphetamine‐type stimulants on the global market more than doubled from 2009 to 2013 (UNODC 2015).

These drugs are known as substituted amphetamines, and they are characterised by enhanced hallucinogenic properties (Greene 2008). Their use is emerging as a truly global phenomenon (UNODC 2015). Today, methamphetamine, amphetamines and ecstasy are now the main forms of amphetamine‐type stimulants available worldwide and the most widely consumed synthetic stimulants (UNODC 2015).

The most widespread recreational use of psychostimulants continues to be in North America (annual prevalence rates: cocaine 1.7%, amphetamines 1.4%, ecstasy 0.9%), South America (cocaine 1.2%, amphetamines 0.5, ecstasy 0.4%), and Western and Central Europe (cocaine 1%, amphetamines 0.5%, ecstasy 0.5%). The market in recent years has expanded in in Australia and New Zealand, where it has reached annual prevalence rates of 1.6% for cocaine, 2.1% for amphetamines and 2.5% for ecstasy (UNODC 2015).

Cocaine and amphetamine‐type stimulant dependence

Over the last 20 years, cocaine, amphetamines and ecstasy have attracted new categories of users seeking their stimulating effects. There is considerable diversity among cocaine users; they include occasional cocaine users, socially integrated regular users and more marginalised and often dependent users, who inject cocaine or use crack cocaine. Some studies have reported that amphetamine and cocaine users who smoke or inject have a higher risk of dependence than those who use intranasally (McKetin 2006; Volkow 2004).

Cocaine and amphetamine‐type stimulant abuse and dependence continue to represent a significant public health problem and are a treatment priority because of the highly addictive properties of these agents. Abuse and dependence may cause serious somatic and psychiatric damage (Gawin 1988), as well as a variety of neuropsychological complications, and it has a chronic, relapsing and progressive course (Dackis 2001). Psychostimulant disorders are reported to be the most common illicit drug use disorders after disorders related to opioids (Degenhardt 2013; Degenhardt 2014).

In 2010, there were an estimated 24.1 million psychostimulant‐dependent people: 6.9 million for cocaine and 17.2 million for amphetamines, equating to a point prevalence of 0.10% (0.09% to 0.11%) for cocaine, and 0.25% (0.22% to 0.28%) for amphetamines (Degenhardt 2014). Some 9.3 million individuals with amphetamine dependence were living in Asia and Oceania (57.8% of all cases), with the highest prevalence estimates for Southeast Asia and Australasia. The highest prevalence of cocaine dependence was in high‐income North America and Latin America (Degenhardt 2013). Consequently, treatment demand for cocaine use is mainly associated with the Americas, while demand for treatment relating to the use of amphetamine‐type stimulants is most common in Asia (UNODC 2015).

Both cocaine and amphetamine dependence have been associated with negative social, physical and psychological outcomes (Degenhardt 2012). These include psychotic symptoms; cardiovascular disease; the blood‐borne viral infections HIV, hepatitis C (HCV) and hepatitis B (HBV); and sexually transmitted infections (Conner 2008; Cornish 1996; Cregler 1989; Darke 2004; Degenhardt 2005; Degenhardt 2012; Falck 2003; Haasen 2005; Kaye 2004; Marzuk 1992; Mathers 2008; Mooney 2006; Ribeiro 2006; Roy 2001). Several studies show a close link between illicit drug use, including crack cocaine and amphetamines, and crime, sexual abuse and interpersonal violence (Atkinson 2014).

Description of the intervention

At the present time, there is no widely accepted treatment for psychostimulant disorders. No evidence for efficacy has been found for pharmacological treatments (Castells 2010; Knapp 2007; Minozzi 2015; Pani 2010). This may suggest that either no particular drug is effective or illness behaviour is present. Psychosocial treatments may be a suitable alternative approach.

We included in this systematic review only textbook‐recognised, standardised psychosocial interventions (De Leon 1995; NICE 2007).

The interventions that we considered for inclusion were: cognitive behavioural therapy, contingency management, motivational interviewing, interpersonal therapy, psychodynamic therapies and 12‐step facilitation. We did not consider clinical management, case management or drug counselling.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is a structured psychotherapy focused on resolving current problems and adjusting dysfunctional cognitive and behavioural patterns (Beck 2011). We describe the various forms of CBT considered in this review below.

Cognitive therapy

Cognitive therapy is based on the assertion that drug misuse is related to an individual's dysfunctional beliefs and associated cognitive processes. Cognitive therapy for drug misuse consists of different elements alongside the use of cognitive and behavioural techniques, such as collaboration, case conceptualisation, structure and socialisation to the cognitive model. Among the cognitive techniques used are advantages‐disadvantages analysis, activity monitoring and scheduling, Socratic questioning, monitoring of drug‐related beliefs, and role‐playing (Beck 2011).

Coping skills training/relapse prevention

Coping skills training and relapse prevention interventions are focused on reducing the possibility of relapse by strengthening the individual's ability to cope with high‐risk situations. These interventions are specifically designed to identify and reduce subjective craving for the substance. The aim is to help patients in dealing with high‐risk situations for psychostimulant misuse and developing strategies to cope and control the urge. In this approach, patients are encouraged to reduce substance use, to explore the consequences of misuse, to recognise high‐risk situations for relapse, to develop strategies to deal with craving, to be prepared for emergencies and to identify alternative activities to misuse (Carroll 2005).

Community reinforcement approach

Community reinforcement approach is a multicomponent approach that considers that environmental events influence habitual substance misuse. It is focused on providing skills training, improving relations, offering employment and vocational counselling, and cultivating new activities and social networks (Bickel 1997). In various randomised controlled trials (RCTs) the community reinforcement approach has been associated with contingency management. In a meta‐analysis, this approach has been demonstrated to be more efficacious than usual care in the treatment of cocaine misuse, either when associated with incentives or not (Roozen 2004).

Contingency management

Contingency management provides a system of incentives built to make abstinence more attractive than continual drug use (Hall 1977). Since its inception, contingency management has been widely studied for substance misuse (NICE 2007), and it now comprises different methods to provide reinforcement, which usually happens when providing negative urine analysis for the tested drug. The reinforcement can be monetary‐based, voucher‐based, prize‐based or even based on clinic privileges (Rawson 2002; Shoptaw 2006).

Motivational interviewing

Motivational interviewing is a psychosocial intervention that aims to evoke and strengthen personal motivation for change. It was first developed for people with alcohol misuse then applied to drug abuse services (Miller 1992; Miller 2003). A meta‐analysis has shown motivational interviewing to have a small to moderate effect for many target problems (Hettema 2005).

Interpersonal therapy

Interpersonal therapy is a supportive, time‐limited psychotherapy, originally developed for the treatment of depression. It is based on the assumption that psychiatric disorders are due to defective interpersonal relationships, which may be related to the genesis and protraction of the disorders (Van Schaik 2006).

Psychodynamic therapy

Psychodynamic therapies view substance misuse in a broad context considering the individual's interpersonal and intrapsychic functioning. The unconscious, core conflictual relationship themes and defences make it difficult to stop drug misuse. Psychodynamic psychotherapists apply supportive, expressive and interpretative techniques to patients' relationships features, which mostly interfere with the accomplishment of a patients' goals (Shedler 2010).

12‐step facilitation

Twelve‐step facilitation consists of a structured and brief intervention to facilitate early recovery from alcohol and drug misuse (Chappel 1999). It is based on cognitive, behavioural and spiritual principles. The path is designed in 12 steps, which are the core of the intervention, based on groups such as Narcotics Anonymous (NA) (Ferri 2006).

How the intervention might work

Recent studies with functional magnetic resonance imaging highlight how psychosocial treatments can influence the reward system by inhibiting the activation in brain regions that respond to satiety (Feldstein 2011). Indeed, cocaine‐dependent patients present with a poor cognitive control, cue‐reactivity and craving that leads them through appetitive motivational states toward psychostimulant‐seeking behaviours (Worhunsky 2013). Psychosocial interventions act on all of these domains by acting on memory and learning. Memory and learning bring neuroadaptive changes and neural plasticity (Koob 2010). Neural plasticity entails changes in the brain structure and circuitry, which may occur as a result of experience or learning. Indeed, neural plasticity is present at multiple levels and facilitates cognitive control (Bryck 2012). This circle, starting from an at‐risk condition of poor cognitive control, and arriving at neuroadaptive changes and neural plasticity (Koob 2010), shows us how psychotherapies can change the brain structure and reminds us that mind and brain are intimately correlated. Under this assumption, psychosocial interventions may alleviate psychostimulant use disorders, reducing cravings and the risk of relapse.

Why it is important to do this review

The Cochrane Drugs and Alcohol Group has performed various reviews on psychosocial treatments for different addictions (e.g. Amato 2011a; Amato 2011b; Klimas 2014; Smedslund 2011). Most of these reviews found only preliminary evidence due to the scarcity of high quality studies. However, in recent years research on psychosocial treatments for psychostimulant disorders has rapidly developed, in part due to the relatively inefficacy of drug treatments. High dropout rates suggest that specific approaches to compliance are important and that some types of psychosocial interventions may be promising treatments, helping patients to have realistic beliefs and to set short‐term objectives. This may keep patients in treatment and abstinent, and may also help to prevent relapses (Carroll 2005).

Objectives

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

Methods

Criteria for considering studies for this review

Types of studies

Randomised controlled trials (RCTs).

