Psychosocial interventions for cannabis use disorder.
Psychosocial interventions for cannabis use disorder.
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DOI：
10.1002/14651858.cd005336.pub4
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发表时间：
2016-05-05
期刊：
影响因子：
--
通讯作者：
Gowing L
中科院分区：
文献类型：
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作者：
Gates PJ;Sabioni P;Copeland J;Le Foll B;Gowing L
大麻使用障碍是一般人群中最常报告的非法物质使用障碍；尽管国际上对保健服务援助的需求正在增加，但只有少数患有这种疾病的人寻求专业援助。治疗研究已经发表，但制定公共政策的压力要求对成人大麻特异性治疗进行最新的系统审查。评估在门诊或社区环境中对成年人进行大麻使用障碍的心理社会干预（与非活动对照和/或替代治疗相比）的效果。我们检索了Cochrane Central Register of Controlled Trials （Central; 2015，第6期）、MEDLINE、EMBASE、PsycINFO、护理与相关健康文献累积索引（CINAHL）和参考文献列表。检索文献包括2015年7月之前发表的所有文章。所有检查大麻使用障碍心理社会干预（无药物干预）与最小或无效治疗对照或心理社会干预替代组合的随机对照研究。按照Cochrane Collaboration的要求，我们使用了标准的方法程序。我们纳入了23项随机对照试验，涉及4045名受试者。总共有15项研究在美国进行，澳大利亚2项，德国2项，瑞士、加拿大、巴西和爱尔兰各1项。研究人员提供了大约7个疗程（范围，1至14），持续约12周（范围，1至56）。总体而言，各研究的偏倚风险为中等，即没有试验存在选择偏倚、消耗偏倚或报告偏倚的高风险。此外，试验包括了大量的参与者，每个试验都确保了所提供治疗的保真度。相比之下，由于所提供的干预措施的性质，参与者盲法是不可能的，研究人员盲法的报告往往不清楚或没有提供。在回顾的研究中，有一半包括附带验证或尿液分析来确认自我报告数据，这导致了对表现和检测偏差的担忧。最后，对其他偏见的担忧是基于相对一致地缺乏对非大麻物质使用或在试验之前或期间使用额外治疗的评估。一组研究提供了足够的细节来比较任何干预与非活动对照对早期随访（中位，4个月）主要结果的影响。结果显示，中等质量的证据表明，10名干预参与者中约有7人按预期完成了治疗（效应值（ES） 0.71, 95%置信区间（CI） 0.63至0.78,11项研究，1424名参与者），接受心理社会干预的参与者使用大麻的天数少于不进行干预的对照组（平均差异（MD） 5.67, 95% CI 3.08至8.26,6项研究，1144名参与者）。此外，低质量证据显示，接受干预的患者更有可能报告点流行性戒断（风险比（RR） 2.55, 95% CI 1.34至4.83,6项研究，1166名受试者），并且报告的依赖症状（标准化平均差（SMD） 4.15, 95% CI 1.67至6.63,4项研究，889名受试者）和大麻相关问题较少（SMD 3.34, 95% CI 1.26至5.42,6项研究，2202名受试者）。最后，非常低质量的证据表明，接受干预的患者报告说，与不活动对照组相比，他们每天使用的关节更少（SMD为3.55,95% CI为2.51至4.59,8项研究，1600名参与者）。值得注意的是，亚组分析发现，与低强度干预相比，为期一个月以上的四次以上的干预（高强度）在短期内持续产生更好的结果（特别是在大麻使用频率和依赖程度方面）。最一致的证据支持在早期随访中使用认知行为疗法（CBT）、动机增强疗法（MET），特别是它们的组合有助于减少大麻使用频率(MET: MD 4.45, 95% CI 1.90至7.00，四项研究，612名参与者；CBT: MD 10.94, 95% CI 7.44至14.44，一项研究，134名参与者；MET + CBT: MD 7.38, 95% CI 3.18至11.57,3项研究，398名参与者)和依赖程度（MET: SMD 4.07, 95% CI 1.97至6.17,2项研究，316名参与者；MET + CBT: SMD 7.89, 95% CI 0.93至14.85,3项研究，573名参与者），尽管在9个月或更晚的随访中没有特定的干预措施始终有效。此外，六项研究中有五项的数据支持为大麻阴性尿液增加基于凭证的奖励措施，以增强对大麻使用频率的治疗效果。一项单独的研究在12个月的随访期间发现了截然不同的结果，因为治疗后与大麻使用频率总体减少相关的结果倾向于单独使用CBT，而不添加基于戒断或基于治疗的应急管理。相比之下，药物咨询、社会支持、复发预防和正念冥想的证据薄弱，因为确定的研究很少，治疗结果的信息不足，治疗依从率低。与其他药物使用的治疗一致，戒断率总体上相对较低，大约四分之一的参与者在最后的随访中戒断。最后，三项研究发现，在精神病诊所的参与者中，干预与常规治疗相当，并且在任何纳入的结果中没有报告组间差异。纳入的研究在许多方面都是异质的，关于最有效的持续时间、强度和干预类型的重要问题被提出并部分解决。研究结果的普遍性尚不清楚，最明显的原因是地方数量有限，寻求治疗的人的样本也很均匀。戒断率低且不稳定，尽管与其他药物使用的治疗相当。与最低限度的治疗控制相比，社会心理干预显示出至少在短期内以相当持久的方式减少使用频率和严重依赖。在包括的干预类型中，基于MET和CBT结合以及基于戒断的激励措施的四次以上的强化干预最一致地支持用于治疗大麻使用障碍。
Cannabis use disorder is the most commonly reported illegal substance use disorder in the general population; although demand for assistance from health services is increasing internationally, only a minority of those with the disorder seek professional assistance. Treatment studies have been published, but pressure to establish public policy requires an updated systematic review of cannabis-specific treatments for adults. To evaluate the efficacy of psychosocial interventions for cannabis use disorder (compared with inactive control and/or alternative treatment) delivered to adults in an out-patient or community setting. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 6), MEDLINE, EMBASE, PsycINFO, the Cumulaive Index to Nursing and Allied Health Literature (CINAHL) and reference lists of articles. Searched literature included all articles published before July 2015. All randomised controlled studies examining a psychosocial intervention for cannabis use disorder (without pharmacological intervention) in comparison with a minimal or inactive treatment control or alternative combinations of psychosocial interventions. We used standard methodological procedures as expected by The Cochrane Collaboration. We included 23 randomised controlled trials involving 4045 participants. A total of 15 studies took place in the United States, two in Australia, two in Germany and one each in Switzerland, Canada, Brazil and Ireland. Investigators delivered treatments over approximately seven sessions (range, one to 14) for approximately 12 weeks (range, one to 56). Overall, risk of bias across studies was moderate, that is, no trial was at high risk of selection bias, attrition bias or reporting bias. Further, trials included a large total number of participants, and each trial ensured the fidelity of treatments provided. In contrast, because of the nature of the interventions provided, participant blinding was not possible, and reports of researcher blinding often were unclear or were not provided. Half of the reviewed studies included collateral verification or urinalysis to confirm self report data, leading