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Cocaina, abuso y dependencia: Tratamientos basados en la evidencia
(3 votos, media: 3.33 de 5)
Evidencia sobre - Evidencia sobre
Escrito por María Isabel Tamayo Velázquez   
Sábado, 07 de Marzo de 2009 23:57
Tratamientos basados en la evidencia para el

 

ABUSO Y DEPENDENCIA DE COCAINA

 

 

 

 


A) Resumen de la evidencia

A) Breve resumen de la evidencia

 

 

Ha demostrado claramente su eficacia:

 

Combinación de tratamiento farmacológico y psicoterapia

El disulfiram y la terapia cognitivo conductual resultan efectivas para el tratamiento de la adicción a la cocaína.

 

  • Ensayo controlado aleatorizado en el que participaron 121 pacientes con adicción a la cocaína.

  • Se establecieron 4 condiciones de tratamiento, de modo que los participantes fueron aleatorizados a recibir durante 12 semanas:

  1. Disulfiram (250 mg/día) más terapia cognitivo conductual

  2. Disulfiram (250 mg/día) más psicoterapia interpersonal

  3. Placebo más terapia cognitivo conductual

  4. Placebo más psicoterapia interpersonal

  • El disulfiram redujo significativamente el uso de la cocaína comparado con el placebo.

  • La terapia cognitivo conductual también redujo significativamente el uso de la cocaína comparado con la psicoterapia interpersonal.

  • Los beneficios fueron mayores para aquellos participantes que se abstuvieron de beber alcohol durante todo el tratamiento.

 

Referencia: Arch Gen Psychiatry 2004 Mar;61(3):264 External link

 

El manejo de contingencias y el bupropión pueden reducir el uso de cocaína en pacientes que abusan de ésta y de los opiáceos.

  • Ensayo controlado aleatorizado en el que se incluyeron 106 participantes adictos a los opiáceos, consumidores de opiáceos y cocaína.

  • Todos los participantes recibían clorhidrato de metadona (rango: 60-120 mg), y fueron aleatorizados a recibir una de las 4 condiciones de tratamiento:

  1. manejo de contingencias más placebo

  2. manejo de contingencias más 300 mg/día de bupropión (comenzando a la 3ª semana)

  3. Control de cupones (se daba dinero para presentar muestras de orina tanto positivas como negativas) más placebo

  4. Control de cupones más bupropión

  • Todos los grupos de tratamiento mostraron una disminución en el consumo de opiáceos.

  • El tratamiento que incluía manejo de contingencias y bupropión proporcionó la mayor reducción de consumo de cocaína.

 

Referencia: Arch Gen Psychiatry 2006 Feb;63(2):219 External link

 

 

Psicoterapia

 

Los programas de terapia conductual grupal pueden reducir el consumo de drogas en pacientes con enfermedad mental severa y persistente

 

  • Ensayo controlado aleatorizado, en el que participaron 175 pacientes ambulatorios con enfermedad mental severa y persistente y abuso de drogas (cocaína, heroína y cannabis).

  • Los participantes fueron aleatorizados a recibir terapia conductual para el abuso de sustancias en pacientes con enfermedad mental severa y persistente. Esta terapia consiste en una intervención de aprendizaje social que incluye entrevistas motivacionales, manejo de contingencias mediante análisis de orina, y entrenamiento en habilidades sociales.

  • Los participantes asignados al grupo control recibían tratamiento mediante grupos de discusión para la recuperación de la adicción. Estos grupos apoyaban y animaban a los pacientes a mantener un entorno seguro y a compartir ideas y sentimientos.

  • La duración del tratamiento era de 6 meses, y recibían la intervención dos veces por semana por terapeutas entrenados.

  • Los programas se llevaban a cabo en grupos de 4 a 6 personas.

  • 129 pacientes asistieron al menos a una sesión, 110 (63%) se comprometieron al tratamiento y fueron analizados.

  • Los resultados mostraron que la terapia conductual grupal para el abuso de sustancias fue significativamente más efectiva que los grupos de discusión.

  • La terapia conductual grupal obtuvo mejores resultados en cuanto a los test de orina, permanencia en el tratamiento y asistencia a las sesiones.

  • La terapia conductual grupal también resultó más efectiva en cuanto a hospitalización, disponibilidad de dinero para gastos y calidad de vida.

 

Referencia: Arch Gen Psychiatry 2006 Apr;63(4):426 External link

 

Seguimiento telefónico

 

La continuidad de cuidados a través de seguimiento telefónico parece efectiva después del tratamiento de estabilización para la adicción a la cocaína y el alcohol.

  • Ensayo controlado aleatorizado en el que participaron 359 adictos al alcohol y/o a la cocaína.

  • Los participantes fueron aleatorizados a recibir:

a) atención telefónica (sesiones grupales de apoyo semanales durante 4 semanas combinadas con breves contactos de apoyo telefónico durante 12 semanas)

b) prevención de recaídas cognitivo conductual 2 veces por semana

c) terapia grupal estándar.