Types of participants

Adults (18 years and older) with a diagnosis of psychostimulant misuse (dependence or problematic use) according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) III, IV or V or the ninth or tenth International Classification of Diseases (ICD‐9 or ICD‐10) criteria, irrespective of pattern of use, sex, age or nationality. We considered psychostimulants to be any substance that activates, enhances or increases neural activity (WHO 2006). We included trials in participants with additional diagnoses of abuse/dependence on other substances, such as alcohol or cannabis, and people with comorbid psychiatric disorders. We also included trials in participants with opiate dependence or in methadone maintenance schemes. We excluded studies aiming to prevent relapse in participants who were already detoxified.

Types of interventions

Experimental intervention

We considered any of the following psychosocial treatments.

Cognitive behavioural approach, including: cognitive therapy, community reinforcement approach, coping skills training (CST), relapse prevention.
Contingency management approach.
Motivational interviewing approach (motivational interviewing, motivational enhancement).
Interpersonal therapy approach.
Psychodynamic therapy and supportive expressive therapy.
12‐step approach.

We included studies if they considered the above treatments alone or in combination with other types of treatment.

We did not include other eclectic approaches. We only included structured and standardised interventions.

Case management and counselling are usually provided in standard care (treatment as usual), so we did not consider them among the experimental interventions.

We excluded studies that compared the same type of intervention as a different modality or at a different intensity (e.g. intensive versus standard, group versus individual, long versus short).

Control intervention

No treatment
Treatment as usual (including counselling, case management, clinical management, pharmacotherapy or other active intervention also provided to the experimental group)
Other psychosocial treatment
Pharmacological treatment

Types of comparisons foreseen

Any psychosocial approach versus no treatment (including studies where any psychosocial intervention was given in addition to any other treatment , included treatment as usual, which was received by both groups)
Any psychosocial approach versus treatment as usual
Any psychosocial approach versus an alternative psychosocial approach

Types of outcome measures

Primary outcomes

Dropouts from treatment: number of participants who did not complete the study protocol
Use of primary substance of abuse, measured as:
- Point abstinence (number of participants abstinent at the end of treatment, self reported);
- Point abstinence (number of participants with negative urine samples at the end of treatment);
- Continuous abstinence (number of participants with continuous abstinence during treatment, self reported);
- Continuous abstinence (number of participants with negative urine during treatment);
- Frequency of drug intake;
- Longest period of abstinence.

Secondary outcomes

Craving, as measured by validated scales (e.g. Brief Substance Craving Scale (BSCS), visual analogue scale (VAS)).
Adverse events.
Severity of dependence, as measured by validated scales (e.g. Addiction Severity Index (ASI), Clinical Global Impression scale (CGI‐S), Clinical Global Impression ‐ Observer Scale (CGI‐O)).
Depression, as measured by validated scales (Hamilton Depression Rating Scale, Beck Depression Inventory).

We assessed the above outcomes at the end of the intervention and at the longest available follow‐up.

Search methods for identification of studies

Electronic searches

We searched the following electronic databases.

Cochrane Drugs and Alcohol Group (CDAG) Specialised Register (inception to November 2015), using the search strategy outlined in Appendix 1.
Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 11), using the search strategy outlined in Appendix 2.
MEDLINE (via PubMed) (January 1966 to November 2015), using the search strategy outlined in Appendix 3.
EMBASE (Elsevier, EMBASE.com) (January 1974 to November 2015), using the search strategy outlined in Appendix 4.
CINAHL (EBSCO HOST) (1982 to November 2015), using the search strategy outlined in Appendix 5.
Web of Science (Thomson Reuters) (January 2006 to November 2015), using the search strategy outlined in Appendix 6.
PsycINFO (EBSCOhost) (1800 to June 2015), using the search strategy outlined in Appendix 7.

We searched the databases using medical subject headings (MeSH) and text words relating to psychological interventions and psychostimulant abuse/dependence. We combined the PubMed search with the Cochrane Highly Sensitive Search Strategy for identifying RCTs in MEDLINE: sensitivity‐maximising version (2008 revision; Lefebvre 2011). We revised this strategy appropriately for each database to take account of differences in controlled vocabulary and syntax rules.

We searched for ongoing clinical trials and unpublished trials via Internet searches on the following websites.

ClinicalTrials.gov (www.clinicaltrials.gov) (8 March 2016);
World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (apps.who.int/trialsearch/) (8 March 2016).

Searching other resources

We also used the following sources.

References of the articles obtained by any means.
Conference proceedings likely to contain trials relevant to the review. These included proceedings from the Society for the Study of Addiction, International Harm Reduction Association and the American Association for the Treatment of Opioid Dependence.
Contact with investigators and relevant trial authors, seeking information about unpublished or incomplete trials.

All searches included non‐English language literature, and we assessed studies with non‐English abstracts for inclusion. When we considered that the studies likely met the inclusion criteria, we had them translated.

Data collection and analysis

Selection of studies

Three authors (FDC, SM, RS) independently screened the abstracts of all publications obtained by the search strategy. Three authors (FDC, SM, RS) independently assessed the full text of potentially relevant studies for inclusion. We resolved any disagreement by discussion between all the authors.

Data extraction and management

Two authors (RS, FDC) extracted data. SM checked all the data extraction forms. We resolved any doubts by discussion between all the authors. We extracted the following information: number and characteristics of participants, setting, type of experimental and control intervention, length of follow‐up, types of outcomes, country of origin, funding and conflicts of interest.

Assessment of risk of bias in included studies

Three authors (SM, RS, FDC) independently assessed the risk of bias of the included studies. We used the criteria recommended by the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). The recommended approach for assessing risk of bias in studies included in Cochrane Reviews is a two‐part tool, addressing the following specific domains: sequence generation and allocation concealment (selection bias), blinding of participants and personnel (performance bias), blinding of outcome assessors (detection bias), incomplete outcome data (attrition bias), and selective outcome reporting (reporting bias). The first part of the tool involves describing what was reported to have happened in the study, and the second elicits a judgement of low, high or unclear risk of bias for that entry. To make these judgements we used the criteria indicated by the Cochrane Handbook for Systematic Reviews of Interventions, adapted to the addiction field. See Appendix 8 for details.

We addressed the domains of sequence generation and allocation concealment (avoidance of selection bias) by a single entry for each study.

We considered blinding of participants, personnel and outcome assessor (avoidance of performance bias and detection bias) separately for objective outcomes (e.g. dropout, use of substance of abuse measured by urine analysis, participants relapsed at the end of follow‐up) and subjective outcomes (e.g. duration and severity of signs and symptoms of withdrawal, participant reported use of substance, adverse events, craving, psychiatric symptoms).

We considered incomplete outcome data (avoidance of attrition bias) for all outcomes except for dropout from the treatment, which is very often the primary outcome measure in trials on addiction.

Measures of treatment effect

We analysed dichotomous outcomes by calculating the risk ratio (RR) for each trial with the uncertainty in each result being expressed with 95% confidence interval (CI). We analysed continuous outcomes by calculating the mean difference (MD) with 95% CI when the studies used the same instrument for assessing the outcome. We used the standardised mean difference (SMD) when the studies used different instruments. We did not use data presented as the number of positive urine tests over the total number of tests in the experimental and control group as a measure of substance use. We made this decision because using the number of tests instead of the number of participants as the unit of the analysis violates the hypothesis of independence among observations. In fact, the results of test done for each participant are not independent.

Unit of analysis issues

For multiarm studies included in the meta‐analyses, when one arm was considered more than once in same comparisons (e.g. two different experimental treatments compared with the same control group) we combined all the relevant experimental groups into a single group and compared it with the control to avoid double‐counting participants in the control groups.

Assessment of heterogeneity

We analysed heterogeneity by means of the I² statistic and the Chi² test. The cut‐off points to establish heterogeneity were I² values of more than 50% and a P value for the Chi² test of less than 0.1.

Assessment of reporting biases

We visually inspected funnel plots (plots of the effect estimate from each study against the sample size or effect standard error) to indicate possible publication bias. We acknowledge the funnel plot should be seen as a generic means of displaying small‐study effects ‒ a tendency for the intervention effects estimated in smaller studies to differ from those estimated in larger studies, so that asymmetry could be due to publication bias, but small‐study effects may be due to reasons other than publication bias, such as greater risk of bias in smaller studies, inclusion of a more restricted and thus responsive population, or merely due to the role of chance. We inspected funnel plot symmetry when there were at least 10 studies included in the meta‐analysis.

Data synthesis

We combined the outcomes from the individual trials through meta‐analysis where possible (comparability of intervention and outcomes between trials) using a random‐effects model because we expected a certain degree of heterogeneity among trials.

Subgroup analysis and investigation of heterogeneity

We performed subgroup analyses for studies including more than 30% of participants with opiate dependence or in methadone treatment.

If the included studies treatments differed substantially in their definition of treatment as usual (TAU), we planned to divide studies in two groups: studies with low complexity TAU (counselling, case management, clinical management) and studies with high complexity TAU (cognitive behavioural therapy, contingency management, interpersonal therapy, psychodynamic therapy, 12‐step facilitation), and to perform subgroup analyses to assess the effect of adding on another psychosocial intervention to low‐complexity TAU or high‐complexity TAU. We did not do this because we didn't find high/low complexity differences in the included studies.

Sensitivity analysis

To incorporate our assessment of risk of bias in the review process, we first plotted the intervention effects estimates, stratified by risk of bias for allocation concealment (selection bias), blinding of outcome assessors (detection bias) and attrition bias. If there were differences in the results between studies with different risks of bias, we performed sensitivity analyses by excluding studies with a high risk of bias from the analysis. We found no significant differences for the primary outcomes; excluding studies at high risk of bias for the three domains did not change results.

