CATR: Dr. Newton, how do patients with cocaine disorder typically come to seek help?
Dr. Newton: Well, most people have had the problem for a very long time. People often don’t come in for help until they have been using for about 10 years, and using quite a bit. Most people don’t have the resources to continue functioning at a relatively high level when they have been using a lot of drugs. So at some point, things fall apart. They just get sick of it and get treatment. It is typically when the downward slope is obvious and either the patient or the people who care about them decide that it is time to do something about it.
CATR: In terms of presentations, are there any clinical subtleties that providers misinterpret or perhaps overlook?
Dr. Newton: Patients’ main complaint is that they are using too much cocaine and they don’t have any money left. However, there are changes that can occur to the nose if people are snorting cocaine. People can also report that they had a seizure when they really didn’t. It turns out that they experienced what is called “falling out.” This is a big response to the cocaine that users think is a seizure. Some people also have panic attacks from having too much cocaine, as well as paranoia.
CATR: Can you describe what happens when a patient has this experience of ‘falling out’?
Dr. Newton: It can be difficult to figure out what is going on when people have behaviors that resemble seizures, but may not actually be epileptiform. When someone has a true seizure they obviously don’t know what is happening because they are unconscious and friends and family don’t have the faintest idea of what to look for. With cocaine users, people will report that they thought they had a seizure, but they didn’t lose consciousness and they weren’t unable to control their extremities. Although they may have been moving, they felt like they couldn’t control the movements.
CATR: So there is a disturbance of consciousness without paralysis?
Dr. Newton: Yes, often they will describe that they fell down and couldn’t control what was happening to them; it was very frightening and they felt that they had a seizure. Even if a cocaine user has a real seizure, they probably don’t need anti-seizure medication because it occurred in the context of cocaine use and sleep deprivation.
CATR: Are there any particular populations that are more affected by cocaine addiction?
Dr. Newton: Inner city African Americans and Hispanics continue to be most affected. Why is that? Is it just that this is where the drugs are delivered? In other words, you are going to shop at Macy’s if there is a Macy’s in your neighborhood. Interestingly, the opposite is true for methamphetamine use. About 90% of meth users are Caucasian and 10% at most African American. People who use cocaine will tell you that methamphetamine is a horrible drug; it lasts forever and it makes you paranoid. Then people who use methamphetamine will say that cocaine is a huge waste of money because it only lasts 30 minutes and you have to buy more right away.
CATR: Given the opportunity, will users cross over based on availability?
Dr. Newton: Some people do. These are more often people who are generalized polysubstance users who use whatever they can get their hands on. Most people will have a very definite opinion about which one is better and really don’t like the other one.
CATR: How often is cocaine involved with the use of other substances?
Dr. Newton: It is relatively rare that you will see somebody, at least in my experience, who is only a cocaine user. They are typically polysubstance users, and the number one additional substance is alcohol, and the number two substance is marijuana, in addition to cigarettes of course.
CATR: In what ways is cocaine addiction different than other substance use disorders?
Dr. Newton: I think cocaine is built into the community in a way that is different than other drugs. You buy cocaine and use it in a certain environment. When you are out of that environment, the odds are you are not going to seek it and you won’t use it.
CATR: So cocaine use disorder is highly context dependent?
Dr. Newton: I think so. The typical person who has problems with cocaine is relatively poor and living in the inner city and that is going to feed into their problem. There are different societal forces maintaining addiction for cocaine than there are for other drugs.
CATR: Do cocaine use disorders respond differently to treatment than, say, alcohol or opioid use disorders?
