psychosocial approaches to psychostimulant dependence: a systematic review

Journal of Substance Abuse T

Regular article

Psychosocial approaches to psychostimulant dependence:

A systematic review

James Shearer, (B.A., Grad. Dip. (Economics))4

National Drug and Alcohol Research Centre, University of New South Wales, Sydney NSW 2052, Australia

Received 3 March 2006; received in revised form 2 June 2006; accepted 16 June 2006

Abstract

This review examines the nature and evidence for the effectiveness of psychosocial interventions for psychostimulant dependence.

Psychostimulant dependence and related harms continue to increase in many parts of the world, while treatment responses are predominantly

limited to psychosocial interventions. The effectiveness of psychosocial interventions is compromised by poor rates of treatment induction

and retention. As with other substance use disorders, increasing the diversity of treatment options is likely to improve treatment coverage and

outcomes across a broader range of users. Identifying medications that might enhance treatment induction and retention would also enhance

the effectiveness of psychosocial programs. It is concluded that psychosocial interventions are moderately effective in reducing

psychostimulant use and related harms among psychostimulant-dependent persons. D 2007 Elsevier Inc. All rights reserved.

Keywords: Psychosocial intervention; Psychostimulant drugs; Systematic review

1. Introduction

Presentations to treatment services for psychostimulant-

related problems have increased in many countries. Psy-

chostimulant-related harms include psychological morbidity,

dependence, medical complications, impaired social func-

tioning, criminal behavior, and elevated HIV risk due to

unsafe injecting and unprotected sex (Baker, Lee, & Jenner,

2004; Platt, 1997). In the United States, cocaine has been a

leading cause of emergency room visits (Kissin & Ball,

2003), while methamphetamine use has recently emerged as

a public health issue (Brecht, Greenwell, & Anglin, 2005;

Office of National Drug Control Policy, 2004; Rawson,

Gonzales, & Brethen, 2002). Cocaine powder and crack

cocaine use, related mortality, and treatment demand have

grown strongly in the United Kingdom, the Netherlands, and

Spain (EMCDDA, 2005). In Australia, cocaine has become

entrenched among heroin injectors (Darke, Kaye, & Topp,

2002), and increases in psychosis have coincided with the

0740-5472/07/$ – see front matter D 2007 Elsevier Inc. All rights reserved.

doi:10.1016/j.jsat.2006.06.012

4 Tel.: +61 2 9385 0333; fax: +61 2 9385 0222.

E-mail address: [email protected].

advent of purer methamphetamine forms, specifically bbase,Qan injectable moist preparation, and bice,Q a smokeable

crystalline preparation (McKetin, McLaren, & Kelly, 2005).

Most methamphetamine is consumed in Asian countries,

with particularly high rates of consumption and related

problems, such as psychosis, occurring in Thailand, Philip-

pines, and Taiwan (Farrell, Marsden, Ali, & Ling, 2002;

UNODC, 2004).

Psychostimulant dependence is a chronic, relapsing

condition that is highly treatment refractory. The situation

is compounded by limited treatment options and clinical

experience. Services with regular contact with psychostimu-

lant users commonly manage acute presentations associated

with psychosis (such as mental health services and hospital

emergency departments) or provide harm reduction services

(such as needle and syringe programs). Psychostimulant

dependence, arguably the underlying maladaptive pattern of

drug use causing many of these problems, is often not

specifically addressed. There are, as yet, no pharmacological

approaches recognized as safe or effective in achieving and

maintaining abstinence from illicit psychostimulant use

among dependent persons (De Lima, Oliveira Soares,

reatment 32 (2007) 41–52

J. Shearer / Journal of Substance Abuse Treatment 32 (2007) 41–5242

Reisser, & Farrell, 2002; Kreek, Laforge, & Butelman, 2002;

Shearer & Gowing, 2004). The mainstay of treatment of

psychostimulant dependence has been psychosocially based

interventions. These include counseling, behavioral and

cognitive therapies, interpersonal psychotherapy (IPT), and

abstinence-oriented interventions such as residential rehabil-

itation and managed withdrawal or detoxification.

This review examines these psychosocial approaches to

psychostimulant dependence by describing the rationale

underpinning each treatment approach, the elements of the

treatment, and the evidence for effectiveness in psychosti-

mulant users. Most studies have been conducted among

cocaine users in the United States, although there is

evidence that cocaine and amphetamine users have a similar

response to treatment (Copeland & Sorenson, 2001; Rawson

et al., 2000). The neurobiological effects of cocaine and

amphetamine are similar, apart from the much shorter half-

life of cocaine of 30 minutes. It has also been postulated that

dependence on both cocaine and amphetamine is similarly

mediated through effects on the dopamine system (White &

Kalivas, 1998). Differences in the treatment response

between the two substances may yet emerge, given that so

few controlled studies have been published, particularly in

the area of amphetamine dependence.

The goals of psychosocial interventions are (1) to engage

dependent users into the treatment process, (2) to work to

retain them in treatment, (3) to encourage treatment com-

pliance, and (4) to provide relapse prevention (RP) support.

