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Adding another formal psychotherapy, such as cognitive– behavioural therapy (CBT) or motivational enhancement therapy (MET), to contingency management (CM) was found in a systematic review with meta-analysis (Sheridan et al., 2020, 12 studies, N = 1654) to have no effect in:
improving both treatment end and at post-treatment follow-up compared with CM only
no evidence of a synergistic effect in PPA at treatment end (relative risk (RR) 0.97, 95% CI 0.85 to 1.09; p=0.57)
sensitivity analysis of studies featuring CBT/MET also found no evidence of an effect (RR 0.92; 95% CI 0.79 to 1.08; p=0.32)
none of the secondary outcomes showed any evidence of benefit.
Naloxone administration (intranasal/intramuscular) was assessed in a systematic review (Chou et al., 2017, 13 studies) and results showed that:
at the same dose (2 mg), 1 trial found similar efficacy between higher-concentration intranasal naloxone (2 mg/mL) and intramuscular naloxone,
1 trial found that lower-concentration intranasal naloxone (2 mg/5 mL) was less effective than intramuscular naloxone but was associated with decreased risk for agitation
Intranasal administration of naloxone was found in a review with meta-analysis (Yousefifard et al., 2020) to be as effective as intramuscular/intravenous administration in the pre-hospital management of opioid overdose:
the success rate (defined as the recovery of patients’ consciousness and spontaneous respiration) of the intranasal and intramuscular/intravenous administration of naloxone was 82.54% (95% CI: 57.97 to 97.89%) and 80.39% (95% CI: 57.38 to 96.04%) respectively with no difference between the two routes (OR=1.01; 95% CI: 0.42 to 2.43; P=0.98)
the prevalence of major side-effects was non-significant for both intranasal (0.00%) and intramuscular/intravenous (0.05%) routes and there was no difference in the prevalence of major (OR=1.18; 95% CI: 0.38 to 3.69; P=0.777) and minor (OR=0.64; 95% CI: 0.17 to 2.34; P=0.497) side-effects between the two routes.
The odds of needing a rescue dose were 2.17 times higher for intranasal naloxone than intramuscular/intravenous naloxone (OR=2.17; 95% CI: 1.53 to 3.09; P<0.0001), however since it does not require intravenous access and its re-administration does not cause serious complications, this limitation does not seem major enough to prevent its use.
Naloxone distribution was found in an umbrella review of systematic reviews (Razaghizad et al., 2021, 6 SR containing 87 unique studies) effective in:
reducing opioid-related mortality. High-concentration intranasal naloxone (> 2 mg/mL) was as effective as intramuscular naloxone at the same dose, whereas lower-concentration intranasal naloxone was less effective.
Alpha2-adrenergic agonists (Clonidine and lofexidine) were found in a systematic review (Gowing et al., 2016, 26 RCT, N=1 728) to be more effective than placebo in:
ameliorating withdrawal in terms of the likelihood of severe withdrawal (risk ratio (RR) 0.32, 95 % CI 0.18 to 0.57, 3 studies, N=148)
increasing completion of treatment (RR 1.95, 95 % CI 1.34 to 2.84, 3 studies, N=148)
When compared to reducing doses of methadone
duration of treatment was significantly longer with reducing doses of methadone (SMD -1.07, 95 % CI -1.31 to -0.83, 3 studies, N=310)
hypotensive or other adverse effects were significantly more likely with alpha2-adrenergic agonists (RR 1.92, 95 % CI 1.19 to 3.10, 6 studies, N=464)
no significant difference in rates of completion of withdrawal treatment were found (RR 0.85, 95 % CI 0.69 to 1.05, 9 studies, N=659)
Anti-alcohol/cannabis community interventions were analyzed in a review of reviews (McGrath et al., 2006, 29 reviews) and weak studies due to lack of control groups suggested a reduction in:
Mass-media campaign in combination with school-based, community-based or national programmes were found in a systematic review (Carson et al., 2017, 8 studies, N= 17 385) to be inconclusive regarding:
reduced smoking behaviour of young people (3 studies (n = 17,385) found some evidence but the remaining 5 studies (n = 72,740) did not detect a significant effect on smoking behaviour)
Unknown effectiveness
tobacco
improve behavioural life skills, reduce substance use
Coordinated, widespread, multi-component community interventions include age restrictions on tobacco purchase, programs for prevention of disease (like heart disease), mass media and school programs. Such interventions were found in a systematic review of 17 studies (Sowden and Stead, 2003) to:
reduce smoking prevalence when compared to no intervention control and to school-based programmes only;
reduce the rate of increase in smoking prevalence when compared to mass-media campaign alone.
