The data on the treatment of cocaine-related disorders are limited, for two reasons. When a treatment for depression is studied, cases “related to cocaine” or “involving cocaine” are generally excluded, unless studies are specifically conducted on this subtype of depression.
People with cocaine-related problems also tend not to follow treatment regularly. It is therefore difficult to accumulate a sufficiently large sample to draw statistically reliable conclusions.
One point should first be clarified. Treatments for addiction and treatments for abuse may be different. These are two different situations: abuse is a condition involving loss of control over the quantity, frequency, and circumstances of use, with negative consequences, but it remains linked to certain factors. One of these factors, the most obvious, is that the person still derives pleasure from cocaine, even though it also causes some harm. Another factor is that euphoria itself, even before use, may drive the person to use cocaine, whereas this does not occur when mood is more balanced.
Abuse can therefore be addressed by controlling the factors that drive cocaine use, or by increasing awareness of its negative effects. Usually, the whole issue revolves around mood and mood stability. The greater the fluctuations and the more elevated the general mood, the weaker the inhibition and the greater the impulsivity.
As for addiction, numerous treatments have been studied. The same treatments have often produced favorable results in some studies and unfavorable results in others. Pharmacologically, the approach has attempted to reproduce what is achieved in other addictions:
a) drugs that produce a chemical signal in the brain that “switches off” the urge to use cocaine, without the drug itself becoming a substance of abuse and without producing toxic effects. This category includes all the “dopaminergic” drugs, already available for use as antidepressants, anti-Parkinsonian agents, or for other indications (bupropion, bromocriptine, pramipexole, ropinirole, etc.). However, they cannot always be used, either because they increase impulsivity or because the signal they produce is not sufficiently strong and stable to keep the desire for cocaine suppressed. Maintaining stimulation of the dopamine system, in fact, unlike what occurs with some other neurotransmitter systems, may produce a condition in which the side effects are unacceptable.
b) drugs that interfere with the pleasurable effects of cocaine, increasing unpleasant aspects or reducing pleasant ones, or both. This category includes naltrexone, and to some extent certain particular dopaminergic drugs (ropinirole, aripiprazole), as well as some mood stabilizers. A special case is disulfiram, which is also used for this purpose in alcohol dependence: in this case, however, the person cannot consume alcohol. An attempt has also been made with an anti-cocaine “vaccine,” designed to prevent cocaine from reaching the brain without directly acting on craving from the outset.
c) drugs that modulate euphoria, both before and during cocaine use. This category includes all anti-manic drugs, although only those that do not intensify craving are appropriate; in such cases, the effect is either absent or detrimental.
d) drugs that selectively block cocaine-seeking behavior without affecting either the drug’s effects or conscious craving. In addictions, drug-seeking behavior can in fact begin independently of conscious desire and can “replace” normal craving, in the sense that the person experiences an urge to use cocaine rather than simply a desire for the effects of cocaine. Examples may include drugs in category c, as well as biperiden.
Treatment management
In conclusion, the important steps in the treatment of a cocaine-use disorder are:
1 – Diagnose the type of disorder, distinguishing addiction from abuse and from other situations.
2 – Assess the severity and decide whether outpatient treatment is appropriate or whether an initial period of hospitalization is necessary, mainly on the basis of whether the person is expected to be able to manage treatment or whether this is unlikely at the outset.
3 – Try one of the possible treatments. In this case, medication should be accompanied by information, also provided to family members, explaining the rationale and expected timing of treatment, with these concepts revisited whenever necessary (for example, during the first relapses).
It is important that, regardless of the treatment—which may remain unchanged for weeks—the person and the family should not begin with the idea of a “day zero” on which the person will start making an effort to stop, followed by an attempt to understand why relapse occurs.
Rather, treatment should begin with a “day zero” of the therapeutic process, and relapses should be managed with the aim of bringing them progressively to an end. This does not depend on the person’s willpower, but on the treatment.
The effectiveness of the treatment is an independent factor and, of course, does not depend either on the physician or on the patient. However, one of the factors that can cause treatment to fail, even when the treatment itself is effective, is stopping it too early and responding to relapses in an agitated or dramatic manner, leading to constant changes in decisions, opinions, and relationships with those close to the patient.