What are the efficacies of different substance dependency treatments, including 12-step programs (Twelve-Step Programs)?

From the Guidelines

The most effective treatment approach for substance dependency is a combination of contingency management and community reinforcement approach, which has been shown to be the most efficacious and acceptable treatment in both the short and long term, as demonstrated by a 2018 network meta-analysis of 50 clinical studies 1.

Overview of Treatment Approaches

The efficacy of dependency treatments varies widely, with no single approach working for everyone. Twelve-step programs like Alcoholics Anonymous show modest success rates, though they provide valuable peer support and are freely accessible.

• Medication-assisted treatment (MAT) demonstrates higher efficacy, particularly for opioid and alcohol dependencies.
• For opioid use disorder, medications like methadone, buprenorphine, and naltrexone can reduce relapse rates by 40-60% when combined with counseling.
• Cognitive-behavioral therapy (CBT) shows 40-60% effectiveness across various substance dependencies by addressing underlying thought patterns.
• Contingency management, which provides tangible rewards for sobriety, demonstrates 40-50% success rates.

Most Effective Treatment Approach

The combination of contingency management and community reinforcement approach has been shown to be the most effective treatment approach, with the highest efficacy and acceptability rates in both the short and long term, as demonstrated by a 2018 network meta-analysis of 50 clinical studies 1.

• This approach combines pharmacological interventions with behavioral therapies and social support, tailored to individual needs, severity of dependency, and personal circumstances.
• Treatment duration of at least 90 days is associated with better outcomes, with many individuals requiring multiple treatment attempts before achieving lasting recovery.

Importance of Integrated Care

Substance use disorder is a chronic medical condition and should be managed as such, with a focus on integrated care that addresses the physical, emotional, and social aspects of addiction, as recommended by the American College of Physicians 1.

• This approach includes behavioral therapies, medication-assisted therapies, and peer support/12-step fellowship approaches.
• Evidence-based medication-assisted therapy approaches are available for the treatment of opioid use disorder, tobacco, and alcohol, with no medication-assisted therapy yet determined to be effective for the treatment of substance use disorders related to cocaine or stimulant use.

From the Research

Efficacies of Different Substance Dependency Treatments

The efficacies of different substance dependency treatments, including 12-step programs, have been studied in various research papers.

• Cognitive Behavioral Therapy (CBT) has been shown to be efficacious in the treatment of substance use disorders, with effect sizes in the small-to-moderate range 2.
• CBT combined with other evidence-based treatments, such as Motivational Interviewing, Contingency Management, or pharmacotherapy, is also efficacious compared to minimal and usual care control conditions 2.
• The compatibility of CBT-based approaches with 12-Step programs has been explored, highlighting the importance of flexibility when working with patients who identify with the cultural values of 12-Step programs 3.
• Other psychosocial interventions, such as social behavior and network therapy, cognitive behavioral therapy, and motivational enhancement therapy, have been shown to be effective, but no one appears to be superior to another 4.
• The use of naltrexone has demonstrated consistent effects in reducing alcohol consumption in the context of behavioral therapy, while acamprosate did not show significant benefits on treatment outcomes relative to placebo 4.

Comparison of Treatment Approaches

• A narrative review of evidence suggests that CBT and mindfulness-based cognitive therapy (MBCT) are effective interventions for substance use disorders, but the studies showed a high degree of heterogeneity 5.
• Acceptance and commitment therapy (ACT) and dialectical behavior therapy (DBT) in substance use disorder management are limited to few studies and results are therefore inconclusive 5.
• The evolution of CBT for addictions has been reviewed, indicating a modest effect size with evidence of relatively durable effects, but limited diffusion in clinical practice 6.
• Technology may provide a means for CBT interventions to circumvent the "implementation cliff" and offer a flexible, low-cost, standardized means of disseminating CBT in a range of novel settings and populations 6.