How is cocaine addiction treated?
In 2013, cocaine accounted for almost 6 percent of all admissions to drug abuse treatment programs. The majority of individuals (68 percent in 2013) who seek treatment for cocaine use smoke crack and are likely to be polydrug users, meaning they use more than one substance.36 Those who provide treatment for cocaine use should recognize that drug addiction is a complex disease involving changes in the brain as well as a wide range of social, familial, and other environmental factors; therefore, treatment of cocaine addiction must address this broad context as well as any other co-occurring mental disorders that require additional behavioral or pharmacological interventions.
Presently, there are no medications approved by the U.S. Food and Drug Administration to treat cocaine addiction, though researchers are exploring a variety of neurobiological targets. Past research has primarily focused on dopamine, but scientists have also found that cocaine use induces changes in the brain related to other neurotransmitters—including serotonin, gamma-aminobutyric acid (GABA), norepinephrine, and glutamate.37 Researchers are currently testing medications that act at the dopamine D3 receptor, a subtype of dopamine receptor that is abundant in the emotion and reward centers of the brain.38 Other research is testing compounds (e.g., N-acetylcysteine) that restore the balance between excitatory (glutamate) and inhibitory (GABA) neurotransmission, which is disrupted by long-term cocaine use.39 Research in animals is also looking at medications (e.g., lorcaserin) that act at serotonin receptors.40
Several medications marketed for other diseases show promise in reducing cocaine use within controlled clinical trials. Among these, disulfiram, which is used to treat alcoholism, has shown the most promise. Scientists do not yet know exactly how disulfiram reduces cocaine use, though its effects may be related to its ability to inhibit an enzyme that converts dopamine to norepinephrine. However, disulfiram does not work for everyone. Pharmacogenetic studies are revealing variants in the gene that encodes the DBH enzyme and seems to influence disulfiram’s effectiveness in reducing cocaine use.41–43 Knowing a patient’s DBH genotype could help predict whether disulfiram would be an effective pharmacotherapy for cocaine dependence in that person.41–43
Finally, researchers have developed and conducted early tests on a cocaine vaccine that could help reduce the risk of relapse. The vaccine stimulates the immune system to create cocaine-specific antibodies that bind to cocaine, preventing it from getting into the brain.44 In addition to showing the vaccine’s safety, a clinical trial found that patients who attained high antibody levels significantly reduced cocaine use.45 However, only 38 percent of the vaccinated subjects attained sufficient antibody levels and for only 2 months.45
Researchers are working to improve the cocaine vaccine by enhancing the strength of binding to cocaine and its ability to elicit antibodies.44,46 New vaccine technologies, including gene transfer to boost the specificity and level of antibodies produced or enhance the metabolism of cocaine, may also improve the effectiveness of this treatment.47 A pharmacogenetics study with a small number of patients suggests that individuals with a particular genotype respond well to the cocaine vaccine—an intriguing finding that requires more research.48
In addition to treatments for addiction, researchers are developing medical interventions to address the acute emergencies that result from cocaine overdose. One approach being explored is the use of genetically engineered human enzymes involved in the breakdown of cocaine, which would counter the behavioral and toxic effects of a cocaine overdose.49 Currently, researchers are testing and refining these enzymes in animal research, with the ultimate goal of moving to clinical trials.49
Many behavioral treatments for cocaine addiction have proven to be effective in both residential and outpatient settings. Indeed, behavioral therapies are often the only available and effective treatments for many drug problems, including stimulant addictions. However, the integration of behavioral and pharmacological treatments may ultimately prove to be the most effective approach.50
One form of behavioral therapy that is showing positive results in people with cocaine use disorders is contingency management (CM), also called motivational incentives. Programs use a voucher or prize-based system that rewards patients who abstain from cocaine and other drugs. On the basis of drug-free urine tests, the patients earn points, or chips, which can be exchanged for items that encourage healthy living, such as a gym membership, movie tickets, or dinner at a local restaurant. CM may be particularly useful for helping patients achieve initial abstinence from cocaine and stay in treatment.39,50–52 This approach has recently been shown to be practical and effective in community treatment programs.51
Research indicates that CM benefits diverse populations of cocaine users. For example, studies show that cocaine-dependent pregnant women and women with young children who participated in a CM program as an adjunct to other substance use disorder treatment were able to stay abstinent longer than those who received an equivalent amount of vouchers with no behavioral requirements.28 Patients participating in CM treatment for cocaine use who also experienced psychiatric symptoms—such as depression, emotional distress, and hostility—showed a significant reduction in these problems, probably related to reductions in cocaine use.53
Cognitive-behavioral therapy (CBT) is an effective approach for preventing relapse. This approach helps patients develop critical skills that support long-term abstinence—including the ability to recognize the situations in which they are most likely to use cocaine, avoid these situations, and cope more effectively with a range of problems associated with drug use. This therapy can also be used in conjunction with other treatments, thereby maximizing the benefits of both.50
Recently, researchers developed a computerized form of CBT (CBT4CBT) that patients use in a private room of a clinic.54–56 This interactive multimedia program closely follows the key lessons and skill-development activities of in-person CBT in a series of modules. Movies present examples and information that support the development of coping skills; quizzes, games, and homework assignments reinforce the lessons and provide opportunities to practice skills.54–56 Studies have shown that adding CBT4CBT to weekly counseling boosted abstinence54 and increased treatment success rates up to 6 months after treatment.55
Therapeutic communities (TCs)—drug-free residences in which people in recovery from substance use disorders help each other to understand and change their behaviors—can be an effective treatment for people who use drugs, including cocaine.57 TCs may require a 6- to 12-month stay and can include onsite vocational rehabilitation and other supportive services that focus on successful re-integration of the individual into society. TCs can also provide support in other important areas—improving legal, employment, and mental health outcomes.57,58
Regardless of the specific type of substance use disorder treatment, it is important that patients receive services that match all of their treatment needs. For example, an unemployed patient would benefit from vocational rehabilitation or career counseling along with addiction treatment. Patients with marital problems may need couples counseling. Once inpatient treatment ends, ongoing support—also called aftercare—can help people avoid relapse. Research indicates that people who are committed to abstinence, engage in self-help behaviors, and believe that they have the ability to refrain from using cocaine (self-efficacy) are more likely to abstain.59 Aftercare serves to reinforce these traits and address problems that may increase vulnerability to relapse, including depression and declining self-efficacy.59
Scientists have found promising results from telephone-based counseling as a low-cost method to deliver aftercare. For example, people who misused stimulants who participated in seven sessions of telephone counseling showed decreasing drug use during the first 3 months, whereas those who did not receive calls increased their use.60 Voucher incentives can boost patients’ willingness to participate in telephone aftercare, doubling the number of sessions received according to one study.61
Community-based recovery groups—such as Cocaine Anonymous—that use a 12-step program can also be helpful in maintaining abstinence. Participants may benefit from the supportive fellowship and from sharing with those experiencing common problems and issues.62