There's currently no FDA-approved medication to treat coke dependence.
On August 1, 2016, Jamie Blyth walked down to the river a couple of miles from his home with only thought on this mind—to kill himself. His plan was to hang himself by jumping off the bank, but his weight pulled him down, his feet touched the ground, and his suicide attempt failed.
Jamie first started taking cocaine in college. Twenty years later, his addiction consumed him totally. Just a year before his suicide attempt, Jamie's wife had given birth to their daughter, but by then, the drug had already taken over every aspects of his life, preventing him from fully engaging with fatherhood. "I didn't want to live. I didn't care about anybody or anything. I had reached a point in my life where darkness was the only option. That is all I wanted, pitch black," he says.
The youngest of a family of seven, Jamie had always longed to be noticed. Growing up, he saw that cocaine and alcohol tended to attract people, acting as a catalyst an automatic social circle. Before he knew it, he was taking both everyday. "Cocaine was my lifeblood. Every single decision I made was drug-related. My primary relationship was not with a loved one, it was with drugs. Nothing else mattered," he explains.
His suicide attempt changed everything and he was sent to a rehab program in South Africa, far away from his home in the UK. "On August 6, 2016, after I landed in Cape Town, I gave up drinking and drugs forever," he says. He knows the path ahead will not be easy. Cocaine addiction is a lifelong disease, for which there is currently no specific FDA-approved medication.
Snorted, injected or smoked as crack, coke is consumed by nearly 19 million people worldwide. Therapy and drug counseling can help some individuals like it did with Jamie, but many end up relapsing. "Targeting the psychological and social factors involved in cocaine addiction is crucial, as no intervention can be effective otherwise," says Owen Bowden Jones, an addiction specialist with the UK's Royal College of Psychiatrists. "Treatment has to be multidisciplinary. But this is a devastating disease, and it's also very important that we find new pharmaceutical treatments for addiction, based on good, evidence-based research."
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This is precisely what some researchers have started doing, widening their horizons to investigate original and innovative treatment options. Commonly used as a human anesthetic or as an animal tranquilizer in veterinary medicine, ketamine is also a popular party drug, due to the changes in consciousness it can produce. Led by Elias Dakwar, a psychiatrist at Columbia University, scientists have come up with a radical idea—what if ketamine could be given to cocaine dependent individuals to address their cocaine-related problems?
"What spurred this research was the finding that ketamine is effective for depression. Depression and addiction have various vulnerabilities in common, so we thought it was logical to study ketamine for cocaine addiction," Dakwar says. In a study published at the end of 2016 in the Journal of Molecular Psychiatry, his team found that in strict medical settings, ketamine infusions could help reduce drug use in cocaine-addicted patients.
Twenty participants were administered either ketamine or a psychoactive control called midazolam (which has side-effects similar to that of ketamine, but no known effects on disrupting cocaine problems). Twenty-eight hours later, they had to choose between immediately using cocaine in the lab or receiving a monetary reward later.
The researchers observed that those who had taken ketamine were more likely to choose the money than the others. In fact, among these subjects, they observed a significant decrease in cocaine use—by 67 percent relative to baseline. A few of them even remained abstinent for two weeks.
"We think that the reason ketamine works is that it creates new synapses and neural networks that promote healthier communication between different parts of the brain," Dakwar says. The team has recently tested the effects of ketamine in a much larger clinical trial and hope to publish their results sometime next year to back up this earlier study.
Other research teams have also gone down the same route of "repurposing" an existing drug—that is testing whether an old drug approved to treat completely different conditions may also work in treating addiction. One such trial has just begun at Boston Medical Center. Over the next two years, researchers will test whether a weight-loss drug called lorcaserin can reduce cravings by targeting a specific brain pathway—the serotonin 5-HT pathway.
"The 5HT 2C receptor is abundant in regions of the brain associated with pleasure and reward," principal investigator, Eric Devine, explains. "We believe that stimulation of the 5-HT 2C receptors will reduce the release of dopamine and thus reduce reward of cocaine use. If the medication works and using cocaine is less compelling, this may help people to achieve abstinence from using cocaine."
Although both projects focus on repurposing old drugs, the ketamine research is more controversial. When told about the research, Jamie seems concerned that people who are vulnerable to addiction, like him, may become hooked to the treatment that's supposed to help them.
Dakwar says the idea would be to only give this drug under medical supervision. "Ketamine can be associated with an irresponsible use, but it doesn't mean that we should disregard it when it comes to using it in a responsible, medical context," he points out. Administered by doctors, the ketamine treatment wouldn't have much to do with the party drug that is sometimes sold on the street and mixed with other harmful substances.
The ketamine and lorcaserin studies are just two studies out of the increasing research regarding addiction treatment. A method known as repetitive transcranial magnetic stimulation (rTMS) has also been receiving a lot of interest. RTMS involves the use of a magnetic field generator placed near the head of patients, and producing small electric currents in the brain. So far, this technique has only been clinically approved to treat depression.
However, a 2013 study in the medical journal Nature showed that in rats addicted to cocaine, electrically stimulating a brain region linked to impulse control helped them get rid of their habit. Luigi Gallimberti, an Italian addictologist and professor who spent his career trying to treat cocaine-addicted patients was fascinated by the possibilities that this opened.
So in 2013, he designed a protocol for humans involving regular sessions of rTMS over six months and targeting the prefrontal cortex of the brain—an area implicated in decision making and social behaviour. In the last four years, he's treated over 450 patients. "Thirty-four percent have never relapsed, and about 80 percent have become drug-free after a number of relapses. Never in all my years of clinical practice had I seen something so efficient," he says.
One of these patients is 50-year-old Alessandro*, whose history with cocaine goes back three decades. Nearly fifteen years ago, as his consumption turned into a full-blown addiction, Alessandro went to Gallimberti and was offered psychotherapy and antidepressants. But after three years, Alessandro relapsed and went back to taking cocaine nearly every day.
After talking to Gallimberti, he decided to give rTMS a try. Since his first session this past July, he has not turned to coke. "Cocaine used to always be on my mind. Since I started rTMS that's changed completely. I've stopped caring about cocaine from my first session. I have been offered the drug since, and I have not wanted it—it's like a light is switched off," Alessandro says.
This is encouraging, but it does not mean we should view rTMS as a miracle just yet. Robust randomized clinical trials are needed. Some have just been launched, including one at the Medical University of South Carolina. As bold and original scientific research continues to progress, there are hopes that we'll soon be able to defeat cocaine addiction. Still, it's unlikely a pill or an intervention on the brain will be enough on its own.
This is a complex disease, and the most effective treatments will be those that can be combined with psychological and social support. For Jamie, this was a crucial part of his recovery.
*Source prefers to use his first name only.
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