Treatment, for cocaine

Because chronic cocaine use appears to reduce the efficiency of central dopamine neurotransmission, a number of dopaminergic compounds, including amantadine, bromocriptine, mazindol, and methylphenidate, have been examined as treatments for cocaine abuse. It is thought that these relatively slow-onset dopaminergic agents, with low or relatively low abuse potential, would correct the dopamine dysregulation and alleviate withdrawal symptoms following chronic stimulant use. 

Carroll et al. (2004) conducted another study examining psychotherapy and disulfiram treatment for cocaine dependence. In this randomi2ed, doubleblind, placebo-controlled study, patients (iV=121) were assigned to one of four conditions 1) disulfiram plus CBT 2) disulfiram plus interpersonal therapy (IPT), which addressed adherence to a medical model of psychiatric problems, interpersonal functioning, and supportive therapeutic exploration 3) placebo plus CBT or 4) placebo plus IPT. The patients who received disulfiram reduced their cocaine use, relative to those who received placebo, and the patients who received CBT reduced their cocaine use, relative to those who received IPT. Cocaine abstinence among the patients who received CBT plus placebo was not statistically different from that of the patients who re-... 

Rawson RA, Huber A, McCann M, et al A comparison of contingency management and cognitive-behavioral approaches during methadone maintenance treatment for cocaine dependence. Arch Gen Psychiatry 59 817—824, 2002 Rohsenow DJ, Monti PM, Martin RA, et al Motivational enhancement and coping skills training for cocaine abusers effect on substance use outcomes. Addiction... 

Once the crash has abated, the patient should be reassessed and treatment recommendations made. Psychosocial treatments are the mainstay of treatment for cocaine addicts. Intensive outpatient programs and partial hospitalization programs are most effective during the initial phase of treatment. Psychotherapy and self-help treatment can help the patient devise means to manage craving and sustain sobriety. 

Buprenorphine is only recommended in the rehabilitation and continuing care stages of treatment for cocaine dependence if the patient is also addicted to an opioid. 

The possible treatments for cocaine misuse and the evidence for their effectiveness have been the subject of many reviews (e.g. Withers et al. 1995, de Lima et al. 2002, O Leary Hennessey et al. 2003, Preti 2007), and can be divided into pharmacological and non-pharmacological, or psychosocial . 

It is known, however, that drugs are readily available in many prisons, and the rate of adverse incidents and the time and effort spent in detecting smuggling of drugs in has been enough to persuade some authorities that at least the basics of treatment should be available. The most routine option has become to provide a detoxification for opiate misusers, with for instance lofexidine or dihydrocodeine, and also benzodiazepines will often be issued if there is a history of abuse of these and it is intended to avoid the possibility of fits with a short withdrawal course. The adverse incidents in custody and prisons have included some deaths in users of crack cocaine, with physical explanations postulated but no very satisfactory treatment for cocaine withdrawal indicated. Prison services have typically been wary of methadone, and in favouring lofexidine use it was encouraging that a randomized double-blind trial carried out by prison specialists found lofexidine to be as effective as methadone in relief of withdrawal symptoms (Howells et al. 2002). 

Castells X, Casas M, Vildal X, Bosch R, Roncero C, Ramos-Quiroga JA Capella D (2007) Efficacy of central nervous system stimulant treatment for cocaine dependence a systematic review and meta-analysis of randomized controlled clinical trials. Addiction, 102, 1871-87 Chaisson RE, Bacchetti P, Osmond D, Brodie B, Sande MA Moss AR (1989). Cocaine use and HIV infection in intravenous drug users in San Francisco. Journal of the American Medical Association, 261, 561-5 Chapleo CB Walter DS (1997). The bupre-norphine-naloxone combination product. Research and Clinical Forums, 19, 55-8 Cheskin LJ, Fudala PJ Johnson RE (1994). A controlled comparison of buprenorphine and clonidine for acute detoxification from opioids. Drug and Alcohol Dependence, 36, 115-21... 

Grahowski J, Rhoades H, Stotts A, Cowan K, Kopecky C, Dongherty A, MoeUer FG, Hassan S Schmitz J (2004). Agonist-hke or antagonist-hke treatment for cocaine... 

O Leary Hennessy G, De Menil V Weiss RD (2003). Psychosocial treatments for cocaine dependence. Current Psychiatry Report, 5, 362-4... 

Preliminary Drug Design, Synthesis, and Preclinical Evaluation of a Series of Novel Slow-Onset, Long-Acting DA Substitution Medications as Potential Treatments for Cocaine Addiction... 

Other drugs of the depressant, antianxiety, antipyschotic, and anticonvulsive types are being investigated as treatments for cocaine abuse. Those which have been or will be covered in this course include the heterocyclic antidepressants desipramine and imipramine, which diminish cocaine use and craving as well as improve the outcome in the first few months of treatment. Buprenorphine (depressant) may augment the reward system (it has been found to suppress self-administration of cocaine in monkeys). Lithium sometimes works for those who are clinically depressives. Carbamazapine, bromocriptine and mazindol are also used as well as fluphenthixol and buspirone. 

The medicinal use of ayahuasca, a plant beverage with psychotropic effects, has been proposed as a possible treatment for cocaine addiction. Proponents of this approach argue that DMT and other hallucinogens allow the substance abuser to modify his state of consciousness. In this altered state, the substance abuser looks for a meaning in his life. 

Approximately 50% of all people entering treatment for cocaine abuse or addiction to painkillers also report abusing a benzodiazepine. As with Rohypnol users with a simultaneous alcohol addiction, those with an addiction to other drugs in addition to Rohypnol must undergo a more complex withdrawal treatment than those who are addicted to Rohypnol alone. 

The picture for the pharmacotherapy of cocaine dependence is not nearly as good as it is for opioid dependence. You have seen that a number of drug treatments for cocaine dependence have been tried, but so far none has proved to be effective consistently across clinical trials (Litten Allen, 1999). T he treatment of choice for cocaine dependence is a structured behavioral program, as we discuss in the next section. 

An attempt will be made here to distill down the essence of the SAR of cocaine as it relates to its stimulant properties. In many cases, compounds have been reported that have not been tested in vivo, but have only been compared for affinity at the monoamine transporters or in an in vivo assay. Some of these data will be summarized if they are reported in the context of the stimulant effects of cocaine. Similarly, there have been numerous attempts to develop cocaine analogs that may bind to the dopamine transporter and actually block the stimulant or reinforcing effects of cocaine itself, in efforts to develop treatments for cocaine addiction. This chapter largely ignores many of those studies unless they contain in vivo data suggestingthey are relevant to a discussion of stimulant effects. Nevertheless, because stimulant properties have been associated with bindingto the DAT, a good deal of the SAR discussion here must be discussed in the context of in vitro DAT affinity. 

Spellicy CJ, Kosten TR, Hamon SC, Harding MJ, Nielsen DA (2013) ANKK1 and DRD2 pharmacogenetics of disulftram treatment for cocaine abuse. Pharmacogenet Genomics 23 333-340... 

Shorter D, Kosten TR (2011) Novel pharma-cotherapeutic treatments for cocaine addiction. BMC Med 9 119... 

Petrakis IF, Carroll KM, Nich C, Gordon FT, McCance-Katz EF, Frankforter T, Rounsaville BJ (2000) Disulfiram treatment for cocaine dependence in methadone-maintained opioid addicts. Addiction 95 219-228... 

The proportion of clients seeking treatment for cocaine use is increasing in many countries. Howfarthis is linked to heroin use or has developed from heavy recreational use of other drugs is unclear. 

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