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Helping your patients beat cocaine addiction

The four dimensions of treatment

Hani Raoul Khouzam, MD, MPH

VOL 105 / NO 3 / MARCH 1999 / POSTGRADUATE MEDICINE

 

CME learning objectives

To define the phases of cocaine intoxication and withdrawal To specify common medical complications of cocaine intoxication To summarize pharmacologic, psychological, social, and spiritual dimensions of care in cocaine-addicted patients

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Preview: Even though the dramatic increase in cocaine use that began in the 1970s is abating, primary care physicians today can still expect to encounter patients with cocaine intoxication and withdrawal and the health problems that result from long-term use. Among the nearly 3 million current users of cocaine are half a million users of the highly addictive form, crack. Dr Khouzam describes the distinctive clinical characteristics, medical complications, and accompanying psychiatric disorders of patients with cocaine addiction. He also explains the various dimensions of treatment that are required to provide comprehensive care to these patients.

Cocaine has been used by South American natives for more than 2,000 years in the coca-leaf form. Its use in the United States dates back to the 19th century. Before 1980, the most commonly used form was cocaine hydrochloride, the water-soluble crystalline salt that is the principal product of extraction from the coca leaf. Cocaine hydrochloride can be either injected parenterally or absorbed through nasal inhalation (often called snorting).

In the mid-1980s, use of a crystallized freebase form of cocaine, called crack (probably because of the sound made during heating and vaporization in a glass pipe), became widespread. Crack cocaine is sold in small, precooked, ready-to-smoke portions (thus another nickname, rock). It is very potent and extremely addictive; there are even reports of addicts who have sold their children into prostitution to obtain money for the drug (1,2). Therefore, although recreational use of cocaine has declined throughout the general population, use by a smaller but more addicted segment made up of users who are young, female, and among the lower socioeconomic classes is on the rise (2).

Characteristics of cocaine intoxication and withdrawal

Acute cocaine intoxication usually runs its course within 48 hours. Clinical manifestations may include extreme agitation, irritability, impaired judgment, aggressive behavior, impulsive sexual behavior, increased psychomotor activity and, at times, manic excitement (3). Abnormal vital signs, delirium, disorientation, violent behavior, and psychosis may also occur during periods of acute intoxication. Repeated use of cocaine (ie, runs) can last for weeks until the first phase of abstinence (ie, a crash) occurs. If abstinence is continued longer than 24 hours, cocaine withdrawal usually begins.

The three phases of cocaine abstinence and clinical manifestations of withdrawal are outlined in table 1 (4). A recent clinical study (5) suggests that abstinence symptoms in patients with uncomplicated cocaine addiction may be relatively mild and could steadily decrease over the first month without medical treatment.

 

Table 1. Three phases of cocaine abstinence and withdrawal Phase Time course Symptoms 1. Crash 9 hr-4 days Early

Agitation

Sadness

Loss of appetite

High craving for cocaine

 Middle

Fatigue

Sadness

Insomnia with increasing need for sleep

No cocaine craving

 

Late

Extreme tiredness

Oversleeping

Overeating

No cocaine craving

 

2. Withdrawal 1-10 wk Early

Normal sleep restored

Normal mood

Low cocaine craving

Low anxiety

 Middle and late

Loss of ability to enjoy pleasurable activities

Loss of energy

Anxiety

High cocaine craving

 

3. Extinction Indefinite Ability to enjoy pleasurable activities regained

Normalized mood

Episodic craving for cocaine

Craving and relapse may be triggered by environmental cues, financial means, availability of drugs, contact with cocaine users

 Adapted, with permission, from Hall et al.4 Medical complications of cocaine intoxication

Table 2 lists medical complications of cocaine intoxication (1,2). Nasal inhalation of cocaine may lead to bronchitis, pulmonary edema, and nasal septum perforation. Intravenous use may result in infection and abscess formation at the site of injection and spread of HIV through sharing of needles and heightened, unsafe sexual activity (2). Despite claims made about the aphrodisiac properties of cocaine, its chronic use may lead to impotence, ejaculatory dysfunction, and gynecomastia in men and anorgasmia, menstrual cycle dysfunction, galactorrhea, and infertility in women (1).

