Treatment Strategies For Cocaine Abuse


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Treatment Strategies For Cocaine Abuse

  1. 1. Treatment Strategies for Cocaine Abuse
  2. 2. Epidemiology <ul><li>Tropane ester alkaloid found in leaves of the Erythroxylum coca plant, a bush that grows in the Andes Mountain region of South America. </li></ul><ul><li>1860 a German graduate student, Albert Niemann isolated the active ingredient </li></ul><ul><li>Commercial products began featuring cocaine </li></ul><ul><ul><li>“ Coca-Cola” - non-alcoholic beverage originally named “French Wine Cola”. It contained 0.75mg of cocaine per ounce </li></ul></ul>
  3. 3. Epidemiology (continued) <ul><li>Cocaine is used by an estimated 14 million people worldwide (UNODC, 2003) </li></ul><ul><li>Cocaine is currently the second most commonly used illicit drug in the U.S., being out placed only by marijuana. </li></ul><ul><li>Illegal drug most often associated with visits to US hospital emergency departments. </li></ul>
  4. 4. Patterns of Use <ul><li>Classic Binge Paradigm </li></ul><ul><li>Some may use excessively and continuously until there sources of money or cocaine are depleted, or their access to the drug is restricted </li></ul><ul><li>Small percentage may self-medicate an underlying psychiatric disorder with regular low doses of cocaine. </li></ul><ul><ul><li>This final population may not experience significant dose escalation over time (Levin et al, 1993; Myers et al, 1995) </li></ul></ul>
  5. 5. Multiple Drug Use <ul><li>Concurrent use of alcohol and cocaine produces cocaethylene. </li></ul><ul><li>Formed through transesterification (Jenkins et al, 1998). </li></ul><ul><li>Similar pharmacologic actions, lower potency and longer half-life when compared to the parent compound cocaine (Cami et al, 1998; Hart et al, 2000). </li></ul><ul><li>Hepatotoxic </li></ul>
  6. 6. Clinical Manifestations <ul><li>Depend on: </li></ul><ul><ul><li>Age of the individual being examined </li></ul></ul><ul><ul><li>Type of exposure to cocaine (acute or chronic) </li></ul></ul><ul><ul><li>Time since last exposure. </li></ul></ul><ul><li>Wide variability in the signs and symptoms (SSx): </li></ul><ul><ul><li>Inborn (genetic) variances </li></ul></ul><ul><ul><li>Psychological characteristics of the individual </li></ul></ul><ul><ul><li>Previous drug experience </li></ul></ul><ul><ul><li>Environment in which the drug is taken </li></ul></ul><ul><ul><li>Existence of psychiatric or medical co-morbidity </li></ul></ul>
  7. 7. Clinical Manifestations <ul><li>Wide variability may account for the poor correlation observed between plasma cocaine concentration and subjective as well as toxic effects. </li></ul><ul><li>Fatal cases of cocaine intoxication have been found to present with 100 fold variance in plasma cocaine levels </li></ul>
  8. 8. Clinical Manifestations <ul><li>Behavioral changes observed in the acute phase include: </li></ul><ul><ul><li>Restlessness, agitation, tremor, dyskinesia, and repetitive or stereotyped behaviors such as picking at the skin or foraging for drugs (&quot;punding,&quot; &quot;hung-up activity&quot;) (Rosse et al, 1993). </li></ul></ul><ul><li>Physiological effects observed in this stage include: </li></ul><ul><ul><li>Tachycardia, pupil dilation, diaphoresis, and nausea, all reflecting stimulation of the sympathetic nervous system. </li></ul></ul>
