National Drug Strategy
National Drug Strategy

National Amphetamine-Type Stimulant Strategy Background Paper: Monograph Series No. 69

5.5 Psychosocial interventions

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Psychosocial treatment modalities have most commonly been used to treat ATS users, in part because of the absence of a strong evidence base demonstrating the effectiveness of pharmacotherapies. Kamieniecki and colleagues (1998) reported that the following non-pharmacological interventions had been used with psychostimulant users: inpatient programs, therapeutic communities, 12-step programs, peer interventions, behavioural strategies, cognitive-behavioural interventions, multimodal treatment packages, and non-traditional methods such as acupuncture. Those which demonstrated the most efficacy were relapse prevention, cue exposure/response prevention, and multifaceted behavioural treatment. However, it was noted that many of the interventions had not been properly evaluated.

Research conducted in the subsequent decade suggests that cognitive behavioural therapy is the recommended psychosocial treatment for methamphetamine dependence in Australia (Baker et al., 2005). While this is supported by evidence from controlled studies, comparisons have not been conducted to test the efficacy of other psychotherapeutic approaches. Thus, evidence-based recommendations for psychosocial interventions must be considered in the context of limited research. As noted in the written submission from NDARC, new approaches are currently being explored, including mindfulness therapy (based on meditation techniques) narrative therapy (NT; based on an examination and reconstruction of a client’s life history) and Acceptance and Commitment Therapy (ACT; combines mindfulness strategies with behaviour change strategies). NT is currently being investigated in addition to mirtazepine in a trial being conducted in WA and NSW, with preliminary findings suggesting that NT attendance is a significant predictor of treatment retention (Cruickshank et al., unpublished). A randomised controlled trial of psychotherapy for amphetamine use, comparing relapse prevention skills training with ACT is currently underway in South Australia. It has been noted that given the cognitive deficits experienced as a result of sustained methamphetamine use, such therapies that rely less on cognitive processes may prove beneficial in treating dependent methamphetamine users.

A review of treatment was recently reported by Shearer (2007) who identified 43 unique and original reports of randomised controlled trials of psychosocial interventions primarily targeted toward psychostimulant use, and 10 reports from clinical trials and long-term cohort studies. Interventions included behavioural (contingency management, cue exposure), cognitive (motivational interviewing, relapse prevention, cognitive behaviour therapy), psychotherapy, and abstinence-oriented (detoxification, residential rehabilitation, 12- step programs). It is important to note that most of these studies were conducted among cocaine users in the United States, which may limit the relevance for treatment of ATS users in Australia. It was also noted that the evidence base for psychosocial interventions for psychostimulant dependence is still limited, given there are insufficient controlled trials supporting one intervention over another. In this context, the following discussion is an overview of the most common interventions.

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Brief interventions

Brief interventions (BI) are usually considered pre-treatment tools or secondary prevention techniques with the broad goal of reducing or eliminating drug use to avoid or minimise associated problems: Recent adaptations include brief cognitive-behavioural interventions (BCBIs), which commonly consist of a motivational interview and skills training in the avoidance of high-risk situations, coping with cravings, and relapse prevention (Srisurapanont et al., 2007). Given that the efficacy of BI is largely contingent on the client’s level of motivation, this intervention is usually considered most effective for people with no or low levels of dependence, unless 101
used to divert more severely dependent individuals into more intensive treatment. While the bulk of the evidence for BI relates to drugs such as tobacco and alcohol, they have increasingly been applied to illicit drug problems, including ATS use.

Srisurapanont and colleagues (2007) conducted a study aimed at evaluating the short-term benefits of BI for methamphetamine use disorders. A randomised controlled trial of BI compared to psychoeducation was investigated in youth aged 14-19 years old who met DSM criteria for methamphetamine dependence or abuse. Participants were students living in urban or suburban areas of Chiang Mai, selected due to the prevalence of methamphetamine use in Thai youth. The BI adopted was similar to that used in Australian studies (see Baker et al., 2001b, 2005), with the exception of the component of cognitive-behavioural therapy. The study found that while the frequency and amount of methamphetamine use decreased significantly in both groups, frequency of use for those in the BI group was significantly less than those in the psychoeducation group.

As noted, research conducted in Australia by Baker and colleagues (e.g., 2001b) has investigated the efficacy of BI in treating amphetamine users. This research has resulted in the development of a treatment guide for a brief cognitive behavioural intervention with regular amphetamine users (Baker et al., 2003). The intervention may comprise two or four sessions, with the four-session intervention consisting of motivational interviewing, coping with cravings and lapses, controlling thoughts about amphetamine use and pleasurable activities, and amphetamine refusal skills and preparation for future high-risk situations (Baker et al., 2003). Investigation of the effectiveness of the intervention was conducted in a randomised controlled trial with 214 regular amphetamine users in the Greater Brisbane Region of Queensland and Newcastle in NSW (Baker et al., 2005). The study found that there was a marked reduction in amphetamine use among the sample over time, and a significant increase in the likelihood of abstinence from amphetamine for those receiving two or more sessions (Baker et al., 2005).

