COMORBIDITY OF COCAINE USE AND MENTAL DISORDERS
Comorbid mental illnesses are common in and can worsen CUDs. The factors responsible for morbidity appear to differ among cocaine users with mental illness as compared to cocaine users without mental illness.
Patients with schizophrenia have a high lifetime cocaine use. The concomitant use of cocaine markedly increases suicidal risk, treatment non-adherence, psychosocial maladjustment, readmis-sions to inpatient drug treatment centers and the rates of incarceration in schizophrenia patients. Cognitive deficits and imaging abnormalities in schizophrenia are likely to be worsened by concurrent use of cocaine. avodart 0.5 mg
Cocaine use coexists with and is often diagnosed as bipolar disorder or attention deficit hyperactivity disorder, particularly when the affective symptoms are mild. Cocaine use increases the risk of suicide and complicates remission in bipolar disorders. The cognitive deficits in bipolar disorder, manic type, are trait- and state-dependent. The imaging deficits and cognitive dysfunction that have been described in bipolar disorders may be worsened with co-occurring CUDs.
Another common psychiatric comorbidity in CUDs is depression. Differentiating substance-induced depression from primary depression may be difficult. Recent reports have suggested that individuals with CUDs and depression are retained in treatment at higher rates than individuals with CUDs and no depression. Conversely, individuals with CUDs and ADHD are less likely to complete treatment than individuals with CUDs and no Axis-I diagnosis. A diagnosis of depression in CUDs is associated with poorer psychosocial function, greater mental distress and psychiatric functioning. In addition, treatment-seeking, cocaine-using individuals may have other psychiatric disorders, including other substance use disorders, anxiety and personality disorders.
CLINICAL IMPLICATIONS OF NEUROPSYCHIATRY OF CUDS
It is important to elicit the substance use history in a nonjudgmental manner. Also, collateral information may be critically important. Cases of suspected cocaine overdose should receive a careful medical, neurologic and psychiatric evaluation and a 12-lead electrocardiogram. Resuscitation may require a venous access and urethral catheterization. The urine specimen should be sent for analysis and screening for commonly used drugs.
The toxicology screening should examine for cocaine and its primary metabolites, benzoylecgonine and ecgonine methyl ester, in human urine. Laboratory aids, such as a complete blood count, liver function tests, serum electrolytes and creatine kinase, urine analysis and neuro-imaging studies, may be indicated. Medications that can prolong the Q-T interval must be carefully weighed in CUDs. generic propecia
Neuropsychiatric evaluation in CUDs should examine self-analysis, decision-making, problem-solving, synthetic integration, working memory, information processing and other areas of neuropsychologic functioning (Table 3).
A complete biopsychosocial assessment must be cognizant that social maladies, including prostitution, crime, incarceration, infectious diseases, neonatal drug exposure and adverse employment outcomes, are prevalent in CUDs. Also, the exchange of sex for crack-cocaine is a leading route for HIV transmission. In their 1992 study, Khalsa and colleagues found that approximately 92% of subjects who reported having sex in the past year used condoms on an irregular basis. Indeed, the constellation of psychiatric and neurologic complications of cocaine is no less significant than the sociobehavioral consequences, and it has been suggested that cocaine abuse itself is a neuropsychiatric disorder.
Neuropsychologic treatment planning. Indeed, the occurrence of neurocognitive dysfunction in CUDs is underrecognized. Few cocaine rehabilitation programs have taken into account the patients’ cognitive deficits, although the extent that cognition improved during abstinence is unknown. Thus, the advisability of rigorous counseling during cocaine rehabilitation is uncertain. Indeed, cognitive remediation has been shown to be effective in schizophrenia, suggesting that treatment outcomes in CUDs may be improved with behavioral treatment plans guided by neuropsychologic assessments. Moreover, the awareness of cocaine-related neuropsychologic impairments might enhance staff attitudes as well as treatment engagement and retention. generic flomax
Psychosocial treatment approaches. Psychosocial treatment of CUDs has not reported desirable remission rates. Some drug programs have advocated harm reduction and encouraged a shift away from change and total abstinence, a theoretical position that has been praised for its practicality and equally criticized for implicit pessimism.
Total abstinence programs might kindle power struggles between therapists and their patients who succumbed to the potent reinforcing effects of cocaine. Frequent admissions for cocaine treatment can familiarize patients with the treatment milieu and its lingo, and this might lead the patients to skip the individual therapy and self-help group sessions. Conversely, patients who have remained in treatment because of pressures from family, friends or the legal system may feel inspired to cheat on urine toxicology specimens. It is possible that an effective pharmacologic treatment of CUDs might help these patients to wage a more successful struggle against the drug habit.
Emerging pharmacologic treatment approaches. Pharmacologic treatment for CUDs was reviewed recently. Novel approaches that specifically target cocaine reward, cocaine craving and cue reactivity are being developed. Preventive approaches include cocaine vaccines as well as strategies to improve cerebrovascular perfusion. These treatments are yet to be adequately studied longitudinally.
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Adverse health consequences of cocaine are yet emerging, owing to the ease of procuring the drug nowadays. Through a number of approaches, greater light is being shed on the pattern of neuropsychiatric effects of cocaine. The growing evidence should strengthen our understanding of the neurobiology of cocaine and improve our therapeutic armamentarium in the management of drug use disorders.
In summary, molecular, cellular, structural and functional changes are commonly seen in the complex presentation of CUDs. The emerging data should stimulate vigorous awareness campaigns involving patients, their families and providers. The evidence indicates that frontal lobe dysfunction may be an important treatment target in CUDs. Intriguingly, individuals who are diagnosed with the neuropsychiatric effects of cocaine, particularly those in inner cities, are entangled in the intricacies of disparate health outcomes that might hold them accountable for poor decision-making. Therefore, our understanding of cocaine-induced brain alterations could be improved through further research with the promise of effective pharmacologic interventions for reversing the brain alterations in this disease.