Cocaine Withdrawal Symptoms and the Treatment of Cocaine Dependence Cocaine dependence is a difficult addiction to treat. One of the most troublesome aspects of treating cocaine dependent patients is identifying the appropriate type and intensity of treatment. Not all cocaine dependent patients respond to treatment in the same way. A method of reliably identifying patients who need a higher intensity of psychosocial treatment, or who are more likely to respond well to a particular pharmacological treatment would be a great service to treatment providers. Cocaine withdrawal symptoms, measured by an instrument called the Cocaine Selective Severity Assessment (CSSA), may provide a way to predict response to both psychosocial treatment for cocaine dependence and possibly response to certain pharmacotherapies for cocaine dependence. The CSSA is an 18-item, interviewer administered instrument that measures signs and symptoms most often associated with the abrupt cessation of cocaine use. Each item on the CSSA is rated on a 0-7 scale, and a total score is derived by summing the individual items. The CSSA appears to be a valid measure of cocaine withdrawal symptoms. Items that receive the highest score on the CSSA are consistent with criteria for cocaine withdrawal identified in DSM IV; these include depressed mood, lethargy, increased sleep, increased appetite, and irritability. CSSA scores are specific to cocaine withdrawal. Patients withdrawing from alcohol or opiates do not score high on the CSSA. CSSA scores tend to be higher in patients with more severe cocaine dependence and scores tend to decline in patients who maintain abstinence (Kampman et al., 1998). Cocaine withdrawal is certainly not medically significant like alcohol or opiate withdrawal but cocaine withdrawal symptom severity is clinically significant because patients with more severe cocaine withdrawal symptoms tend to respond poorly to treatment. We have now published data from 4 separate trials done in different patient populations all showing that patients who score high on the CSSA at the start of treatment, that is those with scores greater than 20, are either more likely to drop out of treatment or less likely to achieve abstinence from cocaine (Mulvaney et al., 1999; Oslin et al., 2000; Kampman et al., 2001; Kampman et al., 2002). Patient populations in which this was found to be true include cocaine dependent patients participating in cocaine psychotherapy and medication trials, cocaine dependent veterans admitted to a day hospital program and cocaine and alcohol dependent patients screening for a medication trial. The data is very consistent; patients with more severe cocaine withdrawal symptoms don’t do well in standard psychosocial treatment. Cocaine withdrawal symptom severity may also predict response to certain medications. We found that patients with more severe cocaine withdrawal symptoms appear to respond better to medications that are intended to treat cocaine withdrawal. Medications in which we found this to be true in pilot trials include amantadine, propranolol and modafinil (Kampman et al., 2000; Kampman et al., 2001b; Dackis et al., 2002). Conversely, other medications, particularly medications identified as more useful for relapse prevention, appear to be better suited for patients with less severe withdrawal symptoms. For example, the GABAergic medication, topiramate, was tried in a small sample of patients with low CSSA scores who were able to achieve at least a few days of abstinence from cocaine. Preliminary results from this pilot trial suggest that topiramatetreated patients were more likely to remain abstinent during the last 5 weeks of the trial compared to placebo-treated patients. All the medications mentioned here have only been evaluated in pilot trials and larger confirmatory trials need to be done to confirm these results. However, cocaine withdrawal scores may provide an effective way of identifying subgroups of cocaine dependent patients who are more likely to respond to particular pharmacotherapies. The CSSA is a useful tool for the clinician who needs a way of reliably identifying which patients are unlikely to respond well to standard psychosocial treatment for cocaine dependence and need more intensive treatment. The CSSA may also provide a reliable way for researchers to identify more homogenous subgroups of cocaine dependent patients in which to evaluate new medications. References: Dackis, C., Kampman, K., Pettinati, H, Weigley, C., O’Brien, C. An Open-Label Pilot Study of the Effectiveness and Tolerability of Modafinil for Cocaine Dependence. . Drug and Alcohol Dependence 66(suppl.1):s39-s40, 2002. Kampman, K.M., Volpicelli, J., McGinnis, D., Alterman, A.I., Weinrieb, R., D’Angelo, L., Epperson, L. Reliability and validity of the cocaine selective severity assessment. Addictive Behaviors 23: 449-461, 1998. Kampman, K.M., Volpicelli, J.R., Alterman, A.I., Cornish, J., O'Brien, C.P. Amantadine in the treatment of cocaine dependent patients with severe cocaine withdrawal symptoms. American Journal of Psychiatry 157: 2052-2054, 2000. Kampman, K.M., Alterman, A.I., Volpicelli, J.R., Maany, I., Muller, E.S., Luce, D.L., Mulholland, E.M., Jawad, A.F., Parikh, G.A., Mulvaney, F.D., Weinrieb, R.M., O’Brien, C.P. Cocaine withdrawal symptoms and initial urine toxicology results predict treatment attrition in outpatient cocaine dependence treatment. Psychology of Addictive Behaviors 15(1): 52-59, 2001. Kampman, K.M., Volpicelli, J.R., Mulvaney, F., Alterman, A.I., Cornish, J., Gariti, P. Cnaan, A., Poole, S., Muller, E., Acosta, T., Luce, D., O'Brien, C.P. Effectiveness of propranolol for cocaine dependence may depend on cocaine withdrawal symptom severity. Drug and Alcohol Dependence 63(1): 69-78, 2001b. Kampman, K.M., Volpicelli, J.R., Mulvaney, F., Rukstalis, M., Alterman, A.I., Pettinati, H., Weinrieb, R.M., O'Brien, C.P. Cocaine withdrawal severity and urine toxicology results from treatment entry predict outcome in medication trials for cocaine dependence. Addictive Behaviors 27(2): 251-260, 2002. Mulvaney, F.D., Alterman, A.I., Boardman, C.R., Kampman, K. Severity of cocaine use and prediction of treatment attrition. Journal of Substance Abuse Treatment 16: 129-135, 1999. Oslin, D.W., Kampman, K.M., Betteridge, J., Hovan, K.A., Volpielli, J.R., Pettinati, H.M. Baseline drug and alcohol use patterns in patients seeking treatment for cocaine and alcohol dependence. Drug and Alcohol Dependence 60(suppl.1):s164, 2000.