Cognitive-behavioural treatment for amphetamine-type stimulants (ATS)-use disorders

1.1 Cognitive-behavioural treatment for amphetamine-type stimulants-use disorders

2.1 Description of the condition

Amphetamine-type stimulants (ATS) refer to a group of synthetic stimulants including amphetamine, methamphetamine and phenethylamines such as MDMA (3,4-methylenedioxy-methamphetamine) and its analogues. These substances have marked central and peripheral stimulant effects upon people and prolonged use results in a series of mental and physical symptoms that include anxiety, confusion, insomnia, mood disturbances, cognitive impairments, paranoia, hallucinations and delusion (Barr et al., 2006; Baylen & Rosenberg, 2006; Greene, Kerr, & Braitberg, 2008; Montoya, Sorrentino, Lukas, & Price, 2002; Morgan, 2000).

Since the 1990s, ATS use has been widespread globally and it is now the second most popular illicit drug in the world after cannabis. ATS use is of serious concern in East Asia, Southeast Asia, North America, Western Europe and Oceania (Farrell, Marsden, Ali, & Ling, 2002; UNODC, 2012). Statistics from the United Nations Office on Drugs and Crime (UNODC) indicate that approximately 25 million to 80 million people regularly use ATS worldwide (UNODC, 2012). Several new synthetic drugs have been gaining popularity, including MDMA and related amphetamines. These drugs are known as substituted amphetamines and they are characterised by enhanced hallucinogenic properties (Greene et al., 2008).

Amphetamines are highly addictive substances and produce euphoria and elevated mood. The short-term adverse effects of amphetamines include high body temperature; cardiovascular system failure; hostility; irregular or increased heart rate; increased diastolic/systolic blood pressure; increased activity/talkativeness; euphoria; heightened sense of well-being; decreased fatigue/drowsiness; decreased appetite; dry mouth; dilated pupils; increased respiration; heightened alertness/energy; nausea; headache; palpitations; altered sexual behaviour; tremor/twitching of small muscles; release of social inhibitions; and unrealistic feelings of cleverness, great competence and power (Barr et al., 2006; Lee & Rawson, 2008).

Amphetamines can be ingested, injected, smoked and snorted. Prolonged amphetamine use may result in more severe and devastating consequences. These include a series of mental and physical symptoms such as dizziness, mood or mental changes, chronic tiredness or weakness, physiological and behavioural disorders, flushed or pale skin, malnutrition, ulcers, repetitive motor activity, loss of co-ordination and physical collapse, anxiety, confusion, insomnia, mood disturbances, cognitive impairments, paranoia, cardiac arrhythmias, toxic psychosis, amphetamine-induced psychosis, convulsions, coma and death (Baylen & Rosenberg, 2006; Greene et al., 2008; Montoya et al., 2002).

ATS use is also related to infections of HIV/AIDS and other sexually transmitted diseases. The stimulating effects of ATS can impair judgement and inhibition, and lead people to engage in risky sexual behaviours. Moreover, sharing of injecting paraphernalia is common among people who inject drugs and such practice puts them at elevated risk of blood-borne infectious diseases such as HIV, AIDS and hepatitis C (Degenhardt et al., 2010; Ellickson, McCaffrey, & Klein, 2009; King, Nguyen, Kosterman, Bailey, & Hawkins, 2012; Strathdee et al., 2010). Particularly, ATS use and associated HIV infections among men who have sex with men (MSM) poses a serious public health concern. More sexually adventurous MSM are likely to use ATS to increase sexual desire and make sexual intercourse less painful and more pleasurable. Thus, co-occurring ATS use and unprotected risky sexual behaviours increase the risk of HIV and other sexually transmitted diseases (Thu Vu, Maher, & Zablotska, 2015).

The use of MDMA and its analogues is particularly prevalent among young people (UNODC, 2012). These drugs are usually taken orally as a tablet or capsule. Their pattern of use is different from that of 'traditional drugs.' Among young MDMA users, occasional use is most common, typically related to social events and involves the use of a relatively small amount of the drug. Users are likely to use multiple substances at the same time and MDMA tablets frequently contain other substances. Due to the combination of these substances, the consequences of MDMA use are unpredictable (Rogers et al., 2009).

MDMA and related substances have both stimulant and hallucinogenic effects. Therefore, the short-term effects of these substances include increased heart rate and blood pressure, hyperactivity, euphoria, a heightened sense of well-being, decreased fatigue/drowsiness and decreased appetite. In addition, distorted time and exaggerated sensory perception are frequently experienced. In contrast, long-term consequences are not well known because abuse of these substances is relatively recent (Rogers et al., 2009). Young MDMA users frequently use drugs in club or all-night dance parties, known as 'raves.' They tend to take drugs with alcohol and dance for a long time, and this may result in hyperthermia, dehydration, hypertension, and even kidney failure and death (NIDA, 2006).