 

Table 2. Medical and psychiatric complications of cocaine intoxication Central nervous system

Coma

Generalized hyperreflexia

Incontinence

Stereotyped movements (eg, picking, stroking)

Stroke

Sudden headache

Toxic encephalopathy

Tremors

 Cardiovascular system

Arrhythmias

Hypertension or hypotension (intracranial hemorrhage)

Myocarditis

Organ ischemia (myocardial, renal, intestinal infarction) or limb ischemia

Shock

 

Respiratory system

Agonal gasps

Bronchitis

Cheyne-Stokes progressive hypoxia

Dyspnea

Pneumomediastinum

Pneumothorax

Pulmonary edema (crack lung)

Respiratory failure or arrest

 

Psychiatric manifestations

Agitated delirium

Cocaine psychosis

Foraging behavior

Hallucinations

Hyperactivity

Irritability

Labile mood

Paranoid delusions

 

Other

Brain abscess, frontal sinusitis

Fungal cerebritis

Hyperthermia

Infection

Infertility

Nasal septum perforation

Osteolytic sinusitis

Rhabdomyolysis

Sexual dysfunction

Skin abscess formation

Tetanus

Wound botulism

 

Information compiled from Gold et al (1) and Weddington (2). Acute myocardial infarction may occur even in the absence of preexisting coronary artery disease (6). Periods of syncope or acute chest pain are often warning signs that precede sudden death. Death has also been reported after intravenous use of the combination of cocaine and opiates (ie, speedball) (1).

Cocaine and pregnancy

Cocaine addiction among pregnant women has become a growing problem that profoundly affects the expectant mother and the fetus. Prenatal cocaine abuse may lead to spontaneous abortion, stillbirth, intrauterine growth

retardation, premature rupture of membranes, preterm delivery, fetal distress, and an increased incidence of congenital malformations (7). A 1992 experimental study documented that cocaine attaches itself to the sperm of male users and may lead to birth defects in their offspring (1). However, this study has not been replicated. Although several recent reports suggest that most cocaine-exposed infants may not experience the devastating complications previously expected, cocaine intoxication and withdrawal in newborns need to be carefully monitored (8).

Cocaine-induced psychiatric conditions

Table 2 (not shown) also lists psychiatric manifestations of cocaine intoxication (1,2). Cocaine psychosis, a condition typified by transient paranoid ideation, persecutory trends, and perceptual disturbances, may occur during periods of intoxication or withdrawal. Delusional disorder is characterized by overt paranoid delusions (3). Prolonged use of cocaine may lead to development of tactile hallucinations (also known as formication), in which patients feel that bugs are crawling on or under their skin (1). Foraging behavior, involving compulsive searching for pieces of crack cocaine in locations where it was once used, has been reported by some long-term users (1,9).

Cocaine and psychiatric comorbidity

The Epidemiologic Catchment Area study found that 76% of cocaine abusers had at least one accompanying psychiatric illness (10), including mood, anxiety, and personality disorders (11). In addition, attention-deficit hyperactivity disorder is often undiagnosed in patients addicted to cocaine (12). Cocaine-induced panic attacks may persist even after cocaine abstinence has been achieved (11,12). Patients with eating disorders may progress from using amphetamine-containing diet pills to using cocaine and, eventually, to cocaine addiction. Dependence on additional drugs and substances (eg, opioids, cannabis, stimulants and, especially, alcohol) often develops in cocaine-dependent patients.

Cocaine abuse may result in syndromes mimicking psychiatric illness. Therefore, longitudinal evaluation of the patient during abstinence and use of collateral sources of information (eg, family members, associates) are important in establishing the presence or absence of psychiatric comorbidity (13). Treatment of coexisting psychiatric disorders is an essential component in management of cocaine addiction (8).

Managing cocaine intoxication and addiction

In acute cocaine intoxication, treatment goals are immediate control of blood pressure (hypertension or hypotension), seizures, and hyperthermia; removal of ingested cocaine; and correction of rhabdomyolysis (14). Figure 1 (not shown) outlines emergency treatment of a wildly agitated cocaine-intoxicated patient (10).

When cocaine addiction has been confirmed, the next step is to choose the appropriate treatment setting. Inpatient treatment should be recommended for a patient with any of the following characteristics (8,11):

 

Is abusing cocaine uncontrollably by freebasing or injecting

Has severe psychiatric symptoms

Requires detoxification or treatment of polysubstance dependence

Is acutely intoxicated or potentially violent or has suicidal ideation

Lacks an abstinence-support system

Has failed previous attempts at outpatient treatment For patients who require more structure than what is offered in an outpatient setting, partial hospitalization and day-treatment programs may offer an alternative to inpatient therapy (15).

