SCOTTISH ADVISORY COMMITTEE ON DRUG MISUSE: Psychostimulant Working Group Report
CHAPTER 6: TREATMENT APPROACHES
Pharmacological interventions
6.1 A number of systematic reviews have looked at pharmacological treatments for psychostimulant users. There is no strong evidence to support any single treatment for cocaine or amphetamine users. However, there is also no evidence to prove that such treatments are ineffective . The focus of research and practice has been on symptomatic medication that relieve symptoms of withdrawal, rather than medications that provide a substitute.
6.2 However, we recognise that there may be some scope for substitute approaches. For some amphetamine users substitution with dexamphetamine may be appropriate. There does appear to be growing evidence for the role of prescribed dexamphetamine. Equally for some crack/cocaine patients the use of supportive therapy may reduce some of the adverse effects associated with use of this group of drugs.
6.3 Overall, care should be exercised when interpreting prescription data for products that could be used for the pharmacological treatment of stimulant use as most of the products concerned are licensed for other conditions. For instance methylphenidate is increasingly recognised as an appropriate treatment for hyperactivity in children, adolescents and some adults with Attention Deficit Hyperactivity Disorder (ADHD). Current prescription statistics for methylphenidate most probably reflect the presence of a consultant paediatrician with expertise in the diagnosis and assessment of ADHD rather than misuse/inappropriate use of the medication. (See Annex C which reviews research literature relating to treatment.)
Psychological / psychosocial interventions
6.4 Psychological and psychosocial interventions are widely used with psychostimulant users, sometimes as a standalone intervention, and sometimes in conjunction with a pharmacological intervention. These include cognitive behavioural therapy (CBT) which is currently used with psychostimulant users in Scotland. (CBT refers to therapies that aim to alter thinking patterns and behaviour.) As with pharmacological treatments, the research evidence on the effectiveness of psychosocial interventions is limited, but promising. There are a number of reviews and primary research studies underway to examine this further.
6.5 Psychological treatment is predominantly useful to prevent relapse. Discrepancies in treatment outcomes between individuals with similar demography, drug abuse characteristics and severity of the dependence may arise because of existing cognitive impairments which prevent the patient from being able to profit from the treatment on offer. It is therefore important to recognise cognitive deficits early in the treatment programme so that alternative and perhaps more structured and direct approaches can be utilised.
6.6 Complementary therapies, such as auricular acupuncture, are increasingly offered to psychostimulant users. There is little clear evidence of their effectiveness, but there is some evidence to suggest that acupuncture is capable of attracting users into treatment and encouraging them to remain in treatment. Current research emphasises the need to consider the role of complementary therapies in a broader treatment plan, rather than as a standalone intervention. ( See Annex C)
Emergency treatment and management of cocaine/crack users
6.7 Typical symptoms of cocaine/crack users presenting to A&E fall into three categories:
psychological - agitation, paranoia, confusion, hallucinations, aggression;
neurological - collapse, convulsions, cerebovascular accident;
cardiovascular - blood clotting, chest pain, palpitations, breathlessness, increase in blood pressure, heart attack.
6.8 Additional effects due to the mode of use:
short term - airways damage, "crack lung" (crack); runny red nose (cocaine);
long term - probable lung damage (crack), nasal septum damage (cocaine)
6.9 Situations which may bring users into A and E include:
myocardial ischemia/infarction;
seizures and cerebovascular accidents;
collapsed lung;
premature labour;
excited delirium - the physical effects of excited delirium are characterised by hyperthermia and dilated pupils; the psychological effects include extreme agitation, paranoia, violence and disinhibition. Restraint can lead to a paradoxical situation where the patient becomes very tranquil and death may occur. Diazepam is the treatment of choice for excited delirium.
thermal injury from inhalation;
upper airway burns. These are a rare but potentially lethal complication of crack cocaine use; and
the anaesthetic effect of crack cocaine which reduces awareness of the burning effects of smoke.
6.10 In addition there is a potentially dangerous interaction between cocaine and alcohol. The combination increases the euphoric effects of cocaine through the production in the liver of cocaethylene, a long acting ethyl homologue of cocaine, which may increase the risk of sudden death. Alcoholics Anonymous in the UK has recorded a significant increase in the number of members discussing their cocaine use at regular AA meetings.
6.11 The management of emergency situations resulting from the use of cocaine and crack involve the use of, diazepam (psychiatric/psychological effects), aspirin and nitrates (cardiovascular effects) and oxygen (respiratory effects).