A systematic review without meta-analysis (Penzenstadler et al 2019, 5 datasets) found no clear superiority of results of assertive community treatment (ACT) in reducing substance use (compared to control group).
ACT originally developed for patients with severe mental illness, providing personalized, high intensity, holistic and integrated multidisciplinary community care services.
Take home naloxone (THN) programs have been rapidly upscaled in response to increasing opioid-related mortality. One often cited concern is that naloxone provision could be associated with increased opioid use, due to the availability of naloxone to reverse opioid overdose.
A narrative systematic review (Tse et al., 2022, studies =7 - two quasi-experimental studies and five cohort studies, N= 2 578) investigated whether THN provision is associated with changes in substance use by participants enrolled in THN programs and found:
no evidence that THN provision was associated with increased opioid use or overdose.
Behavioural Activation (BA) interventions were found in a systematic review without meta-analysis (Matrínez-Vispo et al 2018, studies = 8, 6 of which RCTs) to potentially improve:
substance use (2 out of 6 RCTs reported statistically significant results in favour of BA)
depressive symptoms (6 out of 8 studies reported statistically significant results in favour of BA)
Unknown effectiveness
co-morbidity
improve mental health outcomes, reduce substance use
A narrative review (Fischer et al., 2015), without meta-analysis, concluded that, despite the fairly substantive body of largely controlled studies, there is:
mixed and short-term evidence, so not conclusive, on the effectiveness of targeted behavioural harm reduction measures, eg. peer-delivered intervention (‘EachOneTea-chOne’; EOTO), enhanced peer-delivered HIV education interventions, standard HIV prevention programs.
Behavioural therapies targeting specifically adolescents were analysed in a systematic review without meta-analysis (Hogue et al., 2014, 8 RCTs) and found that:
cognitive behavioural therapies (CBT) are well established but were outperformed by family-based treatments in several trials
cognitive behavioural therapies (CBT) at group level or at individual level are equally effective
A review of 29 reviews (McGrath et al., 2006) found evidence that booster sessions or similar extra components that aimed to reinforce the effects of a programme have a positive impact on the pre-specified outcomes. However, since the relationship between booster sessions and programme outcomes was not statistically examined, the link should be treated as hypothetical.
A systematic review with meta-analysis (Tanner-Smith et al., 2021, RCTs = 116, N= 64 439) investigated the effectiveness of brief interventions in patients of any age or severity level recruited in general medical settings. Analyses were conducted separately by brief intervention (BI) target substance: alcohol only or drugs. The overall conclusion was that when delivered in general medical settings, alcohol-targeted brief interventions may produce small beneficial reductions in drinking (equivalent to a reduction in 1 drinking day per month), however there is limited evidence regarding the effects of drug-targeted brief interventions on drug use.
Specific results of the analysis found that:
drug-targeted BIs yielded significant small improvements in multiple drug/mixed substance use (Hedges' g = 0.08; 95% CI = 0.002, 0.15), but after adjusting for multiple comparisons, they did not produce significant effects on cannabis use (g = 0.06; 95% CI = 0.001, 0.12), alcohol use (g= 0.08; 95% CI = -0.0003, 0.17), or consequences (g = 0.05; 95% CI = 0.01, 0.10)
drug-targeted BIs yielded larger improvements in multiple drug/mixed substance use when delivered by a general practitioner (g = 0.19; 95% CI = 0.187, 0.193)
alcohol-targeted BIs yielded small beneficial effects on alcohol use (g = 0.12; 95% CI 0.08, 0.16), but no evidence of an effect on consequences (g = 0.05; 95% CI = -0.04, 0.13). However, alcohol-targeted BIs only had beneficial effects on alcohol use when delivered in general medical settings (g = 0.17; 95% CI = 0.10, 0.24); the findings were inconclusive for those delivered in emergency department/trauma centers (g = 0.05; 95% CI = 0.00, 0.10)
Brief interventions (BIs) were analyzed analysed in a narrative systematic review and metanalysis for patients with comorbid substance misuse (Ghosh et al., 2023, 8 studies). The review found some positive but not conclusive effects on:
reducing substance use (Hedges g = 0.752, 95% confidence interval, 0.405–1.099) and alcohol consumption 3 months after the intervention.
