Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

9. Cocaine and Stimulants 209ence now appears to be differentially affecting poor, minority individuals wholive in the inner city. This same population is overrepresented in the AIDSpopulation. This confluence is not surprising, because both sex risk (includingsex workers) and needle risk are associated with chronic use of cocaine. Ittherefore appears that these two epidemics are interconnected in a way thatdeserves close attention.At the same time, there may be reason for cautious optimism with regardto the long-term effects of prenatal exposure to cocaine. Some of the earlyclaims of devastating physical consequences to “crack babies” have proven tobe exaggerated; experts in the perinatal addiction field now consider that manyfactors (e.g., poverty, poor maternal nutrition/health, smoking, and exposure toviolence) combine to influence development. Molecular mechanisms of developmentalneuroadaptation are at the same time beginning to be studied. In thefuture, we hope to understand better the physiological basis for the observedclinical events.In the basic sciences area, we have come to understand more about theinteractions of various neurotransmitters, drug reinforcement, and the rewardpathway. Receptors are being subtyped and cloned. Signal transduction pathways,with their longer range on protein synthesis and genetic regulation, arebeing explored. We are beginning to make inroads in our understanding of sensitizationand tolerance. Although pharmacological treatments for cocaineaddiction have not yet proven successful in clinical trials, there are many excitingnew avenues of pursuit. These prospects for pharmacological interventionare based on the remarkable advances in neuroscience being made in thisdecade.Researchers also have been hard at work testing psychotherapeutic solutionsto this complex problem. Cocaine dependence should not be viewed inisolation from other psychiatric conditions and life problems. Rather, we mustconsider how best to address the problem in the presence of other psychoactivesubstance use and non-substance-use Axis I and Axis II disorders. Dependingon the larger clinical picture, successful treatment may require multiple orhighly select therapies that are matched to the patient’s pathology and adaptivestrengths and resources. It is clear that a “one size fits all” approach to treatmentof cocaine dependence is inappropriate; instead, an array of assessment tools isnecessary to determine patient needs, along with a menu of cost-effective andreadily available therapeutic strategies. Although American Society of AddictionMedicine (Hoffman, Halikas, Mee-Lee, & Weedman, 1991) criteria facilitatepatient placement in an appropriate treatment setting based on addictionseverity, they provide little guidance in terms of specific interventions to bedelivered within those settings. Clinical research aimed at developing therapiesfor specific subtypes of cocaine addicts in a variety of settings is the most promisingapproach we now have.