Summary of findings table

We assessed the overall quality of the evidence for the primary outcome using the GRADE system. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) Working Group developed a system for grading the quality of evidence (GRADE 2004; Guyatt 2008; Guyatt 2011; Schünemann 2006), which takes into account issues not only related to internal validity but also to external validity, such as directness of results. The 'Summary of findings' tables presents the main findings of a review in a transparent and simple tabular format. In particular, they provide key information concerning the quality of evidence, the magnitude of effect of the interventions examined and the sum of available data on the main outcomes.

The GRADE system uses the following criteria for assigning grades of evidence.

High: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate: We are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low: Our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.
Very low: We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.

Grading is decreased for the following reasons.

Serious (−1) or very serious (−2) study limitation for risk of bias.
Serious (−1) or very serious (−2) inconsistency between study results.
Some (−1) or major (−2) uncertainty about directness (the correspondence between the population, the intervention, or the outcomes measured in the studies actually found and those under consideration in our systematic review).
Serious (−1) or very serious (−2) Imprecision of the pooled estimate.
Strong suspicion of publication bias (−1).

Results

Description of studies

Results of the search

We identified 6490 records through database searching and 9 from other sources. After removing duplicates, we were left with 3711 unique references for analysis; we excluded 3566 on the basis of title and abstract. We retrieved 145 articles in full text for more detailed evaluation, 69 of which we excluded for not meeting the inclusion criteria.

We included 52 studies (76 records) that satisfied all criteria required for inclusion in the review. We could include 47 studies in quantitative synthesis (meta‐analyses). We took data for one unpublished study from ClinicalTrials.gov. See Figure 1.

Figure 1

Study flow diagram.

For substantive descriptions of studies, see the Characteristics of included studies and Characteristics of excluded studies tables.

Included studies

We included 52 randomised controlled trials (RCTs), involving a total of 6923 participants (see Characteristics of included studies). The mean study size was 132 participants, ranging from 19 in Crits‐Christoph 1999 to 487 in Petry 2013. Twenty studies recruited fewer than 100 participants. The mean age of participants was 36.7 years, and there were more men (63%) than women. Forty‐one studies took place in the United States, four in Spain, three in Australia, two in Switzerland and two in the UK.

Most trials enrolled outpatients with a diagnosis of cocaine or amphetamine dependence based on DSM‐III, DSM‐ IV, DSM‐TR‐IV or ICD‐10 criteria, and most included patients with comorbid alcohol dependence. In 15 studies, all of the patients had comorbid opioid dependence and were in opioid maintenance therapy (Carroll 2012; Carroll 2014; Dursteler‐MacFarland 2013; Festinger 2014; Ghitza 2007; Knealing 2006; Mitcheson 2007; Peirce 2006; Petry 2005b; Petry 2007; Petry 2012a; Poling 2006; Rawson 2002; Silverman 1996; Silverman 1998). In four studies, the proportion of participants with comorbid opioid dependence and methadone maintenance ranged from 33% to 60% (Baker 2001, Ledgerwood 2006, Petitjean 2014, Petry 2013).

The mean duration of the interventions was four months (range one to nine months); two interventions lasted only one session. The mean duration of follow‐up was 9 months (range 2 to 36 months).

Types of interventions

The included studies considered the psychosocial interventions of cognitive behavioural therapy (CBT), contingency management (CM), motivational interviewing (MI), interpersonal therapy, psychodynamic therapy and 12‐step facilitation.

CBT: Eight studies compared CBT versus no intervention (Baker 2001; Baker 2005; Carroll 2014; Crits‐Christoph 1999; Higgins 2003; Milby 2008; Rawson 2002; Shoptaw 2005), six versus treatment as usual (TAU) (Carroll 1994; Dursteler‐MacFarland 2013; Higgins 1993; Rawson 2002; Sanchez‐Hervas 2010; Shoptaw 2008), three versus 12‐step facilitation (Carroll 1998; Maude‐Griffin 1998; Schottenfeld 2011), three versus interpersonal therapy (Carroll 1991; Carroll 2004; Crits‐Christoph 1999), two versus CM (Rawson 2002; Shoptaw 2005), one versus individual counselling (Crits‐Christoph 1999), and one versus acceptance and commitment therapy (Smout 2010).
CM: Twenty studies compared CM versus no intervention (Festinger 2014; Garcia‐Fernandez 2011; Hagedorn 2013; Higgins 1994; Higgins 2000; Kirby 1998a; McDonell 2013; Menza 2010; Peirce 2006; Petitjean 2014; Petry 2005a; Petry 2005b; Petry 2007; Petry 2013; Petry 2012a; Petry 2012b; Rawson 2002; Roll 2013; Secades Villa 2013; Shoptaw 2005), two versus TAU (Rawson 2002, Garcia‐Rodriguez 2007), six versus non‐contingent reinforcements (McDonell 2013; NCT01140880; Poling 2006; Schottenfeld 2011; Silverman 1996; Silverman 1998), and two versus CBT (Rawson 2002; Shoptaw 2005).
MI: Five studies compared MI versus no intervention (Ingersoll 2011; Marsden 2006; McKee 2007; Mitcheson 2007; Stein 2009).
Interpersonal therapy: One study compared interpersonal therapy versus individual counselling (Crits‐Christoph 1999), and three compared it to CBT (Carroll 1991; Carroll 2004; Crits‐Christoph 1999)
Psychodynamic therapy: One study compared psychodynamic therapy versus no intervention (Crits‐Christoph 1999).
12‐step facilitation: One study compared 12‐step facilitation versus no intervention (Carroll 2012), and three compared it with CBT (Carroll 1998; Maude‐Griffin 1998; Schottenfeld 2011).

Five included studies did not provide useful data for inclusion in the quantitative analyses (Carroll 2004, Ghitza 2007, Landovitz 2015, Ledgerwood 2006; NCT01140880).

Eight studies added pharmacological interventions to the psychosocial ones: disulphiram (Carroll 1998; Carroll 2004; Carroll 2012; Higgins 1993; Higgins 1994), bupropion (Poling 2006), desipramine hydrochloride (Carroll 1994) and methylphenidate (Dursteler‐MacFarland 2013).

Types of comparison

We grouped the studies into three main comparisons.

Any psychosocial intervention versus no intervention (32 studies included), including studies where the psychosocial interventions were given in addition to TAU or another intervention which was received by both groups.
Any psychosocial intervention versus TAU (6 studies included).
Any psychosocial intervention versus an alternative psychosocial intervention (13 studies included).

Within the first two comparisons, we performed some subgroup analysis for each type of psychosocial intervention.

Excluded studies

We excluded 69 studies for various reasons: 22 because participants did not meet inclusion criteria; 22 because the trials did not examine the outcomes of interest; 15 because the interventions did not meet inclusion criteria; 7 because trials compared the same intervention delivered at different intensities, frequencies and modalities; 1 because of an ineligible study design; and 1 because it was impossible to extract useful data: authors provided no information about the number of participants allocated and results concerning each group.

Risk of bias in included studies

See Figure 2; Figure 3. For a detailed description of the reasons supporting our judgment, see the 'Risk of bias' tables in the Characteristics of included studies.

Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Allocation

Random sequence generation

We judged 31 studies to be at low risk of bias; authors did not report any information about methods of sequence random generation for the other studies.

Allocation concealment

We judged 10 studies to be at low risk of bias and 3 studies to be at high risk of bias; the other studies did not report methods of allocation concealment.

Blinding

Performance bias

We judged all subjective outcomes to be at high risk of bias because blinding of participants and personnel was impossible for the types of intervention studied.

We judged all objective outcomes to be at low risk because we considered that the outcome was not likely to be influenced by lack of blinding.

Detection bias

For subjective outcomes, we considered 15 studies to be at low risk of bias and 2 studies to be at high risk of bias. The other studies did not report enough information to make a judgement.

We judged all objective outcomes to be at low risk because we considered that the outcome was not likely to be influenced by lack of blinding.

Incomplete outcome data

We deemed 32 studies to be at low risk of bias and 15 studies to be at high risk of bias. For the other studies authors did not report information about number and reasons of dropouts or missing data for each group.

Selective reporting

We judged 43 trials to be at low risk of bias and 6 studies to be at high risk of bias. Authors of the other studies reported insufficient information to judge the risk of bias.

Effects of interventions

See: Summary of findings for the main comparison Any psychosocial treatment compared to no intervention for psychostimulant misuse; Summary of findings 2 Any psychosocial treatment compared to TAU for psychostimulant misuse

Comparison 1. Any psychosocial intervention versus no treatment

See summary of findings Table for the main comparison.

Dropouts: Psychosocial Interventions reduced the risk of withdrawal at around nine months based on data from 24 studies in 3393 participants (RR 0.83, 95% CI 0.76 to 0.91, moderate quality evidence; see Analysis 1.1). The intervention effect in the subgroup of studies including at least 30% of participants in methadone maintenance therapy was uncertain (RR 0.98, 95% CI 0.79 to 1.20, 8 studies, 907 participants; Baker 2001; Carroll 2012; Carroll 2014; Mitcheson 2007; Peirce 2006; Petitjean 2014; Petry 2005b; Petry 2007). Subgroup analysis by type of intervention provided evidence of a difference for CM versus no intervention.

CBT versus no intervention: 5 studies, 721 participants, RR 0.83 (95% CI 0.63 to 1.09); no significant difference.
CM versus no intervention: 13 studies, 1740 participants, RR 0.80 (95% CI 0.71 to 0.89); results in favour of CM.
MI versus no intervention: 5 studies, 696 participants, RR 0.91 (95% CI 0.65 to 1.27); no significant difference.
12‐step versus no intervention: 1 study, 112 participants, RR 1.58 (95% CI 0.85 to 2.94); no significant difference.
Psychodynamic versus no intervention: 1 study, 247 participants, RR 0.87 (95% CI 0.74 to 1.01); no significant difference.

