best practice

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.

Manualised mindfulness-based interventions (i.e. structured programs of at least 8 sessions) were reviewed to assess the effets of different existing programs in a narrative review (Korecki et. al, 2020, 30 RCTs). The mindfulness-based programs analysed in the review were the following - from the most common and studied to the least:

1. Mindfulness-based relapse prevention (MBRP) - a manualized, structured protocol that integrates formal meditation practices with the cognitive behavioral approach of relapse prevention treatment.
2. Mindfulness oriented recovery enhancement (MORE) - is a protocol that integrates elements of mindfulness training, cognitive restructuring, and positive psychology to address the factors theorized to maintain a substance use disorder.
3. Mindful awareness in body-oriented therapy (MABT) - is a manualized, mindfulness-based approach that is designed to teach interoceptive skills for self-care. Interoception is the ability to process signals that originate in the body and is broadly described as the overall sensations, or state, of the body.
4. Mindfulness-based addiction treatment (MBAT) - is a protocol that closely follows the procedures and rationale of Mindfulness-Based Cognitive Therapy (MBCT) but with the depression focused content removed and replaced with information regarding substance use.
5. Mindfulness training for smoking cessation (MTS) - is a protocol built upon the foundational ideas outlined in both MBSR and MBRP, but was tailored specifically for individuals who are trying to stop smoking.
6. Moment-by-moment in Women’s recovery (MMWR) - developed as an adaptation of MBSR, specifically designed for low income, racially, and ethnically diverse women currently enrolled in residential SUD treatment.

Overall the review found structured mindfulness-based interventions to have beneficial effects on:

• cue-reactivity and thus reducing cravings
• reducing perceived stress

And promising effects on:

• psychiatric outcomes, including depression and anxiety symptoms

A more recent narrative systematic review (Ramadas et al., 2021) confirmed that, despite some heterogeneity regarding the type of MBRP program used, results support the effectiveness of these interventions in the SUD population, especially in reducing cravings, decreasing the frequency of use, and improving depressive symptoms.

A more recent systematic review (Félix-Junior et al., 2022, 21 studies, 11 studies focused on therapeutic communities and 9 in residential treatment) confirmed the effectiveness of Mindfulness-Based Interventions to:

• reduce cravings and improve treatment adherence

It is unclear whether the inpatient context could affect MBI. Only one study from 21 included showed data related to the impact of the context over the implementation. Future studies could further consider the influence of context on MBI.

Substitution therapy has already proved to be effective for smoking and opioid use. Evidence is emerging around the effectiveness of pychostimulants prescription for stimulants related problems.
Psychostimulants, namely modafinil, methylphenidate, or amphetamines (mixed amphetamine salts, lisdexamphetamine, and dextroamphetamine) were found in a systematic review (Tardelli et al., 2020, 38 RCTs, N = 2889) to be effective in:

• increasing rates of sustained abstinence [risk ratio (RR) = 1.45, 95% confidence interval (CI) = (1.10, 1.92)] and duration of abstinence [mean difference (MD) = 3.34, 95%CI = (1.06, 5.62)], particularly in patients with cocaine use disorder (although very low-quality evidence).
• Prescription amphetamines were particularly beneficial in promoting sustained abstinence in patients with cocaine use disorder [RR = 2.44, 95% CI = (1.66, 3.58)], and
• higher doses of PPs (eg. >60 mg/dose of dextroamphetamine) were particularly efficacious for treatment of cocaine use disorder [RR = 1.95, 95% CI = (1.38, 2.77)].
• Treatment with prescription amphetamines also yielded more cocaine-negative urines [MD = 8.37%, 95% CI = (3.75, 12.98)].

There was no effect of PPs on the retention in treatment.

Mobile health (mHealth) is defined as the use of mobile and wireless devices to deliver healthcare. mHealh interventions are divided between static interventions and connected interventions. Static interventions collect data from the individual (e.g., biologic or physiologic data, selfreported data (EMA), or geolocation) but do not provide dynamic feedback, rather use collected data after the fact to alter the treatment plan. Reactive or connected interventions, in contrast, collect data to provide customized responses to user input in real time.

Connected interventions were analysed in a narrative systematic review (Carreiro et al., 2020) and were defined as one that meets all of the following three criteria: 1) uses a wearable device and/or mobile phone/app, 2) collects data from a participant (e.g. biologic samples, physiologic data, geolocation, or self- report/Ecological Momentary Assessment), and 3) includes an intervention that was triggered based on data collected from the participant by the device.

The most commonly studied SUD was alcohol disorders (but 3 studies focused on cannabis and 1 on opioids). The most common intervention was some form of craving management and/or coping assistance (e.g. sending a mindfulness-oriented SMS text when a participant reports a craving).

 Connected mHealth interventions were found to be effective in:

• reducing craving and substance use while the interventions were in use, with a possible sustained behavior change at short term (3–9 month) follow up.

Technology-based (web or computer) motivational and psycho-education interventions and cognitive enhancement therapy were found in a systematic review without meta-analysis (Tatar et al, 2020, 8 studies) to have no significant effect in:

• reducing cannabis use, abstinence or dependence severity in patients with psychosis

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)

Virtual Reality  was found in a narrative systematic review (Segawa et al., 2020) to have heterogenous results and no conclusive effect in:

• reducing craving (studies focused on nicotine, cocaine, alcohol, cannabis, gambling)

However the same review found VR applications to be an effective alternative to in-vivo techniques in triggering cue-reactivity in adult individuals in both substance use disorders and behavioural addictions. In addition, the authors concluded that including coping mechanisms to VR-based interventions may add efficacy in terms of craving reduction.

Virtual Reality is identified in the review as a Human-Computer Interaction platform based on immersive simulations of realistic environments.

A more recent narrative systematic review (Taubin et al., 2022, 5 studies, focus on tobacco) assessed the effect of virtual reality therapies on substance use disorder and arrived at the same conclusions:

• no clear evidence of effect in reducing craving, mood outcomes, anxiety and depression.

Postpartum nonpharmacological adjunctive treatments for women with opioid use disorder were analysised in a narrative systematic review (Martinez and Allen, 2020).  Four studies were identified by the review and while they all reported improvements, overall it was not possible to draw conclusions on their effect on:

• reducing opioid use

Postpartum nonpharmacological adjunctive treatments included group or individual counseling or employemnt interventions.

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.