What treatments are effective for cocaine abusers?

In 2007, cocaine accounted for about 13 percent of all admissions to drug abuse treatment programs. The majority of individuals (72 percent in 2007) who seek treatment for cocaine abuse smoke crack and are likely to be polydrug abusers, or users of more than one substance. The widespread abuse of cocaine has stimulated extensive efforts to develop treatment programs for cocaine. As with any drug addiction, this is a complex disease that involves biological changes in the brain as well as myriad social, familial, and other environmental problems. Therefore, treatment of cocaine addiction must be comprehensive, and strategies need to assess the neurobiological, social, and medical aspects of the patient's drug abuse. Moreover, patients who have a variety of addictions often have other co-occurring mental disorders that require additional behavioral or pharmacological interventions.

Pharmacological Approaches

Presently, there are no FDA-approved medications to treat cocaine addiction. Consequently, NIDA is working aggressively to identify and test new medications to treat cocaine addiction safely and effectively. Several medications marketed for other diseases (e.g., vigabatrin, modafinil, tiagabine, disulfiram, and topiramate) show promise and have been reported to reduce cocaine use in controlled clinical trials. Among these, disulfiram (used to treat alcoholism) has produced the most consistent reductions in cocaine abuse. On the other hand, new knowledge of how the brain is changed by cocaine is directing attention to novel targets for medications development. Compounds that are currently being tested for addiction treatment take advantage of underlying cocaine-induced adaptations in the brain that disturb the balance between excitatory (glutamate) and inhibitory (gamma-aminobutyric acid) neurotransmission. Also, dopamine D3 receptors (a subtype of dopamine receptor) constitute a novel molecular target of high interest. Medications that act at these receptors are now being tested for safety in humans. Finally, a cocaine vaccine that prevents entry of cocaine into the brain holds great promise for reducing the risk of relapse. In addition to treatments for addiction, medical treatments are being developed to address the acute emergencies that result from cocaine overdose each year.

Behavioral Interventions

Many behavioral treatments for cocaine addiction have proven to be effective in both residential and outpatient settings. Indeed, behavioral therapies are often the only available and effective treatments for many drug problems, including stimulant addictions. However, the integration of behavioral and pharmacological treatments may ultimately prove to be the most effective approach.

One form of behavioral therapy that is showing positive results in cocaine-addicted populations is contingency management, or motivational incentives (MI). MI may be particularly useful for helping patients achieve initial abstinence from cocaine and for helping patients stay in treatment. Programs use a voucher or prize-based system that rewards patients who abstain from cocaine and other drug use. On the basis of drug-free urine tests, the patients earn points, or chips, which can be exchanged for items that encourage healthy living, such as a gym membership, movie tickets, or dinner at a local restaurant. This approach has recently been shown to be practical and effective in community treatment programs.

Cognitive-behavioral therapy (CBT) is an effective approach for preventing relapse. CBT is focused on helping cocaine-addicted individuals abstain—and remain abstinent—from cocaine and other substances. The underlying assumption is that learning processes play an important role in the development and continuation of cocaine abuse and addiction. These same learning processes can be harnessed to help individuals reduce drug use and successfully prevent relapse. This approach attempts to help patients recognize, avoid, and cope; that is, they recognize the situations in which they are most likely to use cocaine, avoid these situations when appropriate, and cope more effectively with a range of problems and problematic behaviors associated with drug abuse. This therapy is also noteworthy because of its compatibility with a range of other treatments patients may receive.

Therapeutic communities (TCs), or residential programs, offer another alternative to persons in need of treatment for cocaine addiction. TCs usually require a 6- or 12- month stay and use the program's entire "community" as active components of treatment. They can include onsite vocational rehabilitation and other supportive services and focus on successful reintegration of the individual into society.

Community-based recovery groups—such as Cocaine Anonymous—that use a 12-step program, can also be helpful to people trying to sustain abstinence. Participants may benefit from supportive fellowship and from sharing with those experiencing common problems and issues.

It is important that patients receive services that match all of their treatment needs. For example, if a patient is unemployed, it may be helpful to provide vocational rehabilitation or career counseling along with addiction treatment. If a patient has marital problems, it may be important to offer couples counseling.