More research is needed for robust results, due to the limited number of studies in the review.
Brief interventions for non-treatment seeking young adults (17-25 ys) were found in a systematic review with meta-analysis (Halladay et al., 2019) to have some promising but not conclusive effects when compared to no intervention or usual care in:
improving short-term abstinence - 3 months follow-up (OR 1.73, 95 % CI 1.13 to 2.66, 3 studies, N=666)
reducing the risk of cannabis use disorders (as measured by the CUPIT tool, a brief self-report screening instrument for detection of currently and potentially problematic cannabis use) (SMD -0.14, 95 % CI -0.26 to -0.01, 7 studies, N=1173)
The results were confirmed in a new systematic review with meta-analysis (Steele et al., 2020) that synthetised the evidence regarding the effects of brief behavioural interventions for adolescents (12–20 years) with problematic substance use. Brief interventions were categorized into motivational interviewing (MI), psychoeducation, and treatment as usual. The analysis found that:
use of MI did not reduce cannabis use days, with a net mean difference of 20.05 days per month (95% CrI: 20.26 to 0.14; moderate SoE)
while it confirmed the effectiveness of brief interventions, especially MI, in reducing heavy alcohol use and alcohol use days
Another narrative systematic review (Chazal et al., 2022, 8 studies, N= 2 199) assessed the effectiveness of brief interventions realized in primary care in reducing cannabis use for adolescents and emerging adults. Brief interventions were all based on motivational interviewing techniques or personalized feedback. The results found:
no significant reduction of cannabis use after brief intervention was found for most studies, especially in the long term.
Brief interventions (Bis) were found in a review with metanalysis (Schweer-Collins et al., 2023, k = 116, N= 12,074) to be more beneficial to treat alcohol use in the following target groups:
Females: The study found that among females, brief interventions (BIs) led to significant reductions in binge alcohol consumption (g = 0.09, 95% CI [0.03, 0.14]), frequency of alcohol consumption (g = 0.10, 95% CI [0.03, 0.17]), and alcohol-related consequences (g = 0.16, 95% CI [0.08, 0.25]). The study also found that BIs resulted in greater utilisation of substance use treatment (g = 0.25, 95% CI [0.21, 0.30]).
Individuals with less than a high school level education showed a significant decrease (g = 0.16, 95% CI [0.09, 0.22]) in the frequency of alcohol consumption at the 3-month follow-up.
Motivational interviewing was found to have no different effect than treatment as usual in a systematic review (Darker et al., 2015) in:
reducing use at any time intervals;
reducing drop-outs at any time intervals
A more recent systematic review with meta-analysis (Lynch at al., 2021,, studies = 8, n= 2071) investigated at the effectiveness of brief interventions in primary care compared to usual care. Results found promising yet very low quality (and thus not conclusive) evidence on:
discontinuation of BZRA use at 6 months (eight studies, RR = 2.73, 95% CI = 1.84-4.06) and 12 months post-intervention (two studies, RR = 3.41, 95% CI = 2.22-5.25)
Brief interventions delivered in healthcare settings targeting cannabis users were found in a systematic review with meta-analysis (Imtiaz et al., 2020) to have no conclusive effects when compared to minimal control interventions in:
improving cannabis-specific Alcohol, Smoking and Substance Involvement
Screening Test (ASSIST) scores in the short term (MD = 1.27 points, 95% CI 3.75 - 1.21)
reducing the number of days of cannabis use in the past 30 days in the short term (MD =0.22 days, 95% CI 2.27- 1.82) and long term (MD= 0.28 days, 95% CI 2.42- 1.86)
Buprenorphine substitution treatment was found to be more effective than placebo in a synthesis of evidence (WHO, 2009) and more recenlty in a systematic review (Mattick et al., 2014) in:
improving retention in treatment
at low doses (2-6mg) (RR 1.50, 95 % CI 1.19 to 1.88, 5 studies, N=1131);
at medium doses (7-15mg) (RR 1.50, 95 % CI 1.19 to 1.88, 4 studies, N=887);
at high doses (≥ 16mg) (RR 1.82, 95 % CI 1.15 to 2.90, 5 studies, N=1001)
A new systematic review with network meta-analysis (Lim et al., 2022, 79 RCTs) confirmed the results and found a significant overall effect of Buprenorphine compared to control in:
retaining people in treatment (RR 2.15, 95 % CI 1.76 to 2.69)
in the network analysis Methadone was the highest ranked intervention (Surface Under the Cumulative Ranking [SUCRA] = 0.901) with control being the lowest (SUCRA = 0.000). Methadone was superior to buprenorphine for treatment retention (RR = 1.22; 95% CI = 1.06-1.40) yet buprenorphine superior to naltrexone (RR = 1.39; 95% CI = 1.10-1.80).
