Treatment for Cocaine-induced Disorders with Onset During Withdraw: Mental Health Informed Addiction Treatment
Brandon Bruce Dellario LMSW LASAC
“Most people with dual diagnoses report the onset of substance-use disorder later than the onset of other mental disorders. Prospective studies confirm this temporal order, but with some mental disorders (e.g. anxiety and depression) the risk relationship is recipricol, with these mental disorders predicting increased risk of later substance abuse, and vice versa.
”(Emmelkamp, 2006 pg. 12)
The most effective treatment techniques for cocaine induced disorders with onset during withdraw, may include a combination of psychosocial and pharmacotherapy treatment. Methods of psychosocial treatment can be self-help groups, individual and group counseling, and behavioral approaches. Some of these evidence-based practices are 12 step programs and other mutual-help groups, Cognitive-behavioral therapy (CBT), Contingency management, advice, counseling and residential treatment.
Pharmacotherapy is the use of specific agents to aid in treatment. Evidence-based medications such as disulfiram, topiramate, modafinil and long-acting amphetamines may be helpful in reducing cocaine use.(Rastegar, 2005 pg. 151) Many medications are used by doctors to treat this population including; stimulants like modafinil (Provigil), antiepileptic drugs like topiramate (Topamax), both used to treat stimulant cravings. Bromocriptine (Parlodel), amantadine (Symmetrel), levodopa combined with carbadopa (Sinemet) these are dopamine agonists used to suppress withdraw symptoms and initial stimulant cravings. Antidepressants, Antipsychotics (neuroleptics), Sedatives, and nutritional approaches are all used to treat the depletion of dopamine and neurotransmitters which are caused by cocaine dependence.
The depression, mood disorders, anxiety, sleep disturbances and psychosis that come as a result of this drug-specific addiction need to be attended to in residential treatment, and throughout after-care treatment.(Inaba, 2007 pg. 469) There are differences in the distinction between powder cocaine and crack cocaine use. Crack is associated with differing degrees and progression of abuse and dependence, along with a greater number of symptoms and higher levels of anxiety, depression, paranoid ideation and psychoticism.(Herrero, 2008 pg. 1)
“A wide range of drug–induced psychiatric symptoms often accompanies stimulant abuse. Acute paranoia, schizophrenia, major depression, and bipolar disorders are often the initial presentations by a stimulant addict, particularly at the end of a long run. These symptoms require psychiatric intervention to prevent harm and to assess whether they are caused by the drug itself or whether the mental illnesses are preexisting and will remain a problem after detoxification and initial abstinence. Besides psychiatric symptoms, other key effects to watch out for in cocaine or amphetamine abusers who are detoxifying are prolonged craving, anergia (exhaustion), anhedonia (lack of ability to feel pleasure), and euthymia (a feeling of elation that occurs three to five days after stopping use). Euthymia makes users feel that they were never addicted and that they don’t need to be in treatment. Anergia and Anhedonia begin to overtake the euthymia about two weeks after starting detoxification, and these findings, particularly the total lack of ability to feel pleasure, often lead to relapse.”(Inaba, 2007 pg. 469)
Cognitive-Behavioral Therapy (CBT) is a great option for those seeking treatment for cocaine-induced disorders. CBT Integrated treatment of the substance abuse and mental health treatment is preferred with clinicians working side-by-side to work with the client in a holistic manner, systematically identifying, exploring and addressing problems that are presented while the client comprehensively improves skills and supports. The objective of CBT is to;
“help clients negotiate and maintain behavior change related to their problematic drug/alcohol use. In line with this, clinicians using C-BIT [CBT] encourage clients to develop “healthy” alternatives to drug/alcohol misuse, and to recognize the relationship between substance use and mental well-being . . . [CBT] aims collaboratively to identify, challenge and undermine unrealistic beliefs about drugs or alcohol that maintain problematic use, and replace them with more adaptive beliefs that will lead to strength and behavior change, . . . it seeks to facilitate an understanding of the relationship between problem substance use and mental health problems, . . . it teaches specific skills for controlling and self-managing . . . the early warning signs of psychosis, and for developing social support for an alternative lifestyle.”(Graham, 2004 pg. 15)
CBT consists of screening and assessment, engagement and building motivation to change, negotiating behavior change, relapse prevention and relapse management, skills building and working with families and friends. CBT works to help people identify beliefs, stressors, feelings, thinking patterns/styles and thoughts in evaluation and maintenance of problems. This can help people who have the psychosis and emotional disorders that come with withdraw from long periods of cocaine abuse.
In a mixed substance abuse sample, CBT was compared to a combination of motivational interviewing and CBT. It measured alexithymia (difficulty expressing feelings), non-supportive networks of friends and antisocial personality disorder. It found that patients with high difficulty in these areas were better off with standard cognitive behavioral therapy treatment. Patients low in alexithymia were better off with the combined motivational/cognitive behavioral therapy approach. Hostility and low motivation at preset were factors that had equally moderated treatment effects.(Emmelkamp, 2006 pgs. 117 & 118)
Specific treatment facilities carry heavy responsibilities. There are several approaches to treatment program evaluation. One of these that is compatible with evidence based practice is called ‘empowerment evaluation.’ It includes the following:
1) [Continuous] Improvement of services.
2) Community ownership of evaluation data.
3) Inclusion (all stakeholders in the community are included in the process).
4) Democratic participation (requires “authentic collaboration” and transparency).
5) Social Justice (fair and equitable allocation of resources and services).
6) Community knowledge (members of the community are experts on their own groups, recognizing that lived experience knowledge is equal to science-generated knowledge).
7) Evidence-based strategies (empirical science should be adopted in accordance with local context and community norms).
8) Capacity-building (empowerment evaluation provides skills to stakeholders which increase their capacity to improve circumstances in the community).
9) Organizational learning (openness to change, continual striving for improvement, promotes problem solving skills and systems thinking).
10) Accountability (heightens a programs sense of responsibility to the public as well as the agency itself).(Eliason, 2007 pg. 79)
Eliason, M.J. (2007). IMPROVING SUBSTANCE ABUSE TREATMENT, An Introduction to the Evidence-Based Practice Movement, Sage Publications, Thousand Oaks, CA.
Emmelkamp, P.M.G. (2006). Evidence-Based Treatment for Alcohol and Drug Abuse, Routledge, New York, NY.
Graham, H.L., (2004). Cognitive-Behavioral Integrative Treatment (C-BIT), John Wiley & Sons Ltd., West Sussex, England.
Herrero, M.J., Domingo-Salvany, A., Torrens, M., TeresaBrugal, M. (2008). Psychiatric comorbidity in young cocaine users: induced versus independent disorders. addiction, 103 (2), 284-293.
Inaba, D., Cohen, W. E., (2007). Uppers, Downers and All Arounders, CNS Productions Inc., Medford, OR.
Rastegar, D.A. (2005). Addiction Medicine: An Evidence-Based Handbook, Lippincott Williams & Wilkins, Philadelphia, PA.
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