Cocaine Use in the setting of Methadone treatment for Opioid Use Disorder. My take.

Cocaine Use in the setting of 

Methadone treatment for Opioid Use Disorder

by Donald H Marks MD PhD

October 24, 2023

It seems that increasing numbers of patients in drug abuse treatment programs are testing positive for cocaine use, while undergoing treatment for opioid use disorder (OUD) with methadone (MTD).

Cocaine is a powerfully addictive stimulant drug made from the leaves of the coca plant native to South America. Although healthcare providers can use it for valid medical purposes, such as local anesthesia for some surgeries, recreational cocaine use is illegal. As a street drug, cocaine looks like a fine, white, crystal powder. Street dealers often mix it with things like cornstarch, talcum powder, or flour to increase profits. They may also mix it with other drugs such as the stimulant amphetamine, or synthetic opioids, including fentanyl. Adding synthetic opioids to cocaine is especially risky when people using cocaine don’t realize it contains this dangerous additive. Increasing numbers of overdose deaths among cocaine users might be related to this tampered cocaine.

Widespread use of cocaine by individuals with OUD undermines the effectiveness of methadone treatment programs in reducing illicit drug use, in decreasing criminal behavior, and in slowing the spread of the HCV and HIV. As pointed out elsewhere (Condilli et al. in 1991), some methadone maintenance treatment (MMT) programs have implemented a range of behavioral interventions (see the following list) to manage this growing problem of concurrent use of cocaine and opioids, but with limited effectiveness. 

A recent NIDA report states that once inpatient OUD treatment ends, ongoing support—aftercare—can help people avoid relapse. Some research indicates that people who are committed to abstinence, engage in self-help behaviors, and believe that they have the ability to refrain from using cocaine (self-efficacy) may be more likely to abstain. Aftercare may serve to reinforce these traits and to address problems that may increase vulnerability to relapse, including depression and declining self-efficacy. However, individuals using cocaine should be carefully assessed and monitored for their overall substance use and mental health issues.

Roux et al 2016 found that, although time on MMT had a positive impact on occasional cocaine use, it had no impact on regular cocaine use. Moreover, regular cocaine users were more likely to report opiate injection and to present with ADHD and depressive symptoms. My experience as a prescriber at Aftercare leads me to doubt the conclusion of Roux et al that simply screening for these disorders and prompt tailored pharmacological and behavioral interventions can potentially reduce cocaine use and improve response to MMT.

MMT is primarily used to manage OUD by reducing withdrawal symptoms and cravings. Combining MMT with counseling and support services can be effective in helping patients with OUD alone, and perhaps in combination with cocaine addiction, in their recovery. 

Using cocaine can make it harder to stop using opioids due to several factors that interact with each other. Patients and their counselors need to be aware of this. Interacting factors include: 

• Neurobiological Interactions: The neurobiology of addiction involves complex changes in the brain. Both cocaine and opioids affect the reward pathways, leading to a heightened release of dopamine. When used together, cocaine and opioids can create a more intense euphoria, making it difficult for individuals to quit due to the reinforced pleasure they experience from the combined effects of these drugs [Kosten 2002].

• Polydrug Use: Cocaine and opioids are often used together in a pattern known as "speedballing." This combination can be particularly addictive, as the stimulant effects of cocaine can counteract some of the sedative effects of opioids, leading to a cycle of drug use to maintain the desired effects [Mayo].

• Withdrawal Symptoms: When individuals attempt to quit one of these drugs, they may experience withdrawal symptoms. These symptoms can be intense and highly uncomfortable, which often leads individuals to return to using opioids and cocaine to relieve these very symptoms [NIDA 1].

• Cravings and Triggers: Cocaine and opioids can create powerful cravings and triggers, making it challenging for individuals to resist the urge to use. Even after a period of abstinence, the cravings can persist and lead to relapse [NIDA 1].

• Need for Comprehensive Treatment: Overcoming addiction to both cocaine and opioids typically requires comprehensive treatment that addresses both substances simultaneously. Medications, counseling, and support are essential to help individuals manage their cravings and withdrawal symptoms [SAMHSA 2].

