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Treatments options for cocaine users

This page refers to the current evidence on the effectiveness of the available treatment options for cocaine and crack users. Information on the methodology used and the definition of terms can be found on the methodology page.

Date of last update: 27.03.2013     Next update: May 2014

Effects of available treatments for cocaine users

Summary: Current evidence from randomised controlled trials on pharamcological treatment does not strongly support the use of the six classes of medication tested so far for treating cocaine dependence. Potentially favourable results exist for disulfiram in retaining patients in treatment. Psychosocial interventions, such as cognitive and/or behavioural interventions, have shown encouraging effects.

Beneficial

Disulfiram for the treatment of cocaine dependence

There is limited evidence, at present supporting the clinical use of disulfiram for the treatment of cocaine dependence, but some ongoing studies might improve the results. The findings given here are from a systematic review by Pani et al. (2010) of seven RCTs (N=492).

Disulfiram was found to be statistically significantly better than a placebo in:

  • retaining patients in treatment (two studies, N=87 patients, RR 0.82, 95 % CI 0.66 to 1.03);
  • reducing cocaine use (no pooled results) (results from single studies showed that, one in four comparisons was in favour of disulfiram), number of weeks abstinence, 20 participants, WMD 4.50 (95 % CI 2.93 to 6.07).

Disulfiram was found to be statistically better than naltrexone in:

  • reducing dropouts (three studies, N=131 participants, RR 0.67, 95 % CI 0.45 to 1.01).

Disulfiram was found to be better than no pharmacological treatment in:

  • reducing cocaine use (one study, N=90 participants) maximum weeks of consecutive abstinence, WMD 2.10 (95 % CI 0.69 to 3.51); number of subjects achieving three or more weeks of consecutive abstinence (RR 1.88, 95 % CI 1.09 to 3.23).

Likely to be beneficial

Antidepressants to reduce cocaine use

A multi-treatment meta-analysis (MTM) of 11 studies (N=898, EMCDDA 2014a) found antidepressants to be more effective than placebo in:

  • reducing use of cocaine (RR 0.72, 95 % CI 0.47 to 1.11)

Behavioural interventions

Behavioural interventions clearly performed better (in a systematic review of 27 randomised controlled trials involving 3.663 participants) than clinical management in the number of psychotherapy sessions attended (Knapp et al., 2007).

Behavioural interventions clearly performed better (in a systematic review of 27 randomised controlled trials involving 3.663 participants) than clinical management in reducing the number of patients using cocaine at one and three months (Knapp et al., 2007).

Real life examples
CRA plus vouchers for treating cocaine use, Netherlands

The aim of this project was to adapt, develop and test a standardised treatment approach based on the combination of the Community reinforcement approach and Vouchers (CRA + Vouchers) for cocaine-dependent patients in five treatment centres.
View this project in EDDRA »

Cognitive behavioural interventions

Cognitive behavioural interventions were found to be effective (in a systematic review of 27 randomised controlled trials involving 3.663 participants) in reducing dropouts from treatment and reduction in the use of cocaine, when compared with drug counselling (Knapp et al., 2007).

Dopamine agonists to reduce cocaine use

A multi-treatment meta-analysis (MTM) of 11 studies (N=752, EMCDDA 2014a) found dopamine agonists to be more effective than placebo in:

  • reducing use of cocaine (RR 0.64, 95 % CI 0.30 to 1.35)

Trade-off between benefits and harms

No interventions met the criteria for this category.

Unknown effectiveness

Anticonvulsants for cocaine dependence

There is no current evidence supporting the clinical use of anticonvulsant medication in the treatment of cocaine dependence.

Antidepressants to reduce craving

A multi-treatment meta-analysis (MTM) of 9 studies (N=429, EMCDDA 2014a) found no evidence for antidepressants when compared to placebo in:

  • reducing cocaine craving (RR - 0.03, 95 % CI -0.24 to 0.19)

Antipsychotic medications for cocaine dependence

Amato et al. (2007) found that, at present there is no evidence to support the clinical use of antipsychotic medications in the treatment of cocaine dependence. The antipsychotic drugs studied were risperidone, olanzapine and haloperidol, in seven studies (N=293 participants), and no significant differences were found for any of the efficacy measures comparing any antipsychotic with placebo.

