What are the medications for Cocaine Use Disorder (CUD)?

From the Guidelines

Contingency management is the most efficacious form of treatment for stimulant use disorders, including cocaine use disorder, and should be used as the primary treatment approach. According to the most recent evidence from 1, contingency management is recommended for stimulant use disorders with an evidence rating of AIa. This approach involves providing rewards for periods of recovery from stimulants, such as financial incentives, and has been shown to be effective in reducing cocaine use.

The use of medications for cocaine use disorder is not supported by strong evidence, and there are no FDA-approved medications specifically for this condition. However, some medications such as disulfiram, modafinil, topiramate, bupropion, and baclofen may be used off-label with varying success. These medications should be used as part of a comprehensive treatment program including behavioral therapy, counseling, and support groups, as recommended by 1 and 1.

Key points to consider when treating cocaine use disorder include:

• The importance of contingency management as the primary treatment approach
• The use of medications as part of a comprehensive treatment program
• The need for ongoing monitoring for side effects and efficacy
• The importance of assessing for comorbid conditions such as depression or anxiety
• The use of behavioral therapy, counseling, and support groups as part of the treatment program

Overall, the treatment of cocaine use disorder should prioritize contingency management and comprehensive treatment programs, with a focus on reducing morbidity, mortality, and improving quality of life. As noted in 1, medication treatments for substance use disorders should not be withheld for those receiving antiretroviral therapy or direct-acting antivirals, and strategies to promote tobacco cessation are also recommended.

From the Research

Medications for Cocaine Use Disorder

Medications that have been studied for the treatment of cocaine use disorder include:

• Disulfiram, which has demonstrated the most consistent effect in reducing cocaine use 2
• Baclofen, modafinil, tiagabine, and topiramate, which have shown promise in reducing cocaine use in clinical trials 2
• Clonidine, fenfluramine, and meta-chlorophenylpiperazine (m-CPP), which have shown promise in reducing cocaine craving in the short-term treatment 3
• Amphetamine, biperiden, carbamazepine, lisdexamfetamine, lorcaserin, methamphetamine, mirtazapine, pioglitazone, progesterone, guanfacine, levodopa, and nefazodone, which have shown promise in reducing cocaine craving in the long-term treatment 3

Limitations and Future Directions

Despite the promise of these medications, there are several limitations to their use, including:

• Limited evidence for their efficacy, with many studies having small sample sizes and inconsistent results 4
• High heterogeneity of craving assessments across studies, making it difficult to compare results 3
• Need for further research to confirm the efficacy of these medications and to identify the most effective treatment strategies 2, 3, 4
• Importance of considering the DBH genotype of patients when using disulfiram as a treatment, as it may affect the medication's efficacy 5

Pharmacological Mechanisms

The pharmacological mechanisms underlying the efficacy of these medications are not fully understood, but may involve:

• Inhibition of dopamine β-hydroxylase, which converts dopamine to norepinephrine, and may contribute to the efficacy of disulfiram 6, 5
• Modulation of dopamine and norepinephrine levels in the brain, which may contribute to the efficacy of other medications 6