Cocaine-Related Psychiatric Disorders Medication
- Author: Christopher P Holstege, MD; Chief Editor: David Bienenfeld, MD more...
Benzodiazepines are the drugs of choice for acute cocaine intoxication with extreme agitation. Pharmacologic therapy depends on presenting signs and symptoms (eg, treat chest pain with oxygen, benzodiazepines, aspirin, and nitroglycerin). All possible pharmacotherapies for various cocaine-induced medical conditions are beyond the scope of this article. For a complete review of treating cocaine-induced nonpsychiatric effects, refer to Toxicity, Cocaine.
Avoid use of beta-blockers because of the unopposed alpha-agonist activity. The mood shifts, abnormal sleep and even delusions associated with acute cocaine intoxication or withdrawal often are transient and do not require medications. Persistent mood disorders with mania may be treated with lithium, whereas antidepressants are advocated for mood disorders with depressive features. Antipsychotics are advocated to treat persistent psychotic disorders.
Bind specific benzodiazepine receptor on GABA-receptor complex, thereby increasing GABA affinity for its receptor. Increase the frequency of chlorine channel opening in response to GABA binding. GABA receptors are chlorine channels that mediate postsynaptic inhibition, resulting in postsynaptic neuron hyperpolarization. The final result is a sedative-hypnotic effect that counteracts the stimulant effect of cocaine.
Depresses all levels of CNS (eg, limbic and reticular formation) possibly by increasing activity of GABA. Individualize dose and increase cautiously to avoid adverse effects.
Sedative hypnotic with short onset of effects and relatively long half-life. Increases action of GABA (ie, major inhibitory neurotransmitter in brain). May depress all levels of CNS, including limbic and reticular formation.
Short-acting benzodiazepine used for acute or short-term sedation. Also exhibits amnestic effects.
High-potency antipsychotic agents in the butyrophenone class (eg, haloperidol, droperidol) are used for rapid sedation. Easily titrated and cause less sedation and orthostasis; however, they cause extrapyramidal symptoms more often than lower-potency agents. Used short term to rapidly control psychosis.
Newer antipsychotics (eg, risperidone, olanzapine, quetiapine) are used for long-term management. Improvements over earlier antipsychotics include fewer anticholinergic effects and less dystonia, parkinsonism, and tardive dyskinesia. Affect dopamine and serotonin receptors.
DOC for acute psychosis. Parenteral dosage form may be admixed in same syringe with 2 mg lorazepam for better anxiolytic effects.
DOC for severely disturbed and/or violent patient. Faster acting and more sedating than haloperidol but more likely to cause hypotension. May exert antipsychotic activity through dopaminergic system. Evidence suggests it alters dopamine action in CNS.
Binds to dopamine D2-receptor with 20-times lower affinity than for 5-HT2-receptor. Improves negative symptoms of psychoses and reduces prevalence of adverse extrapyramidal effects.
May inhibit serotonin, muscarinic, and dopamine effects.
May act by antagonizing dopamine and serotonin effects.
While numerous antidepressants are currently available, selective serotonin reuptake inhibitors (SSRIs) provide many advantages over past antidepressants. MAOIs should be avoided in mood disorders with depressive features. MAOIs are lethal if patient relapses from abstinence and combines them with cocaine.
Enhances serotonin activity by selective reuptake inhibition at the neuronal membrane.
Selectively inhibits presynaptic serotonin reuptake with minimal or no effect on reuptake of norepinephrine or dopamine.
Inhibits neuronal serotonin reuptake. Does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors, thus has fewer adverse effects than TCAs.
Alternative DOC. Potent selective inhibitor of neuronal serotonin reuptake. Weak effect on norepinephrine and dopamine neuronal reuptake.
Selectively inhibits presynaptic serotonin reuptake.
Inhibits neuronal serotonin and norepinephrine reuptake. Also causes beta-receptor down-regulation.
American Psychiatric Association. Substance-Related and Addictive Disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013. 561-570.
Center for Behavioral Health Statistics and Quality. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. SAMHSA. Available at http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf. September 2015;
Lopez-Quintero C, Cobos JP, Hasin DS, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: Results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. 2011 May 1. 115(1-2):120-30. [Medline]. [Full Text].
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The DAWN Report: Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Substance Abuse and Mental Health Services Administration. Available at http://www.samhsa.gov/data/sites/default/files/DAWN127/DAWN127/sr127-DAWN-highlights.htm. February 22, 2013;
Kann L, Kinchen S, Shanklin SL, Flint KH, Kawkins J, Harris WA, et al. Youth risk behavior surveillance--United States, 2013. MMWR Surveill Summ. 2014 Jun 13. 63 Suppl 4:1-168. [Medline].