  9. 9. Clinical Manifestations <ul><li>Effects of cocaine on specific organ systems are: </li></ul><ul><ul><li>CNS: seizures, stroke, movement disorders </li></ul></ul><ul><ul><li>CV: myocardial infarction, arrhythmia, cardiomyopathy, and myocarditis </li></ul></ul><ul><ul><li>Respiratory: rhinitis and septal perforation (with intranasal use) cough, wheeze, chest pain (with smoked use) </li></ul></ul><ul><ul><li>GI: xerostomia, gastric ulcers, ischemic colitis </li></ul></ul>
  10. 10. Clinical Manifestations <ul><li>Body Packers (Mules) </li></ul><ul><ul><li>Individuals who swallow large amounts of well-packaged cocaine for the purpose of smuggling. </li></ul></ul><ul><ul><li>Anti-motility agents are used to forestall gastric emptying while the drugs are in transport. </li></ul></ul><ul><ul><li>Followed by the use of promotility agents to hasten emptying upon arrival at their destination. </li></ul></ul><ul><li>SSX: </li></ul><ul><ul><li>Packets are typically palpable on PE </li></ul></ul><ul><ul><li>Anterior-Posterior X-Rays will show packets </li></ul></ul>
  11. 11. Clinical Manifestations
  12. 12. Clinical Manifestations
  13. 13. Treatment <ul><li>Pt must undergo full medical examination with a complete Hx to determine cause of presenting SSx </li></ul><ul><ul><li>Some disorders can mimic cocaine intoxication: </li></ul></ul><ul><ul><ul><li>Hyperthyroidism </li></ul></ul></ul><ul><ul><ul><li>Psychosis related to Schizophrenia </li></ul></ul></ul><ul><li>Symptomatic Body Packers are considered a surgical emergency. </li></ul><ul><ul><li>All other Tx for them is secondary </li></ul></ul>
  14. 14. Tx: Acute Intoxication <ul><li>Pt should be kept in a quiet environment with minimal disturbance to avoid exacerbating Sx. </li></ul><ul><li>Tx staff should interact in a calm and confident manner, using the ART approach developed at San Francisco's Haight-Ashbury Free Clinic: </li></ul><ul><ul><li>A cceptance of the patient's immediate needs (e.g., pain relief, use of the bathroom) </li></ul></ul><ul><ul><li>R eassurance that the condition is due to cocaine and will resolve within a few hours </li></ul></ul><ul><ul><li>T alkdown to provide reality orientation and avoid hostility </li></ul></ul><ul><li>Use of medication or physical restraints should be avoided as much as possible (Khantzian et al, 1979; Hurlbut, 1991). </li></ul><ul><li>Restraint use may increase risk for hyperthermia and rhabdomyolysis. </li></ul>
  15. 15. Treatment <ul><li>Psychotherapy is the primary Tx </li></ul><ul><ul><li>Methods of psychotherapy that have been studied and found effective include: </li></ul></ul><ul><ul><ul><li>Motivational enhancement </li></ul></ul></ul><ul><ul><ul><li>Psychodynamic (but not psychoanalysis) </li></ul></ul></ul><ul><ul><ul><li>Supportive </li></ul></ul></ul><ul><ul><ul><li>Cognitive and behavioral approaches </li></ul></ul></ul><ul><ul><ul><ul><li>Including relapse prevention and contingency management (Carroll, 2005). </li></ul></ul></ul></ul><ul><ul><li>Involvement with peer self-help groups such as Cocaine Anonymous (modeled after Alcoholics Anonymous) improves treatment outcome (Weiss, 2005). </li></ul></ul>
  16. 16. Treatment Pharmacotherapy <ul><li>Adjunctive to Psychotherapy </li></ul><ul><li>Medications found to be ineffective: </li></ul><ul><ul><li>Antidepressants </li></ul></ul><ul><ul><li>Dopamine agonists (e.g. amantadine, bromocriptine, and pergolide) </li></ul></ul><ul><ul><li>Carbamazepine. (Schuckit, 2006). </li></ul></ul>
