The evidence supporting psychosocial interventions is often mixed, which may be due to inconsistency in the delivery of the intervention and methodological limitations of studies examining psychosocial interventions. Available meta-analyses and clinical trials examining the effectiveness of psychosocial interventions for treating OUD do not deviate from this trend.

A 2011 Cochrane Review of 35 RCTs (n=4319) found that, compared to OAT with standard medical management and counselling, the addition of structured psychosocial treatment interventions to OAT did not improve retention in treatment, abstinence from opioid use during or after treatment, or adherence.322  When analyses were stratified by type of psychosocial treatment intervention (i.e., behavioural [n=24]; psychoanalytic [n=4]; counselling [n=7]; and other [n=2]), pooled results remained non-significant for all comparisons and outcomes.322 The authors concluded that there was high-quality evidence that the addition of structured psychosocial treatment interventions to standard OAT does not improve retention or abstinence rates, and moderate-quality evidence that adjunct psychosocial treatment interventions do not improve adherence over standard OAT incorporating clinician-led medical management.322 It is emphasized that the control interventions described in the included studies involved a counselling component in addition to OAT; this conclusion applies to specific structured psychosocial interventions offered as an addition to standard psychosocial support for patients with OAT.

More recently, a 2020 systematic review used network meta-analysis (N=48 RCTs; n=5,404) to compare the effectiveness of 20 unique psychosocial interventions used as adjuncts to OAT in sustaining treatment retention. The meta-analysis showed that the addition of rewards-based interventions, such as contingency management, to OAT was superior to OAT-only.323 There were no statistically significant differences between other psychosocial interventions; the majority of studies found no significant difference between OAT with adjunct psychosocial interventions as compared to OAT alone. The authors also compared the impact adjunct psychosocial interventions on opioid use patterns (18 studies for changes in opioid use and 35 studies for abstinence) and found that included ancillary psychosocial interventions had no statistically significant impact on opioid use outcomes as compared to OAT alone. While calling for more high-quality RCTs to establish more definitive conclusions the authors suggested that contingency management be considered as an adjunct to OAT where appropriate.323

These findings align with the results of available clinical trials, which have yielded mixed results.324 For example, 4 RCTs evaluating OAT with adjunct cognitive behavioural therapy (CBT) found no difference in treatment retention and abstinence compared to standard OAT,325-328 although a subsequent sub-analysis of one trial did report that the addition of CBT to OAT was associated with a significant increase in mean number of opioid-free weeks in individuals with prescription OUD.329  Of 4 RCTs assessing OAT with ancillary contingency management, 2 trials reported significantly higher attendance and retention rates, longer periods of continuous abstinence, and reductions in non-medical opioid use with prize-based contingency management330,331; 1 trial reported significantly higher 12-month retention rates with contingent take-home doses332;  and 1 trial reported no difference in retention, continuous abstinence, or non-medical opioid use for prize-based CM versus standard OAT.327  Of 2 RCTs that evaluated OAT with ancillary counselling, 1 found that ancillary counselling led to significantly higher 12-month retention rates in patients with no previous OAT experience,333  while another found no difference in attendance rates, adherence, or non-medical opioid use with ancillary counselling compared to standard OAT.334,335 A 2019 open-label RCT randomized OAT patients to either personalized psychosocial intervention (a flexible toolkit of change methods, including recovery activities, contingency management, and clinic attendance) along with treatment as usual (n=135) or just treatment as usual (n=135) and found that 16% (n=22) of the intervention group had a treatment response, compared to 7% (n=9) in the treatment as usual group (adjusted log odds: 1.20, 95% CI 0.01–2.37; p=0.048).336 Treatment response was defined as no reported opioid or cocaine use in the past 28 days and at least one negative urine drug test. Participants in the intervention group also reported significantly more opioid-free days (adjusted log odds: 0.39, 95% CI 0.15–0.62).336

Considered together, available evidence does not provide consistent evidence that ancillary psychosocial treatment interventions improve patient outcomes over OAT incorporating standard medical management, although some studies involving contingency management approaches have yielded promising results. Ongoing research is needed to better understand the role and effectiveness of psychosocial treatment interventions in the clinical management of opioid use disorder. Findings to date do, however, underscore that a patient’s decision not to participate in ancillary psychosocial treatment interventions should never preclude or delay provision of evidence-based pharmacological treatments.337    

Assessment and monitoring of emotional and mental health is an essential component of care for patients with OUD, particularly given the high prevalence of concurrent mental health diagnoses in this population (e.g., post-traumatic stress disorder, depression, anxiety).335,338-340 While the evidence for ancillary psychosocial treatment interventions in the general patient population is equivocal, there may be benefits for some individuals, including more complex patient populations typically excluded from RCTs. There is some evidence that the addition of psychosocial treatment interventions can improve both substance use and mental health outcomes for individuals with concurrent disorders, including alcohol and other substance use disorders, post-traumatic stress disorder, and severe mental illness (e.g., schizophrenia, schizoaffective disorder).341-343 However, due to the small number of trials, this evidence is considered to be low quality, with considerable heterogeneity between trials and pooled-effect sizes that are generally small to moderate in scale. 

Further research is required to assess the effect of specific types of psychosocial support (e.g., housing, employment, and legal support services) on treatment outcomes.  Although systematic reviews have examined the impact of providing supports for various social needs; previous studies have demonstrated that addressing housing and other survival needs has a significant positive impact on patient outcomes.344-346 There is likely a benefit to OUD treatment being offered in the context of interdisciplinary care teams that are equipped to address these needs when possible.