The approaches vary according to treatment rationale (often

Table 1

Results of the systematic review of online databases

Term/Source Total citations Lim

Community reinforcement/Medline 47 11

Community reinforcement/PsycINFO 139 33

Contingency management/Medline 230 55

Contingency management/PsycINFO 1,455 99

Cue exposure/Medline 160 30

Cue exposure/PsycINFO 231 31

MI/Medline 272 9

MI/PsycINFO 455 10

RP/Medline 1,002 107

RP/PsycINFO 2,244 167

Cognitive behavioral/Medline 3,336 76

Cognitive behavioral/PsycINFO 13,776 151

Cognitive therapy/Medline 6,026 93

Cognitive therapy/PsycINFO 10,548 100

Behavior therapy/Medline 18,544 188

Behavior therapy/PsycINFO 14,108 111

Psychotherapy/Medline 41,607 292

Psychotherapy/PsycINFO 66,179 258

Detoxification/Medline 10,718 216

Detoxification/PsycINFO 2,211 209

Residential treatment/Medline 2,460 73

Residential treatment/PsycINFO 2,835 81

Therapeutic community/Medline 2,037 55

Therapeutic community/PsycINFO 2,549 56

Self-help groups/Medline 5,677 54

Self-help groups/PsycINFO 1,114 38

based on an underlying hypothesis of dependence) and the

elements or bingredientsQ of the intervention. Interventions

can be further distinguished by the frequency or duration of

treatment (treatment intensity); whether they are inpatient,

outpatient, or outreach (treatment setting); and whether they

are delivered to individuals, groups, or through other

communication channels (treatment format) (Baker & Lee,

2003). Finally, interventions vary according to their resource

requirements such as type and availability of clinical

expertise and training, materials, and other structured

activities. Most psychosocial interventions share core com-

ponents, including psychoeducation (skills and insights),

reinforcing the self-efficacy of patients (personal belief in the

possibility of change), provision of support, and encouraging

therapeutic relationships (Carroll, 1998).

2. Systematic review procedures

A systematic literature review was conducted using the

Medline and PsycINFO databases. The following terms were

searched to identify studies of specific psychosocial

approaches: bcommunity reinforcement,Q bcontingencymanagement,Q bcue exposure,Q bmotivational interviewing,Qbrelapse prevention,Q bcognitive behavioral,Q bcognitive the-rapy,Q bbehavior therapy,Q bpsychotherapy,Q bdetoxification,Qbresidential treatment,Q btherapeutic community,Q and bself-help groups.Q These results were then combined for the search

term bcocaine or amphetamine or methamphetamine or

ited to stimulants Limited to RCTs Selected RCTs

7 4

16 4

29 9

65 12

8 1

16 1

5 2

6 2

35 8

33 3

36 6

47 3

49 10

20 2

55 14

20 3

80 15

48 6

37 3

27 1

4 1

4 0

4 0

3 0

15 2

3 0

J. Shearer / Journal of Substance Abuse Treatment 32 (2007) 41–52 43

stimulantQ to identify studies involving psychostimulant use.

Studies were then limited to reports of randomized controlled

trials (RCTs) published in peer-reviewed journals in English

(see Table 1).

The results of the database searches were further

reviewed to finally reveal 43 unique and original reports

of RCTs of psychosocial interventions primarily targeted

toward psychostimulant use outcomes. These have been

indicated by an asterisk in the general reference list.

Reviews, letters, duplicates, and non-RCTs were excluded.

Studies that reanalyzed previously reported studies, those

that did not report between-group changes in stimulant use,

those that did not have effective control groups for specific

psychosocial approaches, those that did not randomize

subjects, those that were retrospective reports, or pilot

studies superseded by definitive efficacy trials were not

included. Studies examining intervention format or inten-

sity were not included as these did not contribute data

about the relative efficacy of approaches. These data were

supplemented by 10 reports from clinical trials and quality

long-term cohort studies (Baker et al., 2006; Carroll et al.,

2006; Donovan, Rosengren, Downey, Cox, & Sloan, 2001;

Elk et al., 1995; Hubbard, Craddock, & Anderson, 2003;

Iguchi, Belding, Morral, Lamb, & Husband, 1997; Milby

et al., 1996; Miller, Yahne, & Tonigan, 2003; Simpson,

Joe, & Broome, 2002; Simpson, Joe, Fletcher, Hubbard, &

Anglin, 1999) missed due to their recent date of pub-

lication or otherwise not captured by the terms of the

systematic review.

3. Behavioral interventions

Behavioral interventions are based on the view that drug

use is a learned behavior controlled by stimuli that

immediately follow an action. Skinner named such behav-

iors boperantQ because they operate on the environment to

receive reinforcement. Critically, in the case of drug use,

once the operant behavior occurs, its future rate of

occurrence depends upon its immediate pleasurable con-

sequences or reinforcement.

3.1. Community reinforcement approach (CRA)

CRA is a form of contingency management that seeks to

identify individual behavioral reinforcers in the patient’s

life, which are as incompatible as possible with the drug use

reinforcers. Major lifestyle changes need to be initiated and

maintained in the domains of familial relationships, recrea-

tional activities, social networks, and vocational skills. The

objective is to increase satisfaction in a drug-free lifestyle to

compete with the reinforcement from drug use and thereby

reduce the likelihood of continued drug use or relapse. The

elements of CRA include a functional analysis, relationship

counseling, vocational guidance, drug refusal skills, and

recreational and social skills. A manualized version of CRA

plus vouchers for cocaine dependence, produced by the U.S.