ATS-use disorder can be diagnosed by several set of criteria. For example, according to the ICD-10 (International Classification of Diseases – 10th Revision), substance dependence syndrome is characterised by "a cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had greater value." Major diagnostic criteria include a strong desire to use, difficulties in controlling drug use, existence of withdrawal symptoms, evidence of tolerance, progressive neglect of alternative pleasures and persisting with substance use despite clear evidence of harmful consequences (WHO, 2004).

2.2 Description of the intervention

Currently there is no widely accepted treatment for ATS-use disorder. This is especially the case for newly emerged ATS. However, cognitive-behavioural treatment (CBT) is the first-choice treatment (Lee & Rawson, 2008). The effectiveness of CBT for other substance-use disorders (e.g. alcohol-, opioid- and cocaine-use disorders) has been well documented and as such this basic treatment approach has been applied to ATS-use disorder. The treatment of MDMA use and the use of other new ATS drugs has not been extensively studied and the lack of evidence makes it difficult to know how best to treat people who use new ATS drugs (Rogers et al., 2009).

CBT for a substance-use disorder can be defined as a structured approach to help clients reduce substance-use behaviour by modifying their thoughts and behaviours. There are several therapies that are under the broad category of CBT, including behavioural therapy, cognitive therapy, CBY and the 'third-wave' CBT. CBT usually employs a set of structured techniques such as motivational enhancement, relapse prevention, skills training, cognitive restructuring, stress management, emotional control and contingency management.

Moreover, CBT for substance-use disorders has been used in many formats including individual therapy, group therapy and more recently computer-based therapy.

2.3 How the intervention might work

CBT for a substance-use disorder is based on the assumption that drug use is a learned behaviour and it emphasises individual commitment for recovery in order to learn new adaptive behaviours and ways of thinking. From the cognitive-behavioural perspective, substance use is considered the result of coping deficits or maladaptive cognitions, or both. For example, if people do not have an appropriate coping repertoire or have positive outcome expectations towards substance use, or both, they are likely to use drugs in high-risk situations (Marlatt & Witkiewits, 2005; Thombs, 2005). Therefore, coping skills training is considered an essential treatment component in CBT and emerging data suggested that acquisition and performance of skilful coping may account for CBT's effects on substance-use disorders (Kiluk, Nich, Babuscio, & Carroll, 2010; Litt, Kadden, Cooney, & Kabela, 2003). CBT for substance-use disorders is mainly designed to identify drug-using triggers and provides people who use drugs with cognitive and behavioural skills to cope with these triggers to achieve and sustain abstinence from drugs. However, there is competing research which concludes that research currently failed to find solid evidence to explain CBT works through its effects on coping (Morgenstern & Longabaugh, 2000). Considering these findings, it is assumed that coping-skills training may work through dynamic interaction between improvements of other important problem areas such as emotion and cognition (Marlatt & Witkiewits, 2005). Therefore, CBT also addresses thoughts, emotions, outcome expectations and lifestyles associated with drug use in order to address these multiple problem areas.

2.4 Why it is important to do this review

ATS use is increasing worldwide, especially in East Asia, Southeast Asia, North America, Western Europe and Oceania (Farrell et al., 2002; UNODC, 2012). Given this widespread ATS use, a comprehensive review of the effectiveness of treatment targeting ATS users is required to inform future research, clinical practice and policy making. Moreover, this review places a focus on CBT because CBT has multiple strengths over pharmacological treatment. For example, CBT is not associated with adverse effects and tends to have long-lasting effects. Some studies indicated that ATS users who receive CBT reduce their ATS use even after treatment is terminated (Carroll et al., 2000; Rawson et al., 2002).

4.1 Criteria for considering studies for this review

4.2 Search methods for identification of studies

4.3 Data collection and analysis

5.1 Description of studies

See: Characteristics of included studies; Characteristics of excluded studies tables.

5.1.1 Results of the search

We retrieved 813 records through database searching. Further handsearching and personal communication identified an additional two studies. Once duplicates were removed, there were 575 records. We excluded 538 records based on titles and abstracts. We assessed 37 full texts for eligibility and excluded 33 references, with reasons (see Characteristics of excluded studies table). As the result of the eligibility check, only two studies (three articles) were finally included (Martin 2010; Tait et al., 2015). For a further description of our screening process, see the PRISMA study flow diagram (Figure 1).

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Study flow diagram

5.2 Risk of bias in included studies

The details of the risk of bias assessment are given in the 'Risk of bias' table (Figure 2; Figure 3).

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

5.3 Effects of interventions

5.3.1 Single-session motivational and cognitive-behavioural treatment

We found one trial comparing single-session multi-component CBT versus waiting-list control (Martin 2010).