Buprenorphine and methadone for opioid assisted withdrawal was found in a systematic review (Gowing et al., 2017, 27 RCTs, N = 3 048) to be equally effective in treatment outcomes and no difference between the two medications was detected in terms of:
completion rates (RR 1.04, 95% CI 0.91 to 1.20, RCTs = 5; N = 457, moderate quality)
average treatment duration (MD 1.30 days, 95% CI −8.11 to 10.72, RCTs = 2, N = 82, low quality)
Similarly, another systematic review (Baxley et al. 2022, 10 studies, N = 2468) also found that:
buprenorphine effectively reduced cravings
In three studies, there was a greater craving for buprenorphine than methadone. Both methadone and buprenorphine were effective, but this systematic review does not provide enough evidence to determine whether one is more effective than the other.
Methadone maintenance therapy was found to be statistically more effective than Buprenorphine maintenance therapy in a systematic review (Mattick et al., 2014) in:
improving retention in treatment
in flexible doses studies (RR 0.83, 95 % CI 0.72 to 0.95, 5 studies, N=788);
in low doses studies (MMT ≤ 40mg BUP 2-6mg) (RR 0.67, 95 % CI 0.52 to 0.87, 3 studies, N=253);
no difference was observed in reduction of opioid use as measured by urinalysis (SMD -0.11; 95 % CI -0.23 to 0.02, 8 studies, N=1027) or self-reported (SMD -0.11; 95 % CI -0.28 to 0.07, 4 studies, N=501)
However, at medium doses (MMT 40-85mg, BUP 7-15mg) and high doses (MMT ≥ 16mg, BUP ≥ 85mg) no difference was found between Methadone and Buprenorphine treatment in:
improving retention in treatment
medium doses (RR 0.87, 95 % CI 0.69 to 1.10, 7 studies, N=780)
high doses (RR 0.79, 95 % CI 0. 02 to 3.16, 1 study, N=134)
reducing opioid use as measured by urinalysis or self-reported
A new systematic review with network meta-analysis (Lim et al., 2022, 79 RCTs) confirmed the results and found a significant overall effect of Methadone in:
retaining people in treatment (RR 2.62, 95 % CI 2.09 to 3.33) compared to control
in the network analysis Methadone was the highest ranked intervention (Surface Under the Cumulative Ranking [SUCRA] = 0.901) with control being the lowest (SUCRA = 0.000). Methadone was superior to buprenorphine for treatment retention (RR = 1.22; 95% CI = 1.06-1.40) yet buprenorphine superior to naltrexone (RR = 1.39; 95% CI = 1.10-1.80).
In a more recent systematic review with meta-analysis (Degenhardt et al., 2023, 32 RCTs), the primary outcomes considered were retention in treatment, treatment adherence, and extra-medical opioid use; the following results were concluded:
For retention beyond one month, methadone had higher retention rates compared to buprenorphine (RR 0.76, 95% CI 0.67–0.85; I²=74.2%; 16 studies, N=3151)
For extra-medical opioid use, there is some evidence indicating lower rates of buprenorphine compared to methadone as measured by urinalysis (–0.20, 95% CI –0.29 to –0.11; I²=0.0%; 3 studies, N=841)
To summarise, the authors highlight that while methadone may have better treatment retention rates, there are few differences in other comparative outcomes. Therefore, it is important to consider other factors and take a client-centered approach when prescribing.
Beneficial
opioids
reduce substance use, retain patients in treatment
Case management was found in a systematic review with meta-analysis (Vanderplasschen et al., 2019) to be more effective than treatment as usual in:
improving treatment outcomes, including retention in treatment, linkages with services, satisfaction in treatment (SMD = 0.33, 95% CI 0.18–0.48). The largest effect size was found for retention in substance use treatment (SMD = 0.47, 95% CI 0.13 - 0.81) and linkage with substance use services (SMD = 0.23, 95% CI 0.11 - 0.35)
The analysis found a very small but statistically not significant effect on personal functioning outcomes (substance use, health status, legal involvement, risk behavior, and social functioning).