  17. 17. Tx: Pharmacotherapy Disulfiram <ul><li>Found effective in four published trials </li></ul><ul><li>safety concerns have been raised over its interactions with alcohol and cocaine in patients who do not abstain completely. </li></ul><ul><li>Proposed mechanism for reduction in cocaine use involves blocking the action of dopamine β Hydroxylase </li></ul><ul><ul><li>Increases extracellular dopamine concentration. </li></ul></ul><ul><ul><li>Increase produces a reaction that increases unpleasant effects associated with cocaine, such as anxiety and paranoia, (Carroll et al, 2004). </li></ul></ul>
  18. 18. Tx: Pharmacotherapy Modafinil <ul><li>Shown to be effective in single trials. </li></ul><ul><li>Currently used to treat narcolepsy </li></ul><ul><li>Has been shown to enhance levels of glutamate. </li></ul><ul><li>Animal research has shown that repeated exposure to cocaine depletes glutamate levels in brain regions associated with development of dependence and addiction, and that increasing glutamate concentrations will block reinstatement of cocaine self-administration in rats—a model of relapse to drug abuse in humans (Dackis et al, 2005). </li></ul>
  19. 19. Tx: Pharmacotherapy Topiramate & Tiagabine <ul><li>Anti-convulsants that have also been shown effective in single trials of cocaine Tx. </li></ul><ul><li>Topiramate activates GABA-producing neurons and blocks glutamate receptors </li></ul><ul><ul><li>Theoretically this would lessen craving in cocaine-addicted pts by indirectly affecting the mesocorticolimbic dopaminergic reward pathway. </li></ul></ul><ul><li>Tiagabine , a GABAergic agent is also thought to work indirectly on dopaminergic pathways via GABA. (Kampman et al, 2004; Gonzalez et al, 2003). </li></ul>
  20. 20. Tx: Pharmacotherapy Baclofen <ul><li>GABA β receptor antagonist that preliminary results suggest may diminish cocaine intake in some pts. </li></ul><ul><li>Baclofen’s actions at GABA β receptors are thought to mediate an anti-dopaminergic effect that undercuts the high of cocaine (Shoptaw et al, 2003). </li></ul>
  21. 21. Tx: Pharmacotherapy Ondansetron <ul><li>Serotonin (5-HT3) receptor antagonist </li></ul><ul><li>Preliminary data suggest it may diminish subsequent cocaine intake in pts when given during the acute phase of intoxication (Johnson et al, 2006). </li></ul>
  22. 22. Tx: Pharmacotherapy Buprenorphine <ul><li>An opioid mixed agonist-antagonist </li></ul><ul><li>Has shown efficacy in high doses in pts co-addicted with opiates. </li></ul><ul><li>Mechanism still not understood (Montoya et al, 2004). </li></ul>
  23. 23. Tx: Pharmacotherapy Buproprion <ul><li>In combination with a contingency management program (payment for negative urine samples) was found effective in co-addicted patients receiving methadone maintenance. </li></ul><ul><li>DA reuptake inhibitor similar to cocaine </li></ul><ul><li>However, unlike cocaine administration of bupropion may cause subsequent neuroadaptive upregulation of DA receptors (Poling et al, 2006). </li></ul>
  24. 24. Tx: Pharmacotherapy N-acetylcysteine <ul><li>Alters CNS glutamate activity </li></ul><ul><li>Currently under investigation (LaRowe et al, 2006). </li></ul>
  25. 25. Tx: Pharmacotherapy Anti-Cocaine Vaccine <ul><li>Currently under investigation is a conjugated cocaine vaccine </li></ul><ul><li>Well tolerated </li></ul><ul><li>Produces cocaine specific antibodies </li></ul><ul><ul><li>Persist at least six months. (Martell et al, 2005). </li></ul></ul>
  26. 26. Tx: Pharmacotherapy Alternative Txs <ul><li>Alternatives to traditional medical and psychological therapy have also been investigated: </li></ul><ul><li>Acupuncture (Margolin et al, 2002), </li></ul><ul><li>Herbal remedies such as ginko biloba (Kampman et al, 2003) </li></ul><ul><li>They have not, however, been shown to be effective. </li></ul>