What medications are used to treat Cocaine Use Disorder (CUD)?

From the Guidelines

Currently, there are no FDA-approved medications specifically for cocaine use disorder, and treatment typically involves behavioral interventions like cognitive-behavioral therapy and contingency management, as recommended by international clinical guidelines 1.

Medications Under Investigation

Several medications are being investigated in clinical trials for the treatment of cocaine use disorder.

• Disulfiram (Antabuse), typically used for alcohol dependence, has shown some promise at doses of 250-500mg daily.
• Modafinil (100-200mg daily) may help reduce cocaine use by addressing cognitive deficits.
• Topiramate (starting at 25mg daily, gradually increasing to 200-300mg daily) has demonstrated potential in reducing cocaine cravings.
• Some clinicians also use bupropion (150-300mg daily) or stimulants like methylphenidate for selected patients with comorbid ADHD.

Comprehensive Treatment Plan

Any medication should be part of a comprehensive treatment plan that includes psychosocial support, as cocaine addiction affects both dopamine pathways and psychological factors, as noted in a recent systematic review and meta-analysis 1.

Addressing Co-occurring Conditions

Treatment should also address common co-occurring conditions like depression, anxiety, or other substance use disorders to improve overall outcomes, as emphasized in a position paper by the American College of Physicians 1.

Key Considerations

• The combination of pharmacological and behavioral interventions is considered the criterion standard in addiction care, although differences between best practices for alcohol use disorder and other substance use disorders have been noted 1.
• The brain disease paradigm of addiction has been criticized by some, but research reflects the role of genetics and social exposure as important components in the manifestation of this condition 1.
• Policies to address substance use disorders, including federal efforts and state initiatives, are crucial in tackling the opioid epidemic and other substance use disorders, as outlined in the Comprehensive Addiction and Recovery Act (CARA) and the 21st Century Cures Act 1.

From the Research

Medications for Cocaine Use Disorder (CUD)

The following medications have been studied for the treatment of Cocaine Use Disorder (CUD):

• Antidepressants: although widely studied, they appear to have no effect on cocaine use or treatment retention 2
• Bupropion: may improve abstinence 2
• Topiramate: may improve abstinence 2, 3, 4
• Psychostimulants: may improve abstinence 2
• Antipsychotics: may improve treatment retention 2
• Glutamatergic agents: such as N-Acetylcysteine, modafinil 3, 4
• GABAergic agents: such as vigabatrin, tiagabine, baclofen 3, 4
• Agonist replacement therapy: such as sustained-release methylphenidate, d-amphetamine 3, 4
• Dopamine agents: such as disulfiram 3, 4, 5
• Clonidine: may be effective in short-term treatment for cocaine craving 6
• Fenfluramine: may be effective in short-term treatment for cocaine craving 6
• Meta-chlorophenylpiperazine (m-CPP): may be effective in short-term treatment for cocaine craving 6
• Amphetamine: may be effective in long-term treatment for cocaine craving 6
• Biperiden: may be effective in long-term treatment for cocaine craving 6
• Carbamazepine: may be effective in long-term treatment for cocaine craving 6
• Lisdexamfetamine: may be effective in long-term treatment for cocaine craving 6
• Lorcaserin: may be effective in long-term treatment for cocaine craving 6
• Methamphetamine: may be effective in long-term treatment for cocaine craving 6
• Mirtazapine: may be effective in long-term treatment for cocaine craving 6
• Pioglitazone: may be effective in long-term treatment for cocaine craving 6
• Progesterone: may be effective in long-term treatment for cocaine craving 6
• Guanfacine: may be effective in long-term treatment for cocaine craving 6
• Levodopa: may be effective in long-term treatment for cocaine craving 6
• Nefazodone: may be effective in long-term treatment for cocaine craving 6

Limitations of Current Treatments

Most of the pharmacotherapies studied were not effective for treating cocaine use disorder 2 The strength of evidence for some findings was low 2 High heterogeneity of craving assessments across studies 6 Great range of pharmacotherapies 6 Most studies considered abstinence and retention in treatment as the main outcomes, whereas craving was a secondary outcome 6 Some studies evaluated patients with cocaine use disorder with comorbidities 6 Most studies also included non-pharmacological treatments, such as counseling or psychotherapy 6