Case management is defined in the review as an intervention designed to enhance coordination and continuity of care and support, especially for persons with multiple, and complex needs.
A systematic review (Harada et al 2018) of two small RCTs (n=210) addressing the efficacy of cognitive-behavioural treatment (CBT) for people with amphetamine-type stimulants (ATS) use disorder found that there were insufficient data for conclusive assessment of CBT in the treatment of ATS use disorders (SMD -0.28, 95% CI -0.69 to 0.14).
The same result was confirmed by a systematic review of reviews (Ronsley et al., 2020, 29 systematic reviews examining eleven intervention modalities) that found no no significant benefit was identified for abstinence at 12 weeks, at the end of treatment, or at longest follow up.
Specifically for methamphetamine use disorder, a systematic review without meta-analysis (AshaRani et al., 2020) found that most of the behavioural interventions i.e., CBT, GCBT, MI and counselling demonstrated treatment some efficacy in reducing METH use in the participants however, a clear superiority of one over the other was not demonstrated. Moreover, while CM (contingency management) and CBT, both demonstrated positive outcomes individually, no clear synergism was observed when CM interventions were combined together with CBT.
Combined cognitive behavioral therapy (CBT) and pharmacotherapy was found in a systematic review with meta-analysis (Ray et al., 2020, 30 RCTs) to have:
increased benefits compared with usual care and pharmacotherapy
the effect for CBT on posttreatment frequency outcomes was small, homogeneous, and statistically significant (g=0.18 [95%CI, 0.01-0.35]; P = .04; τ2=0.00, Q > 0.05, I2 = 0%)
for quantity outcomes effects were small to moderate, homogenous, and significant (g=0.28 [95% CI, 0.03-0.54]; P = .03; τ2=0.03; Q > 0.05; I2 = 31%).
Outcomes included the following in the decisional hierarchy established by the authors: (1) biological assay measures, (2) measures of frequency or quantity in the form of means (SDs), (3) sample proportions, and (4) other outcomes (eg, diagnostic measures).
CBT did not perform better than another evidence-based modality (eg. contingency management, motivation enhancement therapy, 12-step facilitation, and interpersonal therapy) in this context or as an add-on to combined usual care and pharmacotherapy.
Combined enforcement checks and management training programmes were found in one study included in a systematic review (Bolier et al 2011) to be effective in:
reducing the service to under-age clients (relatively non-significant decrease in intervention group, from 46 % to 42 %).
Likely to be beneficial
alcohol
reduce risk behaviours
Police interventions, Responsible serving trainings and policies
Combined OST and high NSP coverage has been found to be effective in a systematic review with meta-analysis (Platt et al., 2017, 28 studies, N= 11 070 PWID) in:
reducing the risk of HCV acquisition by 74 % (RR 0.26 95% CI 0.07 to 0.89).
Another systematic review (Palmateer et al., 2022, 27 systematic review, 61 studies) confirmed the results and found sufficient evidence to support the combination of OST and NSP in:
the prevention of HCV transmission among PWID.
the prevention of injecting risk behaviour among PWID.
While there are still not enough studies to assess the effect on HIV, considering the positive effect on HCV, experts assume the same positive effect on HIV infections.
The Communities That Care (CTC) approach (i.e. community coalitions that develop a common strategy and mobilise communities in prevention and health promotion initiatives) was found in a systematic review (EMCDDA 2017, studies = 5) to be effective in:
reducing substance use and delinquency behaviours (USA trials)
Likely to be beneficial
not-drug specific
reduce disruptive behaviours, reduce substance use
Community-based interventions showed no significant impact in a systematic review (Stockings et al, 2018, 24 trials, n=249 125, samples subject to high-risk bias) in:
reducing binge-drinking (5 trials, RR 0.97, 95% CI 0.98 to 1.06); and
reducing 12 month marijuana use (2 trials, RR 0.98, 95% CI 0.86 to 1.11).
Community-based interventions showed some impact in a systematic review (Stockings et al, 2018, 24 trials, n=249 125, samples subject to high-risk bias) in:
reducing risky drinking (AUDIT ˃8, 3 trials, RR 0.78, 95% CI 0.62 to 0.99).
