What is the diagnosis and treatment for a patient presenting with cocaine and methamphetamine abuse/toxicity?

Diagnosis and Treatment of Cocaine & Methamphetamine Abuse/Toxicity

Acute Toxicity Recognition and Initial Management

For patients presenting with acute chest pain, cocaine and methamphetamine use should be considered as a primary cause, particularly in younger patients, as both drugs produce a hyperadrenergic state that can cause myocardial ischemia even without obstructive coronary artery disease. 1

Diagnostic Approach

• Obtain urine drug screening immediately - cocaine and methamphetamine typically test positive within 1-4 hours of use and remain positive for 2-4 days 1
• Perform 12-lead ECG - up to 70% of methamphetamine users have abnormal ECGs, most commonly tachycardia, with additional findings including hypertension, pulmonary artery hypertension, and cardiomyopathy 1
• Apply standard risk stratification for chest pain - the frequency of acute coronary syndrome is <10% among cocaine and methamphetamine users, and death is rare 1

Pathophysiology to Recognize

Both drugs block neuronal reuptake of norepinephrine and dopamine, creating catecholamine accumulation that produces: 1

• Dramatic increases in heart rate and blood pressure
• Coronary vasoconstriction with elevated myocardial oxygen demand
• Myocardial ischemia/infarction without obstructive CAD
• Cardiac arrhythmias and increased myocardial contractility
• Increased platelet aggregability and endothelial dysfunction
• Hypertensive vascular catastrophes (aortic dissection, cerebrovascular hemorrhage)
• Decreased myocardial perfusion and reduced coronary sinus blood flow

Acute Toxicity Treatment

Benzodiazepines are first-line for managing acute cocaine and methamphetamine toxicity symptoms including psychomotor agitation, tachycardia, and hypertension. 2

Critical Management Points

• Treat hyperthermia aggressively if present - it increases cocaine toxicity 2
• Do NOT use adrenergic blockers - they are contraindicated in acute cocaine toxicity 2
• Monitor continuously for cardiovascular complications throughout the acute phase 2

Definitive Treatment for Substance Use Disorder

The combination of Contingency Management (CM) plus Community Reinforcement Approach (CRA) is the most effective evidence-based treatment with a number needed to treat of 3.7 (95% CI 2.4-14.2) for sustained abstinence, demonstrating superior efficacy and acceptability for both short-term and long-term outcomes. 1, 3

Treatment Algorithm

First-Line: CM plus CRA 1, 3

• Contingency Management component: Provide tangible rewards (vouchers or prizes) contingent upon drug-free urine samples to create immediate positive reinforcement for abstinence 3, 4
• Community Reinforcement Approach component: Multi-layered intervention involving functional analysis, coping-skills training, and social, familial, recreational, and vocational reinforcements 3, 4
• This combination addresses both immediate behavioral reinforcement and underlying psychological/social factors that maintain addiction 3, 4

Evidence strength: CM plus CRA had the highest number of statistically significant results in head-to-head comparisons, being more efficacious than CBT alone (OR 2.44, P=0.045), non-contingent rewards (OR 3.31, P=0.010), and 12-step programs plus non-contingent rewards (OR 4.07, P=0.031) 1

Second-Line: Cognitive Behavioral Therapy 1, 3

• CBT has a number needed to treat of 10.5 (95% CI 5.8-53.6) 3
• More acceptable than treatment as usual but not significantly more efficacious than CM plus CRA 3
• If pharmacotherapy is used, CBT must be delivered concurrently, not sequentially - combined treatment shows benefit over usual care (effect sizes g=0.18-0.28) 3, 4

Pharmacological Considerations

No FDA-approved medications exist specifically for cocaine or methamphetamine use disorder - psychosocial interventions remain first-line treatment 3

• Medications such as bupropion, topiramate, and disulfiram have low-strength evidence and should only be considered as adjuncts to CM plus CRA, never as monotherapy 3
• Disulfiram has shown the most consistent effect to reduce cocaine use across multiple studies but remains investigational 3

Adjunctive Options (Not Standalone)

• 12-step programs: Not supported by strong evidence as standalone treatment but may be beneficial as adjunct 3
• Non-contingent rewards: Have not shown effectiveness and should be avoided 3

Critical Pitfalls to Avoid

• Do not rely solely on CM without CRA - this leads to relapse after treatment completion when behavioral reinforcement is withdrawn, as CM alone shows efficacy during treatment but effects are not sustained at long-term follow-up 3, 2, 4
• Do not use non-contingent rewards (providing rewards regardless of drug use status) - these have not shown effectiveness 3
• Do not prescribe adrenergic blockers for acute toxicity - they are contraindicated 2
• Do not implement pharmacotherapy without concurrent behavioral interventions - combined treatment is superior to medication alone 4
• Do not fail to provide long-term follow-up - sustained recovery requires continued support after initial treatment 3, 4

Monitoring Strategy

• Regular urine drug screens provide objective evidence of abstinence and are essential for implementing CM effectively 3
• Continued cardiovascular assessment throughout treatment given both drugs' cardiac effects 3, 2
• At least 3 months of follow-up recommended for longitudinal assessment 3
• Screen for co-occurring mental health conditions that may complicate treatment and require integrated approaches 3