Seasonal cocaine abuse

The authors describe two patients with seasonal affective disorder characterized by fluctuations in cocaine craving that paralleled seasonal dysphoria. This extends the range of axis I disorders associated with cocaine self-administration.     

Biopsy-proven cerebral vasculitis associated with cocaine abuse

We report cerebral vasculitis in 2 cocaine users who developed symptoms (transient blindness and persistent headache) while smoking "crack," followed by progressive widespread cerebral dysfunction with focal signs over the next few weeks. One patient had smoked crack exclusively, and the other also used cocaine intravenously. Sedimentation rates were elevated and HIV titers negative. Arteriography was normal in 1 patient and in the other showed multiple large-vessel occlusions without beading. Brain biopsy showed vasculitis involving small vessels in both patients. Multinucleated cells were present in the neuropil, but there were no granulomas or evidence of infection. One patient improved significantly with corticosteroid treatment, and made a good recovery. The other died despite corticosteroid and cyclophosphamide treatment.     

Cerebral vasculitis associated with cocaine abuse.

BACKGROUND: Earlier reports of cocaine-associated cerebral vasculitis have been based primarily on angiographic findings without pathological verification. CASE DESCRIPTION: We present a case of acute encephalopathy following intravenous and intranasal administration of cocaine. Brain biopsy revealed vascular changes involving primarily small arteries. Findings included lymphocytic infiltration, endothelial thickening, and deposition of proteinaceous amorphous material within and around vessel walls. CONCLUSIONS: These abnormalities are consistent with pathological features of arteritis previously reported in association with amphetamine and multiple-drug abuse. Vasospasm-induced changes are an alternative explanation for the vascular picture seen in this case. The patient made modest improvement with high-dose intravenous steroids.     

Cases of buprenorphine abuse in India.

Buprenorphine was introduced as a potent analgesic with low abuse potential. Reports of buprenorphine abuse by opiate abusers have accumulated over the years, highlighting its use as a cheap alternative to heroin. The lower potency compared with heroin is being compensated by using a cocktail of buprenorphine with benzodiazepines or cyclizine. This study of 18 cases seen over 3 years broadly confirms these findings. Four cases reported haematemesis during acute withdrawal, a symptom not reported in earlier studies.     

The treatment of cocaine abuse

Cocaine abuse surged in the 1980s, forcing reevaluation of its previously benign image. Snorted, smoked, and injected, the drug is more widely abused than ever and, the consequences are devastating. Medical complications are frequent and range from mild (eg, cough, itching, headache) to life-threatening (eg. stroke, seizure, cardiovascular failure). Behavioral disturbances constitute the most dramatic and widespread effects of intoxication and withdrawal. Psychopathologic responses may include perceptual disturbances (eg. hallucinations) agitation, aggression, delirium, confusion, and profound delusional ideation. The goals of treatment are abstinence, rehabilitation, and relapse prevention. Hospital care may be necessary in certain circumstances. Regardless of where treatment takes place, a comprehensive program of supportive care, behavioral therapy, urine monitoring, and often psychopharmacologic intervention is required.     

Pharmacologic treatments of cocaine abuse

Because current studies have small sample sizes and limited controls, firm conclusions or treatment recommendations cannot be made at present, but pharmacologic approaches probably have a place in the treatment of cocaine abuse. Pharmacologic treatments of cocaine abusers may relate to underlying psychiatric diagnoses. Cocaine abusers with adult attention deficit disorder appear to respond well to methylphenidate, but other cocaine abusers have increased cocaine craving when getting this medication. Cyclothymic cocaine abusers appear to respond to lithium with reduced cocaine use. Depressed cocaine abusers, who may constitute about 30 per cent of abusers, have decreased cocaine craving and increased abstinence when treated with desipramine. Other cocaine abusers without underlying psychiatric disorders may also respond well to desipramine if they fail to reduce their cocaine use during psychotherapy.     

Nonpharmacologic treatment of cocaine abuse

This article describes nonpharmacologic techniques for treating the cocaine abuser on an outpatient basis. Key issues in assessment and treatment planning are discussed as well as specific relapse prevention strategies and success rates.     

