Medical Care

Acute intoxication requires hospitalization for detoxification and management of acute neurovascular complications.

Treatment of complications from levamisole-laced cocaine is supportive, with immediate cessation of cocaine and levamisole use. Steroids have been used in some patients, without clear evidence of significant benefits. Patients with extensive skin involvement require care in specialized burn units with a multidisciplinary surgical team involvement.^[4]

For long-term management, drug-dependence programs can be effective in decreasing drug use by behavioral interventions. Cognitive behavioral therapy can be effective in decreasing craving for the drug. A systematic review found that contingency management, a behavioral therapy modeled after operant conditioning, appeared to help improve cocaine abstinence and was synergistic to pharmacotherapy when used along with standard cognitive behavioral therapy and other psychotherapies.^[24]

No pharmacotherapies have been approved for cocaine addiction; but some drugs have been tested with promising results.

Disulfiram, amantadine, tiagabine, topiramate, and baclofen are some drugs that have been reported to be of possible benefit in cocaine addiction. Disulfiram has been noted to have a paradoxical effect at lower doses, and, hence, weight-based dosing has been suggested.^[25]Other drugs that have shown potential benefits in small studies include varenicline and galantamine.

Nepicastat, a selective dopamine beta hydroxylase analogous to disulfiram, is being studied in a multicenter, double-blind, placebo-controlled trial for cocaine dependance.

Counseling plus buprenorphine-naloxone maintenance therapy has been reported to be successful for opioid dependence

A double-blinded, placebo-controlled trial of modafinil for cocaine dependence showed that modafinil improved clinical outcomes when combined with psychosocial treatment for cocaine dependence.

The psychotropic analgesic nitrous oxide has been reported in one blinded trial to be effective for the treatment of acute cocaine withdrawal.

In one trial, both quetiapine and risperidone reduced drug cravings from cocaine.^[26]Clonidine may also help lower stress induced by cocaine craving and subsequent relapse.^[27]

A recent randomized, double-blind, placebo controlled trial comparing treatment with bupropion and placebo in combination with standard cognitive behavioral therapy found no statistical difference in bupropion relative to placebo.^[28]

Patients require follow-up for neurological complications.

Use of beta-blockers in cocaine-induced chest pain is a controversial issue.^[29]The American Heart Association (AHA) published a scientific statement on management of cocaine-associated chest pain and myocardial infarction in 2008 which recommends avoiding use of beta blockers which may exacerbate vasospasm.^[30]

Martell et al conducted a phase IIb randomized, double-blind, placebo-controlled trial to evaluate the immunogenicity, safety, and efficacy of a cocaine vaccine in cocaine-dependent and opioid-dependent individuals. Of the 115 patients recruited, 94 (82%) completed the trial. Participants were administered 5 vaccinations with placebo or succinylnorcocaine over 12 weeks. Within the vaccine group, those with serum IgG anticocaine antibody levels ≥43 mcg/mL had significantly more cocaine-free urine samples than those with serum levels < 43 mcg/mL and those who received placebo. Reduction of cocaine use by 50% was significantly greater if a high IgG level was achieved (53% of participants) compared with a low IgG level (23% of participants) (P =.048).^[31]

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Arora NP. Cutaneous vasculopathy and neutropenia associated with levamisole-adulterated cocaine. Am J Med Sci. 2013 Jan. 345(1):45-51. [Medline].
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Pinky Agarwal, MD Clinical Associate Professor, Department of Neurology, University of Washington School of Medicine; Attending Neurologist, Medical Director, Booth Gardner Parkinson's Care Center

Pinky Agarwal, MD is a member of the following medical societies: American Academy of Neurology, International Parkinson and Movement Disorder Society

Disclosure: Nothing to disclose.

Coauthor(s)

Sindhu R Srivatsal, MD, MPH Fellow in Movement Disorders, Department of Neurology, University of Washington School of Medicine; Acting Instructor, Veterans Affairs Puget Sound Healthcare Systems

Sindhu R Srivatsal, MD, MPH is a member of the following medical societies: American Academy of Neurology, International Parkinson and Movement Disorder Society, Washington State Neurological Society

Disclosure: Nothing to disclose.

Souvik Sen, MD, MPH, MS, FAHA Professor and Chair, Department of Neurology, University of South Carolina School of Medicine

Souvik Sen, MD, MPH, MS, FAHA is a member of the following medical societies: American Academy of Neurology, Association for Patient-Oriented Research, American Heart 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

Stephen A Berman, MD, PhD, MBA Professor of Neurology, University of Central Florida College of Medicine

Stephen A Berman, MD, PhD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Edward L Hogan, MD Professor, Department of Neurology, Medical College of Georgia; Emeritus Professor and Chair, Department of Neurology, Medical University of South Carolina

Edward L Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, Society for Neuroscience, American Society for Biochemistry and Molecular Biology, American Academy of Neurology, American Neurological Association, Phi Beta Kappa, Sigma Xi, The Scientific Research Honor Society, Southern Clinical Neurological Society

Disclosure: Nothing to disclose.

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