Key Points

Question Is cognitive behavioral therapy associated with improved outcomes for alcohol and other substance use disorders in the context of pharmacotherapy for addiction?

Findings This systemic review and meta-analysis including 30 studies found that combined cognitive behavioral therapy and pharmacotherapy was associated with increased benefit compared with usual care and pharmacotherapy. Cognitive behavioral therapy did not perform better than another evidence-based modality in this context or as an add-on to combined usual care and pharmacotherapy.

Meaning These findings suggest that best practices in addiction treatment should include pharmacotherapy plus cognitive behavioral therapy or another evidence-based therapy, rather than usual clinical management or nonspecific counseling services.

Introduction

Substance use disorders (SUDs) represent a pressing public health concern, which calls for clinicians and scientists to identify and implement best practices in treatment.^1,2 To that end, the combination of pharmacological and behavioral interventions has long been considered the criterion standard in addiction care,^3-5 although differences between best practices for alcohol use disorder (AUD) and SUD have been noted.⁶ For SUDs without a US Food and Drug Administration (FDA)–approved pharmacotherapy, such as cocaine, methamphetamine, and cannabis, behavioral treatments are the principal approach.⁷ Cognitive behavioral therapy (CBT) is a first-line behavioral approach for treating AUD and other SUDs (AUD/SUD).⁸ Cognitive behavioral therapy is a time-limited, multisession intervention that targets cognitive, affective, and environmental risks for substance use and provides training in behavioral self-control skills to help an individual achieve and maintain abstinence or harm reduction.

Despite the importance of combined pharmacological and behavioral interventions for AUD/SUD, few meta-analyses on this intervention approach have been performed. Typically, meta-analytic reviews in the AUD/SUD literature have been conducted on specific pharmacotherapies,⁹ groups of pharmacotherapies,^10-12 or specific behavioral interventions, such as CBT. As a result, the evidence-informed guideline will relate only to the selection of a single, stand-alone therapy, whether pharmacological or behavioral, and not their combination. For example, in a review of 122 clinical trials of AUD pharmacotherapies delivered in outpatient settings,¹⁰ the authors could not conclude about the efficacy of pharmacotherapies when combined with a behavioral cointervention.

The meta-analytic evidence on CBT supports efficacy at short- and long-term follow-ups.¹³ In an early review (1999) of 26 studies by Irvin et al,¹⁴ the authors found CBT to be generally effective across a range of conditions, but effect sizes were roughly 5 times higher when CBT was combined with pharmacotherapy than when delivered as a stand-alone intervention. This subgroup analysis was based on 4 studies and should therefore be interpreted with caution.¹⁴ In 2009, Magill and Ray¹⁵ followed up this work with a meta-analysis of 53 CBT clinical trials, reporting a similar overall effect size and a larger effect when CBT was combined with pharmacotherapy than when delivered alone, but the difference in effect-size magnitude between groups was smaller than observed in the previous review including 13 studies.

The goal of this meta-analysis is to provide an up-to-date and comprehensive review of CBT in conjunction with pharmacotherapy for AUD/SUD. This meta-analysis provides effect-size estimates across 3 distinct subgroups that may be informative to best-practice guidelines or individual clinician decision-making: (1) CBT plus pharmacotherapy compared with usual care (eg, clinical management, nonspecific drug counseling) plus pharmacotherapy, (2) CBT plus pharmacotherapy compared with another specific therapy (eg, motivational enhancement therapy, contingency management) plus pharmacotherapy, and (3) CBT added to usual care and pharmacotherapy compared with usual care and pharmacotherapy alone. Sensitivity analyses included tests of heterogeneity, study influence, and publication bias. Given the robust literature on CBT for addiction,^15,16 the critical role of pharmacotherapy in addiction treatment,^1,2,17-19 and the notion that combined treatments may be most effective,^3,17,18 this meta-analytic review seeks to inform clinical practice and best-practice guidelines for addiction.

