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Harvard Commentaries
35320
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Minding Your Mind Minding Your Mind
 

Overcoming Cocaine or Stimulant Addiction


July 17, 2012

By Michael Craig Miller M.D.

Harvard Medical School


Millions of Americans either abuse or are dependent on illegal drugs like cocaine, methamphetamine (also known as speed, meth, ice, or crank), and methylenedioxymethamphetamine (often called MDMA or "ecstasy"). These stimulants are among the most commonly abused drugs in the world. They are also some of the toughest substances for addicts to quit.

Some stimulants — such as methylphenidate (Ritalin) and dextroamphetamine (Adderall) — are prescribed for conditions like attention deficit disorder and some sleep disorders. But they can also be abused. When they are crushed, snorted or injected, these drugs create a euphoric sensation.

Most mental health professionals see psychotherapy as the primary way to treat stimulant addiction. If depression or anxiety are aggravating the addiction, medications can help to treat those problems. Although researchers have been working to find medicines to specifically treat stimulant addiction, as yet none are specifically approved by the U.S. Food and Drug Administration for this purpose.

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Behavioral Therapies

Addictive behavior is sometimes called "over-learned" because it is almost completely automatic. Thus, an important goal of psychotherapy is to help addicts "unlearn" their addiction, to adopt routines that may combat cravings and to use techniques that will help them slowly build a drug-free life.

    • Cognitive behavioral therapy helps people to recognize and avoid drug triggers and learn new ways of coping without drugs.

 

    • Contingency management uses tangible rewards and incentives — such as vouchers that can be exchanged for movies or dinner — to encourage people to refrain from using stimulants.

 

    • The Matrix Model is a broad-based treatment that combines behavioral therapy, family education, individual counseling, a 12-step self-help program and drug testing.

 

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Medications

Here are some of the medications being studied as treatments for stimulant addiction.

    • Disulfiram (Antabuse) is approved for treating alcohol dependence. Some research suggests that disulfiram may also help reduce cocaine use. Patients who use cocaine while taking disulfiram report anxiety, paranoia, and lack of euphoria. Although some clinicians are concerned about side effects, disulfiram is generally safe as long as it is prescribed at doses of 250 milligrams or less per day. The most common side effects include headaches, fatigue, sleepiness and anxiety. Experts recommend against using disulfiram to treat cocaine addiction in people with serious cardiovascular or liver problems, or in those with multiple mental disorders.

 

    • Baclofen (Lioresal) is used to treat muscle spasms in a number of neurological conditions. It was proposed as a way to treat co-caine addiction because it slows the release of several chemical messengers in the brain. Research has shown that it may be helpful for people with moderate addiction or for people trying to prevent relapse. It may not be so good at reducing craving or treating severe addiction.

 

    • Topiramate helps prevent seizures. One of its effects is to modify brain circuits involved in reward and reinforcement. In a couple of studies, topiramate helped people addicted to cocaine remain abstinent or it reduced cravings while they also participated in behavioral therapy. But the studies were small, so there is not enough evidence yet to support its use. There is little evidence on whether it is helpful for treating Ecstasy addiction. And it may actually make methamphetamine addiction worse.

 

    • Modafinil (Provigil) is a stimulant that is approved for treating narcolepsy and other sleep disorders. Research suggests that modafinil can reduce cravings for amphetamines or cocaine. Other research has suggested that the drug may help delay the type of impulsive reaction that underlies addiction. Overall, it has not proven to be better than placebo, but it appears to be helpful in some sub-populations of cocaine users (in particular, in people who also have alcohol dependence).

 

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Using the Immune System To Relieve Addiction

Researchers have been working for decades on ways to use the immune system to fight stimulant addiction.

The idea behind drug vaccines is to prod the immune system to make antibodies that recognize and bind to the stimulant. The new molecule that is formed is too large to pass through the membrane that separates the brain from the bloodstream. By blocking the drug's access to the brain, scientists hope to reduce both the pleasurable effects of drug use and the subsequent drug cravings. Scientists are using several methods to try to achieve this.

Researchers are also investigating a technique called "passive immunization." Rather than using a vaccine to stimulate the body to actively produce antibodies, the idea is to inject drug-specific antibodies. Theoretically such antibodies could have the same helpful effect, that is, to bind to the addictive drug and prevent it from getting into the brain.

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Positive Signs

Researchers haven't yet discovered a simple medicine or vaccine that could relieve stimulant addiction. Behavioral therapies and selective use of medication are still the best hope.

The good news is that new statistics give a more encouraging picture of addiction. It turns out that 7 out of 10 Americans do eventually seek treatment for their addictions, even if it takes them a while — sometimes years — to do so. And among the people who don’t seek help, many find a way to limit drug use.

Attitudes about addiction are changing, too. Clinicians have an increasing appreciation that addiction is based on powerful biological processes that are not so easy to resist. Like other mental disorders, addiction cannot be seen as a moral failing.

Clinicians also know that relapse is an almost inevitable part of recovery, so "tough love" and "zero tolerance" approaches are giving way to more respectful attitudes.

The biggest step may be to seek help in the first place. Maybe more people who are struggling with addiction will reach out if they believe they will be treated with respect and understanding, rather than punitive toughness.

Michael Craig Miller, M.D. is editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 25 years.

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