Comparison of the treatments in crack use disorder: A systematic review (2026)

BACKGROUND: Many studies address the different treatments for crack cocaine use disorder without distinguishing between crack use and cocaine use disorder. Furthermore, they highlight various approaches, such as psychotherapeutic methods, medications, and social interventions, whose effectiveness remains contentious for crack use disorder. Our aim was to evaluate the relative effectiveness of these various treatments, specifically for crack use disorder.
METHODS: This systematic review followed PRISMA guidelines; we searched PubMed, Embase, and Web of Science for studies between 2014 and July 2024.
ELIGIBILITY CRITERIA: Due to the limited number of available studies, we included all studies worldwide with full text available in English or French, published between 2014 and 2024, reflecting the recent increase in interest in crack use. Studies included adults aged 18 years or older with a clinical diagnosis of crack cocaine addiction based on a validated clinical scale. We excluded studies that did not distinguish between crack and cocaine use in their assessment of crack cocaine (or crack/cocaine) use disorder. We reported the randomized controlled trials (RCTs) results based on the type of interventions, including various outcomes: reduction of health (within the biopsychosocial model), increased accessibility and retention in healthcare, and reduction in drug use. The reliability of the evidence was assessed using Cochrane's tool for evaluating the risk of bias.
RESULTS: We identified 3,313 records, of which 46 were eligible, and 33 were finally included. Among the 33 studies, 15 were RCTs. Among the RCTs, the majority had a moderate risk of bias (8/15), followed by high risk (6/15), and only one had a low risk of overall bias. Contingency management was associated with higher abstinence, better treatment retention, and improvements in mental health, although the interpretability of these findings is limited by their generalizability. Pharmacological trials with dexamfetamine showed a reduction in drug use and an increase in abstinence, but only in a specific population receiving heroin-assisted treatment. Adjunct trials such as transcranial direct current stimulation yielded mixed findings, with some studies suggesting improvements in abstinence and quality of life, while others reported no significant effects. The findings highlight that tailored interventions supported by a contingency management approach may enhance engagement and treatment effectiveness. [Author's abstract]