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Cocaine and Methamphetamine Dependence: Advances in Treatment

Richard Balon, MD

Wayne State University, Detroit, MI, USA

Edited by Thomas R. Kosten, Thomas F. Newton, Richard De La Garza II, and Colin N. Haile. Arlington, VA: American Psychiatric Publishing; 2012; ISBN 978-1-585-624072; pp 234; $65 (paperback).

Cocaine abuse epidemics come and go. Some of us remember the cocaine epidemic of the 1980s that peaked in 1985 and produced an estimated 2.5 million lifetime stimulant abusers (p 3). Some may assume cocaine abuse was a big problem but hopefully isn’t big anymore. Unfortunately, it still is, and we are facing yet another epidemic.

There are approximately 1.4 million cocaine abusers and 350,000 methamphetamine abusers in the United States (p 3). The cocaine abusers are not just those remaining from the 1980s epidemic; there also has been a steady stream of new users (p 3). This edited volume brings us information that can help us face and fight this new, and in a way, larger and more dangerous epidemic. Why larger and more dangerous? Partially because methamphetamine was not a part of this equation during the previous epidemics. However, nowadays it is atypical to find a patient who abuses only cocaine or only methamphetamines (p 155). “Most stimulant users use these drugs in combination, often with the intent either to increase the effects produced by the primary stimulant or to ‘take the edge off’ a high when they want to control the cardiovascular and subjective effects” (p 155).

In addition, the epidemiology and geography of stimulant abuse is different in the present epidemic, as the distribution of cocaine and methamphetamine is different. Cocaine is being supplied from South America, while amphetamines and methamphetamines are coming from more “home-grown” resources (illegal labs; methamphetamine imported from Mexico is replacing the locally produced methamphetamine) (p 1). Cocaine remains primarily an urban problem. Methamphetamine distribution was predominating in the rural, western, and southern regions of the United States and has moved to rural Midwestern states.

Cocaine and methamphetamine abuse is not a problem limited to North America. Cocaine abuse has recently spread to Europe, starting in Spain. Methamphetamine abuse also is an international problem, “with two-thirds of the world’s 33 million methamphetamine abusers living in Asia” (p 4). The Philippines have the world’s highest rates of methamphetamine abusers: 2.9% of its population (p 4). These are staggering numbers, underscoring the fact that stimulant abuse has become a serious worldwide problem.

This small volume consists of a Foreword (a useful summary of the book) by Herbert Kleber and 8 chapters written by 11 contributors. The first chapter, “Epidemiology and psychiatric comorbidity,” provides a wealth of information (some of it previously mentioned). The epidemiology part also points out some changes in patterns—a shift from inhaled to smoked methamphetamine, or increase of stimulant abuse in the form of pharmaceutical abuse (increasing number of prescriptions led to greater availability, easy access to stimulants through family and friends makes it cheap and attractive) (p 7). The authors also point out that “drug use is more common among patients with mental illnesses than among the general population” (p 9) and that methamphetamine users appear to be at higher risk for developing psychotic symptoms (p 8).

The second chapter, “History, use, and basic pharmacology of stimulants,” includes a great and detailed, yet a bit boring, explanation of stimulants’ pharmacology. The history part includes many interesting pieces of information—Coca-Cola and Red Bull companies use “decocainized” extracts from coca leaves in their drinks; until 1900, Coca-Cola drinks contained some cocaine, and Bolivia now produces a drink called Coca Cola that uses the coca leaf as its base ingredient (p 3-4). Another more important piece of information: most cocaine seized in the United States is adulterated with the agranulocytosis-inducing anthelmintic drug levamisole, which is responsible for numerous hospitalizations and deaths (p 26). The author explains what “crank, ice and crystal meth” means—there is even a photo of crystal meth. The chapter also mentions an interesting clinical fact: cognitive enhancers and anti-inflammatory agents have shown some promise for treating methamphetamine/amphetamine dependence.

The third chapter, “Diagnoses, symptoms, and assessment,” starts with a good discussion of clinical aspects of stimulant abuse. The text emphasizes that the subjective and behavioral responses to stimulants are complex and depend on many variables—dose, route of administration, previous experience with the drug, the environment in which the drug is taken, and patients’ unique response patterns. Other interesting areas discussed are stimulant delirium, serious cardiovascular side effects, and the controversy over the persistence of antidepressant effect of stimulants in depressive states. This chapter also addresses the frequently asked clinical question: “Is use of addictive medications flatly contraindicated in patients with substance dependence in remission, or is such medication prohibited only in instances of use of drugs of the same class (eg, methylphenidate and methamphetamine or cocaine)?” The authors respond that, “In general, a psychiatrist should never rule out the use of any addictive drug if there are good symptom-based reasons for prescribing it. Nor should the psychiatrist assume that an addicting drug of one class (eg, opiates) will be safe for an individual who abused another class, such as stimulants” (p 98). These are wise and cautionary pieces of advice.

Chapter 4, “Behavioral interventions,” provides an introduction to common behavioral-based interventions for stimulant dependence: contingency management, cognitive-behavioral therapy, and group counseling. The chapter also discusses the use of motivational interviewing at length. Motivational interviewing generally is not used as a stand-alone intervention; it is, however, an integral component of the community reinforcement approach (p 139).

The fifth chapter, “Pharmacotherapy,” is fairly brief because there is not much available in this area. An interesting note—disulfiram treatment reduced cocaine use in some studies, and this effect was independent of concomitant alcohol use (p 147). Disulfiram also inhibits, in addition to aldehyde dehydrogenase, other enzymes, such as dopamine β-hydroxylase responsible for the synthesis of norepinephrine from dopamine (but also inhibits the enzyme responsible for cocaine degradation). The chapter also reminds us that studies testing antidepressant use in stimulant abuse largely have been negative with the exception of bupropion (it decreases methamphetamine use in light but not heavy users) (p 149). Reading these 2 chapters, I missed some mention of combining behavioral therapies with pharmacotherapy.

Chapter 6, “Polydrug abuse,” emphasizes finding a patient who abuses only cocaine or only methamphetamines is not typical (p 155). As mentioned, “most stimulant users use these drugs in combination…” (p 155). It seems that medications used for other substance abuse treatment may be useful for treating stimulant abuse or dependence (eg, varenicline and bupropion used for nicotine dependence; modafinil). Another important piece of information about polydrug abuse: cannabis enhances cocaine’s subjective and physiological effects and may trigger a psychosis in vulnerable individuals (p 167).

Chapter 7, “HIV and other medical comorbidity,” reviews the effects of cocaine and methamphetamine on the body (overdose, cardiovascular and cerebrovascular systems, lungs [eg, asthma exacerbation], oral health [periodontal disease and tooth decay and loss], skin, and injuries), effects on fetal development, and effects on infectious diseases, including increased HIV disease progression. The last chapter briefly summarizes the text and provides some future directions.

This is a solid, useful, well-written volume. It is fairly well edited and thus there is not much overlap among chapters. Useful features include the summary of key clinical concepts and resources at the end of each chapter. The book is packed with new information that many clinicians will find interesting and useful. Even at $65 for a paperback, it is a good buy.