eMedicine Specialties > Psychiatry > Addiction
Cocaine-Related Psychiatric Disorders: Follow-up
Updated: May 28, 2008
Follow-up
Further Inpatient Care
- Patients with marked cognitive impairment, acute psychosis, severe depression, delirium, mania, and medical complications should be considered for admission to an inpatient facility. Achieving and maintaining stable abstinence depends on the specific treatment of addiction and on the detection of comorbid psychiatric and general medical disorders. These disorders may include conditions such as anxiety, depression, and bipolar disorder.
- All patients should also be assessed for risk of harm to self or to others. This also may mandate further inpatient care. Careful assessment for suicidal ideation, plans, and level of intent to act on such ideation is crucial. If a plan and intent to act is present, psychiatric hospitalization is almost always warranted, even if requiring involuntary commitment. Also, assessing homicidal ideation, intent, and plan is critical. Not only may the patient require voluntary or involuntary psychiatric hospitalization, but one also may have a duty to warn an intended victim.
- For patients with the more severe additive problems that have not been amenable to outpatient therapy, relatively long stays in residential programs are associated with better outcomes.
Further Outpatient Care
- Outpatient treatment is effective for many patients with cocaine addiction. The goals of treatment for cocaine addiction are 3-fold: (1) achievement of abstinence, (2) prevention of relapse, and (3) rehabilitation. Treatment is available to assist individuals who are addicted to cocaine to achieve these goals.
- Unlike the use of methadone therapy for the treatment of opiate addiction, no safe and effective cocaine replacement therapy is available as an alternative to abstinence. Currently, no FDA-approved pharmacological therapy is available for any stage of cocaine addiction treatment.
- Numerous medications have been studied for the treatment of cocaine addiction, and many show promise. Topiramate, an anticonvulsant, shows some promise for cocaine-dependent patients. Baclofen and tiagabine, as well as modafinil have also shown promise in reducing cocaine use. Disulfiram may increase the aversive effects of cocaine and reduce its use. Other recent work has suggested that a cocaine vaccine may induce the formation of sufficient antibodies to reduce cocaine use.
- Cognitive and behavioral therapies have been designed to prevent relapse in patients addicted to cocaine. These therapies help minimize exposure to drug cues and help modify patients' responses to cues they encounter. For example, a relapse prevention strategy may include minimizing the free cash the cocaine addict has available to buy drugs. Another example is behavioral therapy such as contingency management, in which vouchers are provided and are redeemable for goods or services contingent on performance of desired behaviors.
- Tragically, access to existing outpatient treatments is often limited. In addition, if the addicted patient has insurance, many times the coverage for such therapy is limited, placing further stress on the patient.
- Programs specifically structured for substance abuse should be arranged for patients who abuse cocaine. Twelve-step programs for cocaine addiction may be useful. These self-help groups are based on the principles of Alcoholics Anonymous and include a commitment to abstinence. Psychiatric follow-up at a minimum of within 2 weeks of the initial evaluation aids compliance.
- A more intensive outpatient regimen of daily individual and group therapy and weekly family therapy typically is necessary for many patients. Close monitoring of patients for relapse should be part of treatment. When patients who are addicted relapse, many physicians are too ready to give up. An all-or-nothing attitude by physicians is unrealistic with addiction. Initial treatment may fail, and relapses may occur before a stable remission is achieved.
- Patients with significant mental illness, such as major depressive disorder, bipolar disorder, posttraumatic stress disorder, and anxiety disorders, frequently require treatment specific to their illness (eg, medication, psychotherapy) in addition to a 12-step program. Programs that offer dual-diagnosis groups and 12-step programs are ideal if available. Inadequate treatment of either the mental illness or cocaine addiction increases the risk of relapse of both.
- Multiple drug addictions can also occur, such as addiction to cocaine and alcohol. Treatment, to be successful and safe, requires careful assessment of intake of all possible drugs of addiction and a treatment plan designed to both detoxify from each drug and treat each addiction.
Inpatient & Outpatient Medications
- Cocaine-induced mood disorder: Pharmacotherapy with antidepressant medications, such as SSRIs, may be necessary.
- Cocaine-induced psychotic disorder: Pharmacotherapy with antipsychotic medications may be necessary.
- Cocaine-induced anxiety disorder: Pharmacotherapy with anxiolytics, such as benzodiazepines, may be necessary. Several of the SSRIs and venlafaxine have been approved for generalized anxiety disorder, and, if anxiety or panic attacks persist, these medications may be helpful.
