Lee N.K., Rawson R.A. et al.
Drug and Alcohol Review: 2008, 27(3), p. 309–317.
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After trawling the world literature for randomised trials, reviewers found it is less the case that 'nothing works' with methamphetamine users, more the case that, within reason, everything works for some people to some degree and for some time.
Summary After cannabis, methamphetamine is the most widely used illicit drug in the world and poses significant challenges for treatment providers. Much of the treatment knowledge about methamphetamine users has been extrapolated from studies of treatment for cocaine dependence. Medications have been shown to be of limited effectiveness, making psychological interventions the treatment of choice. This review focuses upon randomised trials of cognitive-behavioural or behavioural (such as contingency management) interventions for methamphetamine users. A systematic search of published literature discovered just 12 reports of intervention studies which tested cognitive-behavioural or behavioural interventions using randomised trial methodology. Most commonly, studies examined cognitive-behavioural therapy and/or contingency management. Cognitive-behavioural therapy appears to be associated with reductions in methamphetamine use and other positive changes, even over very short periods of treatment (two and four sessions). Contingency management studies found a significant reduction of methamphetamine during application of the procedure, but it is not clear if these gains are sustained at post-treatment follow-up. The review highlights that there are effective treatments for methamphetamine dependence. Alcohol and other drug clinicians are familiar with these types of interventions and should use them and convey to clients that they are effective. Services and policy makers should ensure that best practice interventions are implemented in alcohol and other drug services.
The authors concluded that psychological intervention is effective in addressing methamphetamine use and dependence. Cognitive-behavioural therapy and contingency management are two accessible interventions easily implemented in current services. There is still more work to conduct in improving methamphetamine treatment, however, and further research into cognitive-behavioural and behavioural treatments for methamphetamine users is required, with a focus on improving longevity of the effect of intervention and improving effectiveness among more complex presentations.
commentary This review gives the lie to the common assumption that 'There are no effective treatments for stimulant users.' It is true that there are no effective pharmacological treatments, like methadone or naltrexone for opiate dependence, and no specifically effective psychosocial therapies. Psychosocial therapies have been developed which are tailored to stimulant dependence and to the characteristics of the users of these drugs, but these have yet to be shown to be consistently more effective than other therapies, and are not different in kind from the therapies used with other caseloads. However, it is less the case that 'nothing works', more the case that, within reason, any bona fide therapy works for some people to some degree and for some time. This is true of cocaine use and, as the authors of the review concluded, also true of methamphetamine use. As they observed: "Based on the studies reviewed, methamphetamine use appears to be reactive to intervention. In many studies the control group also made significant reductions in methamphetamine use ... assessment and assertive follow-up alone may have a significant impact on use and ... should be a routine part of good clinical practice with methamphetamine users ... The use of assessment, follow-up and a self-help booklet may be good practical advice for a group that is considered to attend treatment for relatively short periods."
In the main study which led to this conclusion, when all patients were assessed and regularly followed up by the researchers, face-to-face therapies led to only modest and statistically non-significant extra reductions in amphetamine use compared to a self-help booklet. Interrupting stimulant use is generally not considered a major difficulty and often happens without any treatment. The review shows that offering therapy and in particular rewarding abstinence through contingency management procedures extends and deepens the interruption, but especially in respect of contingency management, it is unclear whether the gains are sustained.
However, any conclusions are tempered by the limited range of interventions tested and by the limited periods over which patients were followed up. As the authors imply, so far as we can tell, the most important thing is to offer easy-to-access, acceptable and credible treatments (which for many people need not be intensive), and to regularly follow up patients to establish whether the resultant interruption in excessive stimulant use has been sustained and if not, to offer further support.
Thanks for their comments on this entry in draft to Nicole Lee of the Turning Point Alcohol and Drug Centre in Australia and Richard Rawson of the University of California at Los Angeles, USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 05 April 2009
STUDY 2019 Efficacy and cost-effectiveness of an adjunctive personalised psychosocial intervention in treatment-resistant maintenance opioid agonist therapy: a pragmatic, open-label, randomised controlled trial