Methods

Literature Search Strategy

A literature search was conducted by a trained research assistant (J.W.) through July 31, 2019, as part of a broader meta-analysis project on CBT for substance use. First, we performed an all-fields search by treatment (cognitive behavioral therapy OR relapse prevention OR coping skills training), outcome (alcohol OR cocaine OR methamphetamine OR stimulant OR opiate OR heroin OR opioid OR marijuana OR cannabis OR illicit drug OR substances OR dual disorder OR polysubstance OR dual diagnosis), and study terms (efficacy OR randomized controlled trial OR randomized clinical trial) in the PubMed database. Then, we searched the Cochrane Register, Embase, and EBSCO databases (ie, MEDLINE and PsychINFO). Abstract screening was performed by 2 raters in abstrkr.²⁰ A bibliographic search of CBT reviews was also performed to identify any candidate studies not identified by the original search methods^14,16,21-24 This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.

The Figure summarizes study inclusion for the present report on combined CBT and pharmacological interventions for adult AUD/SUD (PRISMA diagram). The final meta-analytic sample consisted of 30 studies and 62 effect sizes. No studies that fit the search criteria have been published since 2016. The protocol for this meta-analysis was not registered but was scientifically reviewed at the National Institutes of Health.

Primary Study Inclusion

Studies were English-language, peer-reviewed articles published from January 1, 1990, through July 31, 2019. Studies were primary outcome reports of randomized clinical trials. Given the importance of experimental contrast type in estimating effect-size magnitude in clinical trials,^25,26 we used this design factor as a primary subgroup variable. Studies were included if they targeted adult populations (aged ≥18 years) meeting criteria for AUD or other drug use disorder (ie, Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised through Fifth Edition) or problematic use.²⁷ Treatment must have been identified as either cognitive behavioral or relapse prevention. Concomitant treatment with pharmacotherapy for AUD/SUD was required for inclusion. Studies of CBT delivered in either individual or group format were included.

Primary Study Characteristic Variables

Several study characteristic variables were examined in this meta-analysis. Study-level descriptors were mean (SD) age, percentage of female participants, percentage of white participants, percentage of black participants, percentage of Latinx participants, primary drug outcome (ie, alcohol, cocaine/stimulants, opioids, other), substance use severity (ie, dependence, abuse, or heavy use), treatment length (ie, number of planned sessions), treatment delivery (ie, individual or group format), study context (ie, community sample, specialty substance use or mental health clinic, medical setting, college setting, criminal justice setting, or other setting), publication country (ie, United States or other), and study-level risk of bias.²⁸ Effect-size subgroup variables were (1) type of experimental contrast (ie, CBT plus pharmacotherapy compared with usual care plus pharmacotherapy, CBT plus pharmacotherapy compared with another specific therapy plus pharmacotherapy, CBT added to usual care and pharmacotherapy compared with usual care and pharmacotherapy alone), (2) type of substance use outcome type (ie, frequency and quantity), and (3) outcome point (posttreatment or follow-up). Data extraction guidelines were detailed in a study codebook available on request. Data were extracted in 2 independent passes conducted by trained raters (L.A.R., L.R.M., and J.W.). Final data entry where disagreement was observed required a consensus review by another author (M.M.).

Primary Study Outcome Variables

The standardized mean difference was used to measure efficacy outcomes in this meta-analysis. The Hedges g statistic includes a correction for a slight upward bias in the estimated population effect.²⁹ Before pooling, effect sizes were weighted by the inverse of the estimate variance to allow larger studies more influence on the overall effect size.³⁰ Primary studies typically provided data on more than 1 outcome; therefore, data for effect-size estimation were selected based on a decisional hierarchy in the following order: (1) biological assay measures, (2) measures of frequency or quantity in the form of means (SDs), (3) sample proportions, and (4) other outcomes (eg, diagnostic measures). Most studies reported posttreatment outcomes only (18 [60%]), and if multiple months of follow-up data were reported, the latest time point was selected. Effect sizes were reverse scored as needed (eg, number of days with alcohol use) such that a positive effect size indicated a positive treatment outcome. Finally, when univariate outcome data were not reported, test statistics were transformed using available formulae.³¹ Effect size magnitude was interpreted using the follow benchmarks: 0.2 indicates small; 0.5, medium; and 0.8, large.³²

