Cocaine

BY
DR.NIRUPAMA
2ND YEAR PG
DEPT. OF PSYCHIATRY
 What is it?
 Pure cocaine was first isolated from the leaves
of the coca bush in 1860.
 Contained in small amounts in the leaves of
erythroxylum (coca) bush
 Researchers soon discovered that cocaine
numbs whatever tissue it touches.
 This lead to it’s use as a local anesthetic.
 Erythoxylon coca

 Native to eastern slopes of

Andes
 Cocaine alkaloid serves as
natural pesticide
 Leaves contain 0.1-0.9%
cocaine

www.cocaine.org
Where does it come from?
 Coca leaves grow on the slopes of the Andes Mountains in
South America.
 For at least 4,500 years, people in Peru & Bolivia have
chewed the coca leaves to lessen hunger & fatigue.
 Most of the world’s supply of coca is grown & refined into
cocaine in Colombia.
Street Names
Known on the street as:
 Coke
 Snow
 Flake
 Blow
 A smokable form of cocaine- crack cocaine.
Sometimes called “rock” or “freebase”
Cocaine: A Short History

• Stimulants: Cocaine.
• In pre-Columbian times, the coca leaf was officially
reserved for Inca royalty.
• Later used by natives but initially banned by the
Spanish.
• Labeled “an evil agent of the Devil”.
• Without it, natives could barely work the fields or gold
mines, . . .So, Distributed to workers 3-4 times a day.
Cultivated even by the Catholic Church.
• Active ingredient isolated by Albert Niemann in 1860.
• Widely used recreationally and medicinally in late 1800’s.
 In the 1880’s, psychiatrist Sigmund Freud wrote and
prescribed cocaine as a treatment for many ailments such as
depression & addiction to alcohol and opiates.
•The first cocaine cartel, the Cocaine
Manufacturers’ Syndicate,founded in 1910.

Merck, along with Sandoz, and Hoffman-LaRoche

A Panacea for Your Ills

www.cocaine.org
A Panacea for Your Ills

www.cocaine.org
A Panacea for Your Ills

“ sustains and refreshes both the body and

brain. . .It may be taken at any time with
perfect safety. . . It has been effectually
proven that in the same space of time more
than double the amount of work could be
undergone when Peruvian Wine of Coca
was used, and positively no fatigue
experienced. . .”
Sears, Roebuck and Co. Consumers’ Guide (1900)
The Pope on Coke

www.cocaine.org
American Ingenuity

 John Pemberton (1832-1888)

Pemberton’s French wine coca

“an intellectual beverage”

“a most wonderful invigorator of the

sexual organs”
  Introduction of Prohibition in 1886

Pemberton’s French wine coca

Coca-Cola
The temperance drink
On May 8, 1886, Dr. John Pemberton sold the first glass
of Coca-Cola at Jacobs' Pharmacy in downtown Atlanta.
Serving nine drinks per day in its first year, Coca-Cola
was new refreshment in its beginning.

Coca-Cola
 “Offering the virtues of coca
without the vices of alcohol”
 “a valuable brain-tonic and cure
for all nervous afflictions”
 The Real Thing: 60 mg cocaine
per serving (until 1903)
EPIDEMIOLOGY
• Cocaine is the second most frequently used illegal drug
globally, after cannabis.
• In a 2010 study Crack cocaine and cocaine was found to be the
third and fifth overall most dangerous drugs respectively.

• Around 14 - 21 million people use the drug each year. With

highest prevalence in USA(2.7) followed by England(2.6),
Australia(2.5) while India has (0.1).
• Cocaine is the most commonly used illicit drug among patients seen
in the ER and drug-treatment centers.
 Cocaine is the most frequent cause of drug-related deaths.
 Adults 18 to 25 years old have a higher rate of current cocaine use
than those in any other age group.
 Overall, men have a higher rate of current cocaine use than do
women.