Assessment of existing psychiatric and medical conditions is important in implementing initial treatment (2,13). However, final assessment of newly diagnosed disorders may need to be deferred for 2 to 3 weeks pending completion of detoxification and/or withdrawal (1,2,11,13). Because the presence of comorbid psychiatric disorders predicts subsequent abuse of cocaine, pharmacologic treatment of attention-deficit hyperactivity disorder and depression in recovering patients may be important in preventing relapse (4,8). Comprehensive treatment of cocaine addiction combines pharmacologic, psychological, social, and spiritual dimensions.

Pharmacologic dimension

The pharmacologic dimension of treatment is aimed primarily at reversing cocaine-induced effects on catecholamines and their receptors. Although no medication has been clearly identified as effective for cocaine-dependent patients, pharmacologic therapy as an adjunct to other forms of therapy may enhance the effects of the other treatment methods and thus improve the overall success rate in maintaining abstinence (8).

Agents that have been the most thoroughly studied for use during the acute phase of cocaine craving, and thus for facilitating recovery, include amantadine hydrochloride, bromocriptine mesylate, levodopa, carbidopa, methylphenidate hydrochloride, mazindol, carbamazepine, and naltrexone hydrochloride (8,16). Tricyclic antidepressants, especially desipramine (17) and imipramine, as well as trazodone hydrochloride, the selective serotonin reuptake inhibitors, and lithium may be useful in the later phases of cocaine withdrawal (18). Since no agent has been found to have clear-cut initial efficacy, however, primary care physicians ordinarily would not prescribe pharmacologic therapy in most cocaine-dependent patients (18).

Psychological dimension

The goal of the psychological dimension of therapy is to help patients modify their internal environment, learning to evoke in themselves a feeling of well-being they previously relied on the substance to provide, and develop a lifestyle in which abstinence is preferable to cocaine addiction. Interpersonal, supportive, behavioral, cognitive, and psychodynamic psychotherapies have all been used in treatment of cocaine addiction (8,11). Studies indicate that the efficacy of psychotherapy depends greatly on the degree and severity of the psychopathology accompanying cocaine addiction (8) and that traditional insight-oriented psychotherapy may not be appropriate in these patients (13).

Better psychotherapeutic outcomes, particularly for the most symptomatic psychiatric patients, may be achieved through the combination of psychotherapy and drug counseling (1,8). Self-help groups and couple, marital, and family therapies are helpful in providing support, encouraging the expression of feelings, and correcting interpersonal conflicts related to peer pressure, disturbed family events, or family patterns that are contributing to cocaine addiction (1,2,8).

Social dimension

The goal of the social dimension of therapy is to help patients adjust to a drug-free lifestyle and construct a positive self-concept. Primary care physicians can teach their patients to consider relapse, should it occur, as part of the addictive process rather than as a treatment failure. They can encourage patients to seek immediate help or hospitalization if relapse occurs and can support them through the feelings of defeat and failure that may accompany relapse.

Groups such as Alcoholics Anonymous, Narcotics Anonymous, and Cocaine Anonymous provide an atmosphere for patients to develop friendships, socialize, and resolve drug-related interpersonal problems. Developing social support is important, because cocaine addiction can lead to social alienation, financial losses, family separation, homelessness, unemployment, eviction, discrimination, legal troubles, and rejection by friends. The social dimension of treatment addresses these factors, which are vital to maintenance of abstinence and recovery (8,13).

Spiritual dimension

The spiritual dimension of treatment encompasses various approaches, such as combining the 12 steps of Alcoholics Anonymous with the personal beliefs of the individual patient. It has at its core honesty, openness, and willingness to examine personal character issues. For this discussion, I define spirituality as recognition of a divine presence underlying the totality of the individual and the universe, with a focus on its application to the meaning and purpose of life (19,20).

In a historic interaction with the cofounder of Alcoholics Anonymous, Carl Jung once said that the compulsion to use alcohol is so great that in all likelihood "only a spiritual experience could overwhelm that compulsion. (19)." The compulsion to use cocaine is even greater. Both animal and human research have shown that the behavioral conditioning (rewarding effects) associated with cocaine use leads to development and maintenance of addictive behavior (18).