Statistical Analysis

Data were analyzed through September 30, 2019. Comprehensive Meta-analysis, version 3.0,³³ was used for all analyses. Effect sizes for alcohol and other drug use were pooled using a random-effects model where there was an assumed distribution for the population effect size with systematic and random sources of variability.³⁴ The significance of the Q test determined whether statistically significant between-study heterogeneity was present, and the I² statistic provided a percentage of heterogeneity estimate, regardless of statistical significance. When I² estimates exceeded 50%,³³ primary drug outcome was tested as an effect-size moderator. We conducted other sensitivity analyses, including trimmed estimates with influential studies (ie, a study that, if removed, would change the substantive interpretation of the pooled effect size) removed and tests for publication bias.

Results

Sample-Level Descriptive Data

The sample included 30 unique AUD/SUD randomized clinical trials^{3 ,7,35-62} that examined CBT in combination with some form of pharmacotherapy. The study publication range was 1992 to 2016. The median sample size was 82 participants, with a range of 30³⁵ to 917.³ The primary substance targeted in these clinical trials was alcohol (15 [50%]), followed by cocaine (7 [23%]) and opioids (6 [20%]). The sample mean (SD) participant age was 39 (6) years, with a mean (SD) of 28% (12%) female participants. Although reporting of race and ethnicity were inconsistent, the mean (SD) percentages were as follows: 66% (26%) white (21 of 30 studies), 35% (28%) black (15 of 30 studies), and 9% (7%) Latinx (15 of 30 studies). Diagnostically, study inclusion primarily (ie, 95%) targeted individuals with abuse or dependence as defined by Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria.⁶³ The CBT portion of these combined interventions was 73% individual and 26% group delivered, and 1 study³⁶ used a mixture of individual and group sessions. The mean number of planned sessions was 16 (range, 4-48), and recruitment contexts were primarily specialty substance use or mental health clinics (20 [68%]), medical settings (5 [16%]), and community advertising (5 [16%]). The following pharmacotherapies were examined in this review: naltrexone hydrochloride and/or acamprosate sodium (26 of 62 effect sizes [42%]), methadone hydrochloride or combined buprenorphine hydrochloride and naltrexone (Suboxone) (11 of 62 [18%]), disulfiram (5 of 62 [8%]), and another pharmacotherapy or a mixture of pharmacotherapies (20 of 62 [32%]) (see Table 1 and Table 2 for details). Study-level risk-of-bias assessment showed 18 studies (60%) were low risk.²⁸ When studies were designated as unclear or high risk, this was typically owing to (1) the presence of baseline differences between conditions, (2) no report of blinding of personnel and participants, and (3) no report of blinding of outcome assessment. Finally, most studies (21 [70%]) were published in the United States. Of studies conducted outside the United States, the following countries were represented: Germany, Sweden, the Netherlands, Switzerland, Finland, China, and Australia.

Tables 1 and 2 describe each study with respect to key design characteristics and effect sizes and are separated by posttreatment and follow-up outcomes, respectively. For outcomes of interest, biological assay/frequency measures and quantity measures are considered primary, and when available both are reported in Tables 1 and 2. Finally, the sample was distributed in roughly equal thirds with respect to the types of conditions to which combined CBT and pharmacotherapy was compared; narrative results and Tables 1 and 2 are organized by these clinically informative subgroups, and given the distinctiveness of these comparator conditions, no overall pooled effect size is reported. For pictorial plot information, see eFigures 1 through 10 in the Supplement.

