THE MANAGEMENT OF WITHDRAWAL SYNDROMES
Abrupt cessation of stimulant (amphetamine, cocaine) use is associated with depression, anergia, anhedonia, increased drug craving, increased appetite, hypersomnolence and increased REM sleep (Weiss, Greenfield & Mirin, 1994). This initial period of intense symptoms is commonly termed the 'crash', which is usually selflimiting to a period of days. There have been reports of myocardial ischaemia occurring in the first week of stimulant withdrawal (Nademanee, Gorelick et al, 1989) although this is uncommon, and other medical effects are relatively minor.
The 'dopamine deficiency' hypothesis of stimulant withdrawal has not been supported by clinical practice - controlled clinical trials of dopamine agonists have yielded inconsistent results. Similarly the use of tricyclic antidepressants to limit the effects of withdrawal on the basis that they inhibit presynaptic catecholamine neurotransmitter uptake, have failed to deliver any significant benefit. Antidepressants may however be useful in the treatment of an on-going depressive disorder associated with stimulant drug misuse.
The stimulant withdrawal syndrome is thus best treated supportively and symptomatically by allowing the patient to sleep and eat as much as necessary. A benzodiazepine
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- The stimulant withdrawal syndrome is best treated supportively and symptomatically by allowing the patient to sleep and eat as much as necessary.
- A benzodiazepine such as chlordiazepoxide may be helpful in selected patients who develop agitation or sleep disturbance.
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such as chlordiazepoxide may be helpful in selected patients who develop agitation or sleep disturbance (Pearsall & Rosen, 1992); these should not be continued any longer than two weeks. Neuroleptics should be avoided because of their potential to induce dysphoric side-effects.
As for opiate drugs, the chronic stimulant misuser is likely to experience a protracted withdrawal syndrome for months or even years which is characterised by depressed mood, lethargy and anhedonia together with intense craving. There is no specific pharmacological antidote for this syndrome or to limit the likelihood of relapse, although concurrent depressive disorder may respond to antidepressants.
In conclusion, the management of stimulant drug misuse is largely psycho-social at all stages.
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The above information is copyright of Dr Bruce Trathen MBBS MRCPsych (2006). ISBN 0-9545164-0-0. The author grants permission for these guidelines to be downloaded, copied and distributed freely, but does not grant permission for their sale.
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