Rachel L. Tomko, PhD Research Assistant Professor Department of Psychiatry and Behavioral Sciences
Jennifer L. Jones, MD Resident Physician Departments of Psychiatry and Behavioral Sciences and Internal Medicine
Amanda K. Gilmore, PhD Research Assistant Professor College of Nursing and Department of Psychiatry and Behavioral Sciences
Kathleen T. Brady, MD, PhD Distinguished University Professor Department of Psychiatry and Behavioral Sciences
Sudie E. Back, PhD Professor Department of Psychiatry and Behavioral Sciences
Kevin M. Gray, MD Professor Department of Psychiatry and Behavioral Sciences
• • • •
Medical University of South Carolina Charleston, South Carolina
Disclosures The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products. This article was supported by National Institutes of Health grants from the National Institute of Drug Abuse (R25 DA020537, R01 DA042114, R01 DA038700, R01 DA026777, K23 DA042935, K02 DA039229, UG1 DA013727) and the National Institute on Alcohol Abuse and Alcoholism (T32 AA007474, R01 AA025086) and the Department of Defense (W81XWH-13-2-0075 9261sc).
Safety and dosing.Suggested dosages for the treatment of cocaine use disorder range from 1,200 to 3,600 mg/d (typically 600 to 1,800 mg twice daily, due to NAC’s short half-life), with higher retention rates noted in individuals who received 2,400 mg/d and 3,600 mg/d.16
Clinical implications.NAC is thought to act as an anti-relapse agent, rather than an agent that can help someone who is actively using stimulants to stop. Consequently, NAC will likely be most helpful for patients who are motivated to quit and are abstinent when they start taking NAC; however, this hypothesis needs further testing.
Cannabis use disorder
There are no FDA-approved treatments for cannabis use disorder. Individuals who use marijuana or other forms of cannabis may be less likely to report negative consequences or seek treatment compared with those who use other substances. Approximately 9% of individuals who use marijuana develop cannabis use disorder20; those who begin using marijuana earlier in adolescence are at increased risk.21 Commonly reported reasons for wanting to stop using marijuana include being concerned about health consequences, regaining or demonstrating self-control, saving money, avoiding legal consequences, obtaining or keeping employment, and reducing interpersonal conflict.22,23 Table 324-27 summarizes initial evidence that suggests NAC may be particularly useful in reducing marijuana use among adolescents (age 15 to 21).24,25
Cessation.An open-label, pilot clinical trial found significant reductions in self-reported marijuana use and craving—but not in biomarkers of use—among 24 adolescents after 4 weeks of NAC, 1,200 mg twice daily.24 In an 8-week, double-blind, randomized controlled trial of 116 adolescents, NAC, 1,200 mg twice daily, plus contingency management doubled the odds of abstinence, but had no effect on self-reported craving or use.25,26 In a sample of 302 adults, a 12-week trial of NAC, 1,200 mg twice daily, plus contingency management was no more effective than contingency management alone in promoting abstinence.27