A systematic review comparing buprenorphine, methadone, and naltrexone in preventing relapse and promoting harm reduction among people with opioid addiction found that:
Methadone is considered the gold standard in MAT and can be started at any withdrawal stage. It requires titration to effective dose, which can be time-consuming and must be administered in specialized clinics.
Buprenorphine is the second most effective Medication-Assisted Treatment (MAT) for reducing harm and preventing relapse. It can be initiated and maintained in primary care settings, has low overdose risk but requires initiation during moderate withdrawal phase.
Naltrexone (Extended-Release, Intramuscular) in its oral form is ineffective due to low adherence, while the injectable extended-release form shown to reduce relapse and improve quality of life, but it requires 7–14 days of opioid abstinence before initiation.
Beneficial
opioids
reduce relapse rates, reduce substance use, retain patients in treatment
Comprehensive approaches involving community and school, were found effective in a systematic review (Jones et al., 2006, 222 studies - 14 systematic reviews; 103 RCTs; 52 Controlled non-randomized studies; 18 CBA; 35 BA) at preventing/delaying/reducing:
all substances when compared with community-only programmes and school-community programmes targeting high-risk youth (SMD = 0.38 and 0.36 respectively), and in high-risk individuals when compared with low-risk individuals (SMD = 0.42 and 0.08);
tobacco when compared with community-only programmes and school-community programmes targeting high-risk youth (SMD = 0.46 and 0.48), and in high-risk individuals when compared with low-risk individuals (SMD = 0.49 and 0.03);
alcohol when compared with community-only programmes and school-community programmes targeting high-risk youth (SMD = 0.49 and 0.49), and in high-risk individuals when compared with low-risk individuals (SMD = 0.56 and 0.05);
cannabis when compared with community-only programmes and school-community programmes targeting high-risk youth (SMD = 0.82 and 0.79), and in high-risk individuals when compared with low-risk individuals (SMD = 0.84 and 0.22);
all illicit drugs when compared with community-only programmes and school-community programmes targeting high-risk youth (SMD = 0.56 and 0.54), and in high-risk individuals when compared with low-risk individuals (SMD = 0.65 and 0.05).
There was no difference in effectiveness between ‘school-community’ programmes and ‘community-only’ programmes. Moreover, low risk population effect sizes were significantly greater across all types of interventions (‘comprehensive’, ‘school-community’, ‘community-only’) for tobacco (SMD = 0.05, SMD = 0.13); and cannabis (SMD = 0.04, SMD = 0.10). No other significant differences were reported.
Comprehensive family-oriented prevention, which includes training for parents, children and whole families, was found to be effective in one study included in a systematic review (Gates et al., 2006, 9 cluster randomised studies and 8 randomised studies, N = 1230) — although with some disagreement and methodological weaknesses — in:
reducing lifetime cannabis use and cannabis use in the past year in adolescents (RR = 0.55, 95 % CI 0.32–0.95 and RR = 0.44 95 % CI 0.20–0.96 respectively, at 6 year follow-up) .
Compulsory drug treatment (including drug detention facilities, short (i.e. 21-day) and long-term (i.e. 6 months) inpatient treatment, community-based treatment, group-based outpatient treatment, and prison-based treatment) was found in a systematic review without meta-analysis (Werb et al., 2016, 9 studies, N=10 699) was found to have no effect on:
drug use or criminal recidivism over other approaches (78% of the studies)
two studies (22 %) detected negative impacts of compulsory treatment on criminal recidivism compared with control arms
only two studies (22 %) observed a significant impact of long-term compulsory patient treatment on criminal recidivism: one reported a small effect size on recidivism after two years, and one found a lower risk of drug use within one week of release from compulsory treatment
Computer-based interventions targeting specifically recreational drug users were found in a systematic review (Wood et al., 2014) to have general positive results in:
reducing use of drugs both immediately and in the mid-term when targeting specifically recreational drug users
Contingency management (CM) interventions for people with HIV and substance use disorder were found in a systematic review with meta-analysis (Ribeiro et al. 2023, five studies) to have a more positive effect when compared to control conditions in:
adherence to antiretroviral therapy during the intervention period (improved patient adherence by 2.69 (95% confidence interval: [0.08, 0.51]; p = .007)).
