Pharmacotherapy plus CBT should be best practice for addiction treatment, data show

Addiction treatment best practices should include pharmacotherapy plus cognitive behavioral therapy or another evidence-based therapy, according to results of a systematic review and meta-analysis published in JAMA Network Open.

“Despite the importance of combined pharmacological and behavioral interventions for AUD [alcohol use disorder]/SUD [substance use disorder], few meta-analyses on this intervention approach have been performed,” Lara A. Ray, PhD, of the department of psychology at University of California, Los Angeles, and colleagues wrote. “Typically, meta-analytic reviews in the AUD/SUD literature have been conducted on specific pharmacotherapies, groups of pharmacotherapies or specific behavioral interventions, such as CBT. As a result, the evidence-informed guideline will relate only to the selection of a single, stand-alone therapy, whether pharmacological or behavioral, and not their combination.”

The investigators sought to provide a comprehensive and up-to-date review of CBT combined with pharmacotherapy among adults with AUD/SUD. They searched five databases between 1990 and July 2019 using keywords in the categories of treatment type, outcome type and study design. They pooled inverse-variance weighted, random-effects estimates of effect size into three clinically informative subgroups — CBT plus pharmacotherapy compared with usual care plus pharmacotherapy; CBT plus pharmacotherapy compared with another specific therapy plus pharmacotherapy; and CBT plus usual care and pharmacotherapy compared with usual care and pharmacotherapy alone. The researchers included assessment of study quality, primary substance moderator effects, publication bias and pooled effect size heterogeneity in sensitivity analyses. Substance use quantity and frequency outcomes after treatment and during follow-up served as main outcomes and measures.

The sample included 30 unique randomized clinical trials with 62 effect sizes, with alcohol (50%), cocaine (23%) and opioids (20%) as the primary substances targeted. Mean patient age was 39 years, with a mean of 28% female participants per study. Pharmacotherapies used included naltrexone hydrochloride and/or acamprosate calcium (42%), methadone hydrochloride or combined buprenorphine hydrochloride and naltrexone (18%), disulfiram (8%) and another pharmacotherapy or mixture of pharmacotherapies (32%). According to random-effects pooled estimates, combined CBT and pharmacotherapy was associated with a benefit over usual care; however, CBT did not appear more effective than another specific therapy. Further, evidence was mixed for the addition of CBT in conjunction with usual care and pharmacotherapy. The researchers observed variability in effect magnitude and direction by primary drug target according to moderator analysis.

“Our results suggest that prescribing clinicians should favor CBT over usual clinical management to ensure optimal clinical outcomes for addiction, in the context of pharmacotherapy,” Ray and colleagues wrote. “This conclusion is based in our comparison of CBT plus pharmacotherapy vs usual care plus pharmacotherapy. [Further], CBT is not superior to other evidence-based behavioral treatments for addiction, yet in the context of its superiority to usual care, our findings suggest that clinicians should favor an evidence-based behavioral therapy, CBT or otherwise, in conjunction with pharmacological treatment.”