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National Amphetamine-Type Stimulant Strategy Background Paper: Monograph Series No. 69

5.4 Withdrawal management

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The nature of ATS dependence, and coincidentally the nature of a withdrawal syndrome, has been debated until relatively recently. This has contributed to a situation where:

The literature pertaining to psychostimulant withdrawal is inconsistent and of mixed quality. … no studies that describe the natural history of methamphetamine withdrawal among dependent individuals could be located and as a result that particular process is still poorly understood (Jenner & Saunders, 2004, p.103).

Although there have been some advances since this conclusion, there is still a dearth of information. What is known is that ATS withdrawal is distinguished from that which occurs with central nervous system depressant drugs such as alcohol or the opioids. The latter drug withdrawal syndromes generally result in symptoms that are the opposite of the drug effects, whereas for ATS, the symptoms might be similar to symptoms of intoxication, including for example agitation and arousal (Jenner & Saunders, 2004). The amphetamine withdrawal syndrome appears to consist of three primary symptom clusters: hyperarousal symptoms, composed of drug craving, agitation, and vivid/unpleasant dreams; reversed vegetative symptoms, consisting of decreased energy, increased appetite and craving for sleep; and anxiety-related symptoms, comprising anxiety, slowing of movement, and loss of interest or pleasure (Srisurapanon et al., 2001). A prospective study of methamphetamine withdrawal syndrome found moderate levels of depression during the first several days of abstinence, with minimal levels thereafter. The most prominent symptoms were anhedonia (inability to experience pleasure from normally pleasurable experiences), irritability and poor concentration (Newton et al., 2004).

More recently, McGregor and colleagues (2005) conceptualised the methamphetamine withdrawal syndrome as comprised of two phases: an acute phase lasting 7-10 days and a subacute phase lasting at least a further 2 weeks. The acute phase was characterised by increased sleeping and eating, a cluster of depression-related symptoms and less severe anxiety and craving-related symptoms (McGregor et al., 2005). Symptoms of mood lability, irritability, sleeping difficulties and cognitive deficits may persist for several months (Volkow et al., 2001).

From their review of the literature, Grabowski and colleagues (2004) concluded that there was a lack of clear protocols for appropriate withdrawal management of methamphetamine users. This was largely due to differing opinions among medical practitioners as to the most effective regimens and available research not supporting one medication over another. The role of pharmacotherapy in withdrawal management is outlined in a subsequent section. An important clinical challenge has been to differentiate the symptoms of ‘crash’ (or the immediate ‘come down’ effects of ATS) from withdrawal. The former, not inconsistent with the ‘hangover effects’ of drugs, such as alcohol, occurs in the ensuing few days after intoxication – the latter tend to commence towards the end of this period and are more enduring. The experience of withdrawal is generally related to the frequency and duration of ATS use, potency of drugs consumed, mode of use, severity of dependence and coexistence of physical and psychiatric conditions (e.g., see Jenner & Saunders, 2004). Symptoms include, in order of most frequently reported, irritability, aches and pains, depressed mood, and impaired social functioning (Cantwell & McBride, 1998). Symptoms can be protracted over several days to several weeks.

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Jenner and Saunders (2004) suggested that ATS withdrawal:

• Can generally be managed on an outpatient basis (except where unsuitable home conditions or co-existing health concerns exist);
• Provision of safe psychosocial support in a non-threatening environment; and
• Can involve pharmacological symptom relief.

These authors also suggested a range of assessment protocols for assessing the potential risks of withdrawal to inform treatment planning and protocols to monitor and respond to the withdrawal syndrome. However, as with other researchers and clinicians, they note that there is a lack of a good evidence base to guide withdrawal management, and in particular, despite a range of current studies, their counsel that there is limited evidence about indicated pharmacotherapies still stands:

Recommendations for psychostimulant detoxification and withdrawal management … tend to be based on clinical opinion and therefore management strategies may vary from setting to setting. The role of pharmacotherapies is currently limited, however benzodiazepines, antipsychotics and antidepressants if necessary are currently considered by clinicians to be the major components of a medicated psychostimulant withdrawal program (Jenner & Saunders, 2004, p.117).

These and other researchers (e.g., Vincent et al., 1999) also note that a significant proportion of people dependent on ATS may also be dependent on other drugs (e.g., alcohol, opioids), and therefore, the more established withdrawal management strategies for these drugs could be employed.

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