National Institute of Drug Abuse, provides a comprehensive

24-week program description with additional components

for HIV/AIDS prevention, other substance use, and other

psychiatric problems (Budney & Higgins, 1998).

CRA plus vouchers has been shown to significantly

increase rates of cocaine abstinence and treatment retention

compared with noncontingent incentives (Higgins, Wong,

Badger, Haug Ogden, & Dantona, 2000), vouchers alone

only during treatment (Higgins et al., 2003), and 12-step

drug counseling (Higgins et al., 1993). The addition of

contingent vouchers to CRA alone significantly improved

treatment retention and cocaine abstinence rates (Higgins

et al., 1994). Evidence for the efficacy of CRA remains

largely limited to RCTs conducted by a single research group

based in a nonmetropolitan area of the United States,

whereas studies of contingency management in other

populations have focused on incentive-based programs

detailed in the next section. Despite robust treatment effects

identified under randomized, controlled conditions, as well

as a long empirical history in the treatment of alcohol, CRA

has yet to be widely implemented (Roozen et al., 2004). High

treatment cost and labor intensity have been cited as potential

barriers to wider implementation (Roozen et al., 2004).

3.2. Incentive-based programs

Incentive- or voucher-based programs are another form

of contingency management, which, together with CRA,

have been recommended as best treatment practice in the

United States (Rawson, 1999). Voucher-based incentive

programs aim to engage stimulant users into treatment and

promote initial abstinence from stimulants. Although they

are most commonly offered in the context of the CRA

outlined above, voucher programs have also been shown to

be effective as stand-alone forms of contingency manage-

ment (Silverman et al., 1996). Patients earn vouchers

exchangeable for retail items most often contingent on

psychostimulant-free urine samples, with other rewarded

behavior including drug treatment attendance (Iguchi et al.,

1997), treatment attendance for other conditions such as

tuberculosis and prenatal classes (Elk, Mangus, Rhoades,

Andres, & Grabowski, 1998; Elk et al., 1995; Jones, Haug,

Silverman, Stitzer, & Svilkis, 2001), or evidence of

employment. The effectiveness of voucher programs may

vary according to their value and the frequency and scale of

rewards (whether constant, escalating, or decreasing over

time; Petry, Martin, & Simcic, 2005; Petry, Peirce, et al.,

2005; Plebani Lussier, Heil, Mongeon, Badger, & Higgins,

2006; Silverman et al., 1998). The scheduling of vouchers

can also be important, with immediate rewards more

effective than weekly vouchers—consistent with the operant

theory of behavior (Kirby, Marlowe, Festinger, Lamb, &

Platt, 1998; Plebani Lussier et al., 2006). Incentive rewards

apart from vouchers include take-home methadone doses

(Chutuape, Silverman, & Stitzer, 1999; Schmitz et al., 1998;


Stitzer, Iguchi, & Felch, 1992), lunch, recreational activity

groups, transport, vocational counseling, and affordable

housing (Milby et al., 1996).

A meta-analysis of 30 clinical trials of voucher-based

reinforcement found moderate but significant effect sizes

compared with control conditions (Plebani Lussier et al.,

2006). Among the 12 studies specifically targeted toward

cocaine use, the estimated effect size was r = .35 (95%

C = 0.27–0.43), which approximated to a between-group

difference of 35%. More immediate voucher delivery and

higher voucher values were associated with larger effect

sizes. This meta-analysis was completed prior to publication

of three large positive studies of incentive-based programs in

mixed cocaine–methamphetamine groups. A large study in

community-based drug treatment programs found that the

addition of prize-based incentives (with an overall relatively

low value) improved treatment retention and abstinence from

stimulants (Petry, Peirce, et al., 2005). A direct comparison

between an escalating voucher schedule and cognitive–

behavioral therapy (CBT) among stimulant-dependent per-

sons found that the contingency management program was

superior to CBT over a 16-week treatment period, with

comparable benefits a year later (Rawson et al., 2006). The

authors attributed this success to superior treatment retention

achieved by the contingency management program. Finally,

stimulant-using methadone patients were twice as likely to

submit negative samples compared with controls using a

very low and random reward schedule (Peirce et al., 2006).

Voucher incentives, however, have been less effective than

day treatment for poor, inner-urban crack users (Kirby et al.,

1998; Marlowe et al., 2003), as well as for dually diagnosed

homeless individuals (those with psychosis and those who

were cocaine dependent; Milby et al., 2000). These latter

findings may be due to the desirability of day care in these

disadvantaged populations. Some studies suggest that the

efficacy of incentive programs may be greatest during the

treatment period when patients receive contingent rewards

and tends to deteriorate after rewards, and their immediate

reinforcement, are withdrawn (Rawson, Huber, et al., 2002;

Schottenfeld et al., 2005).

3.3. Cue exposure

Cue exposure derives from the classical conditioning

theory of learning, which argues that cues have an important

role in the instatement and continuation of addictive behavior

(Heather & Greeley, 1990). Exposure to stimuli associated

with drug use such as drug-using friends, places, para-

phernalia, or life stressors may cue drug craving and relapse.