Risperidone was found to be superior to placebo in diminishing the number of dropouts (four studies, N=178 participants, RR 0.77, 95 % CI 0.77 to 0.98).

The studies did not report useful results on important outcomes such as side effects, use of cocaine during treatment and craving.

Psychostimulants for sustained abstinence

Psychostimulants (bupropion and dextroamphetamine, and modafinil) showed a statistical trend over improving sustained cocaine abstinence (eight studies, including 800 patients, RR 1.41, 95 % CI 0.98 to 2.02, p=0.07) (Castells et al., 2010).

Psychostimulants to reduce use and dropouts, and to increase retention

Psychostimulants were found in a systematic review of 16 RCTs (N=1.345) by Castells et al. (2010) to be not effective in:

  • reducing cocaine use (seven studies, including about 500 patients) (SMD 0.11, 95 % CI –0.07 to 0.29);
  • retention in treatment (16 studies, including about 1.300 participants) (RR 0.97, 95 % CI 0.89 to 1.05);
  • reducing the dropouts caused by adverse events (11 studies, including about 1.000 patients) (RD 0.01, 95 % CI –0.02 to 0.03).

Therapeutic communities for the treatment of drug misuse and dependency

The treatment effectiveness of therapeutic communities was analyzed in a systematic review of seven trials with around 5 000 patients (Smith et al., 2006) as well as in a comprehensive review (EMCDDA 2014b). In both cases the analysis relied mostlyg on US research. Although some studies proved a potential for reducing substance use and criminal activity as well as increasing retention in treatment, there is still not enough robust evidence to prove their efficacy.

Therapeutic communities in prison

Therapeutic communities in prison for the treatment of drug misuse proved to be better than prison in avoiding re-incarceration at 12 months. Significantly fewer inmates assigned to prison therapeutic communities were re-incarcerated at 12 months post-release, compared with prison inmates receiving no treatment or assigned to alternative services (Smith et al., 2006).

Evidence of ineffectiveness

No interventions met the criteria for this category.

References and definitions

List of references

Explanation of terms used

Below you can find definitions and further explanation for some of the terms used in this section of the Best practice portal. A more general glossary for the best practice portal is also available.

Affective-focused prevention intervention

A type of prevention intervention which aims to they aim to modify inner qualities (personality traits such as self-esteem and self-efficacy, and motivational aspects such as the intention to use drugs).

BA

Before-after (BA) study design

BAL

Blood alcohol level (BAL)

Beneficial

Interventions for which precise measures of the effects in favour of the type of intervention were found in systematic reviews of relevant studies. An intervention ranked as ‘beneficial’ is suitable for most patients/contexts. See the relevant module methodology page for further information.

CBA

Controlled before-after (CBA) study design. UCBA stands for Uncontrolled before-after study design.

CBT

Cognitive behavioral therapy is an individual based intervention occurring in three stages. Phase 1 is aimed at determining and prioritizing the patient’s problems and constructing the treatment contract. Phase 2 is aimed at increasing coping competence and reducing risky behaviors. Phase 3 focuses on relapse prevention. Each session is administered once per week over a period of 4-6 months with 60- to 90-minute sessions (Beck AT, Wright FW, Newman CF, Liese B. Cognitive Therapy of substance abuse. New York: Guilford Press, 1993).

CCT

Controlled clinical trials (CCT)

Cohort study

A cohort study is a type of observational study that follows a group of people (i.e. a cohort) over time. In a prospective cohort study, the cohort is formed and then followed over time. In a retrospective cohort study, data is gathered for a cohort that was formed sometime in the past.

Confidence Interval (CI)

The Confidence Interval (CI) is a measure of the precision (or uncertainty) of study results. It is the interval that most likely includes the true value of the parameter we are calculating, where 'most likely' is taken by common usage to be a 95% probability. Thus the current expression of '95 % CI'. A wide CI indicates less precise estimates of effect and vice versa.

Practical interpretation

  • If the RR (the relative risk) = 1, or the CI (the confidence interval) = 1, then there is no significant difference between treatment and control groups
  • If the RR > 1, and the CI does not include 1, events are significantly more likely in the treatment than the control group
  • If the RR < 1, and the CI does not include 1, events are significantly less likely in the treatment than the control group
CPS

Current population survey (CPS)

Cross-sectional study

A cross-sectional study is a study employing a single point of data collection for each participant or system being studied.They are usually conducted to estimate the prevalence of the outcome of interest for a given population at a given point in time.

