What is the recommended approach for managing cocaine abuse patients in the hospital?

From the Guidelines

The recommended approach for managing cocaine abuse patients in the hospital involves a comprehensive strategy combining medical stabilization, symptom management, and preparation for long-term recovery, with benzodiazepines as first-line agents for addressing acute complications such as cardiovascular issues, agitation, and psychosis, as supported by the most recent guidelines 1.

Key Components of Management

• Initial management should focus on addressing acute complications such as cardiovascular issues (hypertension, tachycardia, chest pain) using benzodiazepines as first-line agents, typically diazepam 5-10mg IV or lorazepam 1-2mg IV every 5-10 minutes until agitation is controlled 1.
• For severe hypertension that persists, phentolamine (5-10mg IV) or nitroprusside may be used, while avoiding beta-blockers alone as they can worsen hypertension through unopposed alpha-adrenergic stimulation 1.
• Antipsychotics like haloperidol (5mg IM/IV) can help manage psychosis or severe agitation when benzodiazepines are insufficient 1.
• Patients should be monitored for seizures, hyperthermia, rhabdomyolysis, and cardiac arrhythmias with appropriate supportive care including IV fluids, cooling measures, and cardiac monitoring.

Long-term Recovery

• Once medically stable, patients should be assessed for withdrawal symptoms and comorbid psychiatric conditions.
• Before discharge, clinicians should arrange follow-up addiction treatment, provide naloxone kits if there's concurrent opioid use, and connect patients with community resources including support groups and outpatient programs 1. This approach addresses both the immediate physiological crisis of cocaine toxicity and establishes a foundation for ongoing recovery support, prioritizing morbidity, mortality, and quality of life as outcomes, as emphasized in the guidelines 1.

From the Research

Managing Cocaine Abuse Patients in the Hospital

• The management of cocaine abuse patients in the hospital is a complex issue, and several pharmacological options exist for treatment of cocaine-induced cardiovascular toxicity 2.
• Patients with cardiovascular toxicity from cocaine abuse may present with symptoms such as tachycardia, hypertension, agitation, and chest pain 2.
• The use of β-blockers in cocaine-positive patients has been a topic of debate due to the phenomenon of unopposed α-stimulation, although the evidence for this is limited and inconsistent 2.
• Mixed β-/α-blockers such as labetalol and carvedilol may be safe and effective in treating cocaine-induced cardiovascular toxicity 2.

Treatment Approaches for Cocaine Dependence

• Cocaine dependence is a chronic and destructive illness that is difficult to treat, and several treatment approaches have been explored, including psychosocial and pharmacological interventions 3, 4.
• Cognitive behavioral therapy (CBT) and medications such as bupropion have shown promise in treating cocaine dependence, although the evidence is not yet conclusive 3, 5.
• Combination therapies, such as CBT and pharmacotherapy, may be more effective than individual treatments in achieving long-term abstinence 3.
• Dopamine agonists, such as long-acting amphetamine and modafinil, and glutamatergic and GABAergic agents, such as topiramate, are being investigated as potential pharmacological treatments for cocaine use disorder 4.

Pharmacological Treatments for Cocaine Abuse

• Bupropion, a dopamine and norepinephrine reuptake inhibitor, has been studied as a potential treatment for cocaine dependence, although the results have been mixed 5, 6.
• Bupropion analogs, such as (2S,3S)-hydroxybupropion, are being developed as potential treatments for cocaine addiction and other CNS disorders 6.
• These compounds may act as indirect dopamine agonists or inhibit the reuptake of dopamine and norepinephrine in reward centers of the brain, and may be useful in decreasing cocaine reward and withdrawal 6.