Treatment - Cocaine abuse in adults

Acute intoxication — Treatment of acute intoxication is presented separately.

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.