Evidence of ineffectiveness

Interventions that gave negative results if compared with a standard intervention or no intervention, for example. See the relevant module methodology page for further information.

Additional information for prevention
For ethical reasons this category in prevention should be considered as interventions with negative and undesired (iatrogenic) effect.

IP

Individual psychotherapy is a standard individual treatment based on counseling and motivational interviewing and focused on substance use triggers and strategies for relapse prevention. It includes elements of cognitive-behavioral therapy (CBT).

IQR

Interquartile range (IQR) - also called the midspread or middle fifty - is a measure of statistical dispersion. It is a trimmed estimator, defined as the 25% trimmed mid-range, and is the most significant basic robust measure of scale.

ITS

Intermittent time series design (ITS)

Knowledge-focused prevention intervention

A type of prevention intervention which aims to to enhance knowledge of drugs, and drug effects, and consequences.

Likely to be beneficial

Interventions that were shown to have limited measures of effect, that are likely to be effective but for which evidence is limited. An intervention ranked as ‘likely to be beneficial’ is suitable for most contexts/patients, with some discretion. See the relevant module methodology page for further information.

Number Needed to Treat (NNT)

The Number Needed to Treat (NNT)indicates the number of patients that needs to be treated to obtain one respondent patient. Numerically the NNT is the reciprocal of the difference between the proportion of events in the experimental and the comparison group (absolute risk reduction). Taking into consideration that the ideal NNT would be 1 (the unreal situation in which every single patient succeeded) it is easily understood that a NNT value close to 3 or 4 would be very good.

Adjusted Odds Ratio (AOR)

The Adjusted Odds Ratio is a way of comparing whether the probability of a certain event is the same between two groups, yet they are calculated adjusting for or controlling for other possible contributions from other variables (tipically demographic variables) in the model. An AOR equal to 1 implies that the the event is equally probable in both groups. An AOR greater than 1 implies that the event is more likely in the first group. An AOR less than 1 implies that the event is less likely in the first group.

Odds Ratio (OR)

The Odds Ratio is a way of comparing whether the probability of a certain event is the same between two groups. Like the Relative Risk, an OR equal to 1 implies that the the event is equally probable in both groups. A OR greater than 1 implies that the event is more likely in the first group. A OR less than 1 implies that the event is less likely in the first group. In medical research, the odds ratio is commonly used for case-control studies, as odds, but not probabilities, are usually estimated. Relative risk is used in randomized controlled trials and cohort studies.

p value

A p-value is a measure of how much evidence we have against the null hypothesis. The null hypothesis represents the hypothesis of no change or no effect. The smaller the p-value, the more evidence we have against the null hypothesis thus it is more likely that our sample result is true. Traditionally, researchers will reject a null hypothesis if the p-value is less than 0.05.

RBS

Responsible beverage service (RBS)

RCT

Randomised controlled trial (RCT)

Relative Risk (RR)

The Relative Risk (RR) is used to compare the risk in the two different groups of people, i.e. treated and control groups to see if belonging to one group or another increases or decreases the risk of developing certain outcomes. This measure of effect will tell us the number of times an outcome is more likely (RR > 1) or less likely (RR < 1) to happen in the treatment group compared with the control group.

Practical interpretation

  • If the RR (the relative risk) = 1, or the CI (the confidence interval) = 1, then there is no significant difference between treatment and control groups
  • If the RR > 1, and the CI does not include 1, events are significantly more likely in the treatment than the control group
  • If the RR < 1, and the CI does not include 1, events are significantly less likely in the treatment than the control group
Trade-off between benefits and harms

Interventions that obtained measures of effects in favour of the intervention, but that showed some limitations or unintended effects that need to be assessed before providing them. See the relevant module methodology page for further information.

 
Unknown effectiveness

Interventions for which there are not enough studies or where available studies are of low quality (with few patients or with uncertain methodological rigour), making it difficult to assess if they are effective or not. Interventions for which more research should be undertaken are also grouped in this category.

Additional information for prevention
For prevention interventions,  this  is also known as 'zero effect'.