Cocaine- and amphetamine-dependent individuals have been

found to be highly cue reactive (Ehrman, Robbins, Childress,

& O’Brien, 1992; Topp, Lovibond, & Mattick, 1998).

Treatment consists of repeated exposure to identified stimuli

without drug use, leading to extinction of the autonomic and

subjective response. The approach showed promise in

cocaine users (O’Brien, Childress, McLellan, & Ehrman,

1990). A recent meta-analysis, however, identified only nine

controlled trials of cue-exposure addiction therapy and

concluded there was no clear evidence to support efficacy

(Conklin & Tiffany, 2002).

4. Cognitive interventions

Cognitive models of drug dependence extend the basic

concepts of reinforcement, underpinning earlier behavioral

models by adding the impact of cognition or the way

thoughts and beliefs process internal and external stimuli.

4.1. Motivational interviewing

Ambivalence about changing drug use behavior is a

common reason for treatment failure, which may be

particularly salient for psychostimulant users who have

difficulty entering and remaining in treatment. Motivational

interviewing (MI) is a technique that was developed when

William Miller applied the principles of the Rogerian client-

centered approach to alcohol-dependent patients (Miller,

Benefield, & Tonigan, 1993). Miller and Rollnick (2002)

define MI as ba client-centered, directive method for

enhancing intrinsic motivation to change by exploring and

resolving ambivalenceQ (p. 25). MI involves the application

of four basic principles: (1) expressing empathy through

techniques such as reflective listening, (2) developing

discrepancy between the patient’s self-image as a drug user

and other preferred non-drug-using self-images, (3) brollingwith resistanceQ and avoiding argumentation, and (4)

supporting self-efficacy or the patient’s personal sense of

ability to change (Miller & Rollnick, 2002). MI relies upon

counseling microskills described in Rogers’ client-centered

approach including open-ended questions, reflective listen-

ing, affirmations, and summarizing (Egan, 1998). Various

strategies may be used, depending on the patient’s circum-

stances (Jarvis, Tebbutt, Mattick, & Shand, 2005). These

include exploring the good and less good things about drug

use, exploring the patient’s concerns, and looking back to

past expectations and looking forward to future hopes. MI

can be delivered in two phases; the first builds the patient’s

motivation to enter treatment, and the second seeks to

strengthen treatment adherence including compliance to

prescribed medication (Zweben & Zuckoff, 2002).

A large multisite RCT examined the effectiveness of

integrating MI into the intake procedures of community

drug treatment programs (Carroll et al., 2006). Although MI

significantly improved program retention 1 month post-

enrolment compared with standard intake counseling, there

were no differences in drug use across conditions. Primary

cocaine and methamphetamine users comprised around a

quarter of the sample (half of the subjects were primary

alcohol users), and no detailed analyses for the stimulant

subgroups were available. The lack of effect on substance

use outcomes and longer term retention should be viewed in

Fig. 1. Cognitive–behavioral model of relapse. Source: Witkiewitz & Marlatt. (May–June 2004). Relapse prevention for alcohol and drug problems. American

Psychologist, 59, 224–235, published by the American Psychological Association, reprinted with permission.


the overall context of high retention and good outcomes

achieved at participating treatment centers. A lack of effect

among active treatment seekers may also have been

explanatory. A meta-analysis of 30 clinical trials of MI

yielded moderate standardized effect sizes in drug depend-

ence (mainly alcohol with none specific to psychostimu-

lants) compared with no-treatment or placebo groups

(Burke, Arkowitz, & Menchola, 2003). A qualitative

meta-review of 21 studies of MI in treatment adherence

maintenance found significant adherence effects in 12 stud-

ies, comparable effects to other standard interventions in

5 studies, and no incremental benefit in 4 studies (Zweben

& Zuckoff, 2002).

Two studies among cocaine-dependent populations have

supported the view that MI conveys the greatest benefit to

patients with low initial motivation to change (Rohsenow

et al., 2005; Stotts, Schmitz, Rhoades, & Grabowski, 2001).

These studies also suggested that MI could be counter-

productive among more committed patients, whose drug use

and treatment compliance outcomes actually appeared to

deteriorate. Two other major studies, mainly among cocaine

users, found no effect on treatment adherence or drug use

outcomes, which were variously attributed to an excessively

manual driven approach (Miller et al., 2003) or where the

treatment incentive (hospital care for homeless persons) had

already assured treatment adherence (Donovan et al., 2001).

Although research results are largely in favor of MI, the

negative findings have perhaps even more important

implications for treatment delivery. They reinforce the

underlying rationale that MI must be client directed and

not overly manualized, that it will have greatest benefits for

out-of-treatment groups, and that among committed treat-

ment seekers, negative feedback and creating unnecessary

tension can be highly counterproductive.

4.2. Relapse prevention

RP is based on classical conditioning where the

responding behavior (drug use) is controlled by preceding

stimuli rather than the consequent stimuli that reinforce

operant behavior. The cognitive–behavioral model of

relapse developed by Marlatt and Gordon (1985) focuses

on the events surrounding initial drug use after a period of

abstinence and strategies to prevent a single lapse in

becoming a full-blown relapse (Fig. 1).

