The use of stimulant medications for the treatment of
cocaine dependence is an evolving scientific line of research. To date, the most promising results are with the higher-potency medications, the
amphetamine analogues, or a combination of a dopaminergic medication with a contingency management behavioral intervention. The development of effective
pharmacotherapies for
opioid and
nicotine dependence using an agonist replacement approach suggests that these promising findings needs to continue to be vigorously investigated. In clinical trial reports, there are very few instances of cardiovascular adverse events, which suggests that for well-selected patients with
cocaine dependence, stimulant replacement
therapy can be safe. However, clinical trial eligibility criteria excludes most high-risk patients from participating, and introducing stimulant substitution to the wider treatment community would likely expose more vulnerable patients to the medical risks associated with stimulant treatment while using
cocaine. As treatment development research moves forward, attention must be paid to helping clinicians select patients who are most likely to benefit from stimulant substitution treatment and how to identify those at risk. An additional concern with the use of stimulant medication treatment of
cocaine dependence is prescribing
controlled substances for patients with active
substance use disorders. Again, within a clinical trial, medication supplies are monitored and distributed carefully in small quantities. In a community setting, misuse or diversion will be risks associated with prescribing
controlled substances to patients with addictive disorders, but therapeutic strategies for monitoring and limiting that risk can be implemented. Psychostimulant
pharmacotherapy is a promising line of research for the treatment of
cocaine dependence, a condition for which no effective
pharmacotherapy has been identified. Further research is required to confirm positive results from single-site trials, in particular the study of
amphetamines as a treatment for
cocaine dependence. As this literature evolves, strategies to manage the risk of prescribing
controlled substances to patients with addictive disorders need to be tested and refined. Biases against using
controlled substances as a treatment for
cocaine dependence should be challenged, much in the way the use of agonist treatment transformed the treatment of
opioid dependence despite initial resistance from the field.