Skill-focused prevention intervention

A type of prevention intervention which aims to enhance students’ abilities in generic skills, refusal skills and safety skills.

Standardised Mean Difference (SMD)

The Standardised Mean Difference (SMD) is the difference in means divided by a standard deviation. Note that it is not the standard error of the difference in means (a common confusion). The standardized mean difference has the important property that its value does not depend on the measurement scale. It may be useful if there are several trials assessing the same outcome, but using different scales.

z score (Standard Score)

The z-score (aka, a standard score) indicates how many standard deviations an element is from the mean of the population.

About cocaine use

Case definition

The Diagnostic and statistical manual, 4th edition, text revision (DSM-IV-TR) describes cocaine abuse as problem use leading to limited life problems, and cocaine dependence as compulsive use leading to numerous adverse psychological and physical consequences.

Overall, cocaine remains the second most used illicit drug in Europe, after cannabis, though levels of use vary greatly between countries. It is estimated that around 13 million Europeans have used it at least once in their lifetime, on average 3.9 % of adults aged 15–64 years.

Aetiology

Cocaine clients have one of the largest male to female ratios (five men for every woman) and one of the highest mean ages (around 32 years) among drug treatment clients. This is particularly the case in some countries with large numbers of primary cocaine clients, especially Italy where the sex ratio is 8:1 and the mean age 35 years.

Almost half of cocaine users start using the drug before the age of 20, and 88 % before the age of 30. Long time lags (9–12 years) between first cocaine use and first treatment entry are reported in Spain and Italy.

Prevalence

Cocaine use in Europe remains concentrated in western countries, where the trend is generally stable or still increasing. However, there is evidence of the further diffusion of the drug into other countries. Treatment demands related to cocaine are also growing. From the evidence available, it is possible to conclude that current consumption levels remain high and are not diminishing in established areas, and are continuing to grow elsewhere. In 2007 cocaine was the principal drug reported by users entering treatment in outpatient by the 18 % of the clients.

Treatment

In Europe, public drug treatment facilities are mostly oriented towards the needs of opioid users, and those focusing on the treatment of cocaine users are rare and often private. Some countries (e.g. Ireland, Italy, Spain), however, have implemented strategies or treatment programmes targeting cocaine users, and France is in the process of developing such programmes. The heterogeneity of cocaine users, and of their problems and needs, complicates the organisation and delivery of treatment services to those who need them.

Outcomes

Treatments may not be effective in achieving all the desired outcomes, these outcomes are prioritised.

Primary outcomes

  • Retention in treatment (observational studies* showed that people in treatment are less likely to take risks, and to be involved in crimes).
  • Acceptability of the treatment, side effects experienced during the treatment.
  • Use of cocaine.

* studies such as National Treatment Outcome Research Study – NTORS, Australian Treatment Outcome Study – ATOS

Prognosis

Two main groups of cocaine clients have been identified in treatment — socially integrated individuals using powder cocaine, and a more marginalised group of clients using cocaine (often crack-cocaine) in combination with opioids.

References

American Psychiatric Association (2000), Diagnostic and statistical manual of mental disorders, 4th edition, text revision, American Psychiatric Association, Washington, DC.

EMCDDA statistical bulletin

EMCDDA , Annual report: the state of the drugs problem in Europe, EMCDDA, Lisbon

Minozzi, S., Amato, L., Davoli, M., et al. (2008), ‘Anticonvulsants for cocaine dependence’, Cochrane Database of Systematic Reviews, Issue 2.

Silva de Lima, M., Farrell, M., Lima Reisser, A. A. R. L., Soares, B. (2010), ‘Antidepressants for cocaine dependence’, Cochrane Database of Systematic Reviews, Issue 2.

Soares, B., Lima Reisser, A. A. R. L., Farrell, M. and Silva de Lima, M. (2010), ‘Dopamine agonists for cocaine dependence’, Cochrane Database of Systematic Reviews, Issue 2.

Ongoing studies

Cocaine related ongoing studies (PDF, updated January 2011)

About the EMCDDA

The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is the reference point on drugs and drug addiction information in Europe. Inaugurated in Lisbon in 1995, it is one of the EU's decentralised agencies. Read more >>

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Page last updated: Tuesday, 09 September 2014