CBT Plus Pharmacotherapy Compared With Usual Care Plus Pharmacotherapy

When CBT plus pharmacotherapy was compared with usual care plus pharmacotherapy, the effect for CBT on posttreatment frequency outcomes was small, homogeneous, and statistically significant (g = 0.18 [95% CI, 0.01-0.35]; P = .04; τ² = 0.00, Q > 0.05, I² = 0%),^37,43-49 but only 1 study³⁷ provided follow-up effect-size data (g = 0.24 [95% CI, −0.15 to 0.62]). For quantity outcomes,^{37,43,46,47,49} effects were small to moderate, homogenous, and significant (g = 0.28 [95% CI, 0.03-0.54]; P = .03; τ² = 0.03; Q > 0.05; I² = 31%), and only 2 studies^37,38 provided follow-up effect-size data (g = 0.50 [95% CI, 0.01-0.89] and g = 2.00 [95% CI, 1.40-2.60], respectively). Among the studies in this subgroup, no evidence was found for influential studies or publication bias.

CBT Plus Pharmacotherapy Compared With Another Specific Therapy Plus Pharmacotherapy

Studies that compared CBT with another specific therapy suggested no unique benefit of adding CBT to pharmacotherapy compared with other evidence-based modalities. For posttreatment frequency outcomes, effects were homogeneous and nonsignificant (g = 0.05 [95% CI, −0.13 to 0.23]; P = .58; τ² = 0.03; Q > 0.05; I² = 35%).^{7,45,50-53,55-57} A similar pattern of frequency results was found at follow-up (g = −0.02 [95% CI, −0.29 to 0.26]; P = .89; τ² = 0.03; Q > 0.05; I² = 11%).^{39,52,53,57,60} Quantity posttreatment outcomes were also nonsignificant but statistically heterogeneous (g = 0.09 [95% CI, −0.42 to 0.60]; P = .74; τ² = 0.23; Q < 0.05; I² = 84%).^41,50,51,54 At follow-up, only Longabaugh et al³⁹ reported quantity outcomes (g = 0.34 [95% CI, −0.29 to 0.96]). Sensitivity analyses showed no influential studies or evidence of publication bias.

CBT as an Add-on to Usual Care and Pharmacotherapy Compared With Usual Care and Pharmacotherapy Alone

The final subgroup of studies examined CBT as an add-on to combined usual care and pharmacotherapy and suggested no clear added benefit of CBT in this context. Frequency results were heterogeneous and nonsignificant after treatment (g = 0.06 [95% CI, −0.22 to 0.34]; P = .67; τ² = 0.13; Q < 0.05; I² = 76%)^{3 ,35,36,42,53,54,57-59} and at follow-up (g = 0.17 [95% CI, −0.05 to 0.38]; P = .13; τ² = 0.04; Q > 0.05; I² = 51%).^{3 ,42,53,57,59,60,62} Only 3 studies (all AUD trials) provided quantity effect-size data, and these studies showed very different measures of effect (Anton et al³ : g = 0.08 [95% CI, −0.14 to 0.31]; Epstein et al⁶⁵ : g = −0.14 [95% CI, −0.54 to 0.25]; Morgenstern et al⁴⁰ : g = 2.90 [95% CI, 2.32-3.48]). At follow-up, the effect size for quantity outcomes in the COMBINE Study³ was g = 0.04 (95% CI, −0.19 to 0.26) for collapsed pharmacotherapy, medication management, and combined behavioral intervention conditions vs pharmacotherapy and medication management only conditions. Sensitivity analyses showed no evidence of publication bias but showed 2 influential studies^{35 ,40} (eFigure 3 in the Supplement).