For the above single comparisons; see Analysis 2.1.

Point abstinence, end of treatment: The effects of psychosocial interventions were similar to control based on data from six studies in 1031 participants (RR 1.04, 95% CI 0.92 to 1.18; see Analysis 1.2). The effects of the intervention were uncertain in the subgroup of studies that included at least 30% of participants in methadone maintenance therapy (RR 0.88, 95% CI 0.58 to 1.34, 2 studies, 108 participants; Carroll 2012; Rawson 2002). Subgroup analysis by type of intervention did not provide evidence of a difference between the effects of the subgroups analysed.

CBT versus no intervention: 3 studies, 501 participants, RR 0.97 (95% CI 0.80 to 1.18), no significant difference.
CM versus no intervention: 3 studies, 212 participants, RR 1.09 (95% CI 0.79 to 1.51), no significant difference.
12‐step versus no intervention: 1 study, 112 participants, RR 0.84 (95% CI 0.48 to 1.46), no significant difference.
Psychodynamic versus no intervention: 1 study, 247 participants, RR 1.04 (95% CI 0.81 to 1.34), no significant difference.
Individual counselling versus no intervention: 1 study, 244 participants, RR 1.26 (95% CI 1.00 to 1.59), results in favour of individual counselling.

For the above single comparisons, see Analysis 2.2.

Point abstinence, longest follow‐up: The effects of psychosocial interventions on long‐term abstinence were uncertain based on data from seven studies in 1296 participants (RR 1.09, 95% CI 0.81 to 1.46; see Analysis 1.3). The intervention effect in the subgroup of studies including at least 30% of participants in methadone maintenance therapy was uncertain (RR 1.28, 95% CI 0.30 to 5.42, 2 studies, 132 participants; Baker 2001; Rawson 2002). Subgroup analysis by type of intervention indicated that there may have been a difference between the effects of the subgroups analysed, with one of the subgroups showing an effect favouring control.

CBT versus no intervention: 3 studies, 508 participants, RR 1.65 (95% CI 0.85 to 3.24), no significant difference.
CM versus no intervention: 2 studies, 159 participants, RR 0.63 (95% CI 0.49 to 0.83), results in favour of no intervention.
MIversus no intervention: 2 studies, 384 participants, RR 1.16 (95% CI 0.95 to 1.42), no significant difference.
Psychodynamic versus no intervention: 1 studies, 247 participants, RR 0.96 (95% CI 0.76 to 1.22), no significant difference.
Individual counselling versus no intervention: 1 study, 244 participants, RR 1.11 (95% CI 0.89 to 1.38), no significant difference.

For the above single comparisons, see Analysis 2.3.

Continuous abstinence, end of treatment: Psychosocial interventions may increase the likelihood of continuous abstinence based on data from eight studies in 1241 participants (RR 2.14, 95% CI 1.27 to 3.59, low quality of evidence; see Analysis 1.4). The intervention effect in the subgroup of studies that included at least 30% of participants in methadone maintenance therapy was uncertain (RR 2.54, 95% CI 0.82 to 7.85, 4 studies, 625 participants; Carroll 2014; Peirce 2006; Petitjean 2014; Petry 2007). Subgroup analysis by type of intervention indicated that there may have been a difference favouring CBT and CM versus no intervention.

CBT versus no intervention: 1 study, 101 participants, RR 2.17 (95% CI 1.07 to 4.40), results in favour of CBT.
CM versus no intervention: 7 studies, 1140 participants, RR 2.19 (95% CI 1.19 to 4.06), results in favour of CM.

For the above single comparisons, see Analysis 2.4.

Continuous abstinence, longest follow‐up: The effects of psychosocial interventions on continuous abstinence at follow‐up were uncertain based on data from four studies in 324 participants (RR 2.12, 95% CI 0.77 to 5.86, low quality of evidence; see Analysis 1.5). None of the studies included 30% of participants in methadone maintenance treatment. Subgroup analysis by type of intervention found a difference only for CM versus no intervention.

CBT versus no intervention: 1 studies, 85 participants, RR 1.16 (95% CI 0.93 to 1.46), no significant difference.
CM versus no intervention: 2 studies, 110 participants, RR 4.08 (95% CI 1.22 to 13.63), results in favour of CM.
MI versus no intervention: 1 study, 29 participants, RR 2.12 (95% CI 0.25 to 17.98), no significant difference.

For the above single comparisons, see Analysis 2.5.

Frequency of drug intake, longest follow‐up: Psychosocial interventions may decrease the frequency of drug intake at follow‐up based on data from four studies in 669 participants (SMD −0.20, 95% CI −0.35 to −0.05, see Analysis 1.6). The intervention effect in the subgroup of studies including at least 30% of participants in methadone maintenance therapy was uncertain (SMD −0.45, 95% CI −1.20 to 0.30, 1 study, 29 participants; Mitcheson 2007). Subgroup analysis by type of intervention did not provide evidence of a difference between the effects of the subgroups analysed.

CBT versus no intervention: 1 study, 82 participants, SMD −0.19 (95% CI −0.63 to 0.24), no significant difference.
CM versus no intervention: 2 studies, 256 participants, SMD −0.23 (95% CI −0.47 to 0.02), no significant difference.
MI versus no intervention: 2 studies, 371 participants, SMD −0.18 (95% CI −0.38 to 0.03), no significant difference.

For the above single comparisons, see Analysis 2.6.

Longest period of abstinence: Psychosocial interventions may increase abstinence based on data from 10 studies in 1354 participants (SMD 0.48, 95% CI 0.34 to 0.63, moderate quality of evidence; see Analysis 1.7). The increase of abstinence was significant for psychosocial interventions also in the subgroup of studies which included at least 30% of participants in methadone maintenance therapy (SMD 0.59, 95% CI 0.33 to 0.85, 5 studies, 387 participants; Carroll 2014; Petry 2005b; Petry 2012a; Petry 2013; Petitjean 2014). Subgroup analysis by type of intervention indicated that there may have been a difference favouring CBT and CM versus no intervention.

CBT versus no intervention: 3 studies, 389 participants, SMD 0.34 (95% CI 0.14 to 0.54), results in favour of CBT.
CM versus no intervention: 8 studies, 1005 participants, SMD 0.60 (95% CI 0.36 to 0.84), results in favour of CM.

For the above single comparisons, see Analysis 2.7.

Craving: The effects of psychosocial interventions versus no intervention on craving were uncertain, based on data from only one study on CM; see Analysis 1.8. The study did not include at least 30% of participants in methadone maintenance therapy.

CM versus no intervention: 1 study, 192 participants, SMD −0.19 (95% CI −0.48 to 0.10), no significant difference.

For the above single comparison, see Analysis 2.8.

Severity of dependence: The effects of psychosocial interventions on the severity of dependence were uncertain, based on data from six studies in 293 participants (SMD −0.48, 95% CI −1.22 to 2.26; see Analysis 1.9). The intervention effect in the subgroup of studies which included at least 30% of participants in methadone maintenance therapy was uncertain (SMD 0.13, 95% CI −0.32 to 0.58, 1 study, 77 participants; Petry 2005b). Subgroup analysis by type of intervention did not provide evidence of a difference between the effects of the subgroups analysed.

CM versus no intervention: 4 studies, 224 participants, SMD −0.75 (95% CI −1.83 to 0.34), no significant difference.
MI versus no intervention: 2 studies, 69 participants, SMD 0.01 (95% CI −0.71 to 0.73), no significant difference.

For the above single comparisons, see Analysis 2.9.

Depression: The effects of psychosocial interventions on depression were uncertain, based on data from only one small study on CM; see Analysis 1.10. The study did not include at least 30% of participants in methadone maintenance therapy.

CM versus no intervention: 1 study, 37 participants, SMD −4.75 (95% CI −10.45 to 0.95), no significant difference.

For the above single comparison, see Analysis 2.10.

Comparison 2. Any psychosocial intervention versus treatment as usual (TAU)

See summary of findings Table 2.

We did not perform the subgroup analyses on the following comparisons differentiating TAU as low or high complexity due to the paucity of studies and the scarcity of detailed information regarding TAU.

Dropouts: Psychosocial interventions versus TAU may decrease withdrawal, based on data from six studies in 516 participants (RR 0.72, 95% CI 0.59 to 0.89, moderate quality of evidence; see Analysis 3.1). The studies did not include at least 30% of participants in methadone maintenance. Subgroup analysis by type of intervention provided evidence of effect only for CBT.

CBT versus TAU: 5 studies, 420 participants, RR 0.76 (95% CI 0.61 to 0.95), results in favour of CBT.
CM versus no TAU: 1 study, 82 participants, RR 0.74 (95% CI 0.49, 1.13), no significant difference.

For the above single comparisons, see Analysis 4.1.

Point abstinence, end of treatment: Psychosocial interventions versus TAU may increase the abstinence at the end of treatment based on data from two studies in 210 participants (RR 1.98, 95% CI 1.10 to 3.58; see Analysis 3.2). The intervention effect in the subgroup of studies that included at least 30% of participants in methadone maintenance therapy was in favour of psychosocial interventions (RR: 2.21, 95% CI 1.04, 4.70, 1 study, 82 participants; Rawson 2002). Subgroup analysis by type of intervention provided evidence of effect only for CM.

CBT versus TAU: 2 studies, 183 participants, RR 1.72 (95% CI 0.92 to 3.24), no significant difference.
CM versus TAU: 1 study, 54 participants, RR 2.67 (95% CI 1.23 to 5.77), results in favour of CM.

