Neurologic Effects of Cocaine Treatment & Management: Medical Care

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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]

Freud S. Uber Coca.Neu durchgesehener und vermehrter Separat-Abdruck aus dem Centralblatt fur die gesamte Therapie, II. Vienna: Verlag von Moritz Perles; 1884-1885. 289-314.
Haile CN, Mahoney JJ 3rd, Newton TF, De La Garza R 2nd. Pharmacotherapeutics directed at deficiencies associated with cocaine dependence: focus on dopamine, norepinephrine and glutamate. Pharmacol Ther. 2012 May. 134(2):260-77. [Medline].
elSohly MA, Brenneisen R, Jones AB. Coca paste: chemical analysis and smoking experiments. J Forensic Sci. 1991 Jan. 36(1):93-103. [Medline].
Arora NP. Cutaneous vasculopathy and neutropenia associated with levamisole-adulterated cocaine. Am J Med Sci. 2013 Jan. 345(1):45-51. [Medline].
Center for Behavioral Health Statistics and Quality (CBHSQ). Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. NIH National Institute on Drug Abuse. Available at https://www.drugabuse.gov/publications/research-reports/cocaine/what-scope-cocaine-use-in-united-states.
Johnston L, O’Malley P, Miech R, Bachman J, Schulenberg J. Monitoring the Future National Survey Results on Drug Use: 1975-2015: Overview: Key Findings on Adolescent Drug Use. NIH National Institute on Drug Abuse. Available at https://www.drugabuse.gov/publications/research-reports/cocaine/what-scope-cocaine-use-in-united-states.
Pozzi M, Roccatagliata D, Sterzi R. Drug abuse and intracranial hemorrhage. Neurol Sci. 2008 Sep. 29 Suppl 2:S269-70. [Medline].
Chang TR, Kowalski RG, Caserta F, Carhuapoma JR, Tamargo RJ, Naval NS. Impact of acute cocaine use on aneurysmal subarachnoid hemorrhage. Stroke. 2013 Jul. 44(7):1825-9. [Medline].
Harzke AJ, Williams ML, Bowen AM. Binge Use of Crack Cocaine and Sexual Risk Behaviors Among African-American, HIV-Positive Users. AIDS Behav. 2008 Aug 30. [Medline]. [Full Text].
Grov C, Kelly BC, Parsons JT. Polydrug use among club-going young adults recruited through time-space sampling. Subst Use Misuse. 2009. 44(6):848-64. [Medline]. [Full Text].
Zagnoni PG, Albano C. Psychostimulants and epilepsy. Epilepsia. 2002. 43 Suppl 2:28-31. [Medline].
Lason W. Neurochemical and pharmacological aspects of cocaine-induced seizures. Pol J Pharmacol. 2001 Jan-Feb. 53(1):57-60. [Medline].
Bianco F, Iacovelli E, Tinelli E, Lepre C, Pauri F. Recurrent leukoencephalopathy in a cocaine abuser. Neurotoxicology. 2011 Aug. 32(4):410-2. [Medline].
Zhou W, Lin PH, Bush RL, et al. Acute arterial thrombosis associated with cocaine abuse. J Vasc Surg. 2004 Aug. 40(2):291-5. [Medline].
Lee KC, Ladizinski B, Federman DG. Complications associated with use of levamisole-contaminated cocaine: an emerging public health challenge. Mayo Clin Proc. 2012 Jun. 87(6):581-6. [Medline].
Brody SL, Slovis CM, Wrenn KD. Cocaine-related medical problems: consecutive series of 233 patients. Am J Med. 1990 Apr. 88(4):325-31. [Medline].
Amin M, Gabelman G, Karpel J, Buttrick P. Acute myocardial infarction and chest pain syndromes after cocaine use. Am J Cardiol. 1990 Dec 15. 66(20):1434-7. [Medline].
McCord J, Jneid H, Hollander JE, de Lemos JA, Cercek B, Hsue P. Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation. 2008 Apr 8. 117(14):1897-907. [Medline].
Chang AM, Walsh KM, Shofer FS, et al. Relationship Between Cocaine Use and Coronary Artery Disease in Patients With Symptoms Consistent With an Acute Coronary Syndrome. Acad Emerg Med. 2010 Dec 23. [Medline].
Venkatratnam A, Lents NH. Zinc reduces the detection of cocaine, methamphetamine, and THC by ELISA urine testing. J Anal Toxicol. 2011 Jul. 35(6):333-40. [Medline].
Warner TD, Behnke M, Eyler FD, et al. Diffusion tensor imaging of frontal white matter and executive functioning in cocaine-exposed children. Pediatrics. 2006. 118(5):2014-24. [Medline].
