Psychosocial interventions for pregnant women in outpatient illicit drug treatment programs compared to other interventions
Abstract
Background
Illicit drug use in pregnancy is a complex social and public health problem. It is important to develop and evaluate effective treatments. There is evidence for the effectiveness of psychosocial in this population; however, to our knowledge, no systematic review on the subject has been undertaken.
Objectives
To evaluate the effectiveness of psychosocial interventions in pregnant women enrolled in illicit drug treatment programs on birth and neonatal outcomes, on attendance and retention in treatment, as well as on maternal and neonatal drug abstinence. In short, do psychosocial interventions translate into less illicit drug use, greater abstinence, better birth outcomes, or greater clinic attendance.?
Search methods
We searched the Cochrane Drugs and Alcohol Group's trial register (May 2006), the Cochrane Central Register of Trials (Central‐ The Cochrane Library, Issue 3, 2005); MEDLINE (1.1996‐8.2006); EMBASE (1.1996‐8.2006); CINAHL (1.1982‐8.2006), and reference lists of articles.
Selection criteria
Randomised studies comparing any psychosocial intervention versus pharmacological interventions or placebo or non‐intervention or another psychosocial intervention for treating illicit drug use in pregnancy.
Data collection and analysis
Two reviewers independently assessed trial quality and extracted data.
Main results
Nine trials involving 546 pregnant women were included. Five studies considered contingency management (CM), and four studies considered manual based interventions such as motivational interviewing (MI).
The main finding was that contingency management led to better study retention. There was only minimal effect of CM on illicit drug abstinence. In contrast, motivational interviewing led towards poorer study retention, although this did not approach statistical significance. For both, no difference in birth or neonatal outcomes was found, but this was an outcome rarely captured in the studies.
Authors' conclusions
The present evidence suggests that CM strategies are effective in improving retention of pregnant women in illicit drug treatment programs as well as in transiently reducing illicit drug use. There is insufficient evidence to support the use of MI. Overall the available evidence has low numbers and, therefore, it is impossible to accurately assess the effect of psychosocial interventions on obstetrical and neonatal outcomes.
It is important to develop a better evidence base to evaluate psychosocial modalities of treatment in this important population.
PICOs
Plain language summary
Psychosocial interventions for pregnant women in outpatient illicit drug treatment programs compared to other interventions
The effectiveness of psychosocial interventions in pregnant women enrolled in illicit drug treatment programs.Women who use illicit drugs while pregnant are more likely to give birth early and have low weight infants that are at risk of neonatal abstinence syndrome and requiring intensive care. A pregnant woman reduces the risk of these complications by undergoing prenatal drug treatment. Maternal concern for the infant can also motivate her. The length of time on treatment is important. Psychosocial interventions may help to overcome the many barriers to staying in a treatment program and reduce the use of illicit drugs.Contingency management uses positive, supportive reinforcement with, for example, monetary vouchers or giving work and a salary only when abstaining from drug use or attending treatment to change behaviour. Manual based interventions include motivational interviewing with a
directive, counselling style.
This systematic review found that contingency management is effective in improving retention of pregnant women in illicit drug treatment programs but with minimal effects on their abstaining from illicit drugs. Motivational interviewing over three to six sessions may, if anything, lead to poorer retention in treatment. These findings are based on nine controlled trials over 14 days to 24 weeks, five studies used contingency management (346 women) and four studies (266 women) that considered motivational interviewing.All but one took place in the United States. Many of the young women were African American, single, never married or divorced, and unemployed. They were receiving methadone maintenance, using cocaine, or opiate dependent and marijuana and alcohol use was also involved in six studies. In two trials, almost all women were nicotine dependent. No difference in birth outcomes or length of hospital detoxification for the newborns was found, from two studies.None of the included studies stated how the women were referred to treatment. Manual based interventions are less likely to be effective among coerced individuals. it is also unlikely to be used on their own in clinical practice.
