From the Guidelines
Treatment for cocaine use disorder should involve a comprehensive approach combining behavioral therapies and supportive medications, with cognitive-behavioral therapy (CBT), contingency management, and motivational interviewing as the primary treatment components, as supported by the most recent evidence 1. The primary treatment for cocaine use disorder typically consists of CBT, contingency management, and motivational interviewing, delivered in outpatient settings over 12-16 weeks.
- Behavioral therapies are the cornerstone of treatment, with a focus on addressing the underlying psychological and social factors contributing to cocaine use.
- While no FDA-approved medications exist specifically for cocaine addiction, certain medications may help manage symptoms, such as:
- Disulfiram (250-500 mg daily) to reduce cocaine use
- Modafinil (200-400 mg daily) to decrease cravings
- Topiramate (titrated to 200-300 mg daily) to reduce use
- Antidepressants like bupropion (300 mg daily) for those with comorbid depression
- Treatment should address withdrawal symptoms, including depression, fatigue, and intense cravings, which typically peak within days and subside over 1-2 weeks.
- Regular urine drug screening helps monitor abstinence, and the neurobiological basis of cocaine addiction involves dopamine system dysregulation, explaining the intense cravings and difficulty maintaining abstinence. The American College of Physicians position paper 1 emphasizes the importance of a comprehensive approach to treating substance use disorders, including cocaine use disorder, and highlights the need for increased access to evidence-based treatment, including medication-assisted therapy and behavioral interventions.
- The paper also stresses the importance of addressing the social and environmental factors contributing to substance use disorders, such as poverty, lack of education, and unemployment.
- Additionally, the paper recommends expanding the workforce of professionals qualified to treat substance use disorders and embedding training in the treatment of substance use disorders throughout the continuum of medical education 1.
From the Research
Treatment Options for Cocaine Use Disorder
- Psychosocial treatments, including contingency management and cognitive behavioral therapy, are currently the treatments of choice for cocaine use disorder (CUD) 2.
- Contingency management (CM) has been shown to be effective in increasing cocaine abstinence, improving treatment retention, and acting synergistically with pharmacotherapy 3.
- Cognitive-behavioral therapy (CBT) has also been found to be effective in reducing cocaine use, although its effects may emerge after treatment and be less reliable than those of CM 4.
Comparison of Contingency Management and Cognitive-Behavioral Therapy
- Studies have compared the effectiveness of CM and CBT for cocaine dependence, with some finding that CM alone reliably reduces cocaine use during active treatment, while CBT's positive effects emerge after treatment 4.
- The combination of CM and CBT has been found to have synergistic effects in some trials, but not others 4, 5.
- One study found that the addition of prize-based CM to CBT enhanced treatment effects, especially in the early treatment period 5.
Pharmacological Strategies
- Despite the lack of approved pharmacotherapies for CUD, investigators have sought to develop pharmacological agents to augment the efficacy of psychosocial treatments 2.
- Promising pharmacological strategies for CUD treatment include the use of dopamine agonists, such as long-acting amphetamine and modafinil, or glutamatergic and GABAergic agents, such as topiramate 2.
- Combination drugs may be especially promising for the treatment of CUD 2.
Study Findings
- A randomized, controlled trial found that combined prize-based CM plus CBT was more effective than CBT alone in reducing cocaine use, especially in the early treatment period 5.
- Another study found that CM and CBT had solid evidence of efficacy, although CM's effect was significantly greater during treatment, and CBT appeared to produce comparable long-term outcomes 6.