Neurologic complications of cocaine abuse

Over a 24-month period we evaluated 14 patients with neurologic disease associated with cocaine abuse. Five patients developed previously unreported complications: anterior spinal artery syndrome, lateral medullary syndrome, transient ischemic attacks in the middle cerebral artery and vertebrobasilar artery territories, and partial motor seizures. The recent availability of crack has led to a great increase in neurologic problems associated with the use of this drug.     

Psychiatric diagnosis in cocaine abuse

The Structured Clinical Interview for DSM-III, Axis I was administered to a consecutive series of 30 cocaine abusers entering outpatient treatment. Another mental disorder was diagnosed only if its onset occurred before the onset of any substance dependence disorder. Diagnoses were made on a lifetime basis without regard to hierarchy. Most cocaine abusers had one or more additional diagnoses. We propose a model of two subtypes of cocaine abusers: (1) a primary affective disorder group, which may be split into bipolar versus unipolar or into severely versus mildly depressed subgroups; and (2) a group with other drug dependencies. The small n, limited sample, and methodological problems with diagnosis in the setting of substance abuse make these findings tentative. Future research should combine larger diagnostic studies with treatment trials to test whether such diagnostic subtypes have prognostic or treatment implications.     

Thalamomesencephalic strokes after cocaine abuse

Three young patients developed strokes of rostral midbrain and thalamus shortly following cocaine abuse. Two had infarctions and one had a hemorrhage, but none had clear risk factors other than cocaine for this relatively uncommon type of stroke. Toxicologic analysis confirmed isolated cocaine use in each patient. In the two cases of infarction studied angiographically, one had normal findings and the other had focal narrowing of the P1 segments of the posterior cerebral arteries bilaterally. Since the P1 segment has a uniquely sparse perivascular sympathetic supply, we suggest that direct adrenergic-mediated vasoconstriction is not critical to the production of cocaine-associated stroke.     

Neurovascular complications of cocaine abuse.

A 3-year prospective study of 31,081 admissions to an inner-city, emergency trauma hospital revealed 33 patients less than or equal to 45 years of age who had a total of 35 acute neurovascular events (infarction or hemorrhage) related to cocaine abuse (3% of the total 979 cocaine-related admissions). Fifty-four percent of the events were ischemic, and 46% were hemorrhagic. Six patients died. The majority (63%) of ischemic events were hemispheric and subcortical in distribution. Eleven of 13 angiograms were abnormal (five aneurysms and two arteriovenous malformations were identified). No case of "vasculitis" was seen. Seventy percent of the patients exclusively abused crack cocaine, and 94% of the neurovascular events were related to its use. No first-time cocaine users were identified. During the last year of the study, 29% of the 558 cocaine-related admissions were psychiatric admissions, and most (58%) were for treatment of depressive illness (34 patients were admitted for attempted suicide).     

Desipramine in opioid-dependent cocaine abusers maintained on buprenorphine vs methadone

BACKGROUND: Cocaine abuse occurs in 40% to 60% of patients entering opioid maintenance treatment, and effective pharmacotherapies are needed for this combined dependence. METHODS: This 13-week, randomized, double-blind, placebo-controlled trial evaluated the efficacy of desipramine hydrochloride (0 or 150 mg/d) plus buprenorphine hydrochloride (12 mg/d) or methadone hydrochloride (65 mg/d) in 180 opioid-dependent cocaine abusers (124 men, 56 women). Supervised urine samples were obtained thrice weekly, and self-reported cocaine and heroin use was reported once weekly. Desipramine plasma levels were determined at weeks 4 and 10. RESULTS: In men, opioid abstinence was increased more rapidly over time when treated with methadone than with buprenorphine, whereas cocaine abstinence was increased more with buprenorphine than with methadone. In women, opioid abstinence was increased the least rapidly when treated with buprenorphine plus placebo, while cocaine abstinence was increased more rapidly over time when treated with methadone than with buprenorphine. Regardless of sex or opioid medication, desipramine increased opioid and cocaine abstinence more rapidly over time than placebo. Self-reported opioid use confirmed these findings. Desipramine plasma levels were higher in women than in men, particularly those on buprenorphine maintenance. Higher desipramine plasma levels were associated with greater opioid, but not cocaine, abstinence. CONCLUSIONS: Desipramine may be a useful adjunctive medication in facilitating opioid and cocaine abstinence in opioid-maintained patients. The efficacy of opioid medications to treat opioid or cocaine dependence may differ by sex. These findings highlight the importance of including sex as a factor when examining treatment outcome in these types of trials.     

