Initial Bupropion Dosing for Cocaine Cravings
The recommended initial dose of bupropion for managing cocaine cravings is 150 mg once daily of the XL formulation or 100-150 mg once daily of the SR formulation. 1
Dosing Protocol
Starting dose:
- Bupropion XL: 150 mg once daily
- Bupropion SR: 100-150 mg once daily
Titration schedule:
- For SR formulation: After initial tolerance is established (typically 3-7 days), increase to maintenance dose of 100-150 mg twice daily
- For XL formulation: May increase to 150-300 mg once daily after initial tolerance is established
Maximum dose:
Special Considerations
Seizure risk: Bupropion has a dose-dependent seizure risk of approximately 0.1% at therapeutic doses (≤450 mg/day) 2
Patient screening before initiation:
- Evaluate for seizure risk factors (history of seizures, brain injury, alcohol withdrawal)
- Assess for concurrent medications that may lower seizure threshold
- Check for history of cardiovascular disease or uncontrolled hypertension 2
Dose adjustments for special populations:
- Hepatic impairment: Maximum of 1 tablet daily in moderate to severe impairment
- Renal impairment: Half the normal dose in moderate to severe impairment
- Elderly patients: Consider lower starting doses due to increased risk of adverse effects 2
Monitoring Recommendations
Cardiovascular monitoring: Bupropion can increase blood pressure and heart rate 2
- Baseline vital signs before initiation
- Regular monitoring during dose titration
- Avoid in uncontrolled hypertension
Neuropsychiatric symptoms: Monitor for anxiety, agitation, insomnia, and mood changes 2
Common adverse effects: Insomnia, dry mouth, anxiety/jitteriness, decreased appetite, headache 2
Efficacy for Cocaine Cravings
It's important to note that evidence for bupropion's efficacy in treating cocaine cravings is mixed:
Recent research has not shown significant decreases in cocaine self-administration with bupropion alone or in combination with naltrexone 3
A 2023 study found that bupropion SR may be beneficial for cocaine abstinence initiation in patients with difficulty achieving initial abstinence, though overall benefit was not observed 4
Some patients with previous cocaine use history have reported cocaine-like sensations when taking bupropion, which requires careful monitoring 5
Bupropion does not appear to robustly alter the acute subjective effects of cocaine 6
Clinical Pearls
While bupropion is primarily prescribed for depression and ADHD, it is increasingly being used off-label for various indications 7
Approximately 39-45% of patients remain on bupropion treatment for at least 6 months 7
Avoid sudden discontinuation of bupropion; implement gradual tapering if discontinuation is necessary 2
Patients should be informed about the potential for bupropion to elicit cocaine-like cues and the importance of adhering to prescribed dosages 5