What medications are used to treat cocaine addiction?

Treatment for Cocaine Addiction

There are currently no FDA-approved medications for cocaine use disorder; the most effective treatment is the combination of Contingency Management (CM) plus Community Reinforcement Approach (CRA), which achieves abstinence with a number needed to treat of 3.7. 1

First-Line Treatment: Combined Behavioral Approach

The combination of CM plus CRA should be offered as the initial treatment for all patients with cocaine addiction, as it demonstrates superior efficacy and acceptability for both short-term and long-term outcomes compared to all other interventions. 1, 2

How This Combined Approach Works:

Contingency Management (CM):

• Provides tangible rewards (vouchers or prizes) immediately upon presentation of drug-free urine samples 1, 3
• Creates immediate positive reinforcement for abstinence behavior 1
• Highly effective during active treatment but effects diminish after rewards are discontinued 1, 4

Community Reinforcement Approach (CRA):

• Multi-layered intervention addressing underlying psychological and social factors 1, 3
• Includes functional analysis, coping-skills training, and reinforcement across social, familial, recreational, and vocational domains 1, 3
• Provides the long-term structural support that prevents relapse after CM is discontinued 3, 4

Why the combination is essential: CM alone shows efficacy during treatment but not at long-term follow-up, while CRA addresses the underlying factors that maintain addiction and prevent relapse after behavioral reinforcement is withdrawn. 1, 3, 4

Pharmacological Considerations

No medications are FDA-approved specifically for cocaine use disorder, and psychosocial interventions remain the evidence-based first-line treatment. 1, 2

Medications with Some Evidence (but not FDA-approved):

While the following medications have shown promise in clinical trials, none are approved for cocaine use disorder and should be considered investigational:

• Bupropion: May improve abstinence (RR 1.63,95% CI 1.02-2.59), but low strength of evidence 5
• Topiramate: May improve abstinence (RR 2.56,95% CI 1.39-4.73), but low strength of evidence and efficacy closely associated with concurrent CBT 5, 6
• Psychostimulants: May improve abstinence (RR 1.36,95% CI 1.05-1.77), but low strength of evidence 5
• Disulfiram: Has shown the most consistent effect to reduce cocaine use across multiple studies 7, 8

Important caveat: These medications should only be considered as adjuncts to CM plus CRA, never as monotherapy, and their use remains investigational. 1, 5

Second-Line Psychosocial Options

If CM plus CRA is unavailable or not feasible, consider these alternatives:

Cognitive Behavioral Therapy (CBT):

• More acceptable than treatment as usual (NNT 10.5,95% CI 5.8-53.6) but not significantly more efficacious for achieving abstinence 2, 1
• When combined with pharmacotherapy, shows benefit over usual care (effect sizes g=0.18-0.28) 2, 3
• Should be delivered concurrently with any pharmacotherapy, not sequentially 3

12-Step Programs:

• Not supported by strong evidence as standalone treatment for cocaine addiction 1, 2
• May be beneficial as an adjunct to other evidence-based treatments 1

Critical Pitfalls to Avoid

Do not implement CM without CRA or similar comprehensive approach: This leads to relapse after treatment completion when behavioral reinforcement is withdrawn. 1, 3, 4

Do not use non-contingent rewards: Providing rewards regardless of drug use status has not shown effectiveness. 1

Do not rely solely on pharmacotherapy: Even when medications are used, they must be combined with behavioral interventions, as combined treatment is superior to medication alone. 3, 2

Do not fail to provide long-term follow-up: Sustained recovery requires continued support after initial treatment stabilization. 1, 3, 4

Do not overlook co-occurring conditions: Mental health disorders and other substance use (particularly alcohol) complicate treatment and require integrated approaches. 1

Monitoring Strategy

Urine drug screening:

• Essential for implementing CM effectively, as rewards are contingent upon objective evidence of abstinence 1, 4
• Should be conducted regularly throughout treatment 1

Cardiovascular assessment:

• Continued monitoring for cardiovascular complications is necessary throughout treatment given cocaine's cardiac effects 4, 2
• Patients experience increased risk of cardiovascular dysfunction, neurological disorders, and cognitive deficits 2

Long-term follow-up:

• At least 3 months of follow-up is recommended for longitudinal assessment 2
• Critical for sustained recovery, as treatment effects may not persist without ongoing support 1, 3

Acute Cocaine Toxicity Management

For acute cocaine intoxication presenting with agitation, tachycardia, or hypertension:

• Benzodiazepines are first-line for managing acute symptoms 4
• Treat hyperthermia aggressively if present, as it increases cocaine toxicity 4
• Never use adrenergic blockers—they are contraindicated 4