The central nervous system stimulant cocaine (benzoylmethylecgonine) is extracted and processed from the leaves of the coca plant, which is indigenous to Central and South America. Cocaine has a deserved reputation for being a significant and dangerous drug of abuse, but it was originally presented as a drug that had significant medical uses. It still does retain some restricted medical uses, mostly as a local anesthetic, and is listed under the Schedule II controlled substance category by the United States Drug Enforcement Administration (DEA).

Cocaine abuse became extremely popular in the latter half of the 1900s, but its recreational use has declined significantly due to numerous reasons, including education about its dangers, strict legal penalties for people who possess even small amounts of the drug, and the rising popularity of the abuse of other types of drugs such as other stimulants (e.g., methamphetamine), other illicit drugs (e.g., the return of the popularity of heroin), and prescription medications.

The most popular method of ingesting cocaine is by grinding up the drug into a powder and snorting it, but people can also smoke the drug in various forms, mix it with water or some other liquid and inject it, and even take it orally. The drug produces a very rapid rush of euphoria, heightened energy and awareness, increased talkativeness, decreased appetite, and a decreased need for sleep.

The effects of the drug are typically short-lived, and many abusers will begin to binge on the drug to maintain its psychoactive effects. Continued bingeing of the drug can lead to significant issues with dehydration, psychosis, and even heart attack or stroke. Chronic use of the drug can lead to the development of physical dependence.
 

Physical Dependence on Cocaine

The development of physical dependence on any substance is characterized by the person demonstrating a withdrawal syndrome when they stop using their drug of choice or cannot get enough of it. Physical dependence occurs as a result of a person first developing some level of tolerance to the drug, indicating that the person’s system has altered various aspects of its functioning to account for the presence of the drug, resulting in the person needing more of the drug to feel its effects, and later development of a withdrawal syndrome.
cocaine powder in pile

Some sources still designate between physical and psychological withdrawal syndromes. Physical withdrawal syndromes would consist of nausea, vomiting, seizures, fever, chills, and alterations of blood pressure. A person undergoing a more psychological or emotional withdrawal syndrome would primarily express issues with depression, cravings, anxiety, and lethargy.

In reality, all of the symptoms that occur as a result of withdrawal syndrome are based on the physical process that occurs when a drug is metabolized in the system and then the body eliminates the drug from the system, often referred to as detoxification. The physical process of eliminating the drug from the system reduces levels of the drug and leads to a state of imbalance in the system. This state of imbalance results in the withdrawal symptoms the person experiences. Thus, all withdrawal symptoms have a physical basis, and all withdrawals symptoms are associated with changes in emotions or psychological wellbeing.

In order for any withdrawal symptoms to appear, there must be a decrease of the concentration of the drug in the system. The decrease in this concentration must be significant enough to result in a state of imbalance. This means that the drug will first reach its highest concentration in the bloodstream (peak plasma level) and then begin to dissipate due to normal metabolism. If the person continues to use the drug, high levels will remain in the system, and the person will not experience withdrawal; when they stop using the drug, levels will decline due to the normal process of metabolism.

Peak plasma levels associated with cocaine depend on the method of its administration.

  • For 100 mg of cocaine, peak plasma levels are reached about 30 minutes after snorting the drug.
  • They are reached within 45 minutes after smoking about 50 mg of cocaine.
  • Peak plasma levels are reached within about 5 minutes of injecting 30 mg of cocaine.
  • If 140 mg of cocaine is taken orally, peak plasma levels are reached about an hour later.

Stimulants like cocaine typically have short half-lives (the amount of time it takes the system to reduce the concentration of the drug by half). Cocaine has an extremely short half-life and may not be detectable in a person’s urine after 24–48 hours following discontinuation. Other metabolites (smaller compounds that are produced when the liver begins to break down a substance) may be detected for longer periods of time.

The development of a withdrawal syndrome occurs when the levels of cocaine in the bloodstream have been reduced to such a significant point that the system becomes imbalanced. This particular time period will vary from individual to individual, and it may even demonstrate significant variability within the same individual. There are various factors that can influence the onset of a withdrawal syndrome associated with cocaine use.

