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Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence

This is not the most recent version

Abstract

Background

Maintenance treatments are effective in retaining patients in treatment and suppressing heroin use. Questions remain regarding the efficacy of additional psychosocial services offered by most maintenance programs.

Objectives

To evaluate the effectiveness of any psychosocial plus any agonist maintenance treatment versus standard agonist treatment for opiate dependence in respect of retention in treatment, use of substances, health and social status.

Search methods

We searched: Cochrane Drugs and Alcohol Group's Register of Trials (February 2008), Cochrane Central Register of Controlled Trials (CENTRAL ‐ The Cochrane Library issue 1, 2008), MEDLINE (January 1966 to February 2008), EMBASE (January 1980 to February 2008), CINAHL (January 2003‐February 2008), PsycINFO (January 1985 to April 2003), reference lists of articles.

Selection criteria

Randomised studies comparing any psychosocial plus any agonist with any agonist alone intervention for opiate dependence.

Data collection and analysis

Three reviewers independently assessed trial quality and extracted data.

Main results

Twenty eight trials, 2945 participants, were included. These studies considered twelve different psychosocial interventions and three pharmacological maintenance treatments. Comparing any psychosocial plus any maintenance pharmacological treatment to standard maintenance treatment, results do not show benefit for retention in treatment, 23 studies, 2193 participants, Relative Risk (RR) 1.02 (95% CI 0.97 to 1.07), use of opiate during the treatment, eight studies, 681 participants, RR 0.86 (95% CI 0.65 to 1.13), compliance, three studies, MD 0.43 (95% CI ‐0.05 to 0.92), psychiatric symptoms, four studies, MD 0.02 (‐0.19 to 0.23), depression, four studies, MD ‐1.30 (95% CI ‐3.31 to 0.72) and results at follow up as number of participants still in treatment at the end of the follow‐up , 289 participants, RR 0.91 (95% CI 0.77 to 1.06). In spite of results at follow up as number of participants abstinent at the end of the follow‐up, five studies, 232 participants, show a benefit in favour of the associated treatment RR1.15 (95% CI 1.01 to 1.32). The remaining outcomes were analysed only in single studies considering a limited number of participants.Comparing the different psychosocial approaches, results are never statistically significant for all the comparisons and outcomes.

Authors' conclusions

Results suggest that adding any psychosocial support to maintenance treatments improve the number of participants abstinent at follow up; no differences for the other outcome measures. Data do not show differences between different psychosocial interventions also for contingency approaches, contrary to all expectations. Duration of the studies was too short to analyse relevant outcomes such as mortality.

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

Combined psychosocial and agonist maintenance interventions for treatment of opioid dependence

The abuse of opioid drugs and drug dependency are major health and social issues. Maintenance treatments with pharmacological agents can help to reduce the risks associated with the use of street drugs for drug addicts who are unable to abstain from drug use. Methadone is effective in retaining patients in treatment and reducing heroin use but re‐addiction remains as a substantial challenge. Opiate addicts often have psychiatric problems such as anxiety and depression and may not be able to cope with stress. Psychosocial interventions including psychiatric care, psychotherapy, counselling, and social work services are commonly offered as part of the maintenance programs. Psychological support varies from structured psychotherapies such as cognitive behavioural therapy and supportive‐expressive therapy to behavioural interventions and contingency management.
This review addressed whether a specific psychosocial intervention provides any additional benefit to pharmacological maintenance treatment. The control intervention was a maintenance program, which routinely offers counselling sessions in addition to pharmacological treatment. Present evidence suggests that adding psychosocial support does not change the effectiveness of retention in treatment. Nor does it result in a clear reduction in opiate use during treatment. Findings on retention in treatment were for 12 different psychosocial interventions including contingency management over 6 to 48 weeks. These conclusions are based on 28 randomised trials involving 2945 opiate addicts, some 66% of whom were male. The average age was 37 years (range 27 to 45). All but two studies were conducted in the USA.
The number of participants abstinent at the end of follow up (five trials) and continuous weeks of abstinence (two trials) showed a benefit in favour of the associated treatment. The previous version of this review showed a reduction in opiate use during treatment that was no longer the case with the addition of new studies. The psychosocial interventions are likely to require rigorous assessment of any changes in emotional, interpersonal, vocational and physical health areas of life functioning that may indirectly reduce drug use over longer periods of time.