Pharmacological Approaches
Several medications marketed for other diseases show promise in reducing cocaine use within controlled clinical trials. Among these, disulfiram, which is used to treat alcoholism, has shown the most promise. Scientists do not yet know exactly how disulfiram reduces cocaine use, though its effects may be related to its ability to inhibit an enzyme that converts dopamine to norepinephrine. However, disulfiram does not work for everyone. Pharmacogenetic studies are revealing variants in the gene that encodes the DBH enzyme and seems to influence disulfiram’s effectiveness in reducing cocaine use. Knowing a patient’s DBH genotype could help predict whether disulfiram would be an effective pharmacotherapy for cocaine dependence in that person.
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 people with cocaine use disorders is contingency management (CM), also called motivational incentives. Programs use a voucher or prize-based system that rewards patients who abstain from cocaine and other drugs. 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. CM may be particularly useful for helping patients achieve initial abstinence from cocaine and stay in treatment. This approach has recently been shown to be practical and effective in community treatment programs.
Regardless of the specific type of substance use disorder treatment, it is important that patients receive services that match all of their treatment needs. For example, an unemployed patient would benefit from vocational rehabilitation or career counseling along with addiction treatment. Patients with marital problems may need couples counseling. Once inpatient treatment ends, ongoing support—also called aftercare—can help people avoid relapse. Research indicates that people who are committed to abstinence, engage in self-help behaviors, and believe that they have the ability to refrain from using cocaine (self-efficacy) are more likely to abstain. Aftercare serves to reinforce these traits and address problems that may increase vulnerability to relapse, including depression and declining self-efficacy.
Scientists have found promising results from telephone-based counseling as a low-cost method to deliver aftercare. For example, people who misused stimulants who participated in seven sessions of telephone counseling showed decreasing drug use during the first 3 months, whereas those who did not receive calls increased their use. Voucher incentives can boost patients' willingness to participate in telephone aftercare, doubling the number of sessions received according to one study.
Community-based recovery groups—such as Cocaine Anonymous—that use a -step program can also be helpful in maintaining abstinence. Participants may benefit from the supportive fellowship and from sharing with those experiencing common problems and issues.
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