1999 National Household Survey on Drug Abuse

 Crack is cocaine (cocaine base), but not in the powder
form.
 The powder form (cocaine hydrochloride) is usually
“snorted” intranasally, producing a “high” of less intensity.
 A high temperature (195°C) is required to vaporize
cocaine hydrochloride powder for smoking.
 The powder has a slower onset of action to produce the
euphoric effects compared with crack, which is a solid
formed by mixing cocaine powder with water and baking
soda.
 This transformation makes crack a drug that is easier and
more economical to market and, consequently, much less
expensive.
 Crack is in a form that allows it to be vaporized at a much
lower temperature (98°C), without burning and destroying
excess cocaine.
 Getting cocaine into a vapor form or smoke is important to
cocaine users for 2 reasons.
 The first is that, when smoked, the drug is delivered
through the lungs to the brain almost immediately. It then
causes release of brain chemicals in the pleasure centers of
the brain, resulting in the desired stimulating, euphoric
effects.
 The second reason is that the crack form does not waste
cocaine by burning it up.
Cocaine leaves.

www.cocaine.org
Cocaine Hydrochloride

www.cocaine.org
Free-base cocaine: Crack

www.cocaine.org
How is it used?
Snorted
Smoked
Injected
Pharmacokinetics of Cocaine

NEJM, 345:351, 2001

Neurochemistry
 Cocaine has numerous effects on many important
neurotransmitters in the brain; however, the most
dramatic effect is on the increase as well as the release of
dopamine.
 Dopamine is thought to be the primary neurotransmitter
involved in the pleasure centers of the brain. Its release is
associated with pleasure and a sense of well-being and is
often a “reward” for certain behaviors.
 Excessive dopamine levels have also been hypothesized to be
associated with anger, aggressiveness, hallucinations,
delusions, and other psychotic symptoms.
 Cocaine also initially increases levels of norepinephrine
and serotonin, 2 other essential neurotransmitters.
 Norepinephrine is responsible for alertness, activation,
increase in heart rate and blood pressure, and preparing
the body for emergencies, such as “fight-or-flight”
situations.
 Serotonin is partially responsible for regulating mood,
appetite, and sleep, as well as other essential behaviors.
After repeated use of cocaine causing “instant” release of
these brain chemicals, an overall depletion of dopamine,
norepinephrine, and serotonin gradually occurs. A
person's compulsive use may be an attempt to maintain
the neurotransmitters at homeostatic levels.
Figure 10.7: Reward Pathways in Brain Affected by
Different Drugs
Metabolism of Cocaine

• Serum half life of 45-90 minutes

• Only 1% of the drug is recovered in urine after ingestion.
• Cocaine can be detected in blood or urine only for several hours
after its use.
What happens in the
body after taking
cocaine
 Brain - Cocaine can constrict blood vessels in the
brain, causing strokes. This can happen even in young
people without other risk factors for strokes. Cocaine
causes seizures and can lead to bizarre or violent
behavior.
When someone gets “high” on cocaine, where
does the cocaine go in the brain?

 With the help of a radioactive tracer, this PET scan

shows us a person’s brain on cocaine and the area of
the brain, highlighted in yellow, where cocaine is
“binding” or attaching itself. This PET scan shows us
minute by minute, in a time-lapsed sequence, just how
quickly cocaine begins affecting a particular area of
the brain.
 At the 5- to 8-minute interval, we see that cocaine is
affecting a large area of the brain. After that, the
drug’s effects begin to wear off. At the 9- to 10-minute
point, the high feeling is almost gone.
 Unless the abuser takes more cocaine, the experience is over
in about 20 to 30 minutes.
 We start in the upper left hand corner. You can see that 1
minute after cocaine is administered to
this subject nothing much happens. All areas of the brain are
functioning normally. But after 3 to 4 minutes [the next scan
to the right], we see some areas starting to turn yellow. These
areas are part
of a brain structure called the striatum that is the main target
in the brain bound and activated by cocaine.
 Scientists are doing research to find out if the striatum
produces the “high” feeling and controls our feelings of
pleasure and motivation.
 One of the reasons scientists are curious about specific
areas of the brain affected by drugs, such as cocaine, is to
develop treatments for people who become addicted to
these drugs.
 Scientists hope to find the most effective way to change
an addicted brain back to normal functioning.
Long-term effects of drug abuse

The images in these PET scans, which depict brain

glucose utilization (a marker of brain activity), show that
once the brain becomes addicted to a drug like cocaine, it is
affected for a long time.