RP aims to reduce the likelihood of lapses by teaching

patients effective coping responses to risk situations. Marlatt

and Gordon developed several key concepts in RP. The

abstinence violation effect contains two elements: firstly, the

guilt created by a lapse, and secondly, the loss of self-

efficacy where patients lose confidence in their ability to

cope with risky situations. Another important concept is that

of seemingly irrelevant decisions where patients make

unconscious and apparently innocuous choices, which

ultimately expose them to drug-taking risk situations. The

essential elements of RP are teaching patients: (1) skills to

cope with drug craving, (2) drug refusal skills and

assertiveness, (3) how to recognize seemingly irrelevant

decisions, (4) general problem-solving skills, and (5) how to

cope with drug use lapses.

A meta-analysis of 26 clinical trials found RP to be

generally effective in reducing drug use and improving

psychosocial functioning, although results were signifi-

cantly better for alcohol and polydrug use than cocaine or

tobacco (Irvin, Bowers, Dunn, & Wang, 1999). RP was also

more effective when combined with medication, although

this finding was based on only four trials (three in alcohol,

one in cocaine). A subsequent promising report of combined

RP and naltrexone in cocaine dependence was not replicated

in dual dependence on cocaine and alcohol (Schmitz, Stotts,

Rhoades, & Grabowski, 2001, Schmitz, Stotts, Sayre,

Delaune, & Grabowski, 2004). RP was less effective than

other approaches in the treatment of cocaine dependence

(r = �.03; 95% CI = �0.17 to 0.11), although this finding

was based on only three studies. An earlier qualitative meta-

review of 24 RCTs found RP to be more effective than no

treatment but equally as effective as other treatment

approaches (Carroll, 1996). In contrast to the meta-analysis

published by Irvin et al., Carroll did not find that efficacy

varied by drug type, although both reviews used the

same three cocaine studies. Closer examination of these

three studies shows only selective and modest support for

the effectiveness of RP. In the first study by Carroll,

Rounsaville, and Gawin (1991), the benefit of RP over IPT


did not reach significance except in a subgroup of more

severe users. Their second study found improved outcomes

for RP over case management only at 1-year follow-up, and

this would not have been included in the Irvin meta-

analysis. The third study was a negative report when RP was

compared with 12-step-based counseling where no differ-

ence was found in either treatment retention or cocaine use

(Wells, Peterson, Gainey, Hawkins, & Catalano, 1994).

Subsequent comparisons of individualized RP with standard

group counseling found no additional benefit for RP except

in patients already committed to complete abstinence

(McKay et al., 1999, 1997). No comparable studies have

been conducted among amphetamine users.

4.3. Cognitive–behavioral therapy

CBT was originally developed for the treatment of

depression (Beck, 1963, 1964) and was subsequently

extended to a range of mental disorders, including substance

use disorders (Beck,Wright, Newman, & Liese, 1993). Much

as drug dependence can be viewed as a maladaptive

behavioral pattern, CBT focuses on maladaptive patterns of

thinking, which are also referred to as cognitive errors such

as overgeneralization, catastrophizing, personalization, self-

defeating thinking, and fixed false beliefs (Beck, 2005). A

cognitive–behavioralmodel linksactivatingevents (or triggers)

to the interpretation of these events and the unhelpful thoughts

that lead to negative feelings and undesired behavior such as a

resumption of drug use (Baker, Kay-Lambkin, Lee, Claire, &

Jenner, 2003).

Among psychostimulant users, CBT aims to help patients

recognize and understand drug-related problems and assist

them to restructure or modify dysfunctional cognitions that

may be perpetuating the problem behavior (Baker, Gowing,

Lee, & Proudfoot, 2004). The key active ingredients of CBT

include (1) functional analysis, which explores the patient’s

thoughts, feelings, and circumstances before and after each

occasion of drug use; (2) individually tailored training in RP

skills; (3) monitoring thoughts about drugs; (4) identifying

high-risk situations for relapse; (5) extra-session skills

implementation (bhomeworkQ); and (6) within-session skills

practice (Carroll, 1998).

CBT has not generally been shown to be better than any

other form of psychosocial intervention in initiating

abstinence (Gowing, Proudfoot, Henry-Edwards, & Teeson,

2001; Rawson et al., 2006). More durable posttreatment

effects suggest a useful role in RP (Carroll et al., 1994;

Epstein, Hawkins, Covi, Umbricht, & Preston, 2003;

Rawson, Huber, et al., 2002). Potential limitations of CBT

include the risk of an overly didactic rather than client-

centered approach (Epstein et al., 2003) and less efficacy in

patients who have lower or impaired levels of cognition

(Maude-Griffin et al., 1998).

The CBT component of the Matrix Model, an intensive

multicomponent outpatient program developed for meth-

amphetamine and cocaine users in the United States, was

found to be comparable to contingency management in

reducing posttreatment cocaine use among methadone

patients and superior to the usual treatment (Rawson,

Huber, et al., 2002). A recent evaluation of the entire

16-week Matrix Model program, which includes 36 CBT

sessions, 12 family education group sessions, 4 social

support group sessions, 4 individual counseling sessions,

weekly drug testing, and encouragement to attend weekly

12-step meetings, found significantly better treatment

retention and longer periods of methamphetamine absti-

nence over the course of treatment compared with the usual

treatment for methamphetamine dependence (Rawson, et al.,

2004). These benefits did not, however, persist at the

6-month posttreatment follow-up.

