Effective drug therapy for cocaine dependence: a milestone.

Abstract

In The Lancet, Mascha Nuijten and colleagues 1 Nuijten M Blanken P van de Wetering B Nuijen B van den Brink W Hendriks VM Sustained-release dexamfetamine in the treatment of chronic cocaine-dependent patients on heroin-assisted treatment: a randomised, double-blind, placebo-controlled trial. Lancet. 2016; (published online March 22.)http://dx.doi.org/10.1016/S0140-6736(16)00205-1 Google Scholar present the results of a multicentre, randomised, double-blind, placebo-controlled trial assessing the acceptance, safety, and efficacy of sustained-release dexamfetamine in cocaine-dependent patients on heroin-assisted treatment. The study findings showed that 60 mg/day oral sustained-release dexamfetamine over 12 weeks was well accepted, safe, and superior to placebo in terms of days of cocaine use (mean 44·9 days [SD 29·4] in the sustained-release dexamfetamine group vs 60·6 days [24·3] in the placebo group [95% CI of difference 3·1–28·4]; p=0·031; Cohen's standardised effect size d=0·58) and all self-reported and urine-based cocaine use-related outcomes. Cocaine dependence is prevalent throughout the world and causes major morbidity and mortality. 2 Degenhardt L Hall W Extent of illicit drug use and dependence, and their contribution to the global burden of disease. Lancet. 2012; 379: 55-70 Summary Full Text Full Text PDF PubMed Scopus (868) Google Scholar At present, no effective pharmacotherapy exists. Agonist replacement therapy has been successfully applied to opioid and tobacco dependence, 3 Strain EC Bigelow GE Liebson IA Stitzer ML Moderate- vs high-dose methadone in the treatment of opioid dependence: a randomized trial. JAMA. 1999; 281: 1000-1005 Crossref PubMed Scopus (359) Google Scholar , 4 Aubin HJ Luquiens A Berlin I Pharmacotherapy for smoking cessation: pharmacological principles and clinical practice. Br J Clin Pharmacol. 2014; 77: 324-336 Crossref PubMed Scopus (73) Google Scholar but previous studies examining this approach in cocaine dependence failed to find statistically significant benefits in terms of reduced cocaine use, or showed indecisive results. This could be due to limitations in the methods, such as small sample sizes, 5 Shearer J Wodak A van Beek I Mattick RP Lewis J Pilot randomized double blind placebo-controlled study of dexamphetamine for cocaine dependence. Addiction. 2003; 98: 1137-1141 Crossref PubMed Scopus (120) Google Scholar inadequate dosing schemes, 6 Dursteler KM Berger EM Strasser J et al. Clinical potential of methylphenidate in the treatment of cocaine addiction: a review of the current evidence. Subst Abuse Rehabil. 2015; 6: 61-74 Crossref PubMed Google Scholar or large attrition rates. 7 Grabowski J Rhoades H Stotts A et al. Agonist-like or antagonist-like treatment for cocaine dependence with methadone for heroin dependence: two double-blind randomized clinical trials. Neuropsychopharmacology. 2004; 29: 969-981 Crossref PubMed Scopus (168) Google Scholar The study by Nuijten and colleagues 1 Nuijten M Blanken P van de Wetering B Nuijen B van den Brink W Hendriks VM Sustained-release dexamfetamine in the treatment of chronic cocaine-dependent patients on heroin-assisted treatment: a randomised, double-blind, placebo-controlled trial. Lancet. 2016; (published online March 22.)http://dx.doi.org/10.1016/S0140-6736(16)00205-1 Google Scholar overcomes most of these shortcomings. Sustained-release dexamfetamine in the treatment of chronic cocaine-dependent patients on heroin-assisted treatment: a randomised, double-blind, placebo-controlled trialSustained-release dexamfetamine is a well accepted, effective, and safe agonist pharmacotherapy for comorbid treatment-refractory cocaine dependence in heroin-dependent patients in heroin-assisted treatment. Future research should aim to replicate these findings in chronic cocaine-dependent and other stimulant-dependent patients in more routine treatment settings, including strategies to optimise treatment adherence like medication management interventions and contingency management. Full-Text PDF