In other words, once addicted, the brain is literally

changed.
The memory of drugs
 This slide demonstrates how just the mention of items associated
with drug use may cause an addict to crave or desire drugs. This
PET scan is part of a scientific study that compared recovering
addicts, who had stopped using cocaine, with people who had no
history of cocaine use. The study hoped to determine what parts of
the brain are activated when drugs are craved.
 For this study, brain scans were performed while subjects watched
two videos. The first video, a nondrug presentation, showed nature
images—mountains, rivers, animals, flowers, trees. The second video
showed cocaine and drug paraphernalia, such as pipes, needles,
matches, and other items familiar to addicts.
 This is how the memory of drugs works: The yellow area on the
upper part of the second image is the amygdala , a part of the brain’s
limbic system, which is critical for memory and responsible for
evoking emotions. For an addict, when a drug craving occurs, the
amygdala becomes active and a craving for cocaine is triggered.
 So if it’s the middle of the night, raining, snowing, it doesn’t matter.
This craving demands the drug immediately. Rational thoughts are
dismissed by the uncontrollable desire for drugs. At this point, a
basic change has occurred in the brain. The person is no longer in
control. This changed brain makes it almost impossible for drug
addicts to stay drug-free without professional help. Because
addiction is a brain disease.
Cardiovascular Consequences of
Cocaine Use
 Myocardial  Dilated
ischemia/infarction cardiomyopathies
 Hypertensive Crisis  Stroke
 Aortic Dissection  Limb Ischemia
 Cardiac arrhythmias  Endocarditis
(VT/VF)  Acceleration of
 Myocarditis atherosclerosis
Risk of Myocardial Ischemia and
Infarction in Cocaine Users

 Cocaine use increases risk of acute MI by 24-fold during the first

hour after its use
 Cocaine users have a 7-fold increase in their lifetime risk of MI
than non-users
Risk of Myocardial Ischemia and
Infarction in Cocaine Users
• Cocaine use accounts for up to 25% of AMI in patients 18-45
years of age
• The risk of MI is unrelated to amount of drug used, route of
administration, or the frequency of use.
 Lungs and respiratory system. Snorting cocaine
damages the nose and sinuses. Regular use can cause
nasal perforation. Smoking crack cocaine irritates the
lungs and, in some people, causes permanent lung
damage.
 Sexual function. Although cocaine has a reputation as an
aphrodisiac, it actually may make you less able to finish
what you start. Chronic cocaine use can impair sexual
function in men and women. In men, cocaine can cause
delayed or impaired ejaculation.
ADVERSE EFFECTS
 OVERDOSE (>1.2gm)
 Hyperthermia, cramps, convulsions.
 Respiratory depression
 Episodes of agitation

 IN PREGNANCY
Placental abruptions, malformations, cleft lip& palate

 LAB DIAGNOSIS
 Metabolites of cocaine and amphetamine can be detected in blood, hair, sweat,
saliva, and urine.
 The two most important metabolites of cocaine are benzoylecgonine and ecgonine
methyl ester .
Pregnancy and Cocaine

Increased risk of
 Premature birth
 Low birth weight
 Smaller than normal head size
 Shorter than normal length
 HIV or hepatitis virus exposure
Short-term effects
 Dilated pupils
 Increased body temperature, Blood pressure & heart rate
 Insomnia
 Loss of appetite
 Increased energy
 Reduced fatigue
 Mental clarity
 Talkativeness
Long-term effects
 Paranoia
 Depression
 Ulcers in the membranes of the nose
 Changes in the chemistry of the brain
 Dulled senses of taste & smell
 Weight loss, poor health & sexual dysfunction
 Loss of social & financial supports
 Holes in bony separation between nostrils in nose
 Cocaine’s Physiological Effects

