Cocaine: Withdrawal

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The signs and symptoms of withdrawal from depressant drugs, such as alcohol or heroin, are much easier to recognize than the symptoms of withdrawal from the stimulant drug cocaine, because a cocaine abuser who stops taking the drug has no immediate physical symptoms. Instead, the person feels a severe change in mood. Because of the lack of physical withdrawal symptoms, both medical professionals and the public long believed that cocaine was not an addicting drug. The cocaine epidemic of the 1980s led to greater concern about how cocaine affects users. Researchers studied the drug to determine whether cocaine use leads to dependence and withdrawal.

By conducting interviews with outpatients who had been cocaine users, researchers have identified three phases that occur after a person stops taking the drug:

1. The crash occurs when a person who has used cocaine for an extended period suddenly stops taking the drug. In this state, the person becomes extremely exhausted. The crash can last between nine hours and four days. At the beginning of the crash, the person feels a craving for cocaine, irritability, dysphoria, and agitation. In the middle of the crash, the individual yearns for sleep. In the late crash, the person sleeps excessively. Some individuals may suffer from extreme depression in the early stages of the crash (especially those who have suffered from depression in the past). They may think about or try to commit suicide. Even first-time users of cocaine can experience the crash, depending on how high the dose and how long the period of use.
2. As depression worsens and the desire for sleep increases, the person feels less craving. After waking from a long sleep, the individual enters a brief normal period with mild craving. This is followed by a long period of milder withdrawal, lasting from one to ten weeks. During this time the craving for cocaine returns, and the person enters a state known as anhedonia. With anhedonia, the person can no longer feel pleasure from activities or experiences he or she used to enjoy.
3. The final phase of cocaine withdrawal is called extinction. The extinction phase usually begins two weeks after a person stops using cocaine. The person returns to a normal mood but still feels an occasional craving for cocaine. Because of continued cravings, the chance for relapse is high.

Alcohol and Cocaine. When an individual has drunk alcohol in addition to taking cocaine, the depression of the crash phase can be even worse. Alcohol reduces a person's control over his or her impulses, such as the impulse to commit suicide. Therefore, alcohol use combined with the despair of the crash period can put a person at high risk for suicide. In addition, cocaine has important interactions with alcohol in the body. For example, cocaine plus alcohol in the body produces a compound called cocaethylene. This compound produces more intense and longer euphoria (a feeling of intense well-being), but it also increases the risk of death from cardiac arrhythmia (irregular heartbeat).

Recent studies of cocaine withdrawal suggest that not all users go through three separate phases. One four-week study examined twelveinpatients who were dependent on cocaine. During withdrawal, the subjects suffered from depression, craving, and anxiety. These symptoms improved steadily during the four weeks. By the end of the fourth week, the cocaine users had come out of withdrawal. An important difference between this study and earlier studies is that the researchers worked with inpatients. Inpatients live in the protected setting of a hospital or treatment center. They are not constantly reminded of cocaine by certain people or places in their lives, as are cocaine users who go through outpatient treatment while living on their own. As a result, the phases of cocaine withdrawal may be less distinct for inpatients.

The red and yellow areas of the brain in this PET scan indicate high brain activity. Brain activity is reduced among cocaine users. Note the decreased activity in the frontal lobes of this cocaine abuser (arrows). The frontal lobes are where a person s thoughts and memories are formed.

Treatment for cocaine withdrawal can include treatment as an inpatient or outpatient or a combination of both. Cocaine craving is themajor cause of relapse in individuals trying to quit using cocaine. Reminders of drug use in the person's environment—areas where the person used to buy drugs, the people they used to get high with, and so on—can stimulate craving at any time. As a result, people with severe addiction trying to quit cocaine often do better in an inpatient treatment program. A heavy cocaine user with the support of family or friends and resources may benefit from an inpatient detoxification program that lasts a minimum of one week. This is the peak period for craving. The person may then need to continue as an outpatient for a minimum of one to two years.

Individuals who lack the support of family or friends and who do not have a stable living situation can often benefit from weeks to months as inpatients in a residential treatment center. The crash phase may be milder for inpatients, and addicts who experience less distress may be better able to concentrate on therapy and education. Inpatients may also feel a greater sense of control over themselves. Control is especially difficult to achieve when craving for cocaine is high. However, many patients can develop a false sense of control over their addiction because, as inpatients, they are protected from environmental cues that trigger craving. Inpatients need to be reintroduced gradually to life outside the treatment center.

The depression and despair that follow an end of long-term cocaine use may occur because of conditions in the user's life. When addicts stop using drugs, they must face the shambles of their lives—the destruction of their families, loss of jobs, financial ruin, poor health, injured relationships, and low self-esteem. Addicts may feel that they have entered a state of crisis. During withdrawal, the craving for cocaine may be caused by their desperate wish to feel better. As a result, cocaine users who receive treatment only as outpatients may suffer from more intense depression during withdrawal. Inpatients may feel more protected from the difficult conditions of their lives while living in a treatment center.

Treatment for the crash phase of cocaine withdrawal can include prescription drugs. The two major drugs that have been useful during the crash phase are bromocriptine and amantadine. Both of these drugs enhance or increase the transmission of dopamine, a neurotransmitter. After a cocaine binge, a person generally has reduced levels of dopamine in the brain. Researchers believe that reduced dopamine levels cause the depression, irritability, agitation, and drug craving during the crash phase.

Treatment involving medicines is especially important for cocaine addicts who are also dependent on alcohol or opioids such as heroin.It is very common for users to be dependent on more than one substance. A benzodiazepine drug is usually prescribed for alcohol withdrawal; for opiate withdrawal, the drug of choice may be methadone, clonidine, naltrexone, or combinations of these.

Cocaine; Cocaine Treatment: Behavioral Approaches; Cocaine Treatment: Medications; Tolerance and Physical Dependence.