COMMENTARY

Cocaine and Cannabis Dependence: What Works?

Michael T. Compton, MD, MPH

Disclosures

June 06, 2011

In This Article

Editor's Note:

As the first in a 3-part series on highlights from the 2011 annual meeting of the American Psychiatric Association (APA) in sunny Honolulu, Hawaii, Michael T. Compton, MD, MPH, Associate Professor, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, discusses the management of cocaine and cannabis dependence.

Cocaine Dependence: The Latest in Treatment

The annual meeting of the APA offered a remarkable breadth of sessions, just a few of which are highlighted in this series.

In Symposium 5[1] on Saturday, May 14, titled "Choosing the Right Treatment for Substance Abuse," Dr. Herbert D. Kleber (Professor of Psychiatry and Director of the Division of Substance Abuse at the Columbia University College of Physicians and Surgeons and the New York State Psychiatric Institute, New York, NY), discussed treatments for cocaine dependence in a talk titled "The Elusive Goal of Psychostimulant Dependence Pharmacotherapy." As a brief introduction to the central effects of cocaine and amphetamines, Dr. Kleber noted that when administered acutely, these drugs increase synaptic levels of the monoamines dopamine, norepinephrine, and serotonin. Agonist approaches to treatment may restore monoaminergic function and reverse deficits contributing to ongoing use while reducing craving through substitution. Despite worries about abuse, diversion, and induction of craving, clinical evidence to date does not support these concerns about potential agonist approaches. However, there are possible adverse cardiovascular effects. Agonist agents that have received some research attention include d-methamphetamine, methylphenidate-sustained release, and d-amphetamine-sustained release. There is some evidence that the use of such agonists enhances retention in psychostimulant abuse treatment. Dr. Kleber also mentioned the potential utility of disulfiram, well known in the armamentarium of treating alcohol dependence, which is known to also increase the ratio of dopamine to norepinephrine by blocking dopamine beta hydroxylase. He noted that 7 studies, including a total of more than 300 patients, have assessed effects of disulfiram in treating psychostimulant abuse.

Several other agents are worth considering. Dr. Kleber noted that the effects of modafinil are less clear. That agent, which requires further study, is well tolerated, has no stimulant effects, and has not been associated with indications of abuse/misuse. However, studies to date have had problems with retention (ie, high dropout rates). Bupropion, a dopamine and norepinephrine reuptake inhibitor, reduces subjective effects of psychostimulants and decreases craving in initial laboratory studies.

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