5.3.1.1 Abstinence rate

The percentage of 90-day MDMA abstinence was over four times greater in the treated participants, although this difference was not significant (OR 0.22, 95% CI 0.02 to 2.11; 50 participants). See Analysis 1.1.

5.3.1.2 Drug use

There were significant effects favouring the treated participants for the number of dependence symptoms reported (SMD –0.59, 95% CI–1.16 to–0.02; 50 participants) and the score of the Severity of Dependence Scale (SDS) (SMD –0.62, 95% CI–1.18 to–0.05; 50 participants). The days of ecstasy use on the past 90 days and the mean number of tablets used did not differ between CBT and waiting-list control (days of ecstasy use: SMD –0.45, 95% CI–1.04 to 0.09; mean tablets used: –0.48, 95% CI–1.04 to 0.09; 50 participants). See Analysis 1.2; Analysis 1.3; Analysis 1.4; Analysis 1.5.

5.3.1.3 Dropout from treatment

The study did not report dropouts because the control was waiting-list control.

5.3.1.4 Psychological variables

The study did not report psychological variables.

5.3.1.5 Web-based cognitive-behavioural treatment

We found one trial comparing web-based CBT versus waiting-list control (Tait et al., 2015).

5.3.1.6 Abstinence rate

The study did not report abstinence rate.

5.3.1.7 Drug use

Tait et al. 2015 measured ATS use using the self-report Alcohol, Smoking, Substance Involvement Screening Test (ASSIST). The difference was not significant (SMD –0.05, 95% CI–0.49 to 0.39; 160 participants; Analysis 2.2). However, this measure excluded ATS drug use.

5.3.1.8 Dropout from treatment

The study did not report dropouts because the control was waiting-list control.

5.3.1.9 Psychological variables

There were no significant differences in any of the secondary measures. These outcomes included intended help seeking, actual help seeking, K-10 score, days out of role, days part out of role and quality of life. See Analysis 2.3; Analysis 2.4; Analysis 2.5; Analysis 2.6; Analysis 2.7.

5.3.1.10 Any cognitive-behavioural treatment

We conducted a single meta-analysis of any drug use across these two studies by using the primary outcome of ATS use from the Tait et al. 2015 and averaging the four continuous measures of drug use reported in Martin 2010. We did this given that Martin 2010 did not specify any of these four as a primary outcome. Furthermore, the effects are quite similar across these outcomes, ranging from –0.62 to–0.45. The mean effect for Martin 2010 was an SMD –0.53 and standard error of 0.288 (this was the mean standard error but these standard errors were essentially the same across the four effect sizes). The difference was not significant (SMD –0.28, 95% CI–0.69 to 0.14; 210 participants; Summary of findings table 1). See Analysis 3.1; Figure 4.

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(Analysis 3.1) Forest plot of comparison: 3 Cognitive-behavioural treatment (CBT) versus waiting-list, outcome: 3.2 Drug use

6.1 Summary of main results

Despite extensive searches, only two trials met the eligibility criteria. This result reflects a paucity of RCTs in this area. The purpose of this review was to compare CBT to other types of treatment; however, such RCTs were especially rare. For the treatment for ATS-use disorders, CBT is frequently used and the use of other treatment approaches are rare. This may be because evidence of CBT for other 'traditional' substance-use disorders has been documented.

Interventions conducted in included trials were uncommon. Usually, treatment for substance-use disorders is delivered over numerous weeks and in a face-to-face format, sometimes in a group setting; on the contrary, Martin 2010 evaluated a single-session brief intervention and Tait et al. 2015 evaluated a web-based intervention.

Martin 2010 provided a multi-component intervention in a single session including an assessment, personalised feedback within a motivational interviewing framework and relapse prevention skills training. Typical substance abuse treatment has more therapeutic components such as identification of triggers, coping skills training, emotional management, alternative activities, cognitive restructuring, support network building and lapse management. Because of the nature of the intervention, Martin 2010 left most of these components out.

Only two of the five effects (dependence symptoms, SDS score) were significant given the rather small sample size (25 in each group).

Tait et al. 2015 delivered an Internet-based intervention comprised of three modules: exploration of problems associated to ATS use; the pros and cons of ATS use; and goal setting and behavioural change. All outcome measures used in the study were self-reported and no urinalysis was conducted which is usually recommended in clinical trials of substance-use disorders. This is one of the study limitations and there was no significant effect for the eight outcomes including ATS use, poly-drug use and quality of life.

We identified only two CBT trials and both were 'uncommon' interventions. In usual clinical practice, face-to-face treatment with more, longer therapeutic contacts are common (Galloway et al., 2000; Knapp, Soares, Farrell, & Silva de Lima, 2008). However, there is a paucity of research to evaluate such common CBT interventions and existing RCTs are of relatively low quality. Therefore, we did not have enough evidence to determine whether CBT is effective.