While research has shown that BI can be effective with meth/amphetamine use, Baker and colleagues (2004) observed that, as many ecstasy users do not come into contact with treatment services, it may be appropriate to develop and evaluate the impact of specific brief and opportunistic interventions. These might be delivered in emergency departments, at events such as dance parties, in primary health care settings, in law enforcement setting and through computer/Internet media for remote/anonymous access.

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Cognitive behaviour therapy

As indicated, research into the efficacy of psychosocial interventions for people affected by ATS use is in its early stages, but support has been found for cognitive behaviour therapy (CBT). Such interventions usually progress through stages of motivational interviewing, instruction in cognitive-behavioural coping strategies and relapse prevention.

As discussed in the brief intervention section, Baker and colleagues (2001b) found brief CBT (in durations of either two or four sessions), superior in treatment outcome compared to participants who had been provided with self-help material. Both groups reduced amphetamine use, but greater rates of abstinence were achieved over the 6 month follow up in the CBT group. Other studies have demonstrated the value of CBT with cocaine users, data that may be generalisable to ATS use (e.g., Crits-Cristoph et al., 1999). Brief CBT may also be effective in reducing psychological distress among amphetamine users. Feeney and colleagues (2006) found that a program consisting of refusal self-efficacy, improved coping, improved problem solving and planning for relapse prevention resulted in significantly improved scores on measures of somatic symptoms, anxiety, social dysfunction and depression among an Australian sample of 168 amphetamine users.

Baker and colleagues (2005) recommended that a stepped-care approach should be adopted. This involves the provision of intervention tailored to individual needs, with the employment of more intensive interventions as indicated by the degree of dependence and severity of problems experienced by the individual. Thus, those presenting at non-treatment settings may be involved in a structured assessment of amphetamine use and related problems, provided with self-help materials, and their use and harms regularly monitored. Those presenting to treatment settings may be offered two or more sessions of CBT, depending on extent of use and co-existing problems (e.g., depression).

Contingency management

Contingency management (CM) is based on principles of reinforcement by decreasing the appeal of the drug via delivery of a reward for behaviour change/abstinence. Thus, clients receive incentives upon reaching therapeutic goals. In the United States, contingency management has been proposed as ‘best treatment practice’ for psychostimulant problems (Rawson, 1999; Shoptaw et al., 2006), largely based on research with cocaine users, although there has also been application to methamphetamine dependence. The most often cited reasons for not employing such techniques are the perceived cost and complexity, and doubt over whether it promotes enduring behaviour change (Kirby et al., 2006).

As part of the multi-site trial of the NIDA National Drug Abuse Treatment Clinical Trials Network, Roll and colleagues (2006) evaluated a contingency management intervention in which methamphetamine abusers submitting drug-free urine samples earned draws for chances to win prizes. No differences were found between this group and those in standard treatment for number of counselling sessions attended or retainment in treatment. However, significant differences were found for more drug-free urine samples collected and longer period of continuous abstinence.

In a recent review of the literature on contingency management, Roll (2007) identified one laboratory study and four clinical assessments of the efficacy of CM in treating methamphetamine use disorders, and the most common method was voucher-based reinforcement therapy (VBRT). Roll concluded that adding such methods to other treatment strategies would increase in-treatment abstinence in many methamphetamine treatment settings. However, Roll cautioned against using CM in isolation to address methamphetamine use due to high levels of co-occurring problems. Top of Page

The Matrix Model

The Centre for Substance Abuse Treatment (CSAT) has been involved in developing and implementing a multimodal approach to methamphetamine dependence. The US Methamphetamine Treatment Project (MTP) appears to be the largest randomised clinical trial of psychosocial treatments for methamphetamine dependence to date. The Matrix Model utilised in the project is a manualised 16-week outpatient treatment approach combining approaches and resources developed within cognitive-behavioural principles, including positive reinforcement, family education, relapse prevention and 12-step program participation. The program also includes breath testing and urine screening for drug use. Rawson and colleagues (2004) evaluated the model in comparison to ‘treatment as usual’ with methamphetamine dependent patients. This resource-intensive intervention was found to result in some positive outcomes. 38% of participants were more likely to stay in treatment, 27% were more likely to complete treatment, and 31% were more likely to have negative methamphetamine urine test results. However, the Matrix Model did not produce superior outcomes at discharge or follow-up.

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