Johnston, L. D., O’Malley, P. M., Miech, R. A., et al. Monitoring the Future national survey results on drug use: 1975-2014: Overview, key findings on adolescent drug use. monitoringthefuture.org. Available at http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2014.pdf. 2015; Accessed: December 3, 2015.
Martinez D, Carpenter KM, Liu F, et al. Imaging dopamine transmission in cocaine dependence: link between neurochemistry and response to treatment. Am J Psychiatry. 2011 Jun. 168(6):634-41. [Medline].
Morgan PT, Pace-Schott E, Pittman B, Stickgold R, Malison RT. Normalizing effects of modafinil on sleep in chronic cocaine users. Am J Psychiatry. 2010 Mar. 167(3):331-40. [Medline].
Martell BA, Orson FM, Poling J, Mitchell E, Rossen RD, Gardner T, et al. Cocaine vaccine for the treatment of cocaine dependence in methadone-maintained patients: a randomized, double-blind, placebo-controlled efficacy trial. Arch Gen Psychiatry. 2009 Oct. 66(10):1116-23. [Medline].
von Diemen L, Kapczinski F, Sordi AO, de Magalhães Narvaez JC, Guimarães LS, Kessler FH, et al. Increase in brain-derived neurotrophic factor expression in early crack cocaine withdrawal. Int J Neuropsychopharmacol. 2013 Sep 26. 1-8. [Medline].
Ní Chróinín D, Gaine S. Crack-ing the case: a patient with persistent delirium due to body packing with cocaine. Ir Med J. 2012 Apr. 105(4):118-9. [Medline].
Corominas-Roso M, Roncero C, Eiroa-Orosa FJ, Ribasés M, Barral C, Daigre C, et al. Serum Brain-Derived Neurotrophic Factor Levels and Cocaine-Induced Transient Psychotic Symptoms. Neuropsychobiology. 2013 Sep 13. 68(3):146-155. [Medline].
Roncero C, Ros-Cucurull E, Daigre C, Casas M. Prevalence and risk factors of psychotic symptoms in cocaine-dependent patients. Actas Esp Psiquiatr. 2012 Jul-Aug. 40(4):187-97. [Medline].
Abraham HD, Fava M. Order of onset of substance abuse and depression in a sample of depressed outpatients. Compr Psychiatry. 1999 Jan-Feb. 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. 2000 Winter. 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. 1997 Sep 15. 42(6):472-85. [Medline].
Blanchard DC, Blanchard RJ. Cocaine potentiates defensive behaviors related to fear and anxiety. Neurosci Biobehav Rev. 1999 Nov. 23(7):981-91. [Medline].
Bolla KI, Rothman R, Cadet JL. Dose-related neurobehavioral effects of chronic cocaine use. J Neuropsychiatry Clin Neurosci. 1999 Summer. 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. 1999 Jun. 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. 2000 Jan-Feb. 25(1):99-102. [Medline].
Garbett R. National vocational qualifications?. NT Learn Curve. 1997 May 7. 1(3):15. [Medline].
Gingrich JA, Rudnick-Levin F, Almeida C, et al. Cocaine and catatonia. Am J Psychiatry. 1998 Nov. 155(11):1629. [Medline].
Goldfrank LR, Flomenbaum NE, Lewin NA. Cocaine. 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. 2000 Winter. 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. 1998 Jul. 49(7):935-40. [Medline].
Herning RI, King DE, Better WE, Cadet JL. Neurovascular deficits in cocaine abusers. Neuropsychopharmacology. 1999 Jul. 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. 1995 Dec. 26(6):671-6. [Medline].
Hyman SE. A 28-year-old man addicted to cocaine. JAMA. 2001 Nov 28. 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. 2003 Aug. 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. 1998 Aug. 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. 1998 Sep 1. 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. 1998 Jun. 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. 1998 Aug 15. 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. 2000 Feb. 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. 2000 May. 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. 1999 Winter. 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. 1997 Aug 20. 278(7):569-75. [Medline].
Rutherford MJ, Cacciola JS, Alterman AI. Antisocial personality disorder and psychopathy in cocaine-dependent women. Am J Psychiatry. 1999 Jun. 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. 2000 Apr. 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. 1999 Spring. 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. 2003 Apr 1. 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.