Results of the National Institute on Drug Abuse Collab-

orative Cocaine Treatment Study (Crits-Christoph et al.,

1999) challenged some emerging orthodoxies of drug treat-

ment research including the superiority of psychotherapy to

the usual treatment and the relationship between treatment

retention and outcome. In this study, cognitive therapy

achieved significantly superior treatment retention at

6 months compared with the 12-step-based drug counseling;

yet, cocaine use was significantly greater in the cognitive

therapy group at the 12-month follow-up. The authors

attributed the success of the individual counseling program

to its singular focus on abstinence and the quality of training

and supervision. A rigorous study orientation phase that

required subjects to demonstrate motivation to attend

sessions through three clinic visits and encouraged self-help

group participation may have introduced an element of

selection bias by discouraging potential subjects who had less

interest in 12-step approaches (Carroll, 1999). Further,

subjects in the 12-step-based counseling group were more

likely to attend extracurricular self-help meetings, effectively

increasing their treatment exposure. On the other hand, the

cognitive therapy program focused on maladaptive behavior

rather than strategies to achieve abstinence and gave no

encouragement for additional 12-step participation.

In Australia, CBT has been evaluated in regular amphet-

amine users based on a brief four-session intervention

comprising of an initial motivational interview and three

sessions built around cognitive–behavioral coping strategies

and RP (Baker et al., 2005). Subjects who received two or

more CBT sessions were significantly more likely to be

abstinent at the 6-month follow-up. The authors recom-

mended a stepped-care approach varying in intensity

between nontreatment and treatment settings, intervention

response, and co-occurring depressive symptoms.

5. Psychological interventions

The supportive–dynamic psychotherapeutic model con-

ceives stimulant dependence as a consequence of difficulties

in interpersonal functioning. The focus of IPT is not directly

on drug use but, rather, on the exploration of past and


present personal relationships and experiences (Carroll,

1998). One example is supportive–expressive therapy,

which examines ways to help patients discuss personal

experiences and identify relationship themes with special

attention paid to those themes where drug dependence has

played a part in problem feelings or behaviors. Psychiatri-

cally symptomatic methadone patients significantly reduced

posttreatment cocaine use when treated with this form of

IPT compared with standard drug counseling (Woody,

McLellan, Luborsky, & O’Brien, 1995). Interestingly, the

success of IPT was achieved in a psychiatrically sympto-

matic population, and the gains were most apparent at

posttreatment follow-up—a finding similar to that reported

for CBT in subjects with depressive symptoms. IPT has had

less success in unselected cocaine users, where it produced

significantly lower reductions in cocaine use compared with

individual drug counseling (Crits-Christoph et al., 1999) and

CBT (Carroll et al., 2004).

6. Abstinence-oriented interventions

6.1. Detoxification

There is little empirical evidence to support short-term

detoxification as a stand-alone treatment. In the United

States, 28-day programs were the predominant treatment

modality for cocaine, although their use has steadily

declined (Rawson, 1999). The basic principles of the

clinical management of stimulant withdrawal include

thorough mental health and drug use assessments, suppor-

tive psychosocial therapy, and symptomatic relief medica-

tion such as sedatives, antidepressants, or antipsychotics

where clinically indicated (Jenner & Saunders, 2004).

Stimulant withdrawal symptoms appear to be highly

variable, with some studies reporting moderate symptom

severity in outpatient samples that abated in a linear fash-

ion, making recourse to medication unnecessary (Coffey,

Dansky, Carrigan, & Brady, 2000; Miller, Summers, &

Gold, 1993). More severe and protracted symptoms includ-

ing disturbed sleep, drug craving, low mood, irritability, and

poor concentration have been reported in inpatient studies,

where withdrawal symptoms varied across two distinct time

phases—an initial bcrashQ after sudden discontinuation and asubsequent withdrawal phase (Gawin & Kleber, 1986;

McGregor et al., 2005). The chief limitation of short-term

detoxification is the high rate of relapse that underlines the

importance of engaging patients with longer term psycho-

social treatments postdetoxification (Katz et al., 2004;

Millery, Kleinman, Polissar, Millman, & Scimeca, 2002).