  • Los participantes que recibieron la terapia a tuvieron tasas más altas de abstinencia total a lo largo del seguimiento que aquellos que recibieron terapia b.

  • La atención telefónica continuada parece una forma efectiva para ayudar a mantener la abstinencia para la mayoría de pacientes con adicción al alcohol y a la cocaína que completaron un tratamiento de estabilización inicial, en comparación con intervenciones más intensivas cara a cara.

  • Sin embargo, los pacientes de alto riesgo pueden obtener mejores resultados si reciben primero atención continuada mediante terapia grupal después de completar un programa ambulatorio intensivo.

 

Referencia: Arch Gen Psychiatry 2005 Feb;62(2):199 External link

 

 

 

 

Algunos estudios sugieren que es eficaz:

 

 

Psicoterapia

 

Las intervenciones psicosociales no muestran tener un gran impacto en pacientes con abuso o dependencia de psicoestimulantes.

 

  • Revisión sistemática Cochrane en la que se incluyeron 27 ensayos aleatorizados que evaluaban las intervenciones psicosociales para el tratamiento del abuso o dependencia a los psicoestimulantes en 3.663 pacientes.

  • 26 ensayos evaluaron el abuso de cocaína, 1 ensayo evaluó el abuso de anfetamina oral.

  • El uso de terapia cognitivo conductual se asociaba a un descenso del uso de cocaína en comparación con la terapia de apoyo en 5 de 6 ensayos, sin embargo los resultados sólo fueron significativos en 2 de los ensayos.

  • En un ensayo, la terapia de refuerzo se asoció con tasas más bajas de consumo de cocaína al mes y a los 3 meses en comparación con el tratamiento habitual.

  • Las intervenciones se asociaron con un aumento en el mantenimiento en tratamiento, sin embargo no hubo cambios significativos en cuanto al estilo de vida.

 

Referencia Cochrane Library 2007 Issue 3:CD003023 External link

 

La psicoterapia individual combinada con el apoyo grupal es más efectiva que otras combinaciones.

  • Ensayo controlado aleatorizado.

  • 487 pacientes adictos a la cocaína fueron aleatorizados a recibir 1 de 4 tipos de tratamientos:

a) psicoterapia individual sobre drogas más psicoterapia grupal sobre drogas (CGD)

b) terapia cognitiva más CGD

c) terapia de apoyo-expresiva más CGD

d) únicamente CGD.

  • La duración del tratamiento era de 6 meses incluyendo 36 posibles sesiones individuales y 24 sesiones grupales.

  • Los resultados mostraron que la psicoterapia individual más la psicoterapia grupal sobre drogas era la terapia más eficaz, según el Índice de Severidad de la Adicción (ASI), y según la probabilidad de mantener la abstinencia.

  • El 72% de los pacientes abandonó antes de los 6 meses.

 

Referencia: Arch Gen Psychiatry 1999 Jun;56(6):493 External link

 

 

 

 

No ha demostrado su eficacia:

 

Tratamiento farmacológico

 

No hay evidencia que apoye el uso de antidepresivos para el tratamiento de la adicción a la cocaína.

 

  • Revisión sistemática en la que se incluyeron 18 estudios con 1.177 participantes.

  • El resultado principal era la muestra positiva de metabolitos de cocaína en la orina.

  • No se encontraron resultados significativos con ningún tipo de antidepresivos utilizado.

  • No hay evidencia que apoye el uso de antidepresivos para el tratamiento de la adicción a la cocaína.

 

Referencia: Cochrane Library 2003 Issue 2:CD002950 External link

 

No hay evidencia que apoye el uso de antagonistas de la dopamina para el tratamiento de la adicción a la cocaína

 

  • Revisión sistemática en la que se incluyeron 17 estudios con 1.224 participantes aleatorizados.

  • Los fármacos evaluados fueron amantadina, bromocriptina y pergolida.

  • El resultado principal era la muestra positiva de metabolitos de cocaína en la orina para eficacia, y mantenimiento en tratamiento como una medida de aceptabilidad.

  • No se encontraron resultados significativos.

 

Referencia: Cochrane Library 2003 Issue 2:CD003352 External link

 

La olanzapina, el valproato y la combinación de coenzima Q10 y L-carnitina no son efectivos para el tratamiento de la adicción a la cocaína.

 

  • Ensayo controlado aleatorizado.

  • En el estudio participaron 68 pacientes diagnosticados como adictos a la cocaína. Sólo 39 sujetos completaron el estudio

  • Los sujetos fueron aleatorizados a recibir olanzapina (10 mg/día), valproato (1500 mg /día), combinación de coenzima Q10 (200 mg/día) y L-carnitina (500 mg/día) o placebo, durante un periodo de tratamiento de 8 semanas.

  • Además, todos los sujetos recibieron terapia cognitivo conductual individual durante el tratamiento.

  • Ninguna de las medicaciones estudiadas mostró resultados mejores que el placebo.

 

Referencia: Addiction 2005 Mar;100 Suppl 1:43 External link)

 

Los anticonvulsivos son inefectivos para el tratamiento de la adicción a la cocaína.

