Key points. Cocaine, the second most frequently consumed illicit substance after cannabis in both United States and Europe, remains the psychostimulant of choice for many, often mixed with other psychoactive substances. It is most frequently associated with alcohol, and a diagnosis of alcohol dependence may be made in 50%-90% of cocaine-dependent subjects. When treating cocaine addicts, it is important to characterize not only the modalities of cocaine use but also the modes of consumption of other substances, notably alcohol. Alcohol is often consumed to reduce the anxiety and discomfort resulting from cocaine withdrawal. Alcohol may also trigger an irresistible craving for cocaine, which can result in frequent relapses even after several months of cocaine abstinence. Brief intervention and motivational interview techniques can help to reduce alcohol use and prevent cocaine relapses in this context. In the absence of severe cocaine withdrawal symptoms, the guidelines for treating alcohol withdrawal syndrome may be applied for cocaine and alcohol codependence. Lower doses of benzodiazepine are needed for treating this alcohol-cocaine withdrawal syndrome. Cognitive behavioral therapies, alone or in combination with psychotropic medication, are accepted therapeutic approaches for alcohol-cocaine dependence. It is also accepted that over the long term the combination of psychotherapeutic treatments is usually more effective than any single approach. In the absence of a therapeutic consensus, four drugs (disulfiram, baclofen, topiramate and naltrexone) are most often recommended to promote and maintain abstinence; nevertheless, their efficacy has not been proven and their use remains experimental and off-label: they have not been approved by health authorities as treatment for addictions.
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