What medications can be used to treat cocaine use disorder?

Medications for Treating Cocaine Use Disorder

Currently, there are no FDA-approved medications specifically for cocaine use disorder, but contingency management plus community reinforcement approach is the most effective treatment combination for improving morbidity, mortality, and quality of life outcomes. 1

Psychosocial Interventions (First-Line Treatment)

• Contingency Management (CM) plus Community Reinforcement Approach (CRA) is the most effective treatment combination, with only 4 patients needing treatment to have 1 additional patient achieve abstinence compared to treatment as usual 2, 1
• Contingency Management (CM) alone or combined with Cognitive Behavioral Therapy (CBT) shows superior efficacy compared to treatment as usual 2, 1
• CBT alone is recommended as an alternative when CM+CRA is not available, though it shows less efficacy 1

Pharmacological Options (Adjunctive Treatments)

Medications with Some Evidence of Efficacy:

• Psychostimulants: May improve cocaine abstinence (RR 1.36,95% CI 1.05 to 1.77) though evidence quality is very low 3

  • Dexamphetamine and lisdexamfetamine show promise for reducing cocaine use 3
  • Particularly effective in patients with co-occurring opioid use disorder on methadone maintenance 3

• Bupropion: May increase abstinence rates (RR 1.63,95% CI 1.02 to 2.59) with low strength of evidence 4

  • However, some studies show no significant difference between bupropion and placebo when combined with CBT 5

• Topiramate: May improve abstinence (RR 2.56,95% CI 1.39 to 4.73) with low strength of evidence 4

• Varenicline: Shows potential for decreasing cocaine use and reward in preliminary studies 6

Medications for Specific Symptoms:

• For cocaine craving: Clonidine, mirtazapine, and progesterone have shown some promise in reducing cravings 7

• For co-occurring mental health conditions: Antipsychotics may improve treatment retention (RR 1.33,95% CI 1.03 to 1.75) with moderate strength of evidence 4

Management of Acute Cocaine-Related Complications

• For cocaine-associated chest pain:
  • Benzodiazepines are first-line treatment 2
  • Nitroglycerin can relieve cocaine-associated chest pain and reverse cocaine-associated vasoconstriction 2
  • Avoid beta-blockers as they can worsen coronary vasoconstriction 2, 1
  • Calcium channel blockers should not be used as first-line treatment but may be considered for patients who don't respond to benzodiazepines and nitroglycerin 2

Comprehensive Treatment Approach

• Integrate substance use disorder screening into routine care, particularly for high-risk populations 1, 8
• Assess for medical complications of stimulant use, particularly cardiovascular issues 1
• Provide harm reduction services including naloxone dispensation, safe use education, and referral to syringe services 1, 8
• For patients with co-occurring opioid and stimulant use disorders, medications for opioid use disorder should be initiated without delay 1

Common Pitfalls to Avoid

• Relying solely on drug testing without clinical context can lead to misdiagnosis 1
• Using selective β1-blockers in patients who may continue to use cocaine can lead to unopposed α-adrenergic stimulation 1
• Failing to recognize that stimulant use disorders frequently co-occur with other substance use and mental health disorders 1, 8
• Focusing solely on abstinence rather than harm reduction approaches 8