What is the best course of treatment for a 20-year-old individual with a history of cocaine use disorder (CUD), admitted for lack of sleep and psychotic episodes, who has been sober from cocaine for 3 months but continues to use marijuana and cigarettes?

Treatment Approach for Young Adult with Cocaine Use Disorder, Psychosis, and Continued Cannabis Use

Immediate Treatment Priority: Address Psychosis and Sleep Disturbance

Initiate Contingency Management (CM) plus Community Reinforcement Approach (CRA) as the primary intervention for cocaine use disorder, while simultaneously managing acute psychotic symptoms and addressing continued cannabis use, which significantly worsens withdrawal symptoms and delays recovery. 1, 2

Managing Acute Psychotic Symptoms

• Provide a safe, monitored environment as the first step in managing cocaine-induced psychotic disorder (CIPD), which typically occurs within one month of cocaine intoxication or withdrawal 3
• Administer antipsychotic medication for agitation and psychosis management; olanzapine 10 mg/day (range 5-20 mg/day) is FDA-approved for acute agitation and has demonstrated efficacy in managing psychotic symptoms 4
• Consider adding benzodiazepines (such as clonazepam 1 mg twice daily) if antipsychotic monotherapy proves insufficient, as cocaine-induced postictal psychosis may be antipsychotic-resistant and respond better to combination therapy 5
• Monitor for seizure activity, as large cocaine ingestion can cause seizures followed by postictal psychosis appearing 1 week later, which can progress to chronic psychosis if untreated 5

Critical Issue: Cannabis Continuation

Immediately address ongoing cannabis use, as it significantly worsens cocaine withdrawal severity and depressive symptoms during early abstinence. 6

• Patients with frequent recent cannabis use report higher severity of cocaine withdrawal symptoms after 3 weeks of treatment compared to those without cannabis use 6
• Cannabis use is associated with increased depressive symptoms during early abstinence, complicating recovery 6
• Cannabis cessation should be prioritized alongside cocaine abstinence, as continued use undermines treatment efficacy 6

Sleep Disturbance Management

• Recognize that sleep deterioration is profound during the first 3 weeks of cocaine abstinence, with objective sleep quality worsening even as subjective reports may improve 7
• Sleep-related cognitive performance declines during early abstinence despite patients reporting improved sleep, creating a dangerous disconnect 7
• Monitor sleep objectively rather than relying solely on patient reports, as subjective improvement does not reflect actual sleep quality 7

First-Line Psychosocial Treatment: CM Plus CRA

Implement the combination of Contingency Management and Community Reinforcement Approach immediately, as this has the strongest evidence with a number needed to treat of 3.7 for achieving abstinence. 1, 2, 8

Contingency Management Component

• Provide tangible rewards (vouchers or prizes) contingent upon drug-free urine samples to create immediate positive reinforcement for abstinence 1
• Conduct regular urine drug screening throughout treatment, testing for both cocaine and cannabis metabolites 2
• CM alone shows efficacy during active treatment but effects are not sustained at long-term follow-up, making the addition of CRA essential 9

Community Reinforcement Approach Component

• Conduct functional analysis to identify triggers and high-risk situations for cocaine and cannabis use 1
• Provide coping-skills training to manage cravings and avoid relapse 1
• Engage social, familial, recreational, and vocational reinforcements to create a supportive recovery environment 1
• CRA addresses the underlying psychological and social factors maintaining addiction, providing sustained benefit at long-term follow-up 9

Pharmacological Considerations

No FDA-approved medications exist specifically for cocaine use disorder; psychosocial interventions remain first-line treatment. 1, 2, 10

Investigational Medications (Only as Adjuncts)

• Dopamine agonists (long-acting amphetamine, modafinil) show promise but have low-strength evidence and should only be considered as adjuncts to CM plus CRA, never as monotherapy 1, 10
• Topiramate (glutamatergic/GABAergic agent) may improve abstinence but evidence remains insufficient for routine use 1, 10
• Disulfiram has shown the most consistent effect in reducing cocaine use across multiple studies but remains investigational 1
• Never use pharmacotherapy as monotherapy without concurrent psychosocial interventions 2

Cardiovascular Monitoring Requirements

Assess for cardiac complications immediately and continue cardiovascular monitoring throughout treatment. 2, 8

• Screen for coronary artery spasm, tachycardia, elevated blood pressure, and myocardial infarction risk, as cocaine increases myocardial oxygen demand 9, 2
• Cocaine causes accelerated coronary atherosclerosis in chronic users and can precipitate ischemia even without obstructive disease 9
• Avoid beta-blockers during active cocaine use due to unopposed alpha-adrenergic stimulation; consider only after documented abstinence >6 months in patients with left ventricular dysfunction 2, 8
• Monitor for aortic dissection, coronary artery dissection, myocarditis, and cardiomyopathy as potential complications 9

Alternative Psychosocial Options (When CM+CRA Unavailable)

• Cognitive Behavioral Therapy (CBT) can be used as second-line treatment with a number needed to treat of 10.5, though it shows less efficacy than CM+CRA 1, 8
• 12-step programs may be beneficial as an adjunct to other treatments for maintaining long-term abstinence but are not supported as standalone treatment 1, 8
• CBT should be delivered concurrently with any pharmacotherapy, not sequentially 1

Critical Pitfalls to Avoid

• Do not rely solely on CM without CRA, as this leads to relapse after treatment completion when underlying psychological and social factors remain unaddressed 9, 2
• Do not provide non-contingent rewards (rewards regardless of drug use status), as these have proven ineffective 9, 2
• Do not overlook continued cannabis use, as it significantly worsens withdrawal symptoms and treatment outcomes 6
• Do not rely on patient-reported sleep quality, as subjective reports improve while objective sleep deteriorates during early abstinence 7
• Do not use pharmacotherapy without concurrent psychosocial treatment, as medications alone are ineffective 2
• Do not fail to provide long-term follow-up beyond initial treatment, as sustained recovery requires at least 3 months of longitudinal assessment 2

Distinguishing CIPD from Primary Psychotic Disorder

• Obtain detailed history of psychotic symptoms in relation to substance use timing 3
• CIPD patients are more likely to be male, have longer duration and severity of cocaine use, use intravenous cocaine, and have lower body mass index 3
• Conduct longitudinal assessment over several weeks, as CIPD typically resolves within one month of abstinence while primary psychotic disorders persist 3
• If psychotic symptoms persist beyond one month of documented abstinence from both cocaine and cannabis, consider primary psychotic disorder diagnosis 3

Tobacco Use Consideration

• Recent tobacco use does not appear to significantly affect cocaine withdrawal severity or depressive symptoms during early abstinence 6
• While tobacco cessation is beneficial for overall health, it is a lower priority than addressing cocaine and cannabis use in this acute phase 6