Pharmacology: 

Cocaine use can be extremely dangerous and deadly. The immediate physical effects of cocaine use include constricted blood vessels, dilated pupils, nausea, restlessness and increased body temperature, heart rate, and blood pressure. 

Health complications of cocaine can include: disturbances in heart rhythm. Headaches, chest pain and heart attack, respiratory failure, stroke, stomach pain, nausea, and seizures. 

According to Katz 2010, cocaine use along with MTD resulted in significantly more rapid methadone clearance.  They concluded that regular cocaine use may adversely impact treatment outcomes for opioid dependence in those receiving methadone maintenance by decreasing the effective methadone dose.

Short-term health effects of cocaine can include:

• extreme happiness and energy

• mental alertness

• hypersensitivity to sight, sound, and touch

• irritability

• paranoia—extreme and unreasonable distrust of others

Other health effects of cocaine use include:

• constricted blood vessels

• dilated pupils

• nausea

• raised body temperature and blood pressure

• fast or irregular heartbeat

• tremors and muscle twitches

• restlessness

Long-Term Effects

Some long-term health effects of cocaine depend on the method / route of use and include the following:

• snorting: loss of smell, nosebleeds, frequent runny nose, and problems with swallowing

• smoking: cough, asthma, respiratory distress, and higher risk of infections like pneumonia

• consuming by mouth: severe bowel decay from reduced blood flow

• needle injection: higher risk for contracting HIV, hepatitis C, and other bloodborne diseases, skin or soft tissue infections, as well as scarring or collapsed veins

However, even people involved with non-needle cocaine use place themselves at a risk for HIV because cocaine impairs judgment, which can lead to risky sexual behavior with infected partners 

Here are some key considerations for helping cocaine abuse in OUD patients on MMT:

1. Individual Assessment: Each patient's case is unique. A thorough assessment should be conducted to determine the extent of their opioid and cocaine use, as well as any other medical or psychiatric conditions, and prescription medicine intake.

2. Integrated Care: Integrated treatment that addresses both opioid and cocaine use, along with any other co-occurring disorders, is often more effective in promoting recovery.

3. Risk Mitigation: Providers should be aware of potential interactions and risks associated with combining methadone with cocaine. While methadone is used to treat opioid addiction, it doesn't address cocaine addiction directly. This needs to be explained to patients to avoid misunderstandings and false expectations.

4. Counseling and Support: Patients should receive counseling and support services tailored to their specific needs. Cognitive-behavioral therapy and contingency management therapy are approaches for managing cocaine use that may be effective.

5. Ongoing Monitoring: Continuous monitoring and adjustment of the treatment plan are essential to track progress and adapt interventions as needed.

The consensus best practice seems to be that cocaine use should not automatically bar someone from methadone treatment for opioid addiction. Cocaine use is a common co-occurring issue among individuals with opioid addiction, and it is important to address both substances simultaneously to provide comprehensive care.  Patients at Aftercare should be advised that:

• Cocaine is an addictive drug,

• Cocaine has many potential adverse effects, including those listed above,

• MTD does not provide any treatment benefit to counter cocaine use,

• Encourage patients to stop cocaine use,

• Offer referrals and literature.

Treating hypertension in the presence of cocaine use can be challenging due to the potential interactions between cocaine and antihypertensive medications. It's important to prioritize the treatment of hypertension while addressing the cocaine use. Here are some general considerations:

1. **Stop Cocaine Use:** The first step is to address the cocaine use. Encourage the individual to seek help for addiction and to stop using cocaine, as continued use can exacerbate hypertension.

2. **Monitor Blood Pressure:** Continuously monitor the individual's blood pressure to determine the severity of hypertension. If it's dangerously high, immediate medical attention may be necessary.

3. **Medical Evaluation:** Seek a medical evaluation to assess any potential complications or underlying health issues related to cocaine use and hypertension.