Tumeh SS, Nagel JS, English RJ, Holman BL. Cerebral abnormalities in cocaine abusers: demonstration by SPECT perfusion brain scintigraphy. Work in progress. Radiology. 1990 Sep. 176(3):821-4. [Medline].
Leung IY, Lai S, Ren S, Kempen J, Klein R, Tso MO, et al. Early retinal vascular abnormalities in African-American cocaine users. Am J Ophthalmol. July/2008. 146(4):612-619. [Medline]. [Full Text].
Schierenberg A, van Amsterdam J, van den Brink W, Goudriaan AE. Efficacy of contingency management for cocaine dependence treatment: a review of the evidence. Curr Drug Abuse Rev. 2012 Dec. 5(4):320-31. [Medline].
Haile CN, De La Garza R 2nd, Mahoney JJ 3rd, Nielsen DA, Kosten TR, Newton TF. The impact of disulfiram treatment on the reinforcing effects of cocaine: a randomized clinical trial. PLoS One. 2012. 7(11):e47702. [Medline].
Nejtek VA, Avila M, Chen LA, Zielinski T, Djokovic M, Podawiltz A, et al. Do atypical antipsychotics effectively treat co-occurring bipolar disorder and stimulant dependence? A randomized, double-blind trial. J Clin Psychiatry. Aug/2008. 69(8):1257-66. [Medline]. [Full Text].
Jobes ML, Ghitza UE, Epstein DH, Phillips KA, Heishman SJ, Preston KL. Clonidine blocks stress-induced craving in cocaine users. Psychopharmacology (Berl). 2011 Nov. 218(1):83-8. [Medline].
Shoptaw S, Heinzerling KG, Rotheram-Fuller E, Kao UH, Wang PC, Bholat MA, et al. Bupropion hydrochloride versus placebo, in combination with cognitive behavioral therapy, for the treatment of cocaine abuse/dependence. J Addict Dis. 2008. 27(1):13-23. [Medline].
Dattilo PB, Hailpern SM, Fearon K, Sohal D, Nordin C. Beta-blockers are associated with reduced risk of myocardial infarction after cocaine use. Ann Emerg Med. Feb2008. 51(2):117-25. [Medline].
McCord J, Jneid H, Hollander JE, de Lemos JA, Cercek B, Hsue P. Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation. 2008 Apr 8. 117(14):1897-907. [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].
MacDonald S, Mann R, Chipman M, Pakula B, Erickson P, Hathaway A, et al. Driving behavior under the influence of cannabis or cocaine. Traffic Inj Prev. 2008. 9(3):190-4. [Medline].
Bendersky M, Bennett D, Lewis M. Aggression at Age 5 as a Function of Prenatal Exposure to Cocaine, Gender, and Environmental Risk. J Pediatr Psychol. 2005 Apr 12. [Medline].
Brewer JD, Meves A, Bostwick JM, Hamacher KL, Pittelkow MR. Cocaine abuse: dermatologic manifestations and therapeutic approaches. J Am Acad Dermatol. 2008 Sep. 59(3):483-7. [Medline].
Dackis CA, Kampman KM, Lynch KG, et al. A double-blind, placebo-controlled trial of modafinil for cocaine dependence. Neuropsychopharmacology. 2005 Jan. 30(1):205-11. [Medline].
Fiellin DA, Pantalon MV, Chawarski MC, et al. Counseling plus buprenorphine-naloxone maintenance therapy for opioid dependence. N Engl J Med. 2006 Jul 27. 355(4):365-74. [Medline].
Gillman MA, Lichtigfeld FJ, Harker N. Psychotropic analgesic nitrous oxide for acute cocaine withdrawal in man. 1: Int J Neurosci. 2006. 116(7):847-57. [Medline].
Halkitis PN, Palamar JJ. Multivariate modeling of club drug use initiation among gay and bisexual men. Subst Use Misuse. 2008. 43(7):871-9. [Medline].
Hayaki J, Anderson B, Stein M. Sexual risk behaviors among substance users: relationship to impulsivity. Psychol Addict Behav. 2006. 20(3):328-32. [Medline].
Oyelese Y, Ananth CV. Placental abruption. Obstet Gynecol. 2006. 108(4):1005-16.
Rivero M, Karlic A, Navaneethan SD, Singh S. Possible cocaine-induced acute renal failure without rhabdomyolysis. J Nephrol. Jan-Feb;. 2006. 19(1):108-10. [Medline].
Sofuoglu M, Kosten TR. Novel approaches to the treatment of cocaine addiction. CNS Drugs. 2005. 19(1):13-25. [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, Southern Clinical Neurological Society

Disclosure: Nothing to disclose.

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