Specific related to the person’s use influence withdrawal. These include:

  • How much of the drug the person used
  • The person’s tolerance level
  • The manner in which the person took the drug (e.g., snorting or smoking)
  • If the drug was taken in conjunction with other drugs like alcohol
  • How long they had been regularly abusing cocaine (Typically, individuals who use larger amounts of the drug, who take it via methods that result in quicker absorption (e.g., smoking or injecting it), and who have longer histories of drug abuse will have more intense and lengthy withdrawal syndromes.)
  • The purity of the drug can affect the withdrawal syndrome.
  • Individuals differ in their metabolisms. Individual variation metabolism can affect the timeline on which withdrawal symptoms will appear.
  • The person’s size (mass or weight) can determine how fast or how long it takes withdrawal symptoms to appear. Smaller people are more likely to have a quicker onset of withdrawal symptoms.
In the past, clinicians debated whether chronic cocaine users experienced any form of withdrawal. Eventually, many came to believe that the withdrawal symptoms associated with cocaine abuse were mostly psychological or emotional in their presentation; however, the current conceptualization is that withdrawal from cocaine and other stimulants is a diagnosable condition that consists of both physical and emotional symptoms.

The diagnosis of stimulant withdrawal is based on general symptoms that are common to the withdrawal syndrome associated with numerous stimulants.  The American Psychiatric Association (APA) lists the formal diagnostic criteria for stimulant withdrawal associated with cocaine and other stimulants.

  • The person must have either stopped using cocaine or other stimulants, or has significantly reduced their use after a prolonged period of being a stimulant user.
  • The person experiences dysphoria, which is a state of negative mood (being extremely uneasy or dissatisfied). Negative mood can consist of depression, anxiety, irritability, restlessness, mood swings, or any combination of these.
  • In addition to dysphoria, the person must also experience two or more physical symptoms that consist of insomnia or hypersomnia (excessive sleeping), fatigue, very vivid and unpleasant dreams, increased appetite, and psychomotor retardation (feeling weighed down and having significant trouble moving, or moving as if in slow motion) or psychomotor agitation (jittery, irritable, and/or hyper-type movements).

For a formal diagnosis of stimulant withdrawal due to cocaine use to be made, the person’s symptoms cannot be attributable to the use of some other drug, attributable to some other medical condition, or attributable to some other mental health disorder.

Chronic use of cocaine results in a massive release of certain neurotransmitters in the brain when the drug is being used (e.g., dopamine and norepinephrine), and then a depletion of the availability of these neurotransmitters after the person stops using the drug. When the abuse of cocaine was reaching its peak in the mid-1980s, research defined a specific progression of the withdrawal syndrome associated with chronic cocaine abusers. This withdrawal symdrome includes three stages: a crash, a withdrawal phase, and an extinction phase.

The first stage of the withdrawal syndrome is described as a crash. During this initial crash stage, people experience the acute effects of the massive depletion of the neurotransmitters that were released as result of their drug use. This leads to a severe imbalance in the system and results in the symptoms associated with this stage.

The initial symptoms associated with the crash may last for several hours to several days depending on the person. The symptoms can be quite variable from person to person, but include some or all of the following:
unhappy woman sitting on floor and crying at home

  • Depression, apathy, feelings of hopelessness, and/or anhedonia (difficulty experiencing pleasure)
  • Irritability, restlessness, jitteriness, and even anxiety (in some cases, panic attacks)
  • Irregular heartbeat, changes in blood pressure, sweating, fever or chills, and other flulike symptoms
  • Fatigue, lethargy, and an increased need for sleep
  • Insomnia
  • Significant cravings to use cocaine
  • Dehydration and tremors
  • Psychosis, in very rare instances

In the second phase, the withdrawal phase, the symptoms are typically less severe and consist of intermittent cravings to use cocaine, periods of fatigue, periods of irritability or nervousness, depression, increased sensitivity to stress, problems with attention, difficulty concentrating, and difficulty learning new information. The withdrawal phase can be quite prolonged in some individuals and may last from a week to 10 weeks or more. Typically, the withdrawal phase is distinguished from the crash phase by a marked reduction in the intensity of the initial symptoms, but a longer period of lingering symptoms.

In the final phase, the extinction phase, the person remains vulnerable to stress and other triggers that can induce cravings for cocaine, but the formal symptoms that have been experienced in the previous phases have remitted. Individuals in this phase may experience very intermittent issues with depressive symptoms and anxiety, but the symptoms are significantly reduced in intensity compared to the previous two phases. Cravings may continue to occur for months and even years following the formal withdrawal phase, but will become less intense and less frequent if the person develops a program of relapse prevention.

The above model is simply a guideline to the type symptom progression a person with a chronic stimulant use disorder will most likely experience. In reality, research has indicated that many these stages are not as discrete as they appear in the model. Individuals who are recovering from chronic cocaine abuse may experience very intense withdrawal symptoms initially, a later reduction in the symptoms, and then alterations between very intense cravings and periods where they can manