Treatment for Patients Using Alcohol and Cocaine
The most effective treatment for patients using alcohol and cocaine is a combination of contingency management (CM) plus community reinforcement approach (CRA), which has demonstrated superior efficacy and acceptability for both short-term and long-term outcomes compared to other psychosocial interventions. 1
Assessment and Initial Management
- Perform a thorough substance use assessment including pattern of alcohol and cocaine use, duration of use, and previous treatment attempts 1
- Evaluate for co-occurring psychiatric conditions, as these are common in patients with substance use disorders and may complicate treatment 1
- Assess for medical complications of cocaine and alcohol use, including cardiovascular issues, as cocaine can cause coronary artery spasm, tachycardia, and increased blood pressure 1
- Screen for cocaethylene toxicity, which occurs when cocaine and alcohol are used together, creating a metabolite with a longer half-life that carries an 18-25 fold increased risk of immediate death compared to cocaine alone 2, 3
Psychosocial Interventions
First-Line Treatment
- Contingency Management (CM) plus Community Reinforcement Approach (CRA) is the most effective combination therapy for cocaine and amphetamine addiction 1
- CM provides rewards (incentives) for drug-free urine samples
- CRA involves functional analysis, coping-skills training, and social, familial, recreational, and vocational reinforcements
Alternative Psychosocial Approaches
- Cognitive Behavioral Therapy (CBT) has shown efficacy for treating stimulant use disorders, though less effective than CM+CRA 1
- 12-step programs can be helpful as an adjunct to other treatments 1
- Motivational interviewing techniques can help engage patients who are ambivalent about treatment 1
Pharmacological Interventions
For Alcohol Use Disorder
- Complete abstinence from alcohol is recommended for patients with alcoholic cardiomyopathy 1
- Naltrexone (50 mg daily) can reduce alcohol craving and relapse rates when combined with psychosocial interventions 4
- Requires patient to be opioid-free for 7-10 days before initiation
- Has shown efficacy in reducing drinking days and promoting abstinence
For Cocaine Use Disorder
- There are currently no FDA-approved medications specifically for cocaine use disorder 1, 5
- For patients with cocaine-related cardiomyopathy who have demonstrated abstinence for >6 months, standard therapy for left ventricular dysfunction including β-blockers is reasonable 1
- In patients at risk for relapse to cocaine use, non-selective β-blockers with α-, β1-, or β2-receptor antagonism are preferred over selective β1-blockers to avoid unopposed α-agonism effects of cocaine 1
Special Considerations
- For acute cocaine-related chest pain, sublingual nitroglycerin or calcium channel blockers (e.g., diltiazem 20 mg IV) should be administered rather than beta-blockers 1
- Disulfiram combined with psychotherapy has shown promise for patients with concurrent cocaine and alcohol use disorders 6
- Patients using both cocaine and alcohol typically have worse outcomes and more severe problems than those using cocaine alone, requiring more intensive treatment approaches 7
Treatment Course and Monitoring
- Regular urine drug screening to monitor abstinence 1
- Address barriers to treatment adherence, as many patients with substance use disorders have poor medication compliance 4
- Monitor for withdrawal symptoms from both substances, which may require medical management 1
- Evaluate treatment response regularly and adjust the approach as needed 1
Common Pitfalls to Avoid
- Failing to address both substances simultaneously, as cocaine and alcohol use are strongly related during treatment 6
- Overlooking cardiovascular complications of cocaine use, which can occur even with small amounts 1
- Using selective β1-blockers in patients who may continue to use cocaine, which can lead to unopposed α-adrenergic stimulation 1
- Underestimating the increased toxicity when cocaine and alcohol are used together due to cocaethylene formation 2, 3