Review of the Evidence
for Clinical Management of Psychostimulant Dependence
CERGA1 May 2008
1 Aim: To identify reviews of randomised controlled trials (RCTs) of
psychostimulant treatment and summarise the findings for CERGA.
2 Methods: Search of the Cochrane database for review articles
covering at least the last 10 years. The Cochrane database is a reputable
source of systematically reviewed international evidence of RCTs. It uses
validated methodology to bring rigour to analyses of evidence in the areas
of medical and psychosocial trials to inform work within healthcare
systems and academic settings. A Medline-based search from 2007- to
May 2008 for new papers supplemented the work available through
The evidence for this review will be re-visited in 3 years, or sooner, if
Searching through the Cochrane Database provided reviews covering
pharmacological and psychosocial treatments. The Medline-based search
identified few other relevant studies from 2007 to May 2008.
Pharmacological management of cocaine misuse:
Four Cochrane systematic reviews found no conclusive evidence of
effectiveness in the management of cocaine dependence with medical
therapies such as anti-depressants (including tricyclics, monoamine
oxidase inhibitors (MAOIs) and selective seratonin reuptake inhibitors
(SSRIs)), dopamine agonists (amantadine, bromocriptine and peregolide)
and carbamazepine, nor for the use of auricular acupuncture.
A further meta-analysis comparing five stimulant substances (mazindol,
dextroamphetamine, methylphenidate, modafinil and bupropion) with
placebo1 concluded that the use of such stimulants as substitution therapy
for cocaine dependence did not improve retention in treatment nor
Pharmacological management of amphetamine misuse:
One Cochrane Review on the treatment of amphetamine dependence and
abuse2 was identified which included only 4 studies on an SSRI
antidepressant (fluoxetine), a calcium channel blocker (amlodipine) and 2
tricyclic antidepressants (imipramine and desipramine). Overall limited
benefits were found for the use of these, although fluoxetine significantly
reduced cravings and imipramine significantly increased adherence to
treatment. The low volume of identified literature weakened the strength
of this evidence.
Psychosocial management of psychostimulant misuse:
(Clinical Effectiveness and Reference Group for Addictions)
A large Cochrane Review of a range of psychosocial treatments3 included
27 RCT studies which had to have assessed reduction of drug use and/or
treatment acceptability as one of their main outcomes. The psychosocial
treatments covered included:
- cognitive-behavioural therapy (CBT) including relapse prevention
(RP), coping skills training (CST), cognitive therapy (CT),
behavioural treatment (BT), community reinforcement approach
(CRA), reinforcement-based therapy (RBT), matrix
neurobehavioural treatment, and motivationally enhanced group
- clinical management i.e. non-specific supportive doctor-patient
- interpersonal therapy (IPT)
- supportive-expressive (SE) psychodynamic therapy
- drug counselling
- multi-modal/eclectic treatments
(Descriptions of each of these therapies are available in the review)
The two most studied interventions were relapse prevention and
contingence reinforcement, followed by drug counselling. Overall
significant differences in outcomes were few and where present, effects
were modest. However, there was some evidence that CBT approaches
were better in some outcomes e.g. reducing drop outs and lowering
cocaine use. The most consistently significant improvements in outcome
across studies were in those of contingent reinforcement.
Several studies found no differences in outcomes between group or
individually delivered interventions; where this was found it was not a
consistent effect either way. The number of sessions and length of
treatment varied considerably in the 27 studies included. Again results
were conflicting and therefore non-conclusive on this point.
To conclude, a number of psychosocial interventions showed some
improvements in outcome in the management of cocaine and
amphetamine use, but there was no clear pattern of one model of
psychosocial treatment being better than others. No evidence was found
to support clinical management over CBT approaches, nor professional
psychotherapist-delivered therapy over drug counselling. Generally,
studies compared treatments between them rather than against no
Another more recent review of 43 RCTs4 concludes that psychosocial
interventions are moderately effective in reducing psychostimulant use
and related harm in dependent individuals. The authors suggest that since
the outcomes of behavioural and cognitive approaches are of a similar
magnitude, cost-effectiveness should be considered. On this basis briefer
interventions would have an advantage over comprehensive interventions.
However on several points this review appears to have been incomplete
and therefore of limited value.
The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)
report on cocaine and crack5 presents the European picture of cocaine
prevalence and treatment. The research referred to is not specifically
identified, nor reviewed in a systematic way. Promising findings for
topiramate and cocaine vaccination are noted but psychosocial
interventions are recognised as being the most effective treatment at
The RCGP guidelines6 do not clearly state there is little evidence for
pharmacological interventions and indeed give guidance on using some
pharmacological interventions. These guidelines are not evidence-based
and in light of the above most recent Cochrane Review, findings their
relevance and use should be reviewed.
Generalisability of Findings:
One important caveat when considering these reviewed findings is that
the bulk of research undertaken has been from the United States, where
the demographic profile of cocaine/crack users is quite different from the
UK. In the USA crack use in particular is associated with urban deprivation
in predominately black and Hispanic communities. How findings translate
to the UK context, where the demographic pattern of psychostimulant and
cocaine used seems to be very mixed and includes young experimental
drug users, professionals and poly-drug users using a mixture of opiates
and cocaine is difficult to assess. Crack users in the UK have generally
better welfare and health support systems and thus may have improved
chances of treatment success7,8.
4 Overall Conclusions:
Pharmacological treatment and acupuncture of psychostimulant misuse, in
particular cocaine dependence are not justified based on the evidence
available, with the possible exception of some antidepressants for
amphetamine dependence. This corroborates the National Treatment
Agency’s review of research findings in their briefing paper on treating
and commissioning services for cocaine/crack.
The evidence for psychosocial interventions is more positive although still
very limited. CBT models are the most widely tested (particularly relapse
prevention and contingent reinforcement) and have shown modest
improvements in selected outcomes, as has drug counselling. However,
being in some form of treatment seemed beneficial regardless of the
model of care. This tentatively implies it is not necessarily cost-effective to
have lots of different, complex interventions available. It again
corroborates the NTA summary on commissioning services for
crack/cocaine and Orange Book guidance9, where drug-free interventions
such as counselling on a non-residential basis are advised to be the most
cost-effective option for psychostimulant misuse.
Castells X et al. (2008) Efficacy of central nervous system stimulant treatment for cocaine
dependence: a systematic review and meta-analysis of randomized controlled clinical trials. Addiction
Srisurapanont M, Jarusuraisin N, Kittirattanapaiboon P. Treatment for amphetamine dependence and
abuse. Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No.: CD003022. DOI:
Knapp WP, Soares B, Farrel M, Lima MS. Psychosocial interventions for cocaine and psychostimulant
amphetamines related disorders. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.:
CD003023. DOI: 10.1002/14651858.CD003023.pub2
Shearer J 2007 Psychosocial approaches to psychostimulant dependence: A systematic review.
Journal of Substance Abuse Treatment;32:41-52.
European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) Cocaine and Crack Cocaine: A
Growing Public Health Issue.2007, European Union’s Publication Office.
RCGP Guidelines (2004) Ford C. Guidance for working with cocaine and crack users in primary care.
National Treatment Agency briefing papers (2002) Treating cocaine/crack dependence.
National Treatment Agency briefing (2002) Commissioning cocaine/crack treatment.
Department of Health (England) and the devolved administrations (2007). Drug Misuse and
Dependence: UK Guidelines on Clinical Management. London: Department of Health (England), the
Scottish Government, Welsh Assembly Government and Northern Ireland Executive.