• Increased Alertness • Confused Behavior

• Decreased Fatigue
• Increased Concentration
• Insomnia
• Increased Irritability
• Increased Psychosis
• Increased Fear
• Extreme Paranoia
• Severe Anxiety Attacks
• Hallucinations (in
extreme cases)
• Aggressive Behavior
PSYCHIATRIC IMPLICATIONS
EFFECTS OF COCAINE USE

Initial Effects:

Crack produces effects almost instantaneously, within

seconds, whereas intranasal powder cocaine may
require 5 to 10 minutes to produce effects.

These effects consist of intense euphoria, pleasure, and

ecstasy, states in which everything pleasurable is
intensified.
 After approximately 5 to 20 minutes of this arousal,
the person will start to feel irritable and
uncomfortable.
 “I get restless and agitated and keep doing it. I dunno…
it's crazy.”
 “It's the most horrible depression I ever got. The only
thing to do is do more coke, but it doesn't help… ”
 In an attempt to avoid this discomfort and “recapture”
the initial high, people frequently compulsively smoke
again.
Cocaine Dependence
To satisfy the criteria for the diagnosis of cocaine dependence, only 3
of the following conditions must be present according to the American
Psychiatric Association's Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition:

•Developing tolerance to the euphoric effects of cocaine and requiring

more drug to produce the desired effects.

•Stopping cocaine usually results in withdrawal symptoms (such as

fatigue, sleep disturbances, agitation, or depression), and these
symptoms can be relieved by using cocaine again.
 Using cocaine in large amounts whenever it is
available. (Seldom do people save some for later.)
 Inability to successfully reduce the amount of cocaine
one is using.

 Spending a great deal of time and energy obtaining

and using cocaine, which isolates one from friends and
family, and/or engaging in unlawful activities such as
shoplifting, theft, burglary, or homicide to obtain
money to buy cocaine.
 Inability to successfully maintain employment while
using cocaine because of ineffectiveness at work,
increased absenteeism, inability to hold a job, or
inability to find work.

 Continually using cocaine despite knowing one will

develop mental symptoms, such as paranoia,
hallucinations, and delusions, and/or continually
using cocaine despite medical consequences, such as
weight loss, anemia, or seizures.
 Addiction and Withdrawal

Those who use cocaine heavily or regularly find

it extremely difficult to stop and often suffer
through serious withdrawal symptoms such as:

• Severe Irritability • Excessive Sleep

• Chronic Depression • Eating Disorders
• Paranoia • Nausea / Vomiting
• Loss of Sex Drive • Diarrhea
• Insomnia • Heart Attack
Cocaine Withdrawal

 Dr. Frank Gawin has stated that “the fundamental

effect of cocaine is the magnification of the intensity
of almost all normal pleasures.”
 This is an obvious reason why a person repeatedly uses
cocaine. However, he has also described the patterns
that evolve when cocaine is stopped: the cocaine
abstinence syndrome.
 This syndrome often involves a “crash” and a
withdrawal phase. During the withdrawal phase,
anxiety, hostility, paranoia, and depression have been
observed.
 At this time, levels of the neurotransmitters norepinephrine and
serotonin are thought to be significantly lowered due to the
chronic depletion caused by cocaine use. The rapid reduction in
the intensity of these withdrawal symptoms can constitute a
major reason a crack addict continues use.
 Cocaine also has potent reinforcing effects, defined as “any effect,
positive, negative, or both that maintains the behavior that leads to
continued administration of the drug.”
 Thus, the use of cocaine “rewards” certain parts of the brain with a
release of the neurotransmitter dopamine. In this situation, the
reward is a reduction or elimination of the withdrawal symptoms.
What is a Dual Diagnosis?
 To have a dual diagnosis means that a person has been
evaluated by a professional, and determined be suffering from
both a substance use disorder and some other mental health
condition. Struggling with two disorders at the same time can
be complicated, often leading to:
 More extreme symptoms.
 Difficulty sticking to a treatment or medicine schedule.
 Poor social adjustment.
 Impaired decision making.
 Dysfunctional thought processes.
DIAGNOSIS