Primary Drug Target as a Moderator of Between-Study Heterogeneity

In this review of CBT combined with pharmacotherapy for AUD/SUD frequency and quantity outcomes after treatment and at follow-up, most effect estimates showed little to no statistical heterogeneity. This outcome suggests that the variation between studies within a given pooled effect size was random rather than systematic.³³ The exception was CBT combined with pharmacotherapy in contrast to another specific therapy combined with pharmacotherapy in relation to posttreatment quantity outcomes (Q < 0.05; I² = 84%)^{41 ,50,51,54} and CBT as an addition to combined usual care and pharmacotherapy in relation to posttreatment (Q < 0.05; I² = 76%)^{3 ,35,36,42,53,54,57-59} and follow-up (Q > 0.05; I² = 51%)^{3 ,42,53,57,59,60,62} frequency outcomes. Given that the sample of studies targeted different substances, each primary drug was examined as a subgroup moderator, and residual I² values were reported. Results are presented in Table 3. These analyses show that pooled effect-size direction and/or magnitude varied by primary drug outcome in this review. However, residual heterogeneity was present in 3 of the 8 subgroups, suggesting that this a priori moderator was an informative variable in this meta-analysis but did not explain all the systematic variance between studies. As a result, random-effects estimates are a particularly appropriate metric for this review.

Discussion

To our knowledge, this is the first targeted meta-analysis of CBT in combination with pharmacotherapy for adults with AUD and other SUDs to summarize the data in a manner relevant to clinical practice guidelines. Furthermore, we provided pooled effect size estimates by consumption outcome type and outcome point. Most of these subgroup estimates showed acceptable homogeneity, which suggests that the selected variables were informative effect-size modifiers for the sample of clinical trials reviewed. In the present study, a small and statistically significant effect size was observed across outcome type and time for CBT combined with pharmacotherapy when compared with usual care combined with pharmacotherapy. For context in interpreting this effect, meta-analyses among this patient population generally show effect sizes that are in the small-to-moderate range,^41,66,67 and this includes effect sizes for pharmacological interventions.^11,68,69 This contrast suggests that prescribing clinicians should favor CBT over usual care to improve clinical outcomes for addiction, in the context of pharmacotherapy.

The second subgroup contrast was combined CBT and pharmacotherapy compared with another specific therapy combined with pharmacotherapy. Here, results suggested no unique benefit of adding CBT to pharmacotherapy compared with other evidence-based behavioral modalities. Such modalities may include contingency management, motivation enhancement therapy, 12-step facilitation, and interpersonal therapy, all of which have received some level of empirical support for addiction,^70,71 including meta-analytic support at various follow-up periods.²³ The lack of superiority of CBT over other evidence-based behavioral treatment for addiction is consistent with our recent findings,¹³ and this meta-analysis extends this result to combined pharmacotherapy and behavioral treatments. Although there may be evidence of some advantage for contingency management,⁷² removal of contingency management trials in this review did not change our substantive conclusions. This suggests that CBT is not superior to other evidence-based behavioral treatments for addiction, yet when combined with the aforementioned superiority to usual care, we suggest that clinicians favor an evidence-based behavioral therapy, CBT or otherwise, in conjunction with pharmacological treatments.

The third contrast in this meta-analysis assessed CBT as an add-on to usual care and pharmacotherapy compared with usual care and pharmacotherapy alone. In interpreting these findings, several explanations come to mind. First, there was substantial heterogeneity in the effect sizes obtained in these studies, suggesting unique study-specific factors could further explain outcome variability. This speculation is supported by the 2 influential studies observed in this subgroup.^35,40 Moreover, moderator analyses by primary drug target showed variability in effect-size direction and magnitude with effects for cocaine and stimulant studies showing a range from moderate and negative^35,41 to large and positive^57,58 effects. This variability may be due, in part, to the lack of FDA-approved pharmacotherapy for cocaine/stimulant use disorder.⁷³ In other words, FDA approval in this case was potentially confounded with the primary drug target. Second, some studies reported participants’ poor adherence to the CBT protocol, which may directly affect outcome.^42,65 Third, the COMBINE Study is a large trial, which reported no benefit of the combined behavioral intervention over medication management. Close inspection of the medication management protocol for this study suggests it was a systematic, intensive, and rather robust intervention^74,75 not readily comparable to standard clinical care. Together, these findings speak to the difficulty of measuring the benefit of an add-on component in complex clinical settings where multiple interventions are simultaneously administered.

