Cocaine

cocaine addiction

Quick Fact Sheet

  • What is it? White, crystalline powder derived from coca leaves. Cocaine base (crack) looks like small, irregularly shaped white rocks.
  • Street Names: Coca, Coke, Crack, Crank, Flake, Rock, Snow, Soda Cot,
  • How is it used? Powdered cocaine can be snorted or injected into the veins after dissolving in water. Cocaine base (crack) is smoked, either alone or on marijuana or tobacco. Cocaine is also used in combination with an opiate, like heroin, a practice known as “speedballing.” Although injecting into veins or muscles, snorting, and smoking are the common ways of using cocaine, all mucous membranes readily absorb cocaine. Cocaine users often binge on the drug until they are exhausted or run out of cocaine
  • How does it affect the body? Smoking or injection creates an intense euphoric “rush”. Tolerance builds quickly and leads to an overdose very easily. See cardiac arrhythmias, increased blood pressure, heart rate, restlessness, irritability, anxiety, paranoia, insomnia, loss of appetite, stroke, sudden cardiac arrest, and convulsions. The crash that follows a high is mental and physical exhaustion, sleep, and depression lasting several days. Following the crash, users crave cocaine again.

Cocaine is often contaminated with unusual drugs for enhancing effects such as levamisole (veterinary worming agent) or diltiazem. Profound neutropenia has been noted in users who smoked crack contaminated with levamisole. It is also associated with a vasculitic-type rash.

–DEA

Treatment and Implications

The treatment for cocaine addiction lacks FDA-approved medications and often relies on rehab and addressing cravings, though no approved treatment exists for those either. Managing cravings typically involves prescribing multiple psych medications, leveraging the high medication tolerance often seen in these patients, including older individuals. Cocaine users are often grouped with polysubstance and methamphetamine users due to similar patterns, which allows providers flexibility in medication plans. The goal is to help patients overcome the “cocaine blues” (a term I made up to describe the cravings), gradually reducing medications as cravings subside, tailoring care to the individual’s needs.

Here’s a summarized plan of care:

  1. Establish a Baseline, Focused on Relapse Prevention
    • Regular drug screens are essential to monitor sobriety and set a clear standard for recovery, especially with a history of cocaine use. Reinforce the importance of staying sober is a frequent process.
    • Avoid prescribing substances with addiction potential (e.g., benzodiazepines).
  2. Address Anxiety and Cravings (Blues) 
    • First-line options:
      • Clonidine (0.1–0.3 mg TID): Effective for cravings and anxiety.
      • Hydroxyzine (25–50 mg TID): Good alternative, especially if blood pressure sensitivity is present.
      • Naltrexone: Helpful for reducing cravings and preventing relapse.
      • Propranolol: Useful for anxiety with physical symptoms.
      • Buspirone: An option for generalized anxiety.
      • Bupropion: Ideal for patients with smoking or depressive tendencies but avoid in seizure history.
  3. Manage the Mood Symptoms
    • Recognize that irritability, agitation, and depression are part of cocaine withdrawal (“cocaine blues“). Target the cravings and mood simultaneously.
    • Preferred mood stabilizers:
      • Valproic acid: Reduces agitation and can be used PRN.
      • Topiramate, lurasidone, aripiprazole, or quetiapine: Target cravings, mood swings, and restlessness.
    • Avoid highly demanding medications like lithium and there’s better medications than lamotrigine to treat aggression unless specifically indicated.

Key Focus: Build trust, reinforce boundaries, and prioritize recovery while managing symptoms effectively with non-addictive medications.

What about ADHD?
Now that cravings have subsided, consider ADHD treatment if necessary depending on risks verses benefits. Here’s some considerations to navigate this:

  1. Use Objective and Subjective Data: old prescriptions, psychological testing, or documentation (e.g., letters from parents), the use of self-reported symptoms and rating scales.
  2. Process for Starting Stimulants:
    • Wait 1–2 months post-rehab, ensuring clean drug screens, medication adherence.
    • Begin at the lowest dose, considering past drug use and potential heart issues. Explain the gradual approach as a health precaution.
  3. Positive Drug Screens: if the screen is positive for substances like heroin or meth, restart the process after at least 60 days of sobriety. This timeline helps establish better habits and ensures mood, cravings, and sleep are addressed before introducing stimulants.
  4. Heart History: A heart condition does not rule out stimulants but requires collaboration with the PCP or cardiologist. Start with a low dose to minimize risk, prioritizing patient safety over relapse concerns.

Providers should balance their approach to treating substance abuse, avoiding overly strict policies that may drive patients to relapse. While some providers refuse to prescribe scheduled medications like stimulants for ADHD, this can pose risks, as these medications are FDA-approved and help prevent patients from seeking drugs on the streets. It’s important to enforce protocols without being rigid about medications. Each case should be treated individually, with persistence in protocols ensuring smoother outcomes. The goal is to help patients to reduce or avoid dangerous risks while maintaining ethical and effective treatment standards for ADHD and addiction.

Print Friendly, PDF & Email