With hardly an exception, chemically dependent patients are unable to stop using substances by applying knowledge alone. Patients repeatedly emphasize that they have an illness or "affliction" that only a spiritual experience can conquer. On occasion, spiritual transformations that come with recovery are sudden, but more commonly, slow and steady changes lead to spiritual healing (20). In a hedonistic society, in which members seek pleasure as a priority of living, it is little wonder that a pleasure-producing drug such as cocaine is extremely hard to resist without a spiritual approach (19). Primary care physicians can play an important role in their cocaine-addicted patients' lives by introducing and reinforcing the concept of a spiritual dimension of treatment.

Summary

Despite public health efforts aimed at curbing the steady increase of drug abuse in this country, many patients continue to require treatment for cocaine addiction. A comprehensive treatment approach requires integration of pharmacologic, psychological, social, and spiritual dimensions, although research is needed to demonstrate the efficacy of such an approach in maintaining abstinence. Primary care physicians' assessment and treatment of their cocaine-addicted patients is a critical initial step on the way to specialized psychiatric and/or other specialized care for addicition and, hopefully, to sustained recovery.

 

References

Gold MS, Miller NS, Jonas JM. Cocaine (and crack): neurobiology. In: Lowinson JH, Ruiz P, Millman RB, eds. Substance abuse: a comprehensive textbook. 2d ed. Baltimore: Williams & Wilkins, 1992:222-35 Weddington WW. Cocaine: diagnosis and treatment. Psychiatr Clin North Am 1993;16(1):87-95 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: Am Psychiatric Assn, 1994:221-9 Hall WC, Talbert RL, Ereshefsky L. Cocaine abuse and its treatment. Pharmacotherapy 1990;10(1):47-65 Brown RA, Monti PM, Myers MG, et al. Depression among cocaine abusers in treatment: relation to cocaine and alcohol use and treatment outcome. Am J Psychiatry 1998;155(2):220-5 Lange RA, Hillis LD. Cocaine and the heart. Resident Staff Physician 1993;39(12):49-52 Little DR. Cocaine addiction and pregnancy: education in primary prevention. Resident Staff Physician 1993;39(4):79-84 Kaufman E, McNaul JP. Recent developments in understanding and treating drug abuse and dependence. Hosp Community Psychiatry 1992;43(3):223-36 Khouzam HR, Mayo-Smith MF, Bernard DR, et al. Treatment of crack-cocaine-induced compulsive behavior with trazodone. J Subst Abuse Treat 1995;12(2):85-8 Hillard JR. Emergency treatment of acute psychosis. J Clin Psychiatry 1998;59(Suppl 1):57-60 Nace EP, Davis CW. Treatment outcome in substance-abusing patients with a personality disorder. Am J Addict 1993;2(1):26-33 Ziedonis DM, Rayford BS, Bryant KJ, et al. Psychiatric comorbidity in white and African-American cocaine addicts seeking substance abuse treatment. Hosp Community Psychiatry 1994;45(1):43-9 Khalsa ME, Kowalewski MR, Paredes A. Cocaine abuse after treatment: one-year follow-up. Subst Abuse 1994;15(4):221-36 Mueller PD, Benowitz NL, Olson KR. Cocaine. Emerg Med Clin North Am 1990;8(3):481-93 Galanter M, Egelko S, De Leon G, et al. A general hospital day program combining peer-led and professional treatment of cocaine abusers. Hosp Community Psychiatry 1993;44(7):644-9 Meyer RE. New pharmacotherapies for cocaine dependence revisited. Arch Gen Psychiatry 1992;49(11):900-4 Gawin FH, Kleber HD, Byck R, et al. Desipramine facilitation of initial cocaine abstinence. Arch Gen Psychiatry 1989;46(2):117-21 Gorelick DA, Halikas JA, Crosby RD. Pharmacotherapy of cocaine dependence in the United States: comparing scientific evidence and clinical practice. Subst Abuse 1994;15(4):209-13 Khouzam HR, Marad G, Melvin A. Spirituality and recovery from opiate dependence. (Letter) Subst Abuse 1993;14(3):166-7 Hiatt JF. Spirituality, medicine, and healing. South Med J 1986;79(6):736-43 Dr Khouzam is staff psychiatrist, Veterans Affairs Medical Center, Manchester, New Hampshire; adjunct associate professor of psychiatry, Dartmouth Medical School, Lebanon, New Hampshire; and clinical instructor in medicine, Harvard Medical School, Boston. Correspondence: Hani Raoul Khouzam, MD, MPH, Veterans Affairs Medical Center, 718 Smyth Rd, Manchester, NH 03104-4098.

 


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