Transfer
- If adequate psychiatric inpatient services are not available, consider transfer to a facility with such services.
- If the patient is critically ill due to cocaine intoxication, transfer to a facility with critical care services.
Deterrence/Prevention
- The key to deterrence and prevention is education.
- Thoroughly review the complications of cocaine abuse with these patients at a level at which they can understand.
- The earlier the intervention, the more likely the patient will succeed without long-term adverse health effects.
Complications
- Rhabdomyolysis
- Acute coronary syndrome
- Cerebral vascular accidents
- Acute renal failure
- Seizures
- Hyperthermia
- Pneumothorax
- Pneumomediastinum
- Pulmonary infarct
- Pulmonary edema
Prognosis
- Among subjects who present for cocaine dependence treatment, concurrent alcoholism predicts higher relapse risk and poorer outpatient therapy attendance.
- Studies suggest that patients who have used cocaine as a primary drug of abuse for extended periods constitute a group with particularly high underlying psychopathology.
Patient Education
- Education may be a challenge in patients who are addicted to cocaine if they have a limited educational background, have a low intelligence quotient, or are resistant to educational activities.
- Complications associated with cocaine abuse may be difficult for people who are addicted to understand. An understanding of medical pathophysiology may be difficult for some patients to comprehend. They may be either resistant to the concept or lack insight into the cause-and-effect relationship of their disease process and cocaine abuse.
- Intensive education is an important part of the success of any drug treatment program.
- For excellent patient education resources, visit eMedicine's Substance Abuse Center. Also, see eMedicine's patient education articles Cocaine Abuse and Substance Abuse.
- For further family and patient education, see the following Web sites:
Miscellaneous
Medicolegal Pitfalls
- Failure to thoroughly evaluate cocaine-induced chest pain in a monitored setting: In 1995, Hollander et al reported a prevalence of myocardial infarction in 5.7% of patients reporting of cocaine-induced chest pain.
- Failure to obtain a chest radiograph in cocaine-induced dyspnea: Cocaine can induce significant pulmonary pathology, including pulmonary edema, pneumothorax, pneumomediastinum, and focal parenchyma infarcts.
- Failure to adequately sedate a patient with benzodiazepines who abuses cocaine and is agitated: Benzodiazepines act to suppress the sympathomimetic drive induced by cocaine. Large doses of benzodiazepines may be required to adequately calm these patients. If adequate sedation is not obtained, complications such as rhabdomyolysis may occur. In the patient who is acutely intoxicated with cocaine, antipsychotics should be used with caution. Hyperthermic syndromes are a dreaded complication of acute cocaine intoxication and can lead to the rapid demise of such a patient. Antipsychotics are associated with hyperthermic syndromes (eg, neuroleptic malignant syndrome) and may complicate the clinical picture in a patient acutely intoxicated with cocaine.
- Failure to obtain an adequate temperature in a patient who is febrile and intoxicated with cocaine: Fever associated with cocaine abuse can be a harbinger of serious complications such as seizures, rhabdomyolysis, and renal failure. Adequate core temperatures must be obtained in patients who are intoxicated with cocaine.
- Failure to recognize the risk associated with the use of a nonselective beta-blocker in patients who are intoxicated with cocaine: Unopposed alpha-agonist activity may result in and lead to a hypertensive crisis, coronary vasospasm, or both.
Special Concerns
- Pregnancy: A significant association is evident between cocaine abuse and complications such as spontaneous abortion, placental abruption, low birth weight, intrauterine fetal demise, meconium staining, and low Apgar scores.
- Pediatrics
- Cocaine-induced withdrawal syndromes may be observed in neonates born to women addicted to cocaine.
- Toddlers are at increased risk of toxicity, especially seizures, if they are exposed to cocaine.
- Cocaine crosses into breast milk and may lead to toxicity in children who are exposed.
- Child abuse and neglect are more prevalent in families in which cocaine abuse is present.
More on Cocaine-Related Psychiatric Disorders |
| Overview: Cocaine-Related Psychiatric Disorders |
| Differential Diagnoses & Workup: Cocaine-Related Psychiatric Disorders |
| Treatment & Medication: Cocaine-Related Psychiatric Disorders |
 Follow-up: Cocaine-Related Psychiatric Disorders |
| References |
| « Previous Page |
References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000.
US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. National Survey on Drug Use and Health. Rockville, Md: Office of Applied Studies; 2002. [Full Text].
