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

606 V. TREATMENTS FOR ADDICTIONScal trials for efficacy in humans have shown excellent safety, adequate antibodydevelopment, and reductions in cocaine abuse (Kosten et al., 2002; Kosten &O’Connor, 2003).INTERFACE OF PSYCHIATRIC COMORBIDITYAND SUBSTANCE USE DISORDERSPsychotropic medication treatment of dually diagnosed patients is similar tothat of psychiatric patients without SUDs, with several caveats. Patients withpsychotic disorders treated with medications that block dopamine receptorsmay develop postsynaptic dopaminergic supersensitivity, which has been demonstratedin animal studies (Kosten, 1997). This supersensitivity may enhanceeuphoria from a wide range of abused drugs. Furthermore, patients withchronic psychotic disorders often experience negative symptoms of schizophreniaand dysphoria that may be exacerbated by conventional neuroleptics. Thesepatients will benefit from selection of an atypical neuroleptic that lacks strongdopaminergic antagonism (Kosten & Ziedonis, 1997). Patients with psychoticdisorders who are also alcoholic should be carefully evaluated before beingtreated with disulfiram, a dopamine beta-hydroxylase inhibitor that could exacerbatepsychosis in such patients.Attention-deficit/hyperactivity disorder (ADHD) can occur as a comorbidcondition in cocaine abusers who may self-medicate with this stimulant.Cocaine use in this population is often described as ingestion of small amountsof cocaine taken intermittently throughout the day rather than the classicbinge pattern characterized by use of multiple doses of cocaine in rapid successiondescribed by those with primary cocaine dependence. Treatment withstandard agents used for ADHD, including stimulant medications, may result incessation of cocaine use.Depressive disorders are common in those with cocaine and alcohol usedisorders. SRIs may be a good choice for these patients because they are lesslikely to have significant cardiovascular interactions with cocaine and to belethal in overdose. Monoamine oxidase inhibitors (MAOIs) should never beused in cocaine abusers, because of the risk of hypertensive crisis. Benzodiazepinesshould be used with caution in those with cormorbid psychiatric andSUDs, and particularly in alcoholic patients, because of cross-tolerance withalcohol and additive effects if combined with alcohol. Benzodiazepines may berequired initially to stabilize patients with exacerbation of psychosis or severeagitation but should be tapered as antipsychotics and/or mood stabilizersbecome therapeutic. Alcoholic patients with anxiety disorders can usually beeffectively treated with serotonergic agents (SRIs or partial agonists) or, insome cases, tricyclic antidepressants.