Limitations

This study has some limitations to consider. First, our primary goal was to derive valid, random-effects estimates characterized by effect modifiers. In other words, the goal was to avoid combining apples and oranges,⁷⁶ which is a common criticism against meta-analysis. Although we consider our subgroup approach a strength, some effect size estimates were composed of a small number of primary studies, and this may result in underpowered analyses. Second, there may be some concern about fidelity and other sources of variability in what constituted this sample of CBT interventions, given that a range of manual implementations were reviewed. Unfortunately, fidelity to behavioral intervention protocol is often poorly reported in the clinical trial literature⁷⁷ and could not be consistently measured for the present study. Similarly, this meta-analysis did not account for medication compliance or dose as a potential source of variability. The exclusion of 6 non-English articles is another potential limitation of this study. Finally, study results should be considered in the context of what constitutes an optimal outcome in clinical research with adult AUD/SUD. We selected consumption measures and favored biological assay variables in SUD trials, but equally important may be improvements in overall functioning,⁷⁸ in which behavioral therapies, such as CBT, may be more likely to demonstrate effects.^18,19 Therefore, the degree to which the outcomes presented in this review reflect an ideal end point remains an ongoing discussion for the field.

Conclusions

Current clinical and research practices suggest that the rationale for combining behavioral therapy and pharmacotherapy is to provide support and skills while the patient is waiting for the medication effects to become apparent, to enhance treatment adherence, to improve treatment and study retention, and to address symptoms and problems that the medication will not address (eg, skills building).^18,19,74 In an effort to inform best practices in addiction treatment, the following take-home points are drawn from the results of this meta-analysis. First, our results suggest that prescribing clinicians should favor CBT over usual clinical management to ensure optimal clinical outcomes for addiction, in the context of pharmacotherapy. This conclusion is based in our comparison of CBT plus pharmacotherapy vs usual care plus pharmacotherapy. Second, CBT is not superior to other evidence-based behavioral treatments for addiction, yet in the context of its superiority to usual care, our findings suggest that clinicians should favor an evidence-based behavioral therapy, CBT or otherwise, in conjunction with pharmacological treatment. Third, the add-on benefit of CBT compared with pharmacotherapy and usual care was not clearly supported and suggests that benefit of CBT as an adjunct requires further investigation.

Summary

This meta-analysis investigates the efficacy of combining cognitive behavioral therapy (CBT) with pharmacotherapy in treating alcohol and other substance use disorders (SUDs). Thirty studies were analyzed across three distinct comparison groups.

Findings

Combined CBT and pharmacotherapy demonstrated superior outcomes compared to usual care plus pharmacotherapy. However, CBT did not show greater efficacy than other evidence-based therapies when combined with pharmacotherapy, nor did it provide added benefit when used as an adjunct to existing usual care and pharmacotherapy.

Methods

A comprehensive literature search across multiple databases identified relevant randomized controlled trials. Inclusion criteria specified English-language publications from 1990-2019 focusing on adult AUD/SUD patients receiving CBT alongside pharmacotherapy. Data extraction involved standardized mean difference calculations using Hedges' g statistic. Subgroup analyses explored various factors, including treatment contrast, substance type, and outcome timepoint. Statistical analyses employed a random-effects model to account for between-study heterogeneity.

Results

The meta-analysis revealed a small, statistically significant effect size favoring CBT plus pharmacotherapy over usual care plus pharmacotherapy in post-treatment frequency outcomes. No significant difference emerged when comparing CBT plus pharmacotherapy with other evidence-based therapies plus pharmacotherapy. Similarly, adding CBT to usual care and pharmacotherapy showed no clear added benefit. Subgroup analyses by primary drug target revealed variability in effect size magnitude and direction.

