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 for Cocaine
Nothing is approved to treat cocaine. I tell people it’s only rehab but medications can help so what are we treating? the greater issue, which is the CRAVINGS but nothing is approved for that either so overall the treatment is a very wild experience, almost like cocaine itself.
These patients usually require 5-6 medications just to deal with the cravings. I also put cocaine users in the same category as the polysubstance, meth, or anyone doing party packs, so the only thing that’s good about this is how the patients have a high tolerance for meds and providers can use this to their advantage.
Even my 50-60y/o patients can tolerate a lot of the meds because they need to get over the hump of what I like to call the cocaine blues and eliminate extra meds as the cravings decrease. So I’ll use my typical cocaine user to describe a plan of care.
Derrick is 40y/o and has a hx of ADHD but after the doctor retired he couldn’t find someone to prescribe his Adderall, which led to him using cocaine for more than 20 years, and now he finally decided to go to rehab. After 15 days of rehab, he was discharged to a 3/4 house and is now in your office so what should we tackle first?
- Step 1 have a solid baseline: let Derrick know we have to do regular drug screens to avoid relapses. I don’t care if you prescribe water, regular drug screens reiterate the standard to stay clean. I used to do it only for patients with scheduled medications and it just needs to be the standard for everyone but especially with a cocaine HX. Plus, I want the patient to truly focus on the recovery and not go back to using.
- Step 2 targets the anxiety/CRAVINGS: My go-to meds are; clonidine 0.1-0.3mg TID, hydroxyzine 25-50mg TID, naltrexone, propranolol, buspirone, bupropion. How do you differentiate? go by what work/didn’t work before, overweight or smoking -bupropion is a great option but avoids with an SZ hx, if the patient is already on pressers, then max out hydroxyzine. I would avoid BZD in this population…at this stage, we are still trying to establish boundaries and maintain recovery, not cause another addiction.
- Step 3: what about “mood”? usually, cocaine users are irritable, agitated, restless, and depressed, and it’s not them but look at it as a form of grief aka the cocaine blues. They are missing that high and know they are not supposed to turn into this rabid animal running around in the streets to get drugs. Again target the cravings with mood stabilizers and max out the medications for anxiety. Valproate acid helps with taking that agitation and edge off, it can also be PRN (like a placebo effect). Also consider lurasidone, aripiprazole, topiramate, and quetiapine, because it targets agitation and cravings. I somewhat avoid lithium and lamotrigine because I’m not trying to get a drug that I have to titrate or is demanding and lamotrigine just doesn’t significantly help with the agitation.
Step 4 what about ADHD: so now that the smoke has cleared and the cravings are at bay, Derrick wants to inquire about Adderall. This is when a provider’s expertise will get TESTED. Plus we are competing with ticktock and reddit users who are giving tips about what to say to get a stimulant…so this can be a hawt mess depending on YOUR approach so here are my pearls:
- Derrick needs to provide some evidence; previous scripts, psychological testing, old paperwork, the mother or dad wrote a letter, or anything saying that ADHD was a problem before setting foot in your office. If the patient has none of it, then they need to get tested. I had someone argue like what’s the point? and I simply said adult ADHD is more than what somebody says (or the chief complaint), whereas with kids you can actually observe the deficits. Plus, it’s suspect to insurance companies that all of sudden you need a stimulant to function as an adult. I don’t want to digress, but I’ll make it quick, the patient was arguing how he’s on heroin, homeless, without a job, etc. because he didn’t have treatment for his “ADHD” (this is NOT proof, reiterated how drugs caused these problems and ADHD is a separate issue, which is why you need proof of the diagnosis) so he stormed out but people who really want help, don’t lash out and need to learn how to act proper.
- My process to start a stimulant (or any scheduled medication) is usually 1-2 months post-rehab, drug screens are clean, the patient is being adherent with meds, and got tested or had proof of the ADHD diagnosis/treatment. Then I usually start on the lowest dose and titrate up. Start low because due to past drug use, they probably do have heart problems so I don’t start with 70mg of Adderall just because the patient said that’s the dose they had in 1990. I simply say I’m starting low due to the medical history or you can say due to the body changing with age, I need to make sure the medication doesn’t cause heart issues.
- But what happens if there is a problem and the drug screen came positive for heroin, meth…etc.? It’s not the end of the world. Another option is going back to square one, which is being clean for 2 months. I don’t know if people will agree with this but say if the drug screen came back positive, I aim for at least 60 days to be clean to restart medications. Why 60? because according to science aka google, it takes about 66 days to form a new habit (of not doing drugs). Other reports say it takes 12 weeks, 21 days, etc. But I mainly stick to 2 months because I try to treat the mood/cravings/sleep first before going to stimulants.
- Another problem, what if Derrick does have a heart hx? it doesn’t contraindicate a stimulant, just take precautions and try to collaborate with PCP/cardiology or start the stimulant at a low dose since you really don’t want a person with a heart condition to relapse on drugs. I’ll rather prescribe the stimulant.
Providers have to figure out what’s comfortable for them, however, I do caution not to be a dictator when it comes to treating substance abuse because you will drive yourself crazy. Some providers are strict and refuse to prescribe scheduled medications, and unfortunately, I believe it’s probably not a good area to work in because it puts the patient at risk for relapsing.
It will be a constant conflict of interest if the provider doesn’t want to treat ADHD with stimulants. They are FDA-approved for ADHD and you don’t want your patients to keep going to “the streets”. I get the concern but just be more prepared for the backlash. I don’t baby the patients either, be strict in your protocols but not with the medications.
Like one of my patients tested positive for cocaine, but the level wasn’t too high so it may have been an “accident”… I just wasn’t concerned but said next appointment he has to test clean and I’ve kept him on his Adderall because he was doing the best he’s ever done. Other issues include if the medication isn’t showing up in the urine or the patient claims to be a fast metabolizer …etc.
I’m going to do a write-up about drug testing but the moral of the story is to treat unusual things (including a success story) in a case-by-case situation. So step 5 is to stay persistent in your treatment protocols and things will go 1000% smoother.
The goal is to keep cocaine users OFF the streets because the next high can be fatal. However, if they do go back to the streets like my other patient then it’s what they wanted to do because providers still have to maintain a standard with treating ADHD or any mental health condition while being mindful of addictions.
