Withdrawal — Cocaine withdrawal is treated by allowing the patient to sleep and eat ad lib in a supportive environment. No medication has been proven effective in treating the withdrawal syndrome, although bromocriptine and amantadine have been used on the theoretical basis that dopaminergic agents may ameliorate the hypothesized dopamine deficiency state of cocaine withdrawal. Propranolol has been used to manage severe cocaine withdrawal symptoms but can aggravate coronary vasoconstriction. Hospitalization is rarely indicated on medical grounds, and has not been shown to improve the short-term outcome for cocaine addiction.
A short-acting benzodiazepine such as lorazepam may be helpful in selected patients who develop severe agitation or sleep disturbance. Persistent (more than two to three weeks) depression or suicidal ideation may require antidepressant treatment. The risk of relapse is high during the early withdrawal period, in part because drug craving is easily triggered by stress or encounters with drug-associated stimuli. Patients should be referred to an addiction treatment program for ongoing care.
Treatment of addiction — The mainstay of treatment for cocaine addiction is psychosocial treatment. No medication is FDA labeled for this indication. Several organizations have issued practice guidelines for the treatment of cocaine addiction.
The goal of the initial psychiatric, medical, and psychosocial assessment is to:
- Determine the severity of the addiction problem
- Identify concurrent substance abuse (alcohol, opiates, or cannabis)
- Diagnose co-occurring psychiatric or medical disorders
- Identify strengths (eg, employment, supportive social network)
- Identify weaknesses (criminal behavior, poor social skills)
- Evaluate motivation for treatment
- Discuss treatment preferences
The likelihood of a favorable outcome is enhanced by nonjudgmental empathy with the patient, quick engagement in the treatment program (ideally, within 24 hours), clear and realistic orientation to treatment goals and behavioral expectations, strict monitoring of drug use (eg, by frequent urine testing) with feedback to the patient, involvement of the patient’s social network (to the extent possible), and attention to any concurrent medical, psychiatric, vocational, legal, or social problems. These requirements can be difficult to achieve in the typical primary care setting and are best met in a dedicated substance abuse treatment program.
Treatment setting — Most cocaine addiction treatment occurs in the outpatient setting. Inpatient or residential treatment may be warranted when required by medical or psychiatric comorbidity (eg, seizures, suicidal ideation); lack of patient access to a supportive, drug-free living environment; or history of past failures in intensive outpatient treatment. Explicit, operationalized criteria for selecting appropriate adult patient placement have been developed by the American Society for Addiction Medicine. These criteria are based on multidimensional patient assessment generating placement along a continuum of care with varying lengths of treatment. The criteria can be reliably implemented and result in improved patient outcomes.
In general, patients with a shorter duration of addiction, fewer medical or psychiatric complications and co-morbidities, better psychosocial functioning (eg, employment, absence of anti-social behavior), and a supportive social network tend to have better outcomes, regardless of the treatment. However, adherence to treatment is by far the most important factor in predicting a successful outcome.
Psychosocial treatment — There is no clear evidence that any one psychosocial treatment is significantly better than another for most patients. Several psychotherapy or counseling modalities have been effective in clinical trials, including motivational enhancement, psychodynamic (but not psychoanalysis), supportive, cognitive and behavioral approaches, including relapse prevention and contingency management. A systematic review of psychosocial interventions found only small changes in rates of cocaine use for any intervention, with a suggestion that interventions incorporating contingency management were more effective and had lower drop out rates.
Regardless of the modality used, more intensive treatment (ie, more frequent visits) and longer duration of treatment (minimum of three months) are associated with better outcomes, especially during early abstinence. Long-term abstinence rates rarely approach 50 percent, except in some special patient populations. As an example, specialized programs treating addicted health care professionals have reported long-term abstinence rates exceeding 70 percent. These better outcomes may relate to the strict monitoring, clearly defined and prompt consequences associated with relapse, good premorbid psychosocial functioning, and supportive social network associated with such patients.
Involvement with peer self-help groups such as Cocaine Anonymous (modeled after Alcoholics Anonymous) improves treatment outcome. Information about Cocaine Anonymous, including meeting locations, is available at http://www.ca.org. Outcomes are also improved when addiction treatment is linked to primary medical care, and when appropriate psychiatric care and vocational rehabilitation are provided.
Medication — Systematic reviews of antidepressants, dopamine agonists (eg, amantadine bromocriptine, pergolide), anticonvulsants, and antipsychotics have not demonstrated consistent effectiveness for treatment of cocaine dependence.
Several medications have shown promise in promoting cocaine abstinence in placebo-controlled clinical trials.
- Disulfiram (250 mg daily) was effective in four published trials, but safety concerns have been raised over its interactions with alcohol and cocaine in patients who do not abstain completely.
- Modafinil (400 mg daily) and some anti-convulsants such as topiramate (200 mg daily) and tiagabine (12 mg twice daily) have been effective in one or more phase II clinical trials, although a multi-site controlled clinical trial found modafinil effective only in patients without concurrent alcohol dependence. Other anti-convulsants, such as gabapentin (1800 to 3200 mg/day) are not effective for reasons that are not well understood.
- Preliminary findings from single trials suggest that the GABA(B) receptor agonist, baclofen (20 mg three times daily), the selective serotonin reuptake inhibitor citalopram (10 mg once daily), and the serotonin (5-HT(3)) receptor antagonist, ondansetron (4 mg twice daily) may diminish cocaine intake in some patients.
- Patients co-addicted to opiates as well as cocaine, and who are likely to benefit from opiate agonist maintenance treatment, may do well on high dose (16 to 32 mg daily) buprenorphine.
- Bupropion (300 mg daily) when combined with a contingency management program (payment for negative urine samples) was also effective in co-addicted patients receiving methadone maintenance.
- Other medications undergoing clinical trials include N-acetylcysteine (which alters brain glutamate activity) and an anti-cocaine vaccine.
- Pharmacological treatment is considered more effective when combined with psychosocial treatment, rather than given alone, although few clinical trials address this issue.
Other — The relative lack of effective conventional medical therapy for cocaine dependence has led to the investigation of alternative therapies. Neither acupuncture, nor herbal remedies such as ginkgo biloba have been found to be effective.
David A Gorelick, MD, PhD
H Nancy Sokol, MD