Detoxification from psychostimulants may proceed without the assistance of medications. Unlike withdrawal from substances such as alcohol or opioids, pharmacotherapy for psychostimulant withdrawal is of limited value, with most studies undertaken to date failing to demonstrate significant clinical effects (Gowing et al., 2001) (see Chapter 8: Pharmacological interventions for a thorough review).
There is also no evidence that tapered withdrawal from psychostimulants is preferable to abrupt cessation (Wickes, 1992). Psychostimulant withdrawal is rarely life-threatening but users with profound depression may develop suicidal ideation, or psychotic symptoms may manifest during the acute intoxication/toxicity phase and worsen during the early stages of withdrawal (Murray et al., 2002). In this case, medications may be prescribed as indicated for those disorders.
Use of anxiolytics and sedative hypnotics
Use of antidepressants
Use of antipsychotics
Psychological therapies for psychostimulant detoxification
Use of anxiolytics and sedative hypnoticsAnxiety may be a prominent feature of cocaine and to a lesser extent amphetamine withdrawal. A recent animal study demonstrated the effectiveness of benzodiazepines to reduce cocaine withdrawal-induced anxiety (Paine, Jackman & Olmstead, 2002). Benzodiazepines (particularly long-acting diazepam) if indicated for anxiety or to initiate sleep in early withdrawal should be prescribed for a maximum of two weeks, with dispensing on a daily basis if possible. Results from a recent Australian study revealed that patients who were prescribed a sedative hypnotic (temazepam) were more than twice as likely to complete an in-patient amphetamine detoxification program than those who were not (Cruickshank & Dyer, unpublished).
Use of antidepressantsThere are several guidelines currently available for the pharmacological management of amphetamine withdrawal in Australia if it is indicated. Briefly, Murray and colleagues (e.g. Murray et al., 2002), suggest that an SSRI or tricyclic antidepressant may be prescribed if necessary, with frequent reviews and careful monitoring, as tricyclic antidepressants are cardiotoxic in overdose. Similarly, as relapse to psychostimulant use is common, special care must be taken when prescribing SSRIs as toxicity (due to increased serotonin levels) has been reported with concomitant use of psychostimulants (Barrett, Meehan & Fahy, 1996). It must be recognised, however, that antidepressants need to be taken for about 2 weeks before a therapeutic effect is evident and individuals prescribed these medications must be suitably informed to encourage compliance during this window period. Australian researchers intend to investigate the role of the faster-acting SNRIs in psychostimulant withdrawal in the near future (Dyer, K. pers. comm.).Top of page
Use of antipsychoticsIf psychotic symptoms manifest, antipsychotic medication such as phenothiazine or haloperidol may be prescribed in the short term (one to two weeks). However if psychosis persists or is severe, an immediate psychiatric assessment is indicated and general psychosis management and treatment principles should be applied (Murray et al., 2002).
There is some clinical interest in the prescription of the newer atypical antipsychotic medications during psychostimulant withdrawal, but their role is yet to be empirically determined and further studies are required before clinical recommendations can be confidently made (Srisurapanont et al., 2002). The reader is referred to Chapter 6: Management of acute toxicity and Chapter 10: Psychiatric comorbidity of psychostimulant use in this monograph for a detailed review of the management of psychosis.
It is important to recognise that some clinical investigators have found withdrawal from at least cocaine to be a relatively benign process that can be generally undertaken without the assistance of medication (Miller et al., 1993).