  • Revisión sistemática en la que se localizaron 17 ensayos controlados aleatorizados.

  • 15 estudios cumplieron los criterios de inclusión, con un total de 1066 pacientes.

  • La duración media de los ensayos fue de 11 semanas (rango de 1 a 24 semanas).

  • Todos los ensayos se llevaron a cabo en EE. UU., 16 de ellos con pacientes ambulatorios.

  • Los anticonvulsivos estudiados fueron la carbamazepina, gabapentina, lamotrigina, fenitoína, tiagabina, topiramato y valproato.

  • No se encontraron diferencias significativas entre la eficacia del placebo y de los anticonvulsivos.

  • El placebo incluso resultó superior que la gabapentina en cuanto a la disminución de abandonos (2 estudios con 81 participantes).

  • La fenitoína se asoció a tasas de efectos secundarios más altas que el placebo (2 estudios con 56 participantes)

 

Referencia: Cochrane Database Syst Rev 2008 Apr 16;(2):CD006754 External link

 

La evidencia es insuficiente para apoyar el uso de antipsicóticos en el tratamiento de la adicción a la cocaína.

  • Revisión sistemática en la que se incluyeron 7 ensayos controlados, con un total de 293 participantes adultos, con una edad media de 40 años.

  • Los estudios se llevaron a cabo en EE.UU. e incluían pacientes hospitalizados y pacientes ambulatorios.

  • La duración fue de 5 a 168 días (duración media: 61 días)

  • 6 de los ensayos aleatorizaron a los participantes a recibir un antipsicótico o placebo. El séptimo ensayo comparaba olanzapina con haloperidol.

  • Los antipsicóticos estudiados fueron risperidona, olanzapina y haloperidol.

  • No se encontraron diferencias significativas en cuanto a resultados de eficacia entre ninguno de los antipsicóticos y el placebo.

  • La risperidona se asoció a un menor número de abandonos que el placebo (4 ensayos con 178 pacientes).

 

Referencia: Cochrane Library 2007 Issue 3:CD006306 External link

 

 

 

Otros Tratamientos

 

Acupuntura


La acupuntura no es efectiva en el tratamiento de la adicción a la cocaína.

 

La acupuntura no parece mejorar las tasas de abstinencia a la cocaína, sin embargo la evidencia es limitada.

  • Meta-análisis en el que se incluyeron 9 ensayos aleatorizados donde participaron 1.747 pacientes.

  • 7 de los ensayos utilizaron confirmación bioquímica de abstinencia de cocaína.

  • La tasa media de abandono fue del 50%, lo que limita las conclusiones.

  • Los resultados de esta revisión sistemática y del meta-análisis no apoyan el uso de la acupuntura para el tratamiento de la adicción a la cocaína.

 

Referencia: Harm Reduction Journal 2005 Mar 17;2:4 External link

 

 

  • Ensayo controlado aleatorizado en el que participaron 620 adultos adictos a la cocaína (edad media: 38.8 años, el 69.2% eran hombres)

  • 412 participantes consumían cocaína exclusivamente, mientras que 208 usaban tanto opiáceos como cocaína, además pertenecían a un programa de mantenimiento con metadona.

  • Los pacientes fueron aleatorizados a recibir acupuntura auricular (n=222), una inserción de agujas (n=203), o relajación (n=195).

  • Los tratamientos tenían lugar 5 veces por semana durante 8 semanas.

  • A los pacientes de todos los grupos se les ofrecía psicoterpia simultánea sobre drogas.

  • No se encontraron diferencias en la retención del tratamiento.

  • No se encontraron diferencias significativas en las tasas de cocaína en orina o en las tasas de abandonos.

 

Referencia: JAMA 2002 Jan 2;287(1):55 External link


La acupuntura auricular se muestra inefectiva en el tratamiento de la adicción a la cocaína.

  • Revisión sistemática en la que se incluyeron 7 ensayos controlados aleatorizados en los que participaron 1433 pacientes.

  • Se comparaba la acupuntura auricular con la acupuntura SAAM (un tipo de acupuntura que inserta las agujas de forma aleatoria en la oreja pero no en los lugares específicos indicados para el tratamiento) o con no realizar ningún tipo de tratamiento.

  • Los estudios usaron una gran variedad de técnicas de acupuntura (usando 3, 4 o 5 de los puntos de tratamiento).

  • La mayoría de los ensayos eran de baja calidad.

  • No se encontró evidencia de que ninguna forma de acupuntura auricular fuera efectiva para el tratamiento de la adicción a la cocaína.

 

Referencia: Cochrane Library 2006 Issue 1:CD005192 External link

 

 

 

 

 

María Isabel Tamayo Velázquez

Psicóloga

Técnico Escuela Andaluza de Salud Pública

Consejería de Salud

Última actualización el Miércoles, 20 de Enero de 2010 22:55
 

Grupo Gestión del Conocimiento. Programa de Salud Mental de Andalucía