For the above single comparisons, see Analysis 4.2.

Point abstinence, longest follow‐up: Psychosocial interventions versus TAU may increase the abstinence at follow up based on data from two studies in 164 participants (RR 1.89, 95% CI 1.18 to 3.02; see Analysis 3.3). The intervention effect in the subgroup of studies that included at least 30% of participants in methadone maintenance therapy was in favour of psychosocial interventions (RR 2.17, 95% CI 1.10 to 4.29, 1 study, 82 participants; Rawson 2002). Subgroup analysis by type of intervention provided evidence of effect only for CBT.

CBT versus TAU: 2 studies, 137 participants, RR 1.94 (95% CI 1.20 to 3.14), results in favour of CBT.
CM versus TAU: 1 study, 54 participants, RR 2.00 (95% CI 0.96 to 4.17), no significant difference.

For the above single comparisons, see Analysis 4.3.

Continuous abstinence, end of treatment: The effects of psychosocial interventions were similar to TAU based on data from two studies in 224 participants (RR 1.27, 95% CI 0.94 to 1.72, very low quality of evidence; see Analysis 3.4). The studies did not include at least 30% of participants in methadone maintenance therapy. Subgroup analysis by type of intervention did not provide evidence of a difference between the effects of the subgroups analysed.

CBT vs TAU: 1 study, 128 participants, RR 1.18 (95% CI 0.92 to 1.53), no significant difference.

For the above single comparison, see Analysis 4.4.

Longest period of abstinence: The effects of psychosocial interventions were similar to TAU based on data from only one study on CBT; see Analysis 3.5. The study did not include at least 30% of participants in methadone maintenance therapy.

CBT versus TAU: 1 study, 110 participants, SMD −3.15 (95% CI −10.35 to 4.05), no significant difference.

For the above single comparison, see Analysis 4.5.

Severity of dependence: The effects of psychosocial interventions on the severity of dependence were similar to TAU based on data from only one study on CBT; see Analysis 3.6. The study did not include at least 30% of participants in methadone maintenance therapy.

CBT versus TAU:1 study, 110 participants, SMD −0.05 (95% CI −0.14 to 0.04), no significant difference.

For the above single comparison, see Analysis 4.6.

Comparison 3. Single psychosocial intervention versus alternative psychosocial intervention

CM versus non‐contingent reinforcements

Dropouts: CM was similar to non‐contingent reinforcements for withdrawal, based on data from four studies in 464 participants (RR 1.00, 95% CI 0.59 to 1.70; see Analysis 5.1. Subgroup analysis of studies including at least 30% of participants in methadone maintenance therapy show no difference (RR 1.00, 95% CI 0.65 to 1.55, 2 studies, 143 participants; Poling 2006; Silverman 1996).

Point abstinence, longest follow‐up: Non‐contingent reinforcements may perform better than CM to increase abstinence at follow‐up, based on data from one study in 126 participants (RR 0.54, 95% CI 0.42 to 0.70; see Analysis 5.2). The study did not include at least 30% of participants in methadone maintenance therapy.

Continuous abstinence, end of treatment: CM performed better than non‐contingent reinforcements in improving abstinence at the end of treatment based on data from two studies in 96 participants (RR 8.11, 95% CI 1.62 to 40.55; see Analysis 5.3). In this case, both studies included at least 30% of participants in methadone maintenance therapy.

Frequency of drug intake, longest follow‐up: CM did not significantly differ from non‐contingent reinforcements on the frequency of drug intake at follow‐up, based on data from one study in 107 participants (SMD −1.82, 95% CI −4.14 to 0.50; see Analysis 5.4). The study did not include at least 30% of participants in methadone maintenance therapy.

CM versus interpersonal therapy

The effects of CM were not significantly different from interpersonal therapy regarding all the outcomes considered.

Dropouts: 2 studies, 285 participants, RR 0.80 (95% CI 0.45 to 1.43); see Analysis 6.1.

Point abstinence, end of treatment: 2 studies, 285 participants, RR 1.12 (95% CI 0.59 to 2.15); see Analysis 6.2.

Continuous abstinence, end of treatment: 1 study, 42 participants, RR 2.25 (95% CI 0.82 to 6.18); see Analysis 6.3.

Point abstinence, longest follow‐up: 1 study, 243 participants, RR 1.04 (95% CI 0.82 to 1.32); see Analysis 6.4.

The studies included in this comparison did not include at least 30% of patients in methadone maintenance therapy.

CBT versus 12‐step facilitation

Dropouts: CBT was not significantly different from 12‐step faciliation based on data from one study in 145 participants (RR 0.87, 95% CI 0.62 to 1.24; see Analysis 7.1).

Continuous abstinence, end of treatment: CBT versus 12‐step facilitation had similar effects on abstinence at the end of treatment based on data from two studies in 225 participants (RR: 1.22, 95% CI 0.88 to 1.69; see Analysis 7.2).

Continuous abstinence, longest follow‐up: CBT versus 12‐step facilitation increased abstinence at follow‐up based on data from one study in 51 participants (RR 1.97, 95% CI 1.00 to 3.86; see Analysis 7.3). The studies included in this comparison did not include at least 30% of participants in methadone maintenance therapy.

CBT versus CM

The effects of CBT were not significantly different from CM regarding all the outcomes considered.

Point abstinence, end of treatment: 1 study, 55 participants, RR 0.66 (95% CI 0.38 to 1.16); see Analysis 8.1.

Point abstinence, longest follow‐up: 1 study, 55 participants, RR 1.17 (95% CI 0.73 to 1.87); see Analysis 8.2.

Frequency of drug intake, longest follow‐up: 1 study, 82 participants, MD −0.50 days per month (95% CI −2.82 to 1.82); see Analysis 8.3.

The study included in this comparison included at least 30% of participants in methadone maintenance therapy.

CBT versus individual counselling

Dropouts: The effects of CBT were similar to the individual counselling on withdrawal, based on data from one study in 240 participants (RR 0.86, 95% CI 0.74 to 1.01; see Analysis 9.1).

Point abstinence, end of treatment: Patients randomised to individual counselling were more likely to be abstinent at the end of treatment than patients randomised to CBT in one study with 240 participants (RR 0.70, 95% CI 0.54 to 0.90; see Analysis 9.2).

Point abstinence, longest follow‐up: Patients randomised to individual counselling were no more likely to be abstinent at follow‐up than patients randomised to CBT in one study with 240 participants (RR 0.90, 95% CI 0.72 to 1.13; see Analysis 9.3). The study included in this comparison did not include at least 30% of participants in methadone maintenance therapy.

Interpersonal therapy versus individual counselling

The effects of Interpersonal therapy were not significantly different from individual counselling regarding all the outcomes considered.

Dropouts: 1 study, 245 participants, RR 0.87 (95% CI 0.74 to 1.02); see Analysis 10.1.

Point abstinence, end of treatment: 1 study, 245 participants, RR 0.83 (95% CI 0.66 to 1.04); see Analysis 10.2.

Point abstinence, longest follow‐up: 1 study, 245 participants, RR 0.87 (95% CI 0.69 to 1.09); see Analysis 10.3.

The study included in this comparison did not include at least 30% of participants in methadone maintenance therapy.

CBT versus ACT

The effects of CBT were not significantly different from ACT regarding all the outcomes considered.

Dropouts: 1 study, 104 participants, RR 0.94 (95% CI 0.73 to 1.2); see Analysis 11.1.

Point abstinence, end of treatment: 1 study, 26 participants, RR 1.29 (95% CI 0.47 to 3.51); see Analysis 11.2.

Point abstinence, longest follow‐up: 1 study, 19 participants, RR 0.73 (95% CI 0.26 to 2.07); see Analysis 11.3.

The study included in this comparison did not include at least 30% of participants in methadone maintenance therapy.

Discussion

Summary of main results

We included 52 trials with 6923 participants. In the meta‐analysis, 32 studies compared a psychosocial intervention versus no intervention, 6 studies compared a psychosocial intervention versus treatment as usual, and 13 studies compared one psychosocial intervention versus another.

The psychosocial interventions considered in the studies were: contingency management (27 studies), cognitive behavioural therapy (19 studies), motivational interviewing (5 studies), twelve‐step facilitation (4 studies), interpersonal therapy (3 studies) and psychodynamic therapy (1 study).

When compared to no intervention, we found moderate quality evidence that any psychosocial treatment reduced dropout rate, high quality evidence that the interventions increased the longest period of abstinence, low quality evidence that they increased continuous abstinence at the end of treatment, and low quality evidence that these results were not maintained at the longest follow‐up. Results in the subgroup analysis of participants in the methadone maintenance treatment were no longer significant. However, we didn't find significant differences between groups for point abstinence at the end of treatment or at longest follow‐up, craving, depression or severity of dependence. Frequency of drug intake was less in the group receiving psychosocial treatments. It should be noted that the vast majority of the studies in this comparison assessed the efficacy of a specific psychosocial treatment added to treatment as usual or to another specific psychosocial or pharmacological treatment 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 as an 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 as an add‐on, and this could have led to an underestimation of the true effect of a psychosocial intervention. This is not true for motivational interviewing, which was almost always compared with informative handouts only.

The most studied psychosocial approach to be given as an add‐on seems to be 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, we found moderate quality evidence that any psychosocial treatment reduced dropout rate, but low quality evidence that it did not increase continuous abstinence at the end of treatment or the longest period of abstinence. No studies in this comparison assessed the outcome of continuous abstinence at longest follow‐up. Point abstinence was greater in the group receiving psychosocial intervention both at the end of treatment and at longest follow up, but results came only from two studies with about 200 participants. We found no differences for the longest period of abstinence and severity of dependence.

