What is the recommended treatment for a patient with cocaine use disorder, particularly one with a history of substance-induced psychosis and possible stimulant use?

Treatment of Cocaine Use Disorder

The most effective treatment for cocaine use disorder is the combination of Contingency Management (CM) plus Community Reinforcement Approach (CRA), which achieves a number needed to treat of 3.7 and should be implemented as first-line therapy. 1

First-Line Treatment: CM Plus CRA

Implement CM plus CRA as the initial treatment approach for all patients with cocaine use disorder, regardless of psychiatric comorbidities including substance-induced psychosis. 1, 2

Why This Combination Works Best

• CM plus CRA demonstrates superior abstinence rates at 12 weeks (OR 7.60), end of treatment (OR 2.84), and longest follow-up (OR 3.08) compared to treatment as usual 2
• This combination addresses both immediate behavioral reinforcement through CM and underlying psychological/social factors through CRA, preventing the relapse that occurs when CM is used alone 3, 1
• Treatment retention is significantly better with CM plus CRA, showing 3.92 times fewer dropouts at 12 weeks compared to usual care 2

How to Implement CM Plus CRA

Contingency Management component:

• Provide tangible rewards (vouchers or prizes) contingent upon drug-free urine samples 3, 1
• Conduct urine drug screening regularly (typically 3 times per week during active treatment) to implement CM effectively 1
• Never provide non-contingent rewards (rewards regardless of drug use status), as this approach has been proven ineffective 1, 2

Community Reinforcement Approach component:

• Conduct functional analysis to identify triggers and maintaining factors for cocaine use 3, 1
• Provide coping-skills training specific to the patient's identified high-risk situations 3
• Integrate social, familial, recreational, and vocational reinforcements to build a recovery-supportive lifestyle 3, 1

Integrating Cognitive Behavioral Therapy

Deliver CBT concurrently with CM plus CRA, not sequentially, as combined treatment shows superior outcomes (effect sizes g=0.18-0.28) compared to usual care. 3, 1

• CBT alone has a number needed to treat of 10.5, making it less effective than CM plus CRA as monotherapy 1
• CBT produces sustained effects months after treatment completion, complementing the immediate effects of CM 4, 5
• The combination addresses both immediate behavioral change and long-term cognitive restructuring necessary for sustained recovery 3

Pharmacological Considerations

No FDA-approved medications exist specifically for cocaine use disorder; psychosocial interventions remain first-line treatment, with medications considered only as adjuncts to CM plus CRA, never as monotherapy. 1

Investigational Medications (Adjunct Use Only)

• Prescription psychostimulants show the most promise for promoting sustained abstinence and reducing drug use when combined with psychosocial interventions 6
• Disulfiram has shown the most consistent effect to reduce cocaine use across multiple studies, though remains investigational 1
• Topiramate, bupropion, and modafinil may improve abstinence but have low strength of evidence and should only be considered as adjuncts 1, 7

Critical caveat: Combination pharmacotherapy may be especially promising, but no single medication or combination has yet been proven safe and effective as standalone treatment 7

Special Considerations for Substance-Induced Psychosis

• Address co-occurring psychotic symptoms concurrently with cocaine use disorder treatment, as psychiatric comorbidities complicate treatment outcomes 1
• Continue CM plus CRA as the primary intervention even in the presence of psychosis, as this approach addresses the underlying addiction while psychiatric symptoms are managed separately 1, 2
• Monitor for cardiovascular complications throughout treatment given cocaine's cardiac effects, particularly in patients with stimulant-induced psychosis who may have additional cardiovascular risk 1

Monitoring and Follow-Up Strategy

Implement at least 3 months of intensive follow-up with continued monitoring, as CM effects alone are not sustained without long-term support. 1

• Continue regular urine drug screening throughout treatment and follow-up periods 1
• Assess for cardiovascular complications, neurological disorders, and cognitive deficits at each visit 1
• Maintain CRA components (social support, vocational reinforcement) beyond the acute treatment phase to prevent relapse 3, 2

Common Pitfalls to Avoid

• Never rely solely on CM without CRA, as this leads to relapse after treatment completion when immediate reinforcement ends 3, 1, 2
• Never use pharmacotherapy as monotherapy without integrated behavioral interventions, as combined treatment is superior to medication alone 3
• Never implement 12-step programs as standalone treatment, as they are not supported by strong evidence for cocaine addiction and should only serve as adjuncts 1, 2
• Never provide inadequate long-term follow-up, as sustained recovery requires continued support beyond initial treatment stabilization 3, 1