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[大学生论坛]:可卡因和苯丙胺成瘾者的心理干预的比较疗效和可接受性

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coeng 发表于 2019-1-4 20:56:37 | 显示全部楼层 |阅读模式
Comparative efficacy and acceptability of psychosocial interventions for individuals with cocaine and amphetamine addiction: A systematic review and network meta-analysis

可卡因和苯丙胺成瘾者的心理干预的比较疗效和可接受性:系统评价和网络荟萃分析

Background
Clinical guidelines recommend psychosocial interventions for cocaine and/or amphetamine addiction as first-line treatment, but it is still unclear which intervention, if any, should be offered first. We aimed to estimate the comparative effectiveness of all available psychosocial interventions (alone or in combination) for the short- and long-term treatment of people with cocaine and/or amphetamine addiction.
背景
临床指南建议将可卡因和/或安非他明成瘾的社会心理干预作为一线治疗,但目前尚不清楚应首先提供哪种干预措施(如果有的话)。 我们的目的是评估所有可用的心理社会干预措施(单独或组合)对可卡因和/或苯丙胺成瘾者的短期和长期治疗的相对有效性。

Methods and findings
We searched published and unpublished randomised controlled trials (RCTs) comparing any structured psychosocial intervention against an active control or treatment as usual (TAU) for the treatment of cocaine and/or amphetamine addiction in adults. Primary outcome measures were efficacy (proportion of patients in abstinence, assessed by urinalysis) and acceptability (proportion of patients who dropped out due to any cause) at the end of treatment, but we also measured the acute (12 weeks) and long-term (longest duration of study follow-up) effects of the interventions and the longest duration of abstinence. Odds ratios (ORs) and standardised mean differences were estimated using pairwise and network meta-analysis with random effects. The risk of bias of the included studies was assessed with the Cochrane tool, and the strength of evidence with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We followed the PRISMA for Network Meta-Analyses (PRISMA-NMA) guidelines, and the protocol was registered in PROSPERO (CRD 42017042900). We included 50 RCTs evaluating 12 psychosocial interventions or TAU in 6,942 participants. The strength of evidence ranged from high to very low. Compared to TAU, contingency management (CM) plus community reinforcement approach was the only intervention that increased the number of abstinent patients at the end of treatment (OR 2.84, 95% CI 1.24–6.51, P = 0.013), and also at 12 weeks (OR 7.60, 95% CI 2.03–28.37, P = 0.002) and at longest follow-up (OR 3.08, 95% CI 1.33–7.17, P = 0.008). At the end of treatment, CM plus community reinforcement approach had the highest number of statistically significant results in head-to-head comparisons, being more efficacious than cognitive behavioural therapy (CBT) (OR 2.44, 95% CI 1.02–5.88, P = 0.045), non-contingent rewards (OR 3.31, 95% CI 1.32–8.28, P = 0.010), and 12-step programme plus non-contingent rewards (OR 4.07, 95% CI 1.13–14.69, P = 0.031). CM plus community reinforcement approach was also associated with fewer dropouts than TAU, both at 12 weeks and the end of treatment (OR 3.92, P < 0.001, and 3.63, P < 0.001, respectively). At the longest follow-up, community reinforcement approach was more effective than non-contingent rewards, supportive-expressive psychodynamic therapy, TAU, and 12-step programme (OR ranging between 2.71, P = 0.026, and 4.58, P = 0.001), but the combination of community reinforcement approach with CM was superior also to CBT alone, CM alone, CM plus CBT, and 12-step programme plus non-contingent rewards (ORs between 2.50, P = 0.039, and 5.22, P < 0.001). The main limitations of our study were the quality of included studies and the lack of blinding, which may have increased the risk of performance bias. However, our analyses were based on objective outcomes, which are less likely to be biased.

方法和发现
我们搜索了已发表和未发表的随机对照试验(RCT),比较了任何结构化的心理社会干预与正常的活动对照或治疗(TAU)治疗成人中的可卡因和/或苯丙胺成瘾。主要结局指标是治疗结束时的疗效(戒烟患者的比例,通过尿液分析评估)和可接受性(因任何原因退出的患者比例),但我们还测量了急性(12周)和长期(研究随访时间最长)干预措施的效果和最长的禁欲期。使用具有随机效应的成对和网络荟萃分析估计优势比(OR)和标准化平均差异。使用Cochrane工具评估纳入研究的偏倚风险,并使用建议评估,发展和评估(GRADE)方法评估证据的强度。我们遵循PRISMA进行网络元分析(PRISMA-NMA)指南,该协议已在PROSPERO(CRD 42017042900)中注册。我们纳入了50项RCT评估了12项心理社会干预措施或6,942名参与者的TAU。证据强度从高到低都很高。与TAU相比,应急管理(CM)加社区强化方法是唯一一种在治疗结束时增加戒断患者数量的干预措施(OR 2.84,95%CI 1.24-6.51,P = 0.013),以及12周时(OR 7.60,95%CI 2.03-28.37,P = 0.002)和最长随访时间(OR 3.08,95%CI 1.33-7.17,P = 0.008)。在治疗结束时,CM +社区强化方法在头对头比较中具有最高数量的统计学显着结果,比认知行为疗法(CBT)更有效(OR 2.44,95%CI 1.02-5.88,P = 0.045),非或有奖励(OR 3.31,95%CI 1.32-8.28,P = 0.010),12步计划加非或有奖励(OR 4.07,95%CI 1.13-14.69,P = 0.031)。在12周和治疗结束时,CM加社区强化方法也与TAU相比具有更少的辍学率(分别为OR 3.92,P <0.001和3.63,P <0.001)。在最长的随访中,社区强化方法比非临时奖励,支持表达心理动力疗法,TAU和12步骤方案(OR范围在2.71,P = 0.026和4.58,P = 0.001)更有效,但社区强化方法与CM的结合也优于单独CBT,单独CM,CM加CBT和12步计划加非或有奖励(OR在2.50之间,P = 0.039和5.22,P <0.001)。我们研究的主要局限性是纳入研究的质量和缺乏致盲性,这可能增加了表现偏倚的风险。然而,我们的分析基于客观结果,不太可能有偏见。

Conclusions
To our knowledge, this network meta-analysis is the most comprehensive synthesis of data for psychosocial interventions in individuals with cocaine and/or amphetamine addiction. Our findings provide the best evidence base currently available to guide decision-making about psychosocial interventions for individuals with cocaine and/or amphetamine addiction and should inform patients, clinicians, and policy-makers.

结论
据我们所知,这种网络荟萃分析是对可卡因和/或苯丙胺成瘾者进行心理社会干预的最全面的数据综合。 我们的研究结果为目前可用于指导有可卡因和/或安非他明成瘾者的心理社会干预决策提供了最佳证据基础,并应告知患者,临床医生和政策制定者。


来源:
https://journals.plos.org/plosone/


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