There were only a few small, heterogenous studies comparing two psychosocial interventions, so the results were not informative.

Overall completeness and applicability of evidence

The majority of the studies took place in the United States, and this could limit the generalisability of the results if the location of the studies acts as an effect modifier in the estimation of treatment efficacy and the effects of psychosocial treatments are strongly influenced by the social context and ethnicity.

Moreover, the results of our review do not answer the most relevant clinical question regarding the most effective type of psychosocial approach. There were few studies directly comparing different types of psychosocial approaches, the comparisons were very heterogeneous, and the sample sizes were small. The most promising and most studied psychosocial approach given in addition to another treatment or to treatment as usual was contingency management, but we cannot rule out that other types of treatment showed non‐significant results due lack of statistical power.

Quality of the evidence

The major limitations of the studies were the high risk of performance bias for all the subjective outcomes (self reported abstinence or frequency of use) because the studies could not be blinded for the type of interventions compared; moreover, 25% of the studies were at high risk of attrition bias. Another limitation of the studies was the low quality of reporting on methods influencing the risk of selection bias (we rated 50% of the studies as being at unclear risk for random sequence generation and 75% as unclear for bias related to allocation concealment) and detection bias (we rated 75% of the studies as being at unclear risk for this domain). Overall, we judged the quality of the evidence to be moderate for the outcomes of dropout and the longest period of abstinence, and low or very low for continuous abstinence.

Potential biases in the review process

We inspected funnel plots to assess the possibility of publication bias only for the comparison of any intervention versus no intervention and for the outcomes dropout (Figure 4) and longest period of abstinence (Figure 5), because in the other comparisons and for the other outcomes there were too few studies to make the funnel plot informative. We found insufficient evidence in the funnel plot to suggest any publication bias in favour of studies with positive results (asymmetry only suggested by one small trial in the bottom left quadrant).

Figure 4

Funnel plot of comparison: 1 any treatment vs no intervention, outcome: 1.1 dropout.

Figure 5

Funnel plot of comparison: 1 Any psychosocial treatment vs no intervention, outcome: 1.7 Longest period of abstinence.

A systematic search of ongoing clinical trials and unpublished trials on the websites ClinicalTrials.gov (clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (apps.who.int/trialsearch/), yielded only two completed but unpublished studies. One study's results were reported on ClinicalTrials.gov, while the other study's results were not available.

Agreements and disagreements with other studies or reviews

Results from the present review expand on previous findings supporting psychosocial interventions for individuals with psychostimulant misuse. NICE guidelines recommend considering psychosocial interventions, such as cognitive behavioural therapy, psychodynamic therapy and contingency management (NICE 2007). Only a few literature reviews focus specifically on psychostimulant misuse. A recent review in individuals with substance use disorder highlighted the effectiveness of contingency management in people with cocaine addiction (Secades Villa 2015). Other narrative reviews agree on the importance of psychosocial interventions for treating cocaine dependence and amphetamine dependence (Kampman 2010; Penberthy 2010; Vocci 2009), but to our knowledge, our study is the first to comprehensively and systematically review the field.

Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 4

Funnel plot of comparison: 1 any treatment vs no intervention, outcome: 1.1 dropout.

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Figure 5

Funnel plot of comparison: 1 Any psychosocial treatment vs no intervention, outcome: 1.7 Longest period of abstinence.

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Analysis 1.1

Comparison 1 Any psychosocial treatment versus no intervention, Outcome 1 Dropouts.

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Analysis 1.2

Comparison 1 Any psychosocial treatment versus no intervention, Outcome 2 Point abstinence, end of treatment.

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Analysis 1.3

Comparison 1 Any psychosocial treatment versus no intervention, Outcome 3 Point abstinence, longest follow‐up.

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Analysis 1.4

Comparison 1 Any psychosocial treatment versus no intervention, Outcome 4 Continuous abstinence, end of treatment.

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Analysis 1.5

Comparison 1 Any psychosocial treatment versus no intervention, Outcome 5 Continuous abstinence, longest follow‐up.

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Analysis 1.6

Comparison 1 Any psychosocial treatment versus no intervention, Outcome 6 Frequency of drug intake, longest follow‐up.

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Analysis 1.7

Comparison 1 Any psychosocial treatment versus no intervention, Outcome 7 Longest period of abstinence.

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Analysis 1.8

Comparison 1 Any psychosocial treatment versus no intervention, Outcome 8 Craving.

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Analysis 1.9

Comparison 1 Any psychosocial treatment versus no intervention, Outcome 9 Severity of dependence.

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Analysis 1.10

Comparison 1 Any psychosocial treatment versus no intervention, Outcome 10 Depression.

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Analysis 2.1

Comparison 2 Single treatment versus no intervention, Outcome 1 Dropouts.

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Analysis 2.2

Comparison 2 Single treatment versus no intervention, Outcome 2 Point abstinence, end of treatment.

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Analysis 2.3

Comparison 2 Single treatment versus no intervention, Outcome 3 Point abstinence, longest follow‐up.

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Analysis 2.4

Comparison 2 Single treatment versus no intervention, Outcome 4 Continuous abstinence, end of treatment.

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Analysis 2.5

Comparison 2 Single treatment versus no intervention, Outcome 5 Continuous abstinence, longest follow‐up.

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Analysis 2.6

Comparison 2 Single treatment versus no intervention, Outcome 6 Frequency of drug intake, longest follow‐up.

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Analysis 2.7

Comparison 2 Single treatment versus no intervention, Outcome 7 Longest period of abstinence.

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Analysis 2.8

Comparison 2 Single treatment versus no intervention, Outcome 8 Craving.

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Analysis 2.9

Comparison 2 Single treatment versus no intervention, Outcome 9 Severity of dependence.

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Analysis 2.10

Comparison 2 Single treatment versus no intervention, Outcome 10 Depression.

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Analysis 3.1

Comparison 3 Any psychosocial treatment versus TAU, Outcome 1 Dropouts.

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Analysis 3.2

Comparison 3 Any psychosocial treatment versus TAU, Outcome 2 Point abstinence, end of treatment.

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Analysis 3.3

Comparison 3 Any psychosocial treatment versus TAU, Outcome 3 Point abstinence, longest follow up.

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Analysis 3.4

Comparison 3 Any psychosocial treatment versus TAU, Outcome 4 Continuous abstinence, end of treatment.

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Analysis 3.5

Comparison 3 Any psychosocial treatment versus TAU, Outcome 5 Longest period of abstinence.

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Analysis 3.6

Comparison 3 Any psychosocial treatment versus TAU, Outcome 6 Severity of dependence (ASI).

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Analysis 4.1

Comparison 4 Single treatment versus TAU, Outcome 1 Dropouts.

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Analysis 4.2

Comparison 4 Single treatment versus TAU, Outcome 2 Point abstinence, end of treatment.

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Analysis 4.3

Comparison 4 Single treatment versus TAU, Outcome 3 Point abstinence, longest follow up.

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Analysis 4.4

Comparison 4 Single treatment versus TAU, Outcome 4 Continuous abstinence, end of treatment.

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Analysis 4.5

Comparison 4 Single treatment versus TAU, Outcome 5 Longest period of abstinence.

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Analysis 4.6

Comparison 4 Single treatment versus TAU, Outcome 6 Severity of dependence (ASI).

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Analysis 5.1

Comparison 5 CM versus no CM, Outcome 1 Dropouts.

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Analysis 5.2

Comparison 5 CM versus no CM, Outcome 2 Point abstinence, longest follow‐up.

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Analysis 5.3

Comparison 5 CM versus no CM, Outcome 3 Continuous abstinence, end of treatment.

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Analysis 5.4

Comparison 5 CM versus no CM, Outcome 4 Frequency of drug intake, longest follow‐up.

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Analysis 6.1

Comparison 6 CBT versus interpersonal therapy, Outcome 1 Dropouts.

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Analysis 6.2

Comparison 6 CBT versus interpersonal therapy, Outcome 2 Point abstinence, end of treatment.

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Analysis 6.3

Comparison 6 CBT versus interpersonal therapy, Outcome 3 Continuous abstinence, end of treatment.

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Analysis 6.4

Comparison 6 CBT versus interpersonal therapy, Outcome 4 Point abstinence, longest follow‐up.

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Analysis 7.1

Comparison 7 CBT versus 12‐step facilitation, Outcome 1 Dropouts.

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Analysis 7.2

Comparison 7 CBT versus 12‐step facilitation, Outcome 2 Continuous abstinence, end of treatment.

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Analysis 7.3

Comparison 7 CBT versus 12‐step facilitation, Outcome 3 Continuous abstinence, longest follow‐up.

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Analysis 8.1

Comparison 8 CBT versus CM, Outcome 1 Point abstinence, end of treatment.

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Analysis 8.2

Comparison 8 CBT versus CM, Outcome 2 Point abstinence, longest follow‐up.

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Analysis 8.3

Comparison 8 CBT versus CM, Outcome 3 Frequency of drug intake, longest follow‐up (days/months).

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Analysis 9.1

Comparison 9 CBT versus individual counselling, Outcome 1 Dropouts.

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Analysis 9.2

Comparison 9 CBT versus individual counselling, Outcome 2 Point abstinence, end of treatment.

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Analysis 9.3

Comparison 9 CBT versus individual counselling, Outcome 3 Point abstinence, longest follow‐up.

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Analysis 10.1

Comparison 10 Interpersonal versus individual counselling, Outcome 1 Dropouts.