Abraham HD, Fava M. Order of onset of substance abuse and depression in a sample of depressed outpatients. Compr Psychiatry. Jan-Feb 1999;40(1):44-50. [Medline].
Back S, Dansky BS, Coffey SF, et al. Cocaine dependence with and without post-traumatic stress disorder: a comparison of substance use, trauma history and psychiatric comorbidity. Am J Addict. Winter 2000;9(1):51-62. [Medline].
Biggins CA, MacKay S, Clark W, Fein G. Event-related potential evidence for frontal cortex effects of chronic cocaine dependence. Biol Psychiatry. Sep 15 1997;42(6):472-85. [Medline].
Blanchard DC, Blanchard RJ. Cocaine potentiates defensive behaviors related to fear and anxiety. Neurosci Biobehav Rev. Nov 1999;23(7):981-91. [Medline].
Bolla KI, Rothman R, Cadet JL. Dose-related neurobehavioral effects of chronic cocaine use. J Neuropsychiatry Clin Neurosci. Summer 1999;11(3):361-9. [Medline].
Cacciola JS, Alterman AI, O'Brien CP, McLellan AT. The Addiction Severity Index in clinical efficacy trials of medications for cocaine dependence. NIDA Res Monogr. 1997;175:182-91. [Medline].
Crits-Christoph P, Siqueland L, Blaine J, et al. Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Arch Gen Psychiatry. Jun 1999;56(6):493-502. [Medline].
Cubells JF, Feinn R, Pearson D. Rating the severity and character of transient cocaine-induced delusions and hallucinations with a new instrument, the Scale for Assessment of Positive Symptoms for Cocaine-Induced Psychosis (SAPS-CIP). Drug Alcohol Depend. 2005;May 12:[Medline].
Franken IH, Kroon LY, Hendriks VM. Influence of individual differences in craving and obsessive cocaine thoughts on attentional processes in cocaine abuse patients. Addict Behav. Jan-Feb 2000;25(1):99-102. [Medline].
Garbett R. National vocational qualifications?. NT Learn Curve. May 7 1997;1(3):15. [Medline].
Gingrich JA, Rudnick-Levin F, Almeida C, et al. Cocaine and catatonia. Am J Psychiatry. Nov 1998;155(11):1629. [Medline].
Goldfrank LR, Flomenbaum NE, Lewin NA. Cocaine. In: Goldfrank L, Flomenbaum N, Levin N, Weisman R, Hawland M, Hoffman R, eds. Goldfrank's Toxicologic Emergencies. 6th ed. Stamford, Conn: Appleton & Lange; 1998:1071-89.
Harris D, Batki SL. Stimulant psychosis: symptom profile and acute clinical course. Am J Addict. Winter 2000;9(1):28-37. [Medline].
Havassy BE, Arns PG. Relationship of cocaine and other substance dependence to well-being of high-risk psychiatric patients. Psychiatr Serv. Jul 1998;49(7):935-40. [Medline].
Herning RI, King DE, Better WE, Cadet JL. Neurovascular deficits in cocaine abusers. Neuropsychopharmacology. Jul 1999;21(1):110-8. [Medline].
Hollander JE, Todd KH, Green G, et al. Chest pain associated with cocaine: an assessment of prevalence in suburban and urban emergency departments. Ann Emerg Med. Dec 1995;26(6):671-6. [Medline].
Hyman SE. A 28-year-old man addicted to cocaine. JAMA. Nov 28 2001;286(20):2586-94. [Medline].
Jones RT. Pharmacokinetics of cocaine: considerations when assessing cocaine use by urinalysis. NIDA Res Monogr. 1997;175:221-34. [Medline].
Kampman, K. New Medications for the Treatment of Cocaine Dependence. Psychiatry. December 2005;2:44-48. [Full Text].
Karlsgodt KH, Lukas SE, Elman I. Psychosocial stress and the duration of cocaine use in non-treatment seeking individuals with cocaine dependence. Am J Drug Alcohol Abuse. Aug 2003;29(3):539-51. [Medline].
Levin FR, Evans SM, Coomaraswammy S, et al. Flupenthixol treatment for cocaine abusers with schizophrenia: a pilot study. Am J Drug Alcohol Abuse. Aug 1998;24(3):343-60. [Medline].
Levin FR, Evans SM, Kleber HD. Prevalence of adult attention-deficit hyperactivity disorder among cocaine abusers seeking treatment. Drug Alcohol Depend. Sep 1 1998;52(1):15-25. [Medline].