4. **Antihypertensive Medication:** If blood pressure remains high after stopping cocaine use, antihypertensive medication may be required. The choice of medication will depend on the individual's specific condition and should be determined by a healthcare professional. For example, the anti-hypertensive drug clonidine may be of benefit. Jobes (2011) found that Clonidine was effective in reducing stress-induced (and, at a higher dose, cue induced) craving in a pattern consistent with preclinical findings, although this was significant on only one of several measures. Their findings suggest that alpha-2 adrenergic agonists (like clonidine) may help prevent relapse in drug abusers experiencing stress or situations that remind them of drug use 

5. **Caution with Medications:** Some antihypertensive medications can interact with cocaine and worsen certain symptoms. Avoid medications like beta-blockers, which may increase blood pressure and heart rate in the presence of cocaine. ACE inhibitors and calcium channel blockers might be considered safer options. As noted above, clonidine may be of particular benefit. 

6. **Behavioral Therapy:** Combine medication with behavioral therapy or counseling to address both hypertension and addiction simultaneously. This can help the individual develop healthier habits and coping mechanisms.

7. **Regular Follow-up:** Continue to monitor and adjust treatment as needed, as the individual's condition may change over time.

Healthcare professionals who have experience in treating substance abuse and hypertension should be involved in this situation. They can provide personalized guidance and treatment plans to ensure the best possible outcomes.

Although I have not yet met a patient in methadone treatment, concurrently using cocaine,  who thinks that methadone may help with stopping cocaine use, this may be a possible misconception. I try to mention to all MTD patients whose drug screen shows cocaine that their receiving MTD will not help with stopping cocaine use. 

In summary, the combination of cocaine and opioids can lead to a vicious cycle of addiction, driven by the neurobiological effects, cravings, and withdrawal symptoms associated with each substance. Breaking free from this cycle often necessitates specialized treatment (a higher LOC than aftercare) and support.

References

Condelli WS et al. Cocaine use by clients in methadone programs: Significance, scope, and behavioral interventions. Journal of Substance Abuse Treatment Volume 8, Issue 4, 1991, Pages 203-212, 1991.

Cocaine DrugFacts | National Institute on Drug Abuse (NIDA) (nih.gov)

Drug addiction (substance use disorder) - Symptoms and causes - Mayo Clinic

Jobes ML et al. Clonidine blocks stress-induced craving in cocaine users Psychopharmacology (Berl). 2011 November ; 218(1): 83–88. doi:10.1007/s00213-011-2230-7. 

Kapur BM et al.  Methadone: a review of drug-drug and pathophysiological interactions.  Crit Rev Clin Lab Sci.  . 2011 Jul-Aug;48(4):171-95. doi: 10.3109/10408363.2011.620601. 

Kosten TR, George TP. The neurobiology of opioid dependence: implications for treatment. Sci Pract Perspect. 2002 Jul;1(1):13-20. doi: 10.1151/spp021113. PMID: 18567959; PMCID: PMC2851054. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851054/ 

Marks Donald H. 2023. Treatment guidelines for prescribing anti-psychotics to patients on methadone.https://dhmarks.blogspot.com/2024/02/guidelines-to-prescribing-anti.html

McCance-Katz et al. Effect of cocaine use on methadone pharmacokinetics in humans.  Am J Addict  2010 Jan-Feb;19(1):47-52. doi: 10.1111/j.1521-0391.2009.00009.x. 2010 Jan-Feb;19(1):47-52. doi: 

NIDA. Why are drugs so hard to quit? Why are Drugs so Hard to Quit? | National Institute on Drug Abuse (NIDA) (nih.gov) 

Medications, Counseling, and Related Conditions | SAMHSA

Roux, P. et al. Correlates of cocaine use during methadone treatment: implications for screening and clinical management (ANRS Methaville study). Harm Reduct J 13, 12 (2016). https://doi.org/10.1186/s12954-016-0100-7

What treatments are effective for cocaine abuse? How is cocaine addiction treated? | National Institute on Drug Abuse (NIDA)