Methadone versus buprenorphine with contingency management or performance feedback for cocaine and opioid dependence

OBJECTIVE: Physicians may prescribe buprenorphine for opioid agonist maintenance treatment outside of narcotic treatment programs, but treatment guidelines for patients with co-occurring cocaine and opioid dependence are not available. This study compares effects of buprenorphine and methadone and evaluates the efficacy of combining contingency management with maintenance treatment for patients with co-occurring cocaine and opioid dependence. METHOD: Subjects with cocaine and opioid dependence (N=162) were provided manual-guided counseling and randomly assigned in a double-blind design to receive daily sublingual buprenorphine (12-16 mg) or methadone (65-85 mg p.o.) and to contingency management or performance feedback. Contingency management subjects received monetary vouchers for opioid- and cocaine-negative urine tests, which were conducted three times a week; voucher value escalated during the first 12 weeks for consecutive drug-free tests and was reduced to a nominal value in weeks 13-24. Performance feedback subjects received slips of paper indicating the urine test results. The primary outcome measures were the maximum number of consecutive weeks abstinent from illicit opioids and cocaine and the proportion of drug-free tests. Analytic models included two-by-two analysis of variance and mixed-model repeated-measures analysis of variance. RESULTS: Methadone-treated subjects remained in treatment significantly longer and achieved significantly longer periods of sustained abstinence and a greater proportion drug-free tests, compared with subjects who received buprenorphine. Subjects receiving contingency management achieved significantly longer periods of abstinence and a greater proportion drug-free tests during the period of escalating voucher value, compared with those who received performance feedback, but there were no significant differences between groups in these variables during the entire 24-week study. CONCLUSIONS: Methadone may be superior to buprenorphine for maintenance treatment of patients with co-occurring cocaine and opioid dependence. Combining methadone or buprenorphine with contingency management may improve treatment outcome.     

Treatment of opioid-dependent adolescents and young adults with buprenorphine

Rising rates of opioid use among teenagers and young adults are a public health concern. Despite short durations of opioid use compared with those of adults, youth with opioid dependence have a host of co-occurring conditions, including polysubstance abuse, psychiatric disorders, hepatitis C infection, HIV risk, and high-risk sexual and criminal behaviors. Opioid-dependent youth typically are offered outpatient/residential treatment with brief detoxification, but one study showed that heroin users fare worse following residential treatment. Although abundant research supports the use of medication-assisted treatment for opioid-dependent adults, research is only recently emerging for youth. Buprenorphine, a partial opioid agonist, was proven safe and effective in improving abstinence from opioids in two controlled clinical trials. More research is needed to determine several clinically relevant areas: appropriate duration of agonist treatment, ways to enhance medication adherence, the value of integrated treatments for co-occurring conditions, and the role of opioid antagonists in opioid-dependent youth.     

A zolpidem and cocaine abuse case report

A case is presented of a 30-year-old man, prescribed zolpidem for insomnia arising from cocaine abuse, who sought to use this hypnotic to reduce his craving for cocaine. However, after taking cocaine and up to 300 mg/day zolpidem, he became euphoric and hyperactive. It is suggested that at high doses, zolpidem, like cocaine, has a stimulatory effect on the brain dopaminergic reward pathway. (Int J Psych Clin Pract 2002; 6: 217-219 )     

Fluoxetine treatment of cocaine abuse in heroin addicts

The authors administered fluoxetine to 11 cocaine-abusing heroin addicts entered in a methadone maintenance program to determine whether it would decrease cocaine craving and use. Three patients discontinued treatment within a few days of initiation because of lack of any acute therapeutic effect. The remaining 8 received fluoxetine for at least 1 week and were followed up over 1 to 6 months. Of these 8, 5 (63%) were successfully treated for cocaine abuse. Three case examples are presented. Fluoxetine may prove a useful addition to the therapeutic armamentarium in the treatment of cocaine abuse.