 ICD-10 :
Mental and behavioural disorders due to use of
cocaine – F 14
 DSM-V :
304.20- cocaine dependence
305.60- cocaine abuse

 Neuropsychiatric complications occur in

approximately 40% of cocaine users.
 Paranoia and Psychosis

 Long-term cocaine abuse can elicit temporary psychotic

symptoms such as hallucinations and paranoia. This is known
as cocaine-induced psychosis, and it can be difficult to distinguish
from schizophrenia.

 In these instances, these symptoms are often temporary and stop

once the user maintains abstinence. Cocaine-induced paranoia can
be transient, lasting a few hours to weeks.
 Paranoia occurs in 68% to 84% of patients using cocaine.
 Psychosis, including hallucinations and delusions, has
frequently been reported in cocaine users (from 29% to 53%
of users). These psychotic symptoms may be related to an
imbalance of dopamine.
 Psychosis appears to be more common with the use of crack
compared with other routes, such as intravenous and intranasal
use
 Both the amount of cocaine used and earlier onset of first
use are correlated with the development of cocaine-induced
psychosis, though strangely the total number of years using is
not related.
 Cocaine bugs: A brief case
report of cocaine-induced
delusion of parasitosis

Quarenta J, Martins S, Teixeira T, Ribeiro JP. Cocaine bugs: A brief case report of cocaine-induced delusion of parasitosis. European
Psychiatry. 2021;64(S1):S643-S643. doi:10.1192/j.eurpsy.2021.1708
 Delusional parasitosis (DP), also know as Ekbom
syndrome and in some cases as Morgellons, was first
described in the late 17th century in France.
 It is an obsessive phobic state in which the patient
believes that the is infested by parasites. In the
hallucinatory state, they frequently remove parts of
the skin, identifying them as parasites.
 The cause of DP is unknown. Evidence supporting the
dopamine theory defend that the inhibition of
dopamine reuptake (for example cocaine and
amphetamines) induce symptoms such as
formication.
Clinical case

