Cocaine Abuse: A Review of Current and Experimental Treatments

2015

Cocaine abuse is a recently revived drug problem that is again generating great popular concern. Unfortunately, scientific evaluation of cocaine abuse treatment has been surprisingly sparse kind no consensus exists regarding optimal treatment strategies. This review summarizes current treatment issues and regimens. as well as preliminary data on new, approaches to cocaine abuse treatment.

Since this chapter will deal with treatment of the cocaine abuser, it is important from the outset to define what is meant by that term. Although in some settings any use of illegal drugs equals abuse such a definition is more legal than medical and will not he used here. Instead the definition of drug abuse found elsewhere in the field will be employed namely…“the nonprescription use of psychoactive chemicals by an individual to alter his her psychological state in a situation in which the individual or society incurs some harm” (). The great majority of cocaine users applying for treatment fit into this definition. The most common exception is the individual who defines his use as recreational controlled and nonharmful but is brought to treatment by another (e.g. spouse, parent), while the significant other views the cocaine use as harmful and needing to be stopped at once. It can be argued of course that the existence of such a dispute is in itself evidence that “harm” is occurring. Alternatively, it may be argued that the legal definition is being imposed in such cases. These issues lead to the question of who “needs” treatment? A broad answer is: any cocaine user who finds that be cannot stop or significantly cut back his use in spite of the presence of problems arising from the use.

The above definitions approximate the DSM-III criteria for cocaine abuse: “a pattern of pathological use impairment in social or occupational functioning due to cocaine use, and duration of disturbance of at least one month, “but are broader in their locus on the individual’s self-perception of harm.

It should also he noted that the studies and impressions reviewed here are based only on patients who appear for treatment. It is probable that some cocaine abusers, like some alcohol and nicotine abusers, are able to stop use without treatment. No data is available indicating what proportion of those who want to cease cocaine use are able to do so without treatment. Similarly, the strategies employed and difficulties experienced by those who cease use without treatment have not been systematically studied although Siegel has described longitudinal use patterns which include cessation and abstinence ().

Cocaine, abuse and concurrent disorders: diagnosis

Our clinical experience and the literature agree that individuals who abuse cocaine arc not a homogenous class. Distinctions in characterization of cocaine abusers with clear treatment relevance exist primarily along dimensions of psychiatric symptoms and behavioral-psychosocial disruption.

Greater variation in severity of use may exist in patients seeking treatment for cocaine abuse than in patients seeking treatment for abuse of other substances (). The typical cocaine user probably, begins his her use in a similar way to the typical marijuana user albeit at a later age. Like marijuana cocaine has been labeled by popular culture as “recreational,” and most who try it do so with the firm belief that they will have no difficulty in controlling their consumption. Many people are successful in such an endeavor; some, however, increase their use and appear for treatment.

The point at which treatment is sought can vary dramatically. Because of cocaine’s expense, significant psychosocial disruption leading to treatment can often occur without extreme abuse. The actual abuse in such cases is similar to that occurring with substances such as nicotine and marijuana. At the other end of the cocaine abuse spectrum lies very heavy intravenous () or freebase cocaine abuse (), which is continuous for prolonged periods, in a pattern very similar to that observed in intravenous methamphetamine addicts () over a decade ago. Treatment needs within this diverse population vary based on severity. Flexibility is therefore necessary in designing treatments for cocaine abusers.

Route of administration has been used as an indication of the probability that disruptive use patterns will develop. This has prompted recent controversy (). Severe cocaine abuse has been considered a sequel of administration by routes that provide very rapid changes in plasma stimulant levels, such as intravenous use or cocaine freebase smoking (). Intranasal use has been popularly considered comparatively mild abuse of a “nonaddicting,” “safe” stimulant (). Preliminary evaluations of patients appearing for treatment contradict the assumption that intranasal administration is not associated with severe cocaine abuse. Route of administration is not significantly related to psychosocial disruption (), neuroendocrine abnormalities (), or psychiatric diagnoses (). These data support the impression that severe cocaine abuse can develop with any route of administration. However our experience and that of others is also that intravenous abusers or cocaine freebase smokers are more likely to develop significant distress requiring treatment. Epidemiologic study comparing distress and the need for treatment with mode of administration in the general population of cocaine users has not been done and should be extremely difficult to implement. Since severity of cocaine abuse cannot be determined simply on the basis of route of administration, other factors, such as dosage pattern and duration of use, degree of psychosocial disruption and impulse control, and medical and psychiatric characteristics also require evaluation in assessing severity of cocaine usage and treatment needs. No research clearly: demarcating the contribution of each of these factors or of others to “severity” has been done; therefore assessments remain based, at present on clinical impressions and evaluation.