Levin FR, Evans SM, McDowell DM, Kleber HD. Methylphenidate treatment for cocaine abusers with adult attention- deficit/hyperactivity disorder: a pilot study. J Clin Psychiatry. Jun 1998;59(6):300-5. [Medline].
Lima MS, Reisser AA, Soares BG, Farrell M. Antidepressants for cocaine dependence. Cochrane Database Syst Rev. 2003;CD002950. [Medline].
Mann A. Relationships Matter: Impact of Parental, Peer Factors on Teen, Young Adult Substance Abuse. National Institute on Drug Abuse. Available at www.nida.nih.gov/NIDA-notes/NNVol18. Accessed 5/22/2008.
McCance-Katz EF, Kosten TR, Jatlow P. Concurrent use of cocaine and alcohol is more potent and potentially more toxic than use of either alone--a multiple-dose study. Biol Psychiatry. Aug 15 1998;44(4):250-9. [Medline].
McDowell DM, Levin FR, Seracini AM, Nunes EV. Venlafaxine treatment of cocaine abusers with depressive disorders. Am J Drug Alcohol Abuse. Feb 2000;26(1):25-31. [Medline].
McKay JR, Alterman AI, Cacciola JS, et al. Prognostic significance of antisocial personality disorder in cocaine- dependent patients entering continuing care. J Nerv Ment Dis. May 2000;188(5):287-96. [Medline].
McMahon RC, Malow R, Loewinger L. Substance abuse history predicts depression and relapse status among cocaine abusers. Am J Addict. Winter 1999;8(1):1-8. [Medline].
Mueser KT, Yarnold PR, Rosenberg SD, et al. Substance use disorder in hospitalized severely mentally ill psychiatric patients: prevalence, correlates, and subgroups. Schizophr Bull. 2000;26(1):179-92. [Medline].
Pettinati H. New Pharmacotherapies for Treating the Neurobiology of Alcohol and Drug Addiction. Psychiatry. May 2006;3:14-16. [Full Text].
Rivara FP, Mueller BA, Somes G, et al. Alcohol and illicit drug abuse and the risk of violent death in the home. JAMA. Aug 20 1997;278(7):569-75. [Medline].
Rutherford MJ, Cacciola JS, Alterman AI. Antisocial personality disorder and psychopathy in cocaine-dependent women. Am J Psychiatry. Jun 1999;156(6):849-56. [Medline].
Schubiner H, Tzelepis A, Milberger S, et al. Prevalence of attention-deficit/hyperactivity disorder and conduct disorder among substance abusers. J Clin Psychiatry. Apr 2000;61(4):244-51. [Medline].
Serper MR, Chou JC, Allen MH, et al. Symptomatic overlap of cocaine intoxication and acute schizophrenia at emergency presentation. Schizophr Bull. 1999;25(2):387-94. [Medline].
Serper MR, Copersino ML, Richarme D, et al. Neurocognitive functioning in recently abstinent, cocaine-abusing schizophrenic patients. J Subst Abuse. 2000;11(2):205-13. [Medline].
Siqueland L, Horn A, Moras K, et al. Cocaine-induced mood disorder: prevalence rates and psychiatric symptoms in an outpatient cocaine-dependent sample. Am J Addict. Spring 1999;8(2):165-9. [Medline].
Soares BG, Lima MS, Reisser AA, Farrell M. Dopamine agonists for cocaine dependence. Cochrane Database Syst Rev. 2003;CD003352. [Medline].
Sofuoglu M, Dudish-Poulsen S, Brown SB, Hatsukami DK. Association of cocaine withdrawal symptoms with more severe dependence and enhanced subjective response to cocaine. Drug Alcohol Depend. Apr 1 2003;69(3):273-82. [Medline].
Work Group on Substance Use Disorders. Practice Guideline for the Treatment of Patients With Substance Use Disorders, 2nd edition. Am J Psychiatry Suppl. April 2007;164:72-75.
Further Reading
Keywords
cocaine, coke, crack, psychosis, delirium, anxiety, withdrawal, Erythroxylon coca, E coca, coca leaf, coca plant, cocaine addiction, cocaine abuse, drug abuse, drug addiction, addiction, drugs, drug-related psychosis, drug-related psychiatric disorder, cocaine intoxication, cocaine withdrawal, cocaine delirium, cocaine-induced psychotic disorder with delusions, cocaine-induced psychotic disorder with hallucinations, cocaine-induced mood disorder, cocaine-induced anxiety disorder, cocaine-induced sexual dysfunction, cocaine-induced sleep disorder
