Deborah Brauser

December 12, 2011

December 12, 2011 (Scottsdale, Arizona) — Treatment with the atypical antipsychotic aripiprazole may lead to a reduction in cocaine dependency, new research suggests.

A small, open-label study from Spanish researchers showed that patients with a clinical diagnosis of cocaine dependence had significant improvements in overall symptoms and significant decreases in impulsivity and craving after receiving daily aripiprazole treatment for 6 months.

The results were presented here at the American Academy of Addiction Psychiatry (AAAP) 22nd Annual Meeting & Symposium.

"In Spain, we see a lot of cocaine dependence, especially in young people who often go out and mix alcohol and cocaine," lead author Joaquin Nieto Munuera, MD, PhD, from the University Hospital Arrixaca and the University of Murcia, Spain, told Medscape Medical News.

However, the investigators note that there is currently "no specific pharmacological therapy with established efficacy" for the treatment of this substance use disorder.

"It's a real problem. So there is a huge need for finding new therapies," said Dr. Munuera.

Craving-Reducing Mechanism?

"Aripiprazole has the unique action of being a partial dopamine agonist serving to stabilize brain dopamine systems in both frontal cortical and subcortical areas. As such, it might alleviate cocaine craving," the investigators note.

"So, basically, we wanted to test this theory that aripiprazole might be able to reduce cravings," added Dr. Munuera.

For the study, 46 adults between the ages of 19 and 48 years (mean age, 30.8 years) were treated for 6 months with aripiprazole in doses ranging from 5 mg to 10 mg per day.

The measurements that were used included the Clinical Global Impression (CGI) scale, the Yale-Brown Obsessive Compulsive Scale (YBOCS), the Barrat Impulsivity Scale (BIS), and the Cocaine Selective Severity Assessment (CSSA) scale.

End-of-treatment results showed a significant reduction in the mean score on the YBOCS (32.39 at baseline vs 2.15 at the study's end, P <.001), on the CSSA (68.37 vs 4.61, P < .01), and on the BIS (72.69 vs 28.76, P < .01).

In addition, there was a decrease in scores on the CGI scale from an average of 5–6 to 2–3, but this was not deemed statistically significant.

The investigators note that the study suggests there was clinical improvement in this patient population, but they report that participants were also receiving psychotherapy at the same time.

"These people did get better, but we cannot say that treatment with aripiprazole is definitely why they got better, just that it looked like it helped," said Dr. Munuera.

He noted that a double-blind, controlled study is now needed to answer these questions.

"[W]e'd like to treat 1 group with aripiprazole and 1 with psychotherapy only or treat both groups with psychotherapy and add in aripiprazole to just one to see if it really does help," he said.

"We still don't have good, definite treatments for cocaine dependence, like there is varenicline for nicotine dependence. There's no miracle drug yet, but we're working on it."

New Use for Old Drugs

"I thought this was an interesting study in the sense that everyone all over the place is looking for good solutions for this disorder and no one has found one yet," Shaul Lev-Ran, MD, from the Center for Addiction and Mental Health in Toronto, Canada, told Medscape Medical News.

"It's an interesting shot in an interesting direction because cocaine works through dopamine, among other things, and aripiprazole works through dopamine as a partial agonist. But there's still a distance between that and how clinical trials go," said Dr. Lev-Ran, who was not involved with this research.

Dr. Lev-Ran noted that the study had no control group, and because all participants received psychotherapy, it is unknown how beneficial the additive effect of aripiprazole was.

"So it's interesting and, from a neurobiological mechanism point of view, the study makes some sense. But it has to be refined and replicated in a much more stringent design," said Dr. Lev-Ran.

"Bigger pharmacological trials have a tendency to come out in the United States because of a lot of reasons, mainly financial. So I think this is a great opportunity for someone to look at it and go back to the workplace and say, 'That was interesting, so maybe we'll replicate it now in a larger-scale setting.' It's not that there's a lack of individuals with cocaine dependence in the US. So we can certainly find the clients."

He also noted that it was interesting to see a new use for an old medication.

"Some people are looking at completely new pharmacological agents that treat stimulant, cocaine, amphetamine dependence. But others are saying there are a lot of agents that are already around, and maybe we've overlooked some of them," said Dr. Lev-Ran.

"Someone here at the conference asked, 'How do you find a good pharmacotherapy without having a billion dollars?' One of the ways is maybe not inventing the wheel but realizing there are a lot of different agents working in different neurobiological mechanisms. And maybe some of those can make the transition into other disorders."

The study was supported by the University of Murcia. The study authors have disclosed no relevant financial relationships. Dr. Lev-Ran reported receiving speaker's fees on 1 occasion in the past from the manufacturer of risperidone.

American Academy of Addiction Psychiatry (AAAP) 22nd Annual Meeting and Symposium: Poster Abstract 23. Presented December 9, 2011.

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