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Analysis 10.2

Comparison 10 Interpersonal versus individual counselling, Outcome 2 Point abstinence, end of treatment.

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Analysis 10.3

Comparison 10 Interpersonal versus individual counselling, Outcome 3 Point abstinence, longest follow‐up.

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Analysis 11.1

Comparison 11 CBT versus ACT, Outcome 1 Dropouts.

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Analysis 11.2

Comparison 11 CBT versus ACT, Outcome 2 Point abstinence, end of treatment.

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Analysis 11.3

Comparison 11 CBT versus ACT, Outcome 3 Point abstinence, longest follow‐up.

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Summary of findings for the main comparison. Any psychosocial treatment compared to no intervention for psychostimulant misuse

Any psychosocial treatment compared to no intervention for psychostimulant misuse
Patient or population: adults (18 years and older) with a diagnosis of psychostimulant misuse Settings: outpatients Intervention: any psychosocial treatment Comparison: no intervention
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)
	Assumed risk	Corresponding risk
	No intervention	Any treatment
Dropout Follow‐up: mean 9 months	382 per 1000	317 per 1000 (290 to 348)	RR 0.83 (0.76 to 0.91)	3393 (24 studies)	⊕⊕⊕⊝ Moderate^a
Continuous abstinence end of treatment Follow‐up: mean 11 months	108 per 1000	232 per 1000 (138 to 389)	RR 2.14 (1.27 to 3.59)	1241 (8 studies)	⊕⊕⊝⊝ Low^b,c
Continuous abstinence longest follow‐up Follow‐up: mean 12 months	311 per 1000	660 per 1000 (240 to 1000)	RR 2.12 (0.77 to 5.86)	224 (4 studies)	⊕⊕⊝⊝ Low^d,e
Longest period of abstinence Follow‐up: mean 8 months	—	The mean longest period of abstinence in the intervention groups was 0.48 standard deviations higher (0.34 to 0.63 higher)	SMD 0.48 (0.34 to 0.63)	1354 (10 studies)	⊕⊕⊕⊕ High
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio; SMD: standardised mean difference.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
^aHigh risk of selection bias in one study, unclear risk in the majority of the others. ^bDowngraded one level due to serious risk of bias (high risk for attrition bias for three studies). ^cDowngraded one level due to serious inconsistency (I2 = 70%, p=0.001. Confidence intervals not overlapping). ^dDowngraded one level due to serious risk of bias (unclear risk of selection bias in all but one study, which is at high risk; high risk of attrition bias in one study; high risk of detection bias in one study). ^eDowngraded one level due to serious imprecision (optimal information size (OIS) not met, wide confidence interval).

Summary of findings for the main comparison. Any psychosocial treatment compared to no intervention for psychostimulant misuse

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Summary of findings 2. Any psychosocial treatment compared to TAU for psychostimulant misuse

Any psychosocial treatment compared to TAU for psychostimulant misuse
Patient or population: adults (18 years and older) with a diagnosis of psychostimulant misuse Settings: outpatients Intervention: any psychosocial treatment Comparison: TAU
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)
	Assumed risk	Corresponding risk
	TAU	Any treatment
Dropout N of participants not completing treatment Follow‐up: mean 10 months	575 per 1000	414 per 1000 (339 to 512)	RR 0.72 (0.59 to 0.89)	516 (6 studies)	⊕⊕⊕⊝ Moderate^a
Continuous abstinence end of treatment N of participants with continuous abstinence at the end of treatment Follow‐up: mean 12 months	395 per 1000	454 per 1000 (360 to 577)	RR 1.15 (0.91 to 1.46)	264 (3 studies)	⊕⊕⊝⊝ Low^b,c
Continuous abstinence longest follow‐up N of participants with continuous abstinence at longest follow‐up	—	—	Not estimable	0 (0)	—
Longest period of abstinence	The mean longest period of abstinence in the control groups was 22.4 days	The mean longest period of abstinence in the intervention groups was3.15 lower (10.35 lower to 4.05 higher)	—	110 (1 study)	⊕⊕⊝⊝ Low^d,e
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
^aDowngraded one level due to serious risk of bias (unclear risk of selection bias in all the studies, high risk of attrition bias in two studies). ^bDowngraded one level due to serious indirectness (only urban gay and bisexual men included). ^cDowngraded one level due to serious imprecision (optimal information size (OIS) not met). ^dDowngraded one level due to serious risk of bias (unclear risk of selection bias; high risk of attrition bias). ^eDowngraded one level due to serious imprecision (only one study with 110 participants).

Summary of findings 2. Any psychosocial treatment compared to TAU for psychostimulant misuse

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Comparison 1. Any psychosocial treatment versus no intervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Dropouts Show forest plot	24	3393	Risk Ratio (M‐H, Random, 95% CI)	0.83 [0.76, 0.91]

2 Point abstinence, end of treatment Show forest plot	6	1031	Risk Ratio (M‐H, Random, 95% CI)	1.04 [0.92, 1.18]

3 Point abstinence, longest follow‐up Show forest plot	7	1296	Risk Ratio (M‐H, Random, 95% CI)	1.09 [0.81, 1.46]

4 Continuous abstinence, end of treatment Show forest plot	8	1241	Risk Ratio (M‐H, Random, 95% CI)	2.14 [1.27, 3.59]

5 Continuous abstinence, longest follow‐up Show forest plot	4	224	Risk Ratio (M‐H, Random, 95% CI)	2.12 [0.77, 5.86]

6 Frequency of drug intake, longest follow‐up Show forest plot	4	669	Std. Mean Difference (IV, Random, 95% CI)	‐0.20 [‐0.35, ‐0.05]

7 Longest period of abstinence Show forest plot	10	1354	Std. Mean Difference (IV, Random, 95% CI)	0.48 [0.34, 0.63]

8 Craving Show forest plot	1	192	Std. Mean Difference (IV, Random, 95% CI)	‐0.19 [‐0.48, 0.10]

9 Severity of dependence Show forest plot	6	293	Std. Mean Difference (IV, Random, 95% CI)	‐0.48 [‐1.22, 0.26]

10 Depression Show forest plot	1	37	Mean Difference (IV, Random, 95% CI)	‐4.75 [‐10.45, 0.95]

Comparison 1. Any psychosocial treatment versus no intervention

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Comparison 2. Single treatment versus no intervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Dropouts Show forest plot	24		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 CBT	5	721	Risk Ratio (M‐H, Random, 95% CI)	0.83 [0.63, 1.09]
1.2 CM	13	1740	Risk Ratio (M‐H, Random, 95% CI)	0.80 [0.71, 0.89]
1.3 MI	5	696	Risk Ratio (M‐H, Random, 95% CI)	0.91 [0.65, 1.27]
1.4 12‐step facilitation	1	112	Risk Ratio (M‐H, Random, 95% CI)	1.58 [0.85, 2.94]
1.5 Psychodynamic therapy	1	247	Risk Ratio (M‐H, Random, 95% CI)	0.87 [0.74, 1.01]
2 Point abstinence, end of treatment Show forest plot	6		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

2.1 CBT	3	501	Risk Ratio (M‐H, Random, 95% CI)	0.97 [0.80, 1.18]
2.2 CM	3	212	Risk Ratio (M‐H, Random, 95% CI)	1.09 [0.79, 1.51]
2.3 12‐step facilitation	1	112	Risk Ratio (M‐H, Random, 95% CI)	0.84 [0.48, 1.46]
2.4 Psychodynamic therapy	1	247	Risk Ratio (M‐H, Random, 95% CI)	1.04 [0.81, 1.34]
2.5 Individual counselling	1	244	Risk Ratio (M‐H, Random, 95% CI)	1.26 [1.00, 1.59]
3 Point abstinence, longest follow‐up Show forest plot	7		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

3.1 CBT	3	508	Risk Ratio (M‐H, Random, 95% CI)	1.65 [0.85, 3.24]
3.2 CM	2	159	Risk Ratio (M‐H, Random, 95% CI)	0.63 [0.49, 0.83]
3.3 MI	2	384	Risk Ratio (M‐H, Random, 95% CI)	1.16 [0.95, 1.42]
3.4 psychodynamic	1	247	Risk Ratio (M‐H, Random, 95% CI)	0.96 [0.76, 1.22]
3.5 individual counselling	1	244	Risk Ratio (M‐H, Random, 95% CI)	1.11 [0.89, 1.38]
4 Continuous abstinence, end of treatment Show forest plot	8		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

4.1 CBT	1	101	Risk Ratio (M‐H, Random, 95% CI)	2.17 [1.07, 4.40]
4.2 CM	7	1140	Risk Ratio (M‐H, Random, 95% CI)	2.19 [1.19, 4.06]
5 Continuous abstinence, longest follow‐up Show forest plot	4		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

5.1 CBT	1	85	Risk Ratio (M‐H, Random, 95% CI)	1.16 [0.93, 1.46]
5.2 CM	2	110	Risk Ratio (M‐H, Random, 95% CI)	4.08 [1.22, 13.63]
5.3 MI	1	29	Risk Ratio (M‐H, Random, 95% CI)	2.12 [0.25, 17.98]
6 Frequency of drug intake, longest follow‐up Show forest plot	4	709	Std. Mean Difference (IV, Random, 95% CI)	‐0.20 [‐0.34, ‐0.05]

6.1 CBT	1	82	Std. Mean Difference (IV, Random, 95% CI)	‐0.19 [‐0.63, 0.24]
6.2 CM	2	256	Std. Mean Difference (IV, Random, 95% CI)	‐0.23 [‐0.47, 0.02]
6.3 MI	2	371	Std. Mean Difference (IV, Random, 95% CI)	‐0.18 [‐0.38, 0.03]
7 Longest period of abstinence Show forest plot	10		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

