Cocaine use disorder

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Patients with signs of cocaine intoxication (e.g., loss of consciousness, chest pain, or focal neurologic complaints) will require emergency investigation and treatment. For details on the management of acute cocaine intoxication and the management of toxicity related to body packing see Cocaine toxicity.

Once any urgent signs and symptoms have been addressed, refer the patient to an addiction treatment provider. Engagement and retention in substance use disorder treatment can be a major clinical challenge; it is recommended that healthcare providers proactively engage people who would benefit from treatment at all stages of readiness for change, including those who are uninterested or ambivalent about receiving treatment.

The following strategies are amongst those recommended by the American Society of Addiction Medicine:[50]

Cultivate patient trust by creating a welcoming, nonjudgmental and trauma-sensitive environment.
Do not require abstinence as a condition of treatment initiation or retention.
Build connections to people with a substance use disorder who are not currently seeking treatment.
Seek to re-engage individuals who disengage from care.
Develop treatment plans that are responsive to the individual’s needs and priorities.
Focus on therapeutic strategies over punitive actions.

Psychosocial treatments are the primary options.[51] Treatment is based on whether use is classified as mild, moderate, or severe according to DSM-5 criteria.[27]

Consider and address co-occurring mental and physical health conditions, as required, which may interfere with effective participation in cocaine use disorder treatment. Ideally, substance use programs will be equipped to address co-occurring mental health concerns, including trauma, in the routine course of addiction treatment.[50] Patients with the presence of significant psychiatric symptoms in the setting of acute cocaine use or a history of preexisting mental health issues may benefit from an external mental health referral.

Pharmacotherapy

Evidence suggests that pharmacotherapy has limited efficacy in treating cocaine use disorder.[52][53][54] [ ]

Discussion with a psychiatrist/addiction specialist regarding the need for symptomatic pharmacotherapy, for example, with a benzodiazepine or antipsychotic medication, may be warranted in the presence of severe distress, depending on the individual’s clinical presentation (e.g., where there is severe agitation, confusion, psychosis, or severe acute insomnia).[27][34]

Despite the lack of evidence, nonpsychostimulant drugs and stimulants may be considered for certain patients with cocaine use disorder, particularly when there are coexisting disorders or conditions present (e.g., nicotine/tobacco use, depression, alcohol use disorder, attention deficit hyperactivity disorder).[27] See Emerging for more information.

Mild cocaine use disorder

In general, first-line treatment is with individual or group drug counseling, or a combination of these approaches.[55] An educational component is combined with elements of cognitive, behavioral, and/or supportive therapy. Topics such as identifying and avoiding triggers are covered, and ongoing attendance at mutual help groups is encouraged. See also the UK clinical guidelines, which cover psychosocial treatment in detail.[34]

If standard drug counseling fails, intensive outpatient therapy may be an option, although there is insufficient evidence of better outcomes.[56]

After 2-3 months of intensive outpatient therapy, if the person requires further treatment, depending on availability and their personal preference, options include augmentation with contingency management, or replacing the individual component of intensive outpatient therapy with CBT or motivational interviewing.

Family therapy or couples therapy can be considered if the person with cocaine use disorder is amenable to having their partner or family involved in their care.[57][58] For parents, a psychosocial intervention integrating parenting skills with a substance use component may be helpful.[59]

Moderate to severe cocaine use disorder

Intensive outpatient therapy has been shown to be as effective as inpatient or residential programs.[60][61][62] Individual and group counseling are often combined with couples/family therapy, with typically more than 9 hours of therapy per week over several weeks. However, there is some evidence that lower intensity treatment (for example 6 hours a week) may be just as effective in patients with cocaine use disorder.[63]

Other treatment options include contingency management, CBT, or motivational interviewing.[51] These may be used alone or in combination, depending on clinician and patient preference, and on service availability.

Contingency management uses operant behavioral techniques. Examples include voucher-based reinforcement therapy (VBRT), rewarding the achievement of agreed therapeutic goals. There is a large body of evidence stating that contingency management increases the period of abstinence and reduces the frequency of drug intake for people with stimulant use disorder, and specifically cocaine use disorder.[51][64]
CBT for cocaine use disorder involves recognition of triggers and teaching of coping skills to avoid drug use. Clinical trials in patients with cocaine use disorder comparing CBT with control groups (meditation and relaxation training) or other psychosocial interventions have shown mixed results, although there is some evidence that the coping skills taught with CBT may be effective even once treatment has finished.[51][65][66]
People with more severe substance use disorder symptoms or with comorbid depression may be more likely to benefit from CBT.[57][67]
Computerized CBT delivered in a clinical setting has been shown to be as effective as traditional CBT in a diverse group of patients with substance use disorders. Computerized CBT was also associated with lower dropout rates.[68]
Motivational interviewing is a directive, patient-centered counseling approach that aims to increase people’s motivation to change their behaviors and reach their own goals. Clinical trials have only found motivational interviewing to be effective compared with no treatment, but not compared with control interventions such as relaxation training.[51][69] [ ]

Treatment-resistant cocaine use disorder

If, after up to 12 weeks of the most intensive psychosocial treatment a patient continues to relapse, then consider referring them to an expert in addiction for possible adjunctive medication; however, evidence for this is very limited and there is no established guidance.[70]

Pregnancy

The focus of treatment is on psychosocial interventions, and pharmacotherapy is not recommended for routine treatment.[27] However, because of the risk of harms of ongoing cocaine use to both the mother and fetus, there is a lower threshold for inpatient withdrawal management, which may include nonteratogenic medications for the short-term management of psychologically distressing symptoms.[47]

Management should be provided by services specializing in substance use in pregnancy. In addition to psychosocial interventions, it is important that appropriate social support is given, including assistance with accommodation, life-skills and vocational training, legal advice, home-visiting, and outreach.[47]

A therapeutic workplace (a form of contingency management with salary in base pay vouchers linked to abstinence) has been shown to be superior to usual care in reducing opioid and cocaine use in pregnant and postpartum women with substance use disorders.[47][71]

Use of secondary substances

It is recommended that patients have access to evidence-based treatment for all substance use concerns, and that secondary substance use is not considered a barrier to care. Treatment plans should consider underlying drivers of secondary use, even if cessation is not an immediate goal. Risky use can be addressed over time through psychosocial interventions, provided it does not threaten safety or treatment outcomes. If secondary use undermines progress, collaborate with the patient to incorporate measures to address this within their treatment plan.[50]

Continuing care

Continuing care, rather than care limited to periods of acute exacerbation, is likely to help reduce recurrent use, especially for people with family or social issues.[72] Careful attention to effective transitions between levels of care is recommended.[50] Mutual support groups may be helpful for maintaining abstinence.

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