Variations also exist in the psychiatric characterization of cocaine abusers. Detailed modern psychiatric descriptions are limited. Past attempts have focused on nondiagnostic characterization using instruments such as the MMPI () or have focused on personality attributes or psychoanalytic formulations of cocaine abusers () and the relevance of such work to treatment decisions is unclear. Drug abusers, in general, have been observed to self-regulate painful feelings and psychiatric symptoms via their drug use (). If cocaine use occurs as self-medication conventional treatments modulating self-medicated symptoms would be indicated. The most important and clearly treatable disorders of this type correspond to DSM-III axis I categories. Only two studies of DSM-III axis I symptomatology in cocaine abusers exist. Weiss et al. () recently presented DSM-III diagnostic data for 30 hospitalized cocaine abusers, and Gawin and Kleber () reported Axis 1 data on 17 outpatient cocaine abusers. These independent studies generated very similar results, with depressive disorders (Major depression, Dysthymic disorder. Atypical depression) appearing in 30 percent and bipolar disorders (including Cyclothymic disorder) in 20 percent of each sample. Also, a smaller hut possibly important sub-group of patients with Attention Deficit Disorder-Residual Type (ADD) existed in each sample. Thus a large proportion of cocaine abusers could be self-medicating. Since more and larger studies have not yet been done and methodologic problems require clarification () the actual prevalence, and therapeutic relevance of Axis l-like psychiatric disorder in cocaine abusers requires further examination.

Accurate psychiatric and behavioral characterization of the cocaine abuser is important because symptomatology appearing during abstinence could theoretically provide important guides both to when and what pharmacological adjuncts are indicated (). However, the meaning and importance of such symptoms are at present based only on the self-medication hypothesis. Two further issues confuse the interpretation of symptoms in cocaine abuse. First definitive diagnoses of psychiatric illness other than substance abuse are difficult to make in the context of active drug abuse because symptoms may arise secondarily from the drug use itself, rather than preceding the drug abuse. Second, clarification between the acute depressive symptomatology occurring immediately after an episode of cocaine use (the post-cocaine “crash”) and more enduring symptomatology independent of specific use episodes is also difficult. Thus investigators in the studies thus far have attempted to circumvent these issues by gathering extensive historical and corroborating family history data, and by repeated longitudinal evaluations isolated from periods of acute cocaine use and post-cocaine symptomatology. However, these “diagnostic” studies must be considered tentative in the absence of prospective study or more elaborate investigation because exclusionary criteria based on substance abuse could not be applied

The “diagnoses” in the studies cited may nonetheless be useful as simple descriptions of the clinical state of cocaine abusers. Since symptoms in the cocaine abuser could indicate the presence of enduring cocaine-induced disorders which mimic psychiatric syndromes, or subclinical susceptibility to psychopathology aggravated by cocaine abuse. and both of these potential consequences of cocaine use could be responsive to conventional therapies, it is possible that distinctions between antecedent or consequent symptomatology would not determine initial pharmacological treatment choice. Such distinctions could however, still affect issues such as duration of treatment or prophylactic treatment and require evaluation.

Two groups of pilot efforts that reflect diagnosis in the context of cocaine abuse treatment have been reported. These studies are all non-blind, non-placebo preliminary examinations. The first group consists of descriptions of a total of seven cocaine abusers with diagnoses of ADD by Khantzian et al. () and Weiss et al. (). Six responded to appropriate stimulant medications. The second study consists of a structured open trial of lithium and desipramine () in which lithium administration was associated with cessation of cocaine abuse and diminished cocaine craving in several cyclothymic patients, while non-cyclothymic cocaine abusers did not appear to benefit from lithium. Desipramine also appeared beneficial. but independently of diagnosis. This treatment is discussed more fully in the discussion of pharmacotherapy below. In all, these reports indicate that ADD-Residual Type and cyclothymic disorder bipolar disorder may comprise subgroups of cocaine abusers with distinct treatment needs. More definitive research is obviously needed to substantiate these studies. Future research would benefit from uniform attention to diagnostic issues and to non-homogeneity among cocaine abusers.

Treatment of thc acute complications sometimes associated with cocaine abuse is based on clinical experience rather than rigorous comparisons. Medical complications of acute cocaine use and their treatment are reviewed elsewhere (). Acute psychiatric complications occur in three areas. These include dysphoric agitation, psychotic symptoms, and acute, severe post-use depression. Gay () and Rappolt et al. () employ, diazepam for transient agitation and desribe dramatic amelioration of symptoms with addition of propranolol for more persistent cases. Neuroleptics are routinely used for brief periods for severe cocaine-associated psychotic symptoms. The present authors employ chlorpromazine because of its sedative properties and because evidence from primate studies indicates that a potential interaction between cocaine’s epileptogenic effects and decreased seizure threshold associated with neuroleplics does not occur. Instead chlorpromazine substantially antagonizes epileptogenic and lethal effects of cocaine (). It should be noted that the same study reported increased seizure susceptibility and decreased mean lethal cocaine dose with propranolol but the clinical significance of this is unclear, since Gay et al. () have administered propranolol in several hundred cases without major untoward effects. Finally, suicidal ideation and other depressive symptomatology often occur during the post-cocaine “crash.” Such symptoms are usually transient, require no acute treatment other than close observation, and resolve following sleep normalization (). Prolonged severe depression was discussed earlier. Also, psychotic symptoms may be short-lived in cocaine abuse and usually remit following sleep normalization.

Cocaine abuse treatment strategies

 

Selections from the book: “Cocaine: Pharmacology, Effects, and Treatment of Abuse”. John Grabowski, Ph.D., ed. Content ranges from an introductory overview through neuropharmacology, pharmacology, animal and human behavioral pharmacology, patterns of use in the natural environment of cocaine users, treatment, through commentary on societal perceptions of use. National Institute on Drug Abuse Research Monograph 50, 1984.