Discussion

This study provides novel insights into the role of CBT in SUD treatment. While CBT is superior to usual care when combined with pharmacotherapy, it does not surpass other evidence-based behavioral interventions. The lack of added benefit when CBT is used as an adjunct may be influenced by factors such as protocol adherence, the robustness of alternative interventions (as seen in the COMBINE study's medication management arm), and the lack of FDA-approved pharmacotherapies for certain substances.

Limitations

The study's limitations include the relatively small number of studies within some subgroups, potential variability in CBT intervention fidelity, and the absence of consistent medication compliance or dosage data. The focus on consumption measures as primary outcomes might neglect other relevant indicators of clinical improvement.

Conclusions

The findings indicate that CBT combined with pharmacotherapy is superior to usual care plus pharmacotherapy. However, CBT does not appear to offer a distinct advantage over other evidence-based behavioral therapies when combined with pharmacotherapy, and its added benefit as an adjunct treatment requires further investigation. Clinicians should prioritize evidence-based behavioral therapies, alongside pharmacotherapy, to optimize patient outcomes.

Summary

This meta-analysis investigated the efficacy of combining cognitive behavioral therapy (CBT) with pharmacotherapy for alcohol and other substance use disorders (SUDs). The findings, based on 30 studies, indicate that CBT plus pharmacotherapy is superior to usual care plus pharmacotherapy. However, CBT did not demonstrate superiority over other evidence-based therapies when combined with pharmacotherapy, nor when added to existing pharmacotherapy and usual care. The study suggests that best practice should involve pharmacotherapy with either CBT or another evidence-based therapy.

Methods

A comprehensive literature search across multiple databases was conducted to identify relevant randomized controlled trials. Inclusion criteria specified English-language, peer-reviewed articles published between 1990 and 2019, focusing on adult populations (≥18 years) with AUD/SUDs receiving CBT alongside pharmacotherapy. Data extraction involved a standardized process with multiple reviewers to ensure reliability. The standardized mean difference (Hedges' g) was used to measure treatment efficacy, with subgroup analyses performed based on experimental contrast, substance type, and outcome point. Statistical analyses employed random-effects models to account for heterogeneity between studies.

Results

The meta-analysis included 30 studies encompassing a range of substances and treatment settings. CBT plus pharmacotherapy showed a small but statistically significant positive effect compared to usual care plus pharmacotherapy for both frequency and quantity of substance use, though the effects were generally small. No significant benefit was observed for CBT compared to other evidence-based therapies plus pharmacotherapy or as an add-on to usual care and pharmacotherapy. Heterogeneity was minimal in most analyses, except for specific comparisons.

Discussion

This meta-analysis provides valuable insights into the combined use of CBT and pharmacotherapy for AUD/SUDs. The findings support the use of CBT as a superior alternative to usual care when combined with medication. However, it highlights that CBT does not offer a significant advantage over other evidence-based behavioral therapies in this context, nor does it provide added benefit when used adjunctively. The study acknowledges limitations, including small sample sizes in some subgroup analyses and variability in CBT implementation.

Limitations

Several limitations are noted, including the relatively small number of studies in some subgroups, potential variability in CBT implementation across studies, and the lack of consistent reporting on medication adherence and dosage. The study's focus on consumption measures, potentially overlooking other important outcomes such as overall functioning, also represents a limitation. The exclusion of non-English language studies is also acknowledged.

Conclusions

The study concludes that while CBT combined with pharmacotherapy is superior to usual care plus pharmacotherapy, it is not superior to other evidence-based behavioral therapies in this setting. The add-on effect of CBT to usual care and pharmacotherapy requires further investigation. Clinicians should consider utilizing pharmacotherapy in conjunction with CBT or another validated behavioral therapy, rather than relying solely on usual care.

