Review of: Ray LA et al, JAMA Netw Open 2020;3(6):e208279

When we see patients with addiction for medication management appointments, we often recommend psychotherapy. How helpful is adding a particular psychotherapy like cognitive behavioral therapy (CBT) to medications for substance use disorder (SUD)?

The authors reviewed 30 randomized controlled trials published between 1990 and 2019. They divided the studies into three categories: 1) CBT plus medications compared with “usual care” plus medications; 2) CBT plus medications compared with another specific psychotherapy plus medications; and 3) CBT added to usual care plus medications compared with usual care plus medications alone. For this context, “usual care” meant nonspecific supportive therapy, drug counseling, or clinical management combined with the pharmacotherapy.

The CBT sessions in most studies (73%) were individual vs groups with an average of 16 sessions. Most of the patients were Caucasian (66%) and male (72%). The most common substance used was alcohol (50%), followed by cocaine (23%) and opioids (20%). Pharmacotherapy consisted of naltrexone and/or acamprosate (42%), methadone or buprenorphine/naloxone (18%), disulfiram (8%), or another medication or mixture of medications (32%).

The results were a mixed bag. Adding CBT to drug treatment was statistically better than drug treatment with usual care—with a small to moderate effect size. However, CBT was not superior to other specific psychotherapies, such as motivational enhancement therapy, contingency management, or 12-step facilitation. Adding CBT to usual care plus medications also didn’t confer observed advantages—although this last finding might be skewed due to the inclusion of a large study called COMBINE. That study included 917 patients, and the “usual care” portion did involve some counseling. Adding CBT to this already intensive intervention didn’t contribute much and could have thrown off the results for that data set.

CATR’s Take
Adding CBT to medications for SUD may be preferable to medications alone. But CBT is not any better than a range of other specific therapies, such as 12-step facilitation or motivational enhancement therapy. Adding some form of organized therapy to drug treatment may build recovery capacity, but the extra benefit is not likely to be very large.