to concern about performance and detection bias. Finally, concerns of other bias were based on relatively consistent lack of assessment of non-cannabis substance use or use of additional treatments before or during the trial period. A subset of studies provided sufficient detail for comparison of effects of any intervention versus inactive control on primary outcomes of interest at early follow-up (median, four months). Results showed moderate-quality evidence that approximately seven out of 10 intervention participants completed treatment as intended (effect size (ES) 0.71, 95% confidence interval (CI) 0.63 to 0.78, 11 studies, 1424 participants), and that those receiving psychosocial intervention used cannabis on fewer days compared with those given inactive control (mean difference (MD) 5.67, 95% CI 3.08 to 8.26, six studies, 1144 participants). In addition, low-quality evidence revealed that those receiving intervention were more likely to report point-prevalence abstinence (risk ratio (RR) 2.55, 95% CI 1.34 to 4.83, six studies, 1166 participants) and reported fewer symptoms of dependence (standardised mean difference (SMD) 4.15, 95% CI 1.67 to 6.63, four studies, 889 participants) and cannabis-related problems compared with those given inactive control (SMD 3.34, 95% CI 1.26 to 5.42, six studies, 2202 participants). Finally, very low-quality evidence indicated that those receiving intervention reported using fewer joints per day compared with those given inactive control (SMD 3.55, 95% CI 2.51 to 4.59, eight studies, 1600 participants). Notably, subgroup analyses found that interventions of more than four sessions delivered over longer than one month (high intensity) produced consistently improved outcomes (particularly in terms of cannabis use frequency and severity of dependence) in the short term as compared with low-intensity interventions. The most consistent evidence supports the use of cognitive-behavioural therapy (CBT), motivational enhancement therapy (MET) and particularly their combination for assisting with reduction of cannabis use frequency at early follow-up (MET: MD 4.45, 95% CI 1.90 to 7.00, four studies, 612 participants; CBT: MD 10.94, 95% CI 7.44 to 14.44, one study, 134 participants; MET + CBT: MD 7.38, 95% CI 3.18 to 11.57, three studies, 398 participants) and severity of dependence (MET: SMD 4.07, 95% CI 1.97 to 6.17, two studies, 316 participants; MET + CBT: SMD 7.89, 95% CI 0.93 to 14.85, three studies, 573 participants), although no particular intervention was consistently effective at nine-month follow-up or later. In addition, data from five out of six studies supported the utility of adding voucher-based incentives for cannabis-negative urines to enhance treatment effect on cannabis use frequency. A single study found contrasting results throughout a 12-month follow-up period, as post-treatment outcomes related to overall reduction in cannabis use frequency favoured CBT alone without the addition of abstinence-based or treatment adherence-based contingency management. In contrast, evidence of drug counselling, social support, relapse prevention and mindfulness meditation was weak because identified studies were few, information on treatment outcomes insufficient and rates of treatment adherence low. In line with treatments for other substance use, abstinence rates were relatively low overall, with approximately one-quarter of participants abstinent at final follow-up. Finally, three studies found that intervention was comparable with treatment as usual among participants in psychiatric clinics and reported no between-group differences in any of the included outcomes. Included studies were heterogeneous in many aspects, and important questions regarding the most effective duration, intensity and type of intervention were raised and partially resolved. Generalisability of findings was unclear, most notably because of the limited number of localities and homogeneous samples of treatment seekers. The rate of abstinence was low and unstable although comparable with treatments for other substance use. Psychosocial intervention was shown, in comparison with minimal treatment controls, to reduce frequency of use and severity of dependence in a fairly durable manner, at least in the short term. Among the included intervention types, an intensive intervention provided over more than four sessions based on the combination of MET and CBT with abstinence-based incentives was most consistently supported for treatment of cannabis use disorder.
影响因子：
2.5
作者：
Hjorthøj C;Fohlmann A;Larsen AM;Madsen MT;Vesterager L;Gluud C;Arendt MC;Nordentoft M
通讯作者：
Nordentoft M