Summary

This study reviewed research on whether Cognitive Behavioral Therapy (CBT) improves outcomes for substance use disorders (SUDs) when combined with medication. The analysis of 30 studies showed that CBT, alongside medication, was slightly better than usual care plus medication. However, CBT didn't show a clear advantage over other types of evidence-based therapy when combined with medication, nor did it significantly improve outcomes when added to existing medication and usual care. The findings suggest that addiction treatment should ideally include both medication and an evidence-based therapy (like CBT) rather than just medication and standard care.

Methods

Researchers searched several large databases for studies on CBT and substance use treatment. They included English language, peer-reviewed studies of adult patients (18 and older) with alcohol or other drug use disorders. The studies needed to use randomized controlled trials and include CBT or relapse prevention as treatment with the addition of medication. Data analysis used standardized mean differences to compare the effectiveness of different treatments, focusing on subgroups based on different treatment comparisons and drug types.

Results

The 30 studies included in the meta-analysis had a median of 82 participants each, examining alcohol, cocaine, and opioids most frequently. The results showed a small, but statistically significant benefit of CBT plus medication compared to usual care plus medication in reducing substance use frequency. However, CBT did not perform better than other forms of therapy when combined with medication. Adding CBT to existing medication and usual care showed no significant added benefit. The type of substance impacted the results, with heterogeneity in findings across different drugs.

Discussion

This study is the first of its kind to directly assess CBT's role alongside medication for SUDs. While CBT showed a small advantage over standard care when combined with medication, it didn't prove superior to other therapies. The lack of clear benefit when adding CBT to existing treatment may be due to factors like inconsistent CBT implementation, poor adherence to the CBT protocol, and the complexity of treatment approaches in clinical settings.

Limitations

The study acknowledges several limitations. The limited number of studies in some subgroups could have affected the power of the analysis. Inconsistent implementation of CBT across studies, a lack of data on medication adherence, and exclusion of some non-English-language studies are additional considerations. The study focuses on consumption measures; other factors like overall functioning might show different results.

Conclusions

The findings suggest that combining CBT with medication is better than using medication with standard care alone in the treatment of SUDs. However, CBT does not appear superior to other evidence-based behavioral therapies. Further research is needed to fully understand the benefit of adding CBT to existing medication and care.

Summary

This study looked at whether talk therapy (CBT) helps people with alcohol and drug problems when they're also taking medicine. Scientists looked at many studies and found that CBT plus medicine worked better than just medicine alone. However, CBT didn't work better than other types of talk therapy.

Introduction

Lots of people struggle with alcohol and drug problems. Doctors and scientists want to find the best ways to help. Often, medicine and talk therapy together are best. CBT is a type of talk therapy that helps people change their thinking and actions. It's often used to treat alcohol and drug problems. This study wanted to see how well CBT works when people are also taking medicine.

Methods

Researchers looked at lots of studies on CBT and medicine for adults with alcohol or drug problems. They only used studies that compared CBT plus medicine to other treatments. They then looked at how well each treatment worked by measuring things like how much people drank or used drugs.

Results

The study found that CBT plus medicine was a little better than just medicine alone. But CBT didn't work better than other kinds of talk therapy. Adding CBT to medicine and other treatments didn't seem to help much more.

Discussion

The study showed that CBT can help people with alcohol and drug problems, especially when they're also taking medicine. But it's important to remember that other kinds of talk therapy might also be helpful. It's also hard to say for sure how much CBT helps when people are already getting other treatments.

Limitations

The study had some limits. Some groups of studies were small, making it hard to be completely sure about the results. Also, the study didn't always look at how well people followed the talk therapy plan.

Conclusions

The study suggests that using CBT with medicine is good for people with alcohol and drug problems. While CBT is as good as other therapies, it's important to use evidence-based talk therapies with medicine. More research is needed to see if adding CBT to other treatments helps.