In some excluded studies, people with cocaine use, opiate use or excessive alcohol use were study participants in addition to ATS users and their data could not be excluded. Other studies compared CBT to other types of CBT. These studies were excluded since the purpose of this review is to compare CBT to other types of treatment approaches. However, several trials found positive effects over CBT.

Also, some excluded studies compared CBT to other types of CBT, for example traditional CBT versus mindfulness-based CBT and CBT versus CBT plus "ad-on" interventions such as pharmacotherapy and contingency management. Other studies evaluated CBT targeting subgroup ATS users with specialised treatment needs such as women (Ruglass, Hien, Hu, & Campbell, 2014), MSM (Reback & Shoptaw, 2014; Santos et al., 2014; Shoptaw et al., 2008), people with co-occurring disorders (Baker et al., 2006; Barrowclough et al., 2009; Beutler et al., 2003), and ethnic minorities (Witkiewitz, Greenfield, & Bowen, 2013). These studies found some positive results but were excluded from this review because they did not meet the eligibility criteria. Moreover, most studies were carried out in Western countries. Since ATS use has been spread globally, treatment approaches must be evaluated in a specific cultural and social background. A small number of studies were conducted in other areas such as Japan (Harada, 2010), Taiwan (Yen, Wu, Yen, & Ko, 2004), and Thailand (Suvanchot, Somrongthong, & Phukhao, 2012), and there were some positive results. However, these studies were not included because they did not fulfil the eligibility criteria.

6.2 Overall completeness and applicability of evidence

The review included only two trials and the results found no clear evidence of the benefits of CBT for ATS-use disorders. Both of the included studies examined relatively uncommon approaches such as a one-session brief therapy and a web-based therapy. Therefore, the evidence obtained in this review could not be applicable across the wide range of treatment modalities and settings.

6.3 Quality of the evidence

There were only two studies included in the meta-analysis. Moreover, there were several methodological flaws in the included studies such as possible incomplete blinding, a very small sample size and a large loss to follow-up in one study. Also, Martin 2010 provided no treatment fidelity data and this could pose a concern. These limitations result in performance bias, attrition bias and imprecision of results. Therefore, overall quality of evidence was low.

6.4 Potential biases in the review process

We identified no potential biases.

6.5 Agreements and disagreements with other studies or reviews

We found two systematic reviews of psychological treatment for methamphetamine dependence (Ciketic, Hayatbakhsh, Doran, Najman, & McKetin, 2012; Lee 2008). One was a systematic review of CBT for methamphetamine dependence, which included 12 studies and concluded that CBT and contingency management are effective for the condition (Lee 2008). The review raised a different question from ours and included studies comparing different types of CBT (e.g. CBT versus CBT plus contingency management). The other systematic review included both psychological and pharmacological interventions (Ciketic et al., 2012). They suggested that psychosocial interventions including CBT, contingency management, relapse prevention and other behavioural therapies are promising treatment options. Neither review conducted a meta-analysis or calculated an effect size. These reviews supported the effectiveness of CBT but in our review included only two studies and there was insufficient evidence because of a paucity of research comparing CBT and other types of psychosocial interventions.

We found another Cochrane Review, "Psychosocial interventions for psychostimulant misuse" (Minozzi, Saulle, De Crescenzo, & Amato, 2016). The scope of the review was broader than ours in terms of the intervention and the condition. The review was not limited to CBT and included interventions such as interpersonal therapy, 12-step facilitation, psychodynamic therapy and drug counselling. Most participants were cocaine users and only six of 52 included studies were with ATS users. The review concluded that psychosocial interventions, when compared to no intervention, reduced the dropout rate, increased continuous abstinence at the end of treatment and increased the longest period of abstinence. However, compared to treatment as usual, the dropout rate was significantly reduced but no significant changes in other outcomes.

We found several literature reviews. Baker 2003 reported that CBT and contingency management were effective approaches; however, evidence was very limited because of a paucity of well-conducted controlled studies. Another review, Vocci & Montoya, 2009, concluded that psychological interventions such as CBT and contingency management were moderately effective in achieving abstinence for amphetamine and cocaine users.

In summary, we found several similar reviews and they all agreed that CBT and contingency management seem to be effective. However, evidence was weak because existing RCTs were limited and the research quality was relatively low.

7.1 Implications for practice

Currently, there is insufficient evidence to support the efficacy of cognitive-behavioural treatment (CBT) for amphetamine-type stimulant (ATS)-use disorders.

7.2 Implications for research

More randomised trials are required to establish evidence for CBT for ATS-use disorders, especially CBT should be compared to other types of treatment options, no treatment and treatment as usual without a CBT component. Moreover, more trials are necessary targeting newly emerged ATS users and subgroups of participants who have specific treatment needs including women, adolescents, older people, men who have sex with men, non-Westerners and people with comorbid conditions.