 A 48-year-old woman was brought to the

psychiatric emergency due to psychotic
symptoms following cocaine use. She had a
history of drug abuse.
 She was apparently asymptomatic until October
2019, when, in the background of vague
sensation of something crawling under his skin,
she developed a sudden onset belief that she had
been infested by insects that crawled under his
skin.
 Previous medical observation found no reason for a
skin infection or infestation. Skin examination revealed
itch marks and skin excoriations in the abdomen.
 Mental status examination revealed anxious and
depressive affect, delusion of parasitosis, tactile
hallucination and impaired insight.
 Routine hemogram and urinalysis was unremarkable,
except for the detection of cocaine.
 Conclusions:-- Delusional parasitosis often presents to
nonpsychiatric medical professionals. An awareness of such
illness, with an early recognition and timely referral are
management cornerstones in order to successfully diagnose and
treat patients.
VIOLENCE
• Violence has been associated with cocaine use. Cocaine-induced
psychiatric symptoms undoubtedly contribute to the emergence
of violence. In a study of 31 patients with cocaine-induced
psychiatric symptoms, 55% had cocaine-related violent
behaviors.
• In a telephone survey of 452 cocaine users, the following
symptoms were reported: anger (42%), violence (32%), and
suspiciousness or paranoia (84%).
 Violent crimes were committed by 46% of users,
usually to get crack.
 In this same report, the authors discuss an additional
study, which found that 26% of 200 crack users
admitted to committing a crime while on crack; 95%
of these crimes were violent.
 The authors of this report hypothesized that violent
behavior associated with cocaine use is predictable
based on the effects cocaine has on neurotransmitter
dysfunction.
 Besides an increase in levels of neurotransmitters in the brain's
pleasure centers, dramatic change in levels of norepinephrine
and serotonin in other parts of the brain might provoke
aggression, hyperactivity, impaired judgment, and paranoia.
 Inhalation of crack cocaine has been found to produce a
greater amount of anger and violence than intranasal use of
cocaine. Similarly, daily use of crack cocaine has been
associated with a greater number of illicit activities.
 The neurotransmitter norepinephrine, released by cocaine, is
also involved in “fight-or-flight” behavior. Individuals who
use cocaine are often hyperalert and “armed to the outside
world.”
 Any rapid or unexpected movement by those around them
“may be interpreted as hostile.” All of these factors may
contribute to a cocaine-violence connection.
 Cocaine abusers may have problems with thinking
logically. The most frequently reported cognitive
difficulties involve impaired executive functioning
(decision making, judgment
attention/planning/mental flexibility), and research has
shown that this cognitive domain relates primarily to the
functional integrity of the prefrontal lobe.
 This area of the brain also regulates impulse control. The
resultant effects would be poor judgment in an individual
experiencing impulsivity in the face of severe cocaine craving.
 Homicide
 Homicide also has been associated with cocaine use. In New
York City, 31% of 2824 homicide deaths were found to test
positive for cocaine or its metabolite, benzoylecgonine.
 A marked number of residents of New York City (27%) who
had fatal injuries also tested positive for cocaine use. Fatal
injuries secondary to homicide accounted for 29% of these
victims.
 Other cities have reported similar disturbing findings. One study
found that 18% of homicide victims in New Orleans tested
positive for cocaine. In Los Angeles, violent death occurred in
61% of individuals who died and tested positive for cocaine at
autopsy.
Suicide.

 Suicide can be viewed as a form of self-

destructive, violent behavior.
 In one study of 749 cases of suicide in New
York City, cocaine was present in 18% to
22% of cases.
 Suicide may be caused by depression,
which occurs frequently in people using
cocaine.
 DELIRIUM
 Delirium, a potentially fatal syndrome marked by severe, fluctuating
confusion and autonomic nervous system instability (such as severe
blood pressure changes, pulse changes, and sweating), can occur with
cocaine use.
 Changes in dopamine, norepinephrine, and serotonin levels have been
associated with these effects. Delirium can be accompanied by
psychotic symptoms (such as paranoia, hallucinations, delusions, and
agitated behavior).
 One report noted that 7 individuals with fatal cocaine intoxication
developed an excited delirium with intense paranoia and bizarre and
violent behavior, requiring forcible restraint.
Cocaine Addiction and Depression

 Lifetime prevalence rates of depression among

people seeking treatment for cocaine abuse range
between 25% and 61%. People who are coping
with depression may even experience more
intense euphoria when using cocaine as well as
more intense cravings and withdrawal symptoms
compared to non-depressed users when they do
not use.
 All of these factors may contribute to an even
more severe cocaine dependency among
depressed users.
 Studies indicate that the antidepressant medications prescribed
will work best if they possess a similar, activating effect profile
as cocaine—depressed abusers should not be prescribed sedating
medications, as it may exacerbate the underlying mood disorder.
 Desipramine and buproprion are more stimulating
antidepressant medications that may work best for recovering
cocaine users.
 Two effective therapeutic modalities employed to treat a
dual diagnosis of cocaine abuse and depression
include cognitive behavioral therapy and motivational
interviewing.
 Cognitive-behavioral therapy, is utilized to alter the
mindset of the addicted individual, and curtailing
maladaptive drug use behavior in response to stressors
and other precipitating life events.
 Motivational interviewing uses positive incentives to
promote change.
Bipolar Disorder