6.2. Residential rehabilitation

Therapeutic communities offer detoxified patients the

opportunity for longer term maintenance of abstinence

within a structured residential program often based on

12-step principles that will be discussed later. The ther-

apeutic community simulates a family model to act as a

change agent for individual behavior. Elements include

strictly enforced behavioral norms, group and individual

therapy, and clearly defined hierarchical roles and responsi-

bilities with associated rewards and punishments (Platt,

1997). An RCT of 90-day shelter-based drug treatment

program in homeless cocaine-using men found significant

declines in cocaine use compared with usual care after

21 months (Lam et al., 1995). Generally, however, there are

logistic and ethical impediments in conducting RCTs in

residential facilities, and most available evidence is from

long-term treatment cohort studies. Primary stimulant users

enrolled in a UK drug treatment cohort study who received

treatment in residential rehabilitation services significantly

reduced drug use and associated problems at 1-year follow-

up (Gossop, Marsden, & Stewart, 2000). Drug Abuse

Treatment Outcome Studies (DATOS), a U.S. drug treat-

ment cohort study, found that residential rehabilitation,

outpatient programs, and short-term inpatient programs

were all effective in improving treatment outcomes for

cocaine dependence with higher problem severity and short

treatment duration associated with higher cocaine relapses

(Simpson et al., 1999). A longer term (5-year) follow-up of

the DATOS cohort, however, found that patients in longer

term residential rehabilitation reported significantly reduced

cocaine consumption compared with those from outpatient

methadone and outpatient drug-free groups (Hubbard et al.,

2003), although this result was influenced by significant

attrition favoring treatment completers. These results were

supported by the Australian Treatment Outcome Study,

which found that residential rehabilitation was significantly

more effective than methadone or detoxification in reducing

cocaine use in heroin-dependent individuals after 3 months

of follow-up (Williamson, Darke, Ross, & Teesson, 2006).

The authors attributed this success to the broader aims of

residential rehabilitation to help patients cease all drug use,

whereas the other interventions were more narrowly focused

on heroin use.

6.3. Twelve-step programs

Self-help groups offered by Alcoholics Anonymous,

Narcotics Anonymous, and Cocaine Anonymous are based

on the 12-step philosophy. Nonresidential 12-step programs

are not considered to be a form of treatment per se but may

assist treatment maintenance (Jarvis et al., 2005). The

12-step approach is a common feature of drug treatment

in the United States (see Section 1.3 [Principles of Treat-

ment] in Dackis & O’Brien, 2001 and Daley & Mercer,

2002). The 12-step philosophy views addiction as an illness

that can be arrested 1 day at a time but never cured. The first

step in the process is commitment to a drug-free life, where

individuals accept that they are powerless over their

addiction. Four controlled studies have evaluated 12-step-

oriented programs in psychostimulant users with mixed

Table 2

Summary of psychosocial interventions and commentary on evidence of

efficacy among psychostimulant users

Intervention Comment

Community reinforcement Positive findings with respect to cocaine

use predominantly reported by a single

U.S. research group.

Voucher reinforcement Meta-analysis indicates moderate efficacy


results. One study found 12-step counseling to be com-

parable to RP (Wells et al., 1994); another large multisite

study found 12-step-based individual and group counseling

to be superior to cognitive therapy and IPT (Crits-Christoph

et al., 1999). Conversely, 12-step programs were used as

control conditions in studies supporting CRA plus vouchers

(Higgins et al., 1993) and CBT (Maude-Griffin et al., 1998).

among cocaine users (r = .35). Recent

clinical trials support use in cocaine and

amphetamine users. Less effective in more

severely disadvantaged groups.

Cue exposure No clear evidence of efficacy.

MI Meta-analysis indicates moderate efficacy

in drug use but no cocaine specific studies

included. Less effective in more severely

disadvantaged groups and more severely

dependent users.

RP Meta-analysis indicates RP may be less

effective among cocaine users than for

other drug types (r = �.03). Positivesynergies identified in combination with

pharmacotherapy.

CBT Mixed results in psychostimulant users,

although some value in RP.

Less effective among patients with

cognitive impairment.

Psychotherapy More effective in psychiatrically

symptomatic groups.

Detoxification Very high relapse rates underlines

importance of engaging patients with

longer term psychosocial treatment.

Residential rehabilitation Lack of RCTs. Positive results observed

with respect to cocaine use in cohort

studies. Most effective in more socially

disadvantaged groups.

Twelve-step programs Limited evidence for efficacy in selected

patient groups.

7. Conclusions

The evidence base for psychosocial interventions for

psychostimulant dependence is not strong (Table 2). There

are insufficient controlled trials with comparable, validated

outcomes to support one intervention over another. The

overall impression is, however, that psychosocial interven-

tions are moderately effective in reducing psychostimulant

use and associated problems (Baker et al., 2005; Burke et al.,

2003; Carroll, 1996; Crits-Christoph et al., 1999; Gowing

et al., 2001). No overarching meta-analysis has been

published, although a Cochrane Review protocol has been

prepared (Soares, Lima, & Farrell, 2001). Better outcomes

for behavioral, cognitive, and psychological approaches

have been reported among more severely psychiatrically

symptomatic populations, particularly those with depressive

symptoms (Baker et al., 2006; 2005; Carroll, Carroll, &

Rounsaville, 1995; Maude-Griffin et al., 1998; Woody

et al., 1995), although not all reports have been positive

(Crits-Christoph et al., 1999). Another strength of psycho-

social interventions is the promise of long-term benefits for

patients who are engaged and retained in longer term

treatment (Carroll et al., 1994; Epstein et al., 2003; Rawson,

Huber, et al., 2002).

Behavioral and cognitive interventions have not gener-

ally been effective in retaining acutely disadvantaged groups

of patients in treatment. Incentive-based programs, MI, and

CBT have all been unsuccessful in poor, homeless

populations or in those with unmet complex health and

welfare needs (Aharonovich et al., 2006; Donovan et al.,

2001; Kirby et al., 1998; Marlowe et al., 2003; Maude-

Griffin et al., 1998; Milby et al., 2000). Drug treatment

programs solely focused on psychostimulant use cannot

substitute for comprehensive health and welfare programs

needed by people who lack basic social and economic

support (Brecht et al., 2005). There is evidence that day care

and long-term residential rehabilitation may be successful in

more severely problematic cocaine users (Donovan et al.,

2001; Lam et al., 1995; Marlowe et al., 2003; Milby et al.,

2000; 2003; Williamson et al., 2006; see Table 2).

If the outcomes of most behavioral and cognitive

approaches are broadly comparable, then cost-effectiveness

may be an important consideration in developing future

models of care. Resource use may vary according to patient

contact time, the qualifications of counselor–therapists, the

availability of clinical expertise and training, the cost of

voucher programs, materials, communications costs, and

office-based costs. On this basis, briefer interventions

will have advantage over more comprehensive but

resource-intensive programs, such as the Matrix Program.

Patient selection will also be an important consideration

where more problematic patients may need more resource-

intensive treatments such as 24-hour residential programs

and IPT conducted by highly qualified therapists. Cost-

effectiveness studies may also offer guidance as to the

optimal intervention points (in terms of treatment history)

and intervention targets (i.e., selection of patients with more

severe psychiatric symptoms). This does not mean that

resource-intensive programs such as residential rehabilita-

tion, IPT, and day care programs will be too expensive;

rather, it means that their value is best demonstrated through

examining their costs relative to their outcomes in selected

problematic patient groups (see Schumacher, Mennemeyer,

Milby, Wallace, & Nolan, 2002, for an interesting dis-

cussion of relevant issues in cost analysis).

Early attrition from all forms of drug treatment is high,

which is of particular concern in psychosocial treatment of

psychostimulant dependence where time in treatment is

strongly related to better outcomes (Hubbard et al., 2003;

4Paper identified in systematic review.

yRelevant paper not identified in systematic review.


Simpson et al., 2002, 1999). Studies have variously

estimated attrition in cocaine treatment to be between 55%

and 74% (Gainey, Wells, Hawkins, & Catalano, 1993).

Pretreatment attrition, where eligible patients drop out

during treatment induction, is less often measured. In a

major U.S. study of cocaine treatment, only 27% of eligible

patients were ultimately randomized to treatment (Siqueland

et al., 2002), with most failing to complete pretreatment

induction. Among amphetamine users, attrition was 69%

after 90 days in Californian residential programs and 77%

after 180 days from outpatient programs (Maglione, Chao &

Anglin, 2000a, 2000b). In Australia, treatment for amphet-

amine use is significantly less successful than that for other

drugs. In cases where amphetamines were the principal drug

of concern, fewer treatment episodes were closed due to

completion of treatment and more amphetamine users

ceased treatment without notice (AIHW, 2005). Some

studies have found that severity of current psychostimulant

use predicted treatment dropout (Maglione et al., 2000b;

Miller et al., 2003; Simpson et al., 2002), although others

have not (Carroll, Power, Bryant, & Rounsaville, 1993).

Safe and effective medication would be a valuable adjunct

to most psychosocial programs as an incentive to partic-

ipation and to facilitate retention through providing symp-

tomatic relief in more severely dependent patients.

It has been estimated that only 10% of regular amphet-

amine users receive formal treatment in any given year,

compared with more than half of regular opiate users (Kelly,

McKetin, & McLaren, 2005). Supporting and increasing the

diversity of treatment options for dependent psychostimu-

lant users is one strategy to extend treatment coverage. The

addition of a pharmacotherapy to the range of available

treatments is an effective way to expand treatment coverage,

particularly among more severely symptomatic and depend-

ent users. New pharmacotherapies have significantly

increased the impact of treatment in opiate (Krantz

& Mehler, 2004) and nicotine dependence (Okuyemi,

Ahluwalia, & Harris, 2000). Current research along several

avenues suggests that new pharmacotherapies may become

available within the next 5 years and may be earlier for

those participating in clinical trials. Promising candidates

include the aversive agent disufiram (Carroll et al., 2004),

dexamphetamine substitution (Grabowski, Shearer, Merrill,

& Negus, 2004; Shearer, Sherman, Wodak, & van Beek,

2002), therapeutic vaccines (Kosten et al., 2002), the novel

CNS stimulant modafinil (Dackis, Kampman, Lynch,

Pettinati, & O’Brien, 2005), and the GABA agonist

baclofen (Shoptaw et al., 2003). There have been positive

additive or synergistic effects demonstrated from integrating

psychosocial with pharmacological approaches derived

from medication adherence and posttreatment effects

(Carroll et al., 2000; Irvin et al., 1999; Huber et al., 1997;

O’Brien, 2005; Plebani Lussier et al., 2006; Stitzer &

Walsh, 1997; Zweben & Zuckoff, 2002). The challenge will

be to integrate pharmacological and psychosocial

approaches to optimize outcomes for psychostimulant-

dependent persons.

Acknowledgment

The author is grateful to Associate Professor Shane

Darke at NDARC for comments on earlier drafts of

this review.

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