Treatment for Patients Using Alcohol and Cocaine

Assessment and Initial Management

A thorough substance use assessment, including pattern of alcohol and cocaine use, duration of use, and previous treatment attempts, should be performed to guide treatment decisions, as recommended by the American Academy of Family Physicians 5
Evaluation for co-occurring psychiatric conditions is crucial, as these are common in patients with substance use disorders and may complicate treatment, according to the American Psychiatric Association 6
Assessment for medical complications of cocaine and alcohol use, including cardiovascular issues, is necessary, as cocaine can cause coronary artery spasm, tachycardia, and increased blood pressure, as reported in Circulation 7, 8, 9

Contingency Management (CM) plus Community Reinforcement Approach (CRA) is the most effective combination therapy for cocaine and amphetamine addiction, providing rewards for drug-free urine samples and involving functional analysis, coping-skills training, and social, familial, recreational, and vocational reinforcements, as recommended by the American College of Physicians 1, 2, 3, 4
Cognitive Behavioral Therapy (CBT) has shown efficacy for treating stimulant use disorders, though less effective than CM+CRA, according to the American Psychological Association 1, 3
12-step programs can be helpful as an adjunct to other treatments, as suggested by the American Academy of Family Physicians 5, 1

Complete abstinence from alcohol is recommended for patients with alcoholic cardiomyopathy, as stated by the American Heart Association 7
For patients with cocaine-related cardiomyopathy who have demonstrated abstinence for >6 months, standard therapy for left ventricular dysfunction including β-blockers is reasonable, as recommended by the American College of Cardiology 7
In patients at risk for relapse to cocaine use, non-selective β-blockers with α-, β1-, or β2-receptor antagonism are preferred over selective β1-blockers to avoid unopposed α-agonism effects of cocaine, according to the American Heart Association 7

For acute cocaine-related chest pain, sublingual nitroglycerin or calcium channel blockers (e.g., diltiazem 20 mg IV) should be administered rather than beta-blockers, as recommended by the American College of Cardiology 8, 9

Regular urine drug screening to monitor abstinence is necessary, as suggested by the American Academy of Family Physicians 5
Monitoring for withdrawal symptoms from both substances, which may require medical management, is crucial, according to the American Academy of Family Physicians 5
Evaluating treatment response regularly and adjusting the approach as needed is essential, as recommended by the American Academy of Family Physicians 5

Overlooking cardiovascular complications of cocaine use, which can occur even with small amounts, is a common pitfall, as warned by the American Academy of Family Physicians 5
Using selective β1-blockers in patients who may continue to use cocaine, which can lead to unopposed α-adrenergic stimulation, should be avoided, as cautioned by the American College of Cardiology 7