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Cocaine-Related Psychiatric Disorders Follow-up

  • Author: Christopher P Holstege, MD; Chief Editor: David Bienenfeld, MD  more...
 
Updated: Apr 14, 2016
 

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.

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.

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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.

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Inpatient & Outpatient Medications

See the list below:

  • 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.
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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.

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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.

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Complications

Complications may include the following:

  • Rhabdomyolysis
  • Acute coronary syndrome
  • Cerebral vascular accidents
  • Acute renal failure
  • Seizures
  • Hyperthermia
  • Pneumothorax
  • Pneumomediastinum
  • Pulmonary infarct
  • Pulmonary edema
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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.

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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, see eMedicineHealth's patient education articles Cocaine Abuse and Substance Abuse.

For further family and patient education, see the following Web sites:

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Contributor Information and Disclosures
Author

Christopher P Holstege, MD Professor of Emergency Medicine and Pediatrics, University of Virginia School of Medicine; Chief, Division of Medical Toxicology, Center of Clinical Toxicology; Medical Director, Blue Ridge Poison Center

Christopher P Holstege, MD is a member of the following medical societies: American Academy of Clinical Toxicology, Medical Society of Virginia, Society of Toxicology, Wilderness Medical Society, European Association of Poisons Centres and Clinical Toxicologists, American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Lori Holstege, MD Assistant Clinical Professor, Department of Psychiatry, Michigan State University

Lori Holstege, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.

Nathan P Charlton, MD Fellow in Medical Toxicology, University of Virginia, Blue Ridge Poison Center

Nathan P Charlton, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, South Carolina Medical Association, Wilderness Medical Society, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Additional Contributors

Barry I Liskow, MD Professor of Psychiatry, Vice Chairman, Psychiatry Department, Director, Psychiatric Outpatient Clinic, The University of Kansas Medical Center

Disclosure: Nothing to disclose.

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