Dr. Newton: The best answer to that is that all addictions are chronic, including nicotine, alcohol, cocaine, amphetamines, and heroin. So when you see somebody for the first time, you know at some point they are probably going to have had enough and they will be able to quit. It may not be successful on the first try or even the third try. However, each time the likelihood of success increases, which is the opposite of what people think (Chapman S & MacKenzie R, PloS Med 2010;7(2):e1000216; Prochaska JO et al, Am Psychol 1992;47(9):1102–1114). They think: this person has tried to quit five times so obviously he is never going to quit, but that is not how it works. It is actually the other way around: the more times people have tried, the more likely they are to be able to quit. But that is extremely hard to communicate to patients, families, and payers. They see people as willfully misbehaving and the fact that they continually misbehave is good reason to cut them off.
CATR: Is psychiatric comorbidity common with cocaine use disorders?
Dr. Newton: Most people with cocaine use disorder don’t have a psychiatric comorbidity, but many people with psychiatric comorbidities have cocaine or other substance use disorders. For instance, 90% of people with schizophrenia smoke cigarettes, and many use cocaine and alcohol (Hughes JR et al, Am J Psychiatry 1986;143(8):993–997). Psychiatric disorders such as major depression, posttraumatic stress disorder, and personality disorders, in some ways mark impairments in coping skills, which leads to drug and alcohol abuse.
CATR: We know that psychosocial interventions are useful for cocaine addiction. What about medications?
Dr. Newton: There is something that will surprise people. The single most studied drug for cocaine dependence is disulfiram (Antabuse), which has been used in almost 1,000 people in clinical trials. Beyond that, things get a lot sketchier. By far, the most effective medication in the small number of trials that have been done is sustained-release methamphetamine (Mooney ME et al, Drug Alcohol Depend 2009;101(1–2):34–41). Some studies also show that modafinil (Provigil), which is a wakefulness-enhancing drug, seems to be helpful (Anderson AL et al, Drug Alcohol Depend 2009;104(1–2):133–139; Dackis CA et al, Neuropsychopharmacology 2005;30(1):205–211). More recently, some studies suggest that drugs that block the alpha-1 receptor might be useful (Shorter D et al, Drug Alcohol Depend 2013;131(1–2):66–70). Prazosin (Minipress) can block reinstatement to cocaine self-administration [relapse] in rats (Zhang XY & Kosten TA, Biol Psychiatry 2005; 57(10):1202–1204), and doxazosin (Cardura), which is the long-acting version of that, seems to block the effects of cocaine in people as well (Newton TF et al, PLoS One 2012;7(2):e30854).
CATR: Clinicians are familiar with disulfiram in the context of alcohol treatment, but how do you dose it for cocaine?
Dr. Newton: People originally tried disulfiram as a treatment for cocaine dependence because a lot of cocaine users drank alcohol. In further studies, it worked just as well in people with cocaine dependence who didn’t use alcohol. The recommended dose is 250 mg a day, as it is for chronic treatment for alcohol dependence. However, we have some data suggesting that we really need a higher dose in order for it to work. In one human study, patients had to be taking above 350 mg a day in order for the effects of cocaine to be significantly blunted (Haile CN et al, PLoS One 2012;7(11):e47702).
CATR: So would a clinician expect to see a higher rate of abstinence or less heavy use in patients taking disulfiram?
Dr. Newton: Most of your patients won’t look that much better, but some are able to take advantage of the benefit of the reduced effects of cocaine in order to quit. The way you are going to tell they are quitting, of course, is that their lives start to come back together again. Is their marriage better? Have they kept a job longer than they did last time? Are they paying their bills? Are they not being evicted? All the things that go with not doing drugs.
CATR: Any mistakes that you see clinicians making?
Dr. Newton: Just the mindset. Try to think of cocaine addicts like you think of smokers. For instance, people will try to quit seven times and might still be sneaking cigarettes every now and then. But eventually if they really stick to it, they will probably be able to quit. And nobody feels like they are failures because it took several times to quit smoking. People see them as kind of heroes for sticking with it so long. So that is what you have to remind yourself when you come up with a cocaine user who is on his seventh rehab. You have to prevent yourself from thinking that this guy is obviously never going to quit because it is taking so much time.