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PRACTICE GUIDELINES
OFFICE-BASED TREATMENT GUIDELINE FOR COCAINE AND AMPHETAMINE WITHDRAWAL
The Guideline, developed by the Professional Practices
Committee, was approved by the TSPP Executive Council on April 15, 2005.
Cocaine and amphetamines produce their effects by increasing synaptic dopamine
levels. Cocaine blocks the dopamine transporter, thereby preventing re-uptake of
released dopamine and amphetamines release dopamine from the presynaptic neuron
as well as blocking the dopamine transporter.
Powder cocaine is used intranasally (“snorted”) and reaches a peak effect in 5
to 10 minutes. “Crack” cocaine is a rock-like pellet that is heated and the
vapors inhaled. Its peak effect is within 8-10 seconds and has the most intense
and reinforcing effect. Cocaine also is used intravenously; but, no matter what
the route of administration, the half-life is 40 to 60 minutes. Amphetamines are
used orally, intranasally or intravenously and have a half-life of 10-15 hours.
Withdrawal Symptoms
An identified cluster of symptoms are experienced during the first two to three
weeks following the cessation of chronic cocaine or amphetamine use. DSM-IV
lists the following:
1. Fatigue
2. Vivid unpleasant dreams
3. Insomnia or hypersomnia
4. Increased appetite
5. Psychomotor retardation or agitation
In addition, anxiety, depression, dejection, and hostility are common in the
first few days with resolution over the next three weeks. Craving for the drug
returns within days to weeks with exposure to stimuli related to drug use.
Treatment
No specific treatments are available.
Benzodiazepines- brief use to decrease anxiety, agitation, or insomnia.
Neuroleptics- useful for agitation, paranoid symptoms, hallucinations, or
delusions
A variety of environmental, behavioral, and/or medical factors may indicate that
outpatient treatment is inappropriate and an inpatient placement desirable. For
example, if a patient presents with acute intoxication and is likely to be
withdrawing from high doses of a stimulant or whose history suggests a high risk
of relapse inpatient placement may be preferred.
References:
DSM-IV-TR, American Psychiatric Association, 2000
Fischman, M.W. Pharmacologic Management of Cocaine Abuse and Dependence. 1999
CME Monograph series sponsored by Dannemiller Memorial Educational Foundation
and Alpha and Omega Worldwide LLC, 2000
Fischman, MW and Haney M. Neurobiology of Stimulants. In Galanter M and Kleber
H.D. Textbook of Substance Abuse Treatment (2nd edition), American Psychiatric
Press, Inc pp 21-31, 1999
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FEDERATION
OF TEXAS PSYCHIATRY