 Cocaine dependence among people with bipolar disorder has

lifetime prevalence rates from 15% to 39%. The impact of
substance use on bipolar disorder is overwhelmingly negative,
with more hospitalizations, more aggression, and less adherence
to medications.
 A wide range of specific brain functions may be significantly
more compromised in those with a dual diagnosis of cocaine use
disorder and bipolar disorder than in bipolar disorder alone,
making this particular dual diagnosis one of the strongest risk
factors for poor treatment adherence among people with bipolar
disorder.
 Bipolar patients must take medication in order to manage their
disorder—care must be taken so that any other medication taken to
manage cocaine cravings and/or withdrawal cannot react with
bipolar medications.
 Citicoline is an inexpensive, over-the-counter supplement that has
shown promising results in reducing cocaine cravings. Because it
has no known drug-drug interactions, it is a viable option for
patients with comorbid bipolar disorder who need to take
medication to manage their bipolar symptoms.
 In addition to medication management, therapy continues to be an
important part of dual diagnosis recovery.
Emotional Blunting
• Cocaine addiction can lead to reduced brain activity in
regions related to emotional processing and error
awareness.
• People addicted to cocaine also show problems in social
interactions, placing value on their own gains when
interacting with other people and less concern about how their
behaviors affect both themselves and those around them.
• Cocaine-dependent people have exhibited blunted
emotions and egocentrism, and their risk of having an anti-
social personality disorder is 22 times that of non-users.
• This impaired emotional/social processing and
reduced error recognition can be thought of as
a problem with self-awareness, and it is
present in a number of other psychological
disorders. Adequate social skills can have a
major impact on the development and
outcome of mental disorders as well as
stimulant use disorders, so this cocaine-
induced impairment presents a particular
challenge to this type of dual diagnosis
treatment.
 Cocaine and ADHD
.

 Attention deficit hyperactivity disorder (ADHD) is a

mental disorder characterized by difficulty staying
focused, behavioral control problems and
hyperactivity.

 Adults who have untreated ADHD may be at increased

risk for substance abuse, and rates of ADHD diagnoses
are higher in substance abusers than the general
population. A diagnosis of ADHD is particularly
associated with a higher risk of cocaine use disorder.

Wilens, T.E. (2004). Impact of ADHD and its treatment on substance abuse in
adults. Journal of Clinical Psychiatry, 65(3). 38–45
 Dopamine deficiency is believed to be involved in the
development of ADHD. This means that both ADHD and
cocaine addiction may involve the brain’s real or perceived
deficit of dopamine. Theoretically, the abuse of cocaine
among people diagnosed with ADHD may be a form of self-
medication to relieve ADHD symptoms.
 A dual diagnosis of ADHD and cocaine dependence can be
effectively treated with proper therapy and prescription
medications. Preliminary research trials have evaluated the
efficacy of oral amphetamines in the treatment of cocaine
dependence.
 Studies on extended-release formulations (where the effect
of the medication is experienced over a period of time) are
well-tolerated and have shown significant reductions in
cocaine use.

 In one randomized control trial, extended-release mixed

amphetamine salts taken with cognitive behavioral therapy
sessions was shown to be effective in treating cocaine
dependence and reducing ADHD symptoms.

 It is important to note that the research is still in early

stages and some treatments are not FDA approved yet
MANAGEMENT
 Pharmacotherapy utilizing antidepressants and
anticonvulsants, as well as dopaminergic and opioid
antagonists/mixed agonists, has been used with varying
results.
 Pharmacologic agents that decrease kindling, such as
valproic acid and carbamazepine, may potentially be
useful in treatment.
 All psychiatric symptoms need to be treated aggressively
to prevent them from getting worse as well as more
frequent. If suspiciousness, paranoia, and hallucinations
continue after the person stops using cocaine, a dopamine
blocker, such as haloperidol, should be considered.
 Successful treatment usually involves 12-step
programs, behavioral and supportive psychotherapy,
as well as family therapy, as this illness affects
everyone in a family.
 Recovering addicts may require initial and/or long-term
treatment with nonaddictive medications to help
normalize brain chemistry. All substances with potential
for abuse need to be stopped. Learning and practicing
alternative, safe activities that produce pleasure and
“reinforcement” are essential in treatment and recovery.
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