REVIEW OF: Ray LA et al, JAMA Network Open 2020;3(6):e208279

Does cognitive behavioral therapy (CBT) provide any extra benefit when added to medication treatment for substance use disorders? It’s not clear. Most notably, in the COMBINE study of comparative treatments for alcohol use disorder (see CATR, Nov/Dec 2019), a combined behavioral intervention (that included CBT) added to medical management did not improve outcomes. And yet, in real-world practice, CBT continues to be widely offered. Recognizing this evidence gap in common practice and clinical guidelines, Ray et al did a systematic review and meta-analysis of combined CBT and pharmacotherapy for various substance use disorders.

The researchers searched over 10,000 abstracts to identify 30 studies meeting their inclusion criteria: peer-reviewed, English-language RCTs involving adults receiving either individual or group CBT in addition to medication. Trials mostly included alcohol, cocaine, and opioid use disorders, and medications trialed included naltrexone, disulfiram, nefazodone, desipramine, methadone, buprenorphine, acamprosate, and levodopa. The results were grouped according to three main questions, and an estimate of effect size was reported using Hedges’ g (0.2 small, 0.5 medium, 0.8 large).

The researchers found that CBT plus medications was somewhat superior to usual care interventions plus medications. These “usual care interventions” included basic medication clinic add-ons like clinical management, drug counseling, and group counseling. CBT was better than these basic interventions at reducing both the frequency (g = 0.18) and quantity (g = 0.28) of substance use.

That was the good news for CBT. The bad news was that CBT was not more effective than other specific forms of therapy (eg, motivational enhancement therapy, 12-step facilitation, contingency management [g = 0.05]) and did not demonstrate benefit when included as an add-on to medical management, such as in the COMBINE trial (g = 0.06–0.17).

CATR’s TAKE
This review shows that CBT is at best modestly effective when started alongside medications but not superior to other forms of psychotherapy or when added to medical management. However, before souring on CBT, it’s important to note that this meta-analysis tried to combine many studies of different disorders and medications with varying efficacy. While we wait for more data that match CBT with specific medications for specific substance use disorders, it is reasonable to offer CBT given its low risk and some likelihood that it may build capacity for recovery.