7.1 CBT	3	389	Std. Mean Difference (IV, Random, 95% CI)	0.34 [0.14, 0.54]
7.2 CM	8	1005	Std. Mean Difference (IV, Random, 95% CI)	0.60 [0.36, 0.84]
8 Craving Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

8.1 CM	1	192	Std. Mean Difference (IV, Random, 95% CI)	‐0.19 [‐0.48, 0.10]
9 Severity of dependence Show forest plot	6		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

9.1 CM	4	224	Std. Mean Difference (IV, Random, 95% CI)	‐0.75 [‐1.83, 0.34]
9.2 MI	2	69	Std. Mean Difference (IV, Random, 95% CI)	0.01 [‐0.71, 0.73]
10 Depression Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

10.1 CM	1	37	Mean Difference (IV, Random, 95% CI)	‐4.75 [‐10.45, 0.95]

Comparison 2. Single treatment versus no intervention

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Comparison 3. Any psychosocial treatment versus TAU

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Dropouts Show forest plot	6	516	Risk Ratio (M‐H, Random, 95% CI)	0.72 [0.59, 0.89]

2 Point abstinence, end of treatment Show forest plot	2	210	Risk Ratio (M‐H, Random, 95% CI)	1.98 [1.10, 3.58]

3 Point abstinence, longest follow up Show forest plot	2	164	Risk Ratio (M‐H, Random, 95% CI)	1.89 [1.18, 3.02]

4 Continuous abstinence, end of treatment Show forest plot	3	264	Risk Ratio (M‐H, Random, 95% CI)	1.15 [0.91, 1.46]

5 Longest period of abstinence Show forest plot	1	110	Mean Difference (IV, Random, 95% CI)	‐3.15 [‐10.35, 4.05]

6 Severity of dependence (ASI) Show forest plot	1	110	Mean Difference (IV, Random, 95% CI)	‐0.05 [‐0.14, 0.04]

Comparison 3. Any psychosocial treatment versus TAU

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Comparison 4. Single treatment versus TAU

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Dropouts Show forest plot	6	502	Risk Ratio (M‐H, Random, 95% CI)	0.77 [0.65, 0.92]

1.1 CBT	5	420	Risk Ratio (M‐H, Random, 95% CI)	0.76 [0.61, 0.95]
1.2 CM	1	82	Risk Ratio (M‐H, Random, 95% CI)	0.74 [0.49, 1.13]
2 Point abstinence, end of treatment Show forest plot	2	237	Risk Ratio (M‐H, Random, 95% CI)	2.05 [1.26, 3.34]

2.1 CBT	2	183	Risk Ratio (M‐H, Random, 95% CI)	1.72 [0.92, 3.24]
2.2 CM	1	54	Risk Ratio (M‐H, Random, 95% CI)	2.67 [1.23, 5.77]
3 Point abstinence, longest follow up Show forest plot	2	191	Risk Ratio (M‐H, Random, 95% CI)	1.96 [1.31, 2.93]

3.1 CBT	2	137	Risk Ratio (M‐H, Random, 95% CI)	1.94 [1.20, 3.14]
3.2 CM	1	54	Risk Ratio (M‐H, Random, 95% CI)	2.0 [0.96, 4.17]
4 Continuous abstinence, end of treatment Show forest plot	1	128	Risk Ratio (M‐H, Random, 95% CI)	1.18 [0.92, 1.53]

4.1 CBT	1	128	Risk Ratio (M‐H, Random, 95% CI)	1.18 [0.92, 1.53]
5 Longest period of abstinence Show forest plot	1	110	Mean Difference (IV, Random, 95% CI)	‐3.15 [‐10.35, 4.05]

6 Severity of dependence (ASI) Show forest plot	1	110	Mean Difference (IV, Random, 95% CI)	‐0.05 [‐0.14, 0.04]

6.1 CBT	1	110	Mean Difference (IV, Random, 95% CI)	‐0.05 [‐0.14, 0.04]

Comparison 4. Single treatment versus TAU

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Comparison 5. CM versus no CM

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Dropouts Show forest plot	4	464	Risk Ratio (M‐H, Random, 95% CI)	1.00 [0.59, 1.70]

2 Point abstinence, longest follow‐up Show forest plot	1	126	Risk Ratio (M‐H, Random, 95% CI)	0.54 [0.42, 0.70]

3 Continuous abstinence, end of treatment Show forest plot	2	96	Risk Ratio (M‐H, Random, 95% CI)	8.11 [1.62, 40.55]

4 Frequency of drug intake, longest follow‐up Show forest plot	1	107	Mean Difference (IV, Random, 95% CI)	‐1.82 [‐4.14, 0.50]

Comparison 5. CM versus no CM

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Comparison 6. CBT versus interpersonal therapy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Dropouts Show forest plot	2	285	Risk Ratio (M‐H, Random, 95% CI)	0.80 [0.45, 1.43]

2 Point abstinence, end of treatment Show forest plot	2	285	Risk Ratio (M‐H, Random, 95% CI)	1.12 [0.59, 2.15]

3 Continuous abstinence, end of treatment Show forest plot	1	42	Risk Ratio (M‐H, Random, 95% CI)	2.25 [0.82, 6.18]

4 Point abstinence, longest follow‐up Show forest plot	1	243	Risk Ratio (M‐H, Random, 95% CI)	1.04 [0.82, 1.32]

Comparison 6. CBT versus interpersonal therapy

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Comparison 7. CBT versus 12‐step facilitation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Dropouts Show forest plot	1	145	Risk Ratio (M‐H, Random, 95% CI)	0.87 [0.62, 1.24]

2 Continuous abstinence, end of treatment Show forest plot	2	225	Risk Ratio (M‐H, Random, 95% CI)	1.22 [0.88, 1.69]

3 Continuous abstinence, longest follow‐up Show forest plot	1	51	Risk Ratio (M‐H, Random, 95% CI)	1.97 [1.00, 3.86]

Comparison 7. CBT versus 12‐step facilitation

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Comparison 8. CBT versus CM

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Point abstinence, end of treatment Show forest plot	1	55	Risk Ratio (M‐H, Random, 95% CI)	0.66 [0.38, 1.16]

2 Point abstinence, longest follow‐up Show forest plot	1	55	Risk Ratio (M‐H, Random, 95% CI)	1.17 [0.73, 1.87]

3 Frequency of drug intake, longest follow‐up (days/months) Show forest plot	1	82	Mean Difference (IV, Random, 95% CI)	‐0.5 [‐2.82, 1.82]

Comparison 8. CBT versus CM

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Comparison 9. CBT versus individual counselling

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Dropouts Show forest plot	1	240	Risk Ratio (M‐H, Random, 95% CI)	0.86 [0.74, 1.01]

2 Point abstinence, end of treatment Show forest plot	1	240	Risk Ratio (M‐H, Random, 95% CI)	0.70 [0.54, 0.90]

3 Point abstinence, longest follow‐up Show forest plot	1	240	Risk Ratio (M‐H, Random, 95% CI)	0.90 [0.72, 1.13]

Comparison 9. CBT versus individual counselling

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Comparison 10. Interpersonal versus individual counselling

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Dropouts Show forest plot	1	245	Risk Ratio (M‐H, Random, 95% CI)	0.87 [0.74, 1.02]

2 Point abstinence, end of treatment Show forest plot	1	245	Risk Ratio (M‐H, Random, 95% CI)	0.83 [0.66, 1.04]

3 Point abstinence, longest follow‐up Show forest plot	1	245	Risk Ratio (M‐H, Random, 95% CI)	0.87 [0.69, 1.09]

Comparison 10. Interpersonal versus individual counselling

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Comparison 11. CBT versus ACT

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Dropouts Show forest plot	1	104	Risk Ratio (M‐H, Random, 95% CI)	0.94 [0.73, 1.20]

2 Point abstinence, end of treatment Show forest plot	1	26	Risk Ratio (M‐H, Random, 95% CI)	1.29 [0.47, 3.51]

3 Point abstinence, longest follow‐up Show forest plot	1	19	Risk Ratio (M‐H, Random, 95% CI)	0.73 [0.26, 2.07]

Comparison 11. CBT versus ACT

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Cochrane Review language

Website language

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

PICOs

PICOs

Population

Intervention

Comparison

Outcome

Plain language summary

Psychosocial interventions for cocaine and amphetamines abusers

Visual summary

Authors' conclusions

Implications for practice

Implications for research

Summary of findings

Background

Description of the condition

Cocaine and amphetamine‐type stimulant use

Cocaine and amphetamine‐type stimulant dependence

Description of the intervention

Cognitive behavioural therapy

Cognitive therapy

Coping skills training/relapse prevention

Community reinforcement approach

Contingency management

Motivational interviewing

Interpersonal therapy

Psychodynamic therapy

12‐step facilitation

How the intervention might work

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Types of interventions

Experimental intervention

Control intervention

Types of comparisons foreseen

Types of outcome measures

Primary outcomes

Secondary outcomes

Search methods for identification of studies

Electronic searches

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Measures of treatment effect

Unit of analysis issues

Assessment of heterogeneity

Assessment of reporting biases

Data synthesis

Subgroup analysis and investigation of heterogeneity

Sensitivity analysis

Summary of findings table

Results

Description of studies

Results of the search

Included studies

Types of interventions

Types of comparison

Excluded studies

Risk of bias in included studies

Allocation

Random sequence generation

Allocation concealment

Blinding

Performance bias

Detection bias