Models of intervention and care for psychostimulant users, 2nd edition - monograph series no. 51
Natural history of cocaine withdrawalMost of the literature pertaining to the cocaine withdrawal syndrome has predictably emerged from studies undertaken in the USA where the use of cocaine is prevalent. However, general agreement on the natural history of a 'typical' cocaine withdrawal has yet to be reached. Due to the relatively short half-life (time required for half of the drug dose to be cleared from the body) of cocaine of 90 minutes (Cho & Melega, 2002), withdrawal symptoms may occur quite rapidly following the last dose.
The most commonly cited study into cocaine withdrawal was undertaken by Gawin and Kleber in 1986. Using data collected from 30 cocaine-dependent outpatients, the investigators reported three distinct phases ('crash', 'withdrawal' and 'extinction') of the withdrawal process:
- Phase one, 'the crash', developed rapidly following abrupt cessation of heavy cocaine use and was characterised by acute dysphoria, irritability and anxiety, increased desire for sleep, exhaustion, increased appetite, decreased craving to use.
- Phase two, 'withdrawal' was characterised by increasing craving to use, poor concentration, some irritability and some lethargy, which persisted for up to 10 weeks.
- Phase three, 'extinction', comprises intermittent craving to use in the context of external cues.
Despite the relative persistence of the clinical application of the phasal model to cocaine withdrawal (and to some extent amphetamine withdrawal), results from several other studies have not supported this model, but rather have found a gradual return to normative functioning over time (Coffey, Dansky, Carrigan & Brady, 2000; Miller et al., 1993; Satel, Price, Palumbo, McDougle et al., 1991; Weddington, Brown, Haertzen, Come et al., 1990).
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For example, Miller and colleagues (1993) reported self-described and clinically observed withdrawal symptoms among a group of 150 cocaine-dependent (DSM-III-R criteria) in-patients of an alcohol and drug treatment facility in Florida. The age range was 18–55 years (mean 26 years). Males comprised 64% of the sample. Half of all participants smoked crack cocaine and 29% snorted powder. The investigators reported that following rapid cessation of cocaine use, withdrawal symptoms consisted of 'craving, hyperactivity, slight tremor, insomnia and apprehension' (p. 30), which decreased in a linear fashion. No participants required medication during the withdrawal and no significant psychological problems emerged. Unfortunately, no specific time periods associated with the symptoms were presented, although only 12 patients (8% of the sample) left the 28-day treatment program prior to completion.
A more recent prospective study of cocaine withdrawal was undertaken in the USA by Coffey and colleagues (2000). A small sample of 24 mixed in-patient and outpatient subjects (42% female) who completed all measures over a 28-day period were included in the final analysis (82 cocaine-dependent participants comprised the whole sample). The investigators reported a linear reduction in withdrawal symptoms over the time period, particularly anger and depression, with a corresponding increase in concentration. Interestingly, craving to use cocaine was not identified as a significant issue among this sample, nor were appetite fluctuations and sleeplessness.
Several explanations have been offered for the lack of consistency across studies. These include differences in exposure to drug use cues between in-patient and outpatient samples and variations in sample size and research methodology, such as prospective versus retrospective designs (Lago & Kosten, 1994). Mixed in-patient and outpatient samples as described above may also cloud the clinical picture, particularly when small sample sizes are relied upon. Prospective studies examining the natural history of cocaine withdrawal among both in-patients and outpatients, with attention to gender differences in withdrawal characteristics among dependent cocaine users, are required to clarify some of these issues for the Australian situation.
Figure 1: Gawin and Kleber's Phasal Model of Cocaine Withdrawal (1986)
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Text version of Figure 1Phasal model of cocaine withdrawal:
- Onset within hours to a few days 'Crash'
- no cravings to use
- increased appetite
- 'Withdrawal' 1-10 weeks
- erratic sleep
- strong craving
- emotional liability
- poor concentration
- 'Extinction' up to 28 weeks
- episodic cravings
- some dysphoria
Diagnosis of cocaine withdrawalFor a formal diagnosis of cocaine withdrawal to be made, the DSM-IV-TR (American Psychiatric Association, 2000) lists the following criteria:
- cessation of, or reduction in, heavy or prolonged cocaine use;
- dysphoric mood plus two (or more) of the following, developing within a few hours or several days after A:
- insomnia or hypersomnia;
- psychomotor agitation or retardation;
- increased appetite; and
- vivid, unpleasant dreams;
- the criterion symptoms in B are clinically significant or cause distress in social, occupational or other important areas of functioning; and
- are not due to a medical condition or another cause.
While depression is commonly present during cocaine withdrawal and dysphoria (sadness) is a mandatory criteria as stated above, there is some evidence to suggest that depression (lifetime and current) affects the onset and course of cocaine withdrawal.
In a recent study of 146 cocaine users (who used more than 10 times in any one-month period), those with a lifetime history of depression (according to DSM-IV diagnosis) were five times more likely to self-report ever having experienced a withdrawal syndrome than those with no history of depression (Helmus, Downey, Wang, Rhodes & Schuster, 2001). Unfortunately, the investigators did not determine if the depressed subjects used larger amounts of cocaine than their non-depressed counterparts, as quantity and frequency of use significantly impacts on withdrawal.
In another study, Schmitz, Stoots, Averill, Rothfleisch et al. (2000) reported more severe craving for cocaine among those with comorbid cocaine dependence and depression (n=50) than those with cocaine dependence alone (n=101).
Finally, Roy (2001) reported that of a sample of 214 cocaine-dependent patients admitted to a Department of Veterans' Affairs sponsored drug treatment service in the USA, 39% (n=84) had at least one attempt at suicide during their life (mean 2.1 attempts, range 1-9) and 87% met DSM-IV criteria for lifetime major depression. Those who attempted suicide were more likely to be female (p=<0.001), have a family history of suicide (p=<0.0001) and were more likely to have experienced childhood sexual, emotional or physical abuse than cocaine-dependent individuals with no history of suicide attempts (p=<0.0001).
Assessment issues in cocaine withdrawalIndividuals presenting for treatment should be thoroughly assessed for concomitant mental health disorders due to the high rates of comorbid depression and cocaine dependence (eg, Falck, Wang, Carlson, Eddy & Siegal, 2002; Rounsaville, Anton, Carroll, Budde et al., 1991), the potential role of untreated depression in relapse to problematic substance use (Hasin, Liu, Nunes, McCloud et al., 2002) and the potential for suicide (Falck et al., 2002; Roy, 2001). The issue of comorbid mental health disorders and their impact on assessment and management of psychostimulant users are discussed in detail in Chapter 10: Psychiatric comorbidity of psychostimulant use.
Due to the high prevalence of concurrent dependence on other drugs, particularly alcohol (Carroll, Nich, Ball, McCance et al., 2000; Kampman, Pettinati, Volpicelli, Kaempf et al., 2002; Miller et al., 1993) the cocaine withdrawal syndrome may be complicated by withdrawal from other drugs, hence a thorough assessment of the use of all drug classes is recommended (see Assessment for detoxification section of this chapter). Should concomitant withdrawal syndromes occur, both should be managed simultaneously.