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
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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.,
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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
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Kampman, K.M., Volpicelli, J.R., Mulvaney, F., Rukstalis, M., Alterman, A.I., Pettinati,
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Mulvaney, F.D., Alterman, A.I., Boardman, C.R., Kampman, K. Severity of cocaine use
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Oslin, D.W., Kampman, K.M., Betteridge, J., Hovan, K.A., Volpielli, J.R., Pettinati,
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