Combined CBT and Pharmacotherapy Effective For Substance Use Disorder

Lara Ray, PhD

Cognitive-behavioral therapy combined with pharmacotherapy is more effective than usual care and pharmacotherapy for adults with alcohol or substance use disorder.

Lara Ray, PhD, and a team of investigators found combined cognitive behavioral therapy and pharmacotherapy was associated with increased benefit compared with usual care and pharmacotherapy. The findings suggested best practices for addiction treatment should include both methods or pharmacotherapy with another evidence-based therapy, rather than usual clinical management or nonspecific counseling services.

Ray and colleagues conducted a meta-analysis of published literature on combined cognitive behavioral therapy and pharmacotherapy for adult alcohol use disorder or other substance use disorders. A research assistant conducted a literature search through July 31, 2019. There was an all-fields search by treatment (cognitive behavioral therapy, relapse prevention, or coping skills training, outcome (alcohol, cocaine, methamphetamine, stimulant, opiate, heroin, opioid, marijuana, cannabis, illicit drug, substances, dual disorder, polysubstance, or dual diagnosis), and study terms (efficacy, randomized controlled trial, or randomized clinical trial) in the PubMed database. The team then searched the Cochrane Register, Embase, and EBSCO databases.

The final sample consisted of 30 studies and 62 effect sizes. Those included were English, peer-reviewed articles from January 1, 1990, through July 31, 2019. The studies targeted adult populations >18 years old who met criteria for alcohol use disorder, other drug use disorder, or problematic use. Treatment had to be identified as cognitive-behavioral or relapse prevention.

The mean sample size was 82 participants with a range of 30-917. The main substance targeted in the clinical trials was alcohol (50%), followed by cocaine (23%) and opioids (20%). The mean participant age was 39 years old with a mean of 28% female participants. A majority of participants were white (66%).

For the cognitive behavioral therapy portion of the studies, 73% was individual and 26% was group=delivered. The number of planned sessions was 16 and recruitment contexts were specialty substance use or mental health clinics (68%), medical settings (16%), and community advertising (16%). The pharmacotherapies examined included naltrexone hydrochloride and/or acamprosate sodium (42%), methadone hydrochloride or combined buprenorphine hydrochloride and naltrexone (Suboxone; 18%), disulfiram (8%), and another pharmacotherapy or a mixture of pharmacotherapies (32%).

Estimates showed a benefit associated with combined cognitive behavioral therapy and pharmacotherapy over usual care (g range, .18-.28; k=9). Cognitive-behavioral therapy did not perform better than other specific therapies. What’s more, evidence for the addition of cognitive behavioral therapy as an add-on to combined usual care and pharmacotherapy was mixed.

Current practices suggest the need to combine cognitive behavioral therapy and pharmacotherapy to provide support and skills while the patient waits for their medication effects to become apparent, to enhance treatment adherence, to improve and study retention, and to address symptoms and problems medication might not address. The results of the study emphasized that prescribing clinicians should favor cognitive behavioral therapy over usual clinical management. However, cognitive-behavioral therapy was not superior, and clinicians should favor any evidence-based behavioral therapy.

The study, “Combined Pharmacotherapy and Cognitive Behavioral Therapy for Adults With Alcohol or Substance Use Disorders,” was published online in JAMA Network Open.