Adherence to antiretroviral therapy was measured by counting the increase in CD4 (a type of white blood cell).
Contingency management in psychotic patients with Substance Use Disorders (SUD) was found in a systematic review with meta analysis (Destoop et al., 2021) to be effective compared to standard care in:
Improving abstinence rates of drug use, measured by:
self-reported lower number of days using substance (SMD = −0.52, 95% CI −0.98 to −0.06; p = 0.03
tendency to more negative breath or urine samples for substance use (OR 2.13, 95% CI 0.97 to 4.69; p = 0.06)
However no differences among retention in treatment (RR 1.15, 95% CI 0.90 to 1.45; p = 0.26).
Likely to be beneficial
not-drug specific
improve mental health outcomes, reduce substance use
A recent systematic review with meta-analysis (Bolivar et al., 2021, RCT= 74, N=10 444) found contingency management for patietns receiving medication for opioid use disorder to have:
medium-large effect size for abstinence from stimulants, Cohen d = 0.70 [95% CI, 0.49-0.92]; cigarette use, Cohen d = 0.78 [95% CI, 0.43-1.14]; illicit opioid use, Cohen d = 0.58 [95% CI, 0.30-0.86] and improved medication adherence, Cohen d = 0.75 [95% CI, 0.30-1.21]),
small-medium effect size for increased absitnence from polysubstance use, Cohen d = 0.46 [95% CI, 0.30-0.62] and improved therapy attendance, d = 0.43 [95% CI, 0.22-0.65]).
Collapsing across abstinence and adherence categories, contingency management was associated with medium effect sizes for abstinence (Cohen d = 0.58; 95% CI, 0.47-0.69) and treatment adherence (Cohen d = 0.62; 95% CI, 0.40-0.84) compared with controls.
Contingency management was found in a systematic review (EMCDDA 2016, studies = 20, N=1 676) to be effective in:
helping opioid users in substitution treatment to reduce cocaine use (10 out of 13 studies reported statistically significant results in favour of CM)
helping opioid users in substitution treatment to improve cocaine abstinence (8 out of 8 studies reported statistically significant results in favour of CM)
helping opioid users in detoxification to improve retention in treatment (2 out of 3 studies reported statistically significant results in favour of CM) as well as opioids and cocaine abstinence (7 out of 10 studies reported statistically significant results in favour of CM)
Reducing cannabis use for patients with comorbidities could improve clinical, cognitive, and psychosocial outcomes. Contingency management (CM) for patients with comorbid diagnoses was assessed in a narrative systematic review (Rodas et al., 2022, 6 studies, 4 focused on Schizophrenia and schizoaffective disorder, while the remaining two involved patients with major depressive disorder) and found to have an effect in:
decreasing cannabis use.
More research is needed to establish the implications of CM for improving psychiatric symptoms in patients with comorbidities. Several studies in the current review did not find significant results in reducing psychiatric symptom severity.
Unknown effectiveness
co-morbidity
improve mental health outcomes, reduce substance use
Contingency management (CM) involves participants receiving something of value such as a gift card, voucher or chance to win a prize as a reward for the achievement of a specific and measurable desired behaviour, most commonly a negative urine drug test for stimulants when implemented for the treatment of stimulant use disorder.
CM alone was found in a systematic review of reviews (Ronsley et al., 2020, 29 systematic reviews examining eleven intervention modalities) to be effective in improving:
abstinence at 12 weeks (Odds Ratio [OR] 2.29, 95% Confidence Interval [CI] 1.62, 3.24),
abstinence at the end of treatment (OR 2.22, 95% CI 1.59, 3.10),
dropout at 12 weeks (OR 1.39, 95% CI 1.09, 1.78),
and dropout at the end of treatment (OR 1.41, 95% CI 1.10, 1.82).
However the effect was not sustained at longest follow up (OR 1.10, 95% CI 0.83, 1.46).
Another more recent systematic review with meta-analysis (Bentzley et al., 2021) statistically compared all the different treatment options (157 studies comprising 402 treatment groups and 15 842 participants) looking for the interventions associated with an objective reductions in cocaine use among adults. Excluding other therapies, the largest treatment groups across all studies were psychotherapy (mean [SD] number of participants, 40.04 [36.88]) and contingency management programs (mean [SD] number of participants, 37.51 [25.51]). The analysis found that:
only contingency management programs were significantly associated with an increased likelihood of having a negative test result for the presence of cocaine (OR, 2.13; 95% CI, 1.62-2.80), and this association remained significant in all sensitivity analyses.
METHAMPHETAMINE
A systematic review without meta-analysis (Hayley et al., 2020) described the broad benefits of contingency management, including greater drug abstinence, higher utilization of other treatments and medical services, and reductions in risky sexual behaviour specifically for methamphetamine users.
Another systematic review without meta-analysis (AshaRani et al., 2020) confirmed that CM interventions among all the behavioural interventions consistently showed benefits (reduced drug use, better treatment retention, reduction in psychiatric symptoms and better quality of life) during the treatment period of METH use; however, the sustainability of the effect, post-intervention, is not well-studied. Moreover they found that although CM and CBT, both demonstrated positive outcomes individually, no clear synergism was observed when CM interventions were combined together with CBT.
Continuing care, i.e. interventions following the initial period of more intensive care aimed at manage and sustain recovery (including cognitive behavioural therapies (CBT), recovery management check-ups, 12-step or self-help and technology based interventions) was found in a systematic review with meta-analysis (Blodgett et al., 2014, 19 studies, N=3542) to be more effective than control conditions on:
at least one substance use outcome (Hedges’ g = 0.187, p< 0.001)
The same meta-analysis also found that
longer planned treatments did not have larger effects sizes than studies with shorter prescribed periods of treatment
there was no significant difference between treatments with protocol-specified intervention sessions and those without planned sessions per week
These results were confirmed by another systematic review without meta-analysis (Dennis et al., 2014) that looked specifically at the effects of different types of continuing care:
behavioural therapies showed promising results on use and retention in treatment outcomes, especially for moderate severity clients recovery managements check-ups are primarily effective in linking people back to treatment more robust evidence is still needed for self-help groups and technology-based interventions
Opioid substitution treatment was found in a systematic review (ECDC/EMCDDA, 2018) to be effective in:
reducing post-release mortality.
One cohort study (Degenhardt et al., 2014) enrolling N=16453 people released from prison 60161 times (all opioid dependent people who entered OST between 1985 and 2010 and were released from prison at least once between 2000 and 2012 in Australia) showed that those continuously retained in OST after being released from prison (continuity of care):
had a reduced risk of mortality by 75% (adjusted hazard ration=0.25, 95 % CI 0.12 to 0.53).
One RCT (Dolan et al., 2005, cited in EMCDDA, 2010) suggests that retention in MMT in prison settings is associated with:
reduced mortality from all causes (OR 0.54, 95 % CI 0.20 to 1.43);
Economic evaluations of the pharmacological treatment of opioid use disorder were analysed in a narrative systematic review (Onuoha et al., 2021, studies = 21 - 4 cost-offset studies and 17 cost-effectiveness/cost-benefit studies) that found:
strengthened evidence on the cost-effectiveness of buprenorphine and methadone, indicating that these treatments are both economically advantageous compared with no pharmacotherapy (no evidence was found supporting superior economic value between the two medications)
Four studies focused on the potential reductions in healthcare costs associated with pharmacological treatment of opioid use disorders and found that OST leads to lower healthcare resource utilization and expenditures than nonpharmacologic therapies. Also results from one population-level study indicate significantly lower criminal justice–related costs among participants who received methadone compared with those who received detoxification only.
Further economic research is needed on Naltrexone, as well as other emerging pharmacotherapies, treatment modalities, and dosage forms.
Culturally sensitive programs integrate positive youth development factors such as future orientation, problem-solving, communication, decision-making, and emotional regulation with specific cultural or ethnic factors related to socialisation, identity, and acculturation. Culturally sensitive prevention programs for substance use were assessed in a systematic review and meta-analysis (Bo et al., 2023, 30 studies) and found a small yet significant effect in:
Preventing and reducing substance use (Hedges’s g = - 0.20, 95% CI = [-0.24, -0.16])
Likely to be beneficial
improve knowledge, improve psychosocial functioning, reduce substance use
Culturally sensitive substance use treatment interventions for racial/ethnic minority youth were found in a systematic review with meta-analysis (Steinka-Fry et al., 2017) to have no significant effect in:
reducing use when compared to ‘treatment as usual’ and bona fide comparisons (i.e. intervetions that differed only on the culturally sensitive elements)
