DR. WASSER’S APPROACH to COCAINE, AMPHETAMINE, and ECSTASY WITHDRAWAL SYNDROMES 

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Psycho-stimulant withdrawal (cocaine and amphetamines) has not been typically associated with a withdrawal syndrome.  Withdrawal syndromes have usually been associated with physical withdrawal symptoms such as seizures, tremors blood pressure abnormalities.  There are no such symptoms with stimulant withdrawal.

However, these drugs cause a profound disruption in the balance of brain chemicals.  Specifically, dopamine levels are significantly reduced for at least 3-4 days after cocaine use and perhaps longer with amphetamines.  In addition norepinephrine and seratonin may also be affected.  What results is a profound depression immediately after cessation of these drugs as well as significant drug cravings.  In addition there is a “crash” which last for the same amount of time.  During this time, cognitive ability is decreased resulting in a relative inability to resist the impulse to continue using the drug.  For this reason, many users who are trying to quit often find themselves using again within 1-3 days.

During periods of drug intoxication,  there are effects on the heart and muscles as well as agitation.  There is the possibility of seizures, heart disturbances and hallucinations.  Initial treatment is focused on reducing these effects.  Later on, we may use drugs that mimic Dopamine or try to restore the balance of the other affected brain chemicals.  Many patients have a significant improvement in depression and the level of craving.

 Treatment Of Acute Intoxication

 1-Sedatives-These include tranquilizers like Valium and Ativan.  When a person is quite agitated, calming them down is the first order of business

2-Lopressor- this is a heart medication that protects against high blood pressure, heart attacks and abnormal heart rhythms.  Side effects include fatigue, lightheadedness, and slow heartbeat. Its use may complicate the care of pre-existing asthma and/or diabetes.

3-Tegretol- This is an anti seizure medication that may be used in settings where seizures may be anticipated.  Some persons have found this to reduce cravings as well but its performance is inconsistent. Side effects include a variety of intestinal discomforts; headache, fatigue and possibly confusion but all effects are relieved when the medication is stopped.  Blood problems occur very infrequently.  Thus use of the medication is short term.

4-Zyprexa, Risperdal, Haldol- these are anti-psychotics useful in controlling hallucinations and/or anxiety.  Common side effects include fatigue.  Haldol may also cause EPS.  This is a neurological condition that is usually experienced as muscle spasms about the neck and mouth.  Use of these medications is usually short term.

Long Term Treatment To Reduce Cravings

1-Bromocriptine/Amantadine- these are medications that effect dopamine physiology in the brain.  Cocaine and other stimulants directly affect dopamine levels.  Long-term use will decrease dopamine levels in the brain.  This causes depression, cravings and irritability.  Bromocriptine can stimulate the same receptors in the brain that dopamine does.  Amantidine can increase dopamine levels.  75% of my patients note a reduction in the intensity of the cravings. 

Side effects to Bromocriptine include stomach upset, headache and fatigue.  It is possible that persons, who have a tendency to become psychotic, may do so with this medication.  Amantidine is usually well tolerated.

Unfortunately, many people continue to relapse.  This is because cocaine use has become such a well-learned behavior that it is difficult to extinguish the tendency to reuse the drug.  Such reuse occurs in the absence of cravings-it occurs impulsively related to environment stress or a cue (like seeing the drug)

2-Baclofen-This is a medication that has traditionally been used as a muscle relaxer.  However, it has a unique pharmacological properties and it might interfere with cue-associated cravings.  The physiology of cravings is being worked out.  When we think about the drug, dopamine is released into brain.  This dopamine release creates a situation that is a little like doing the drug; it causes an even greater craving.  It may be what gives strength to the cravings.

There is some thought that Baclofen interferes with this process.  Patients given Baclofen do report a reduction of cravings.  Unfortunately, as a solo agent, the amount of drug used did not significantly decrease in some recent studies.  Nevertheless, I think that there may still be a benefit to be had especially in combination with other drugs.

3-Wellbutrin- This is an antidepressant that has a clinical effect on dopamine physiology.  It may serve to  increase dopamine in the synapse thereby relieving cravings.  It will take some time for it to kick in.   It is more useful if a co-existent depression is felt to exist. 

4-Other anti-depressants - Certain agents have been used in the past such as Prozac-like medication and desipramine with variable success.  Anafranil treats obsessive behavior as well as depression and may be another option. 

The tendency of Ecstasy to permanently damage seratonin-producing neurons suggests seratonin agents might be helpful.  I would opt for Zoloft as this agent is also has more effects on dopamine than other drugs in the class.

5-Chantix-  This medication is indicated for nicotine addiction.  It works by stimulating the nicotine receptor and releasing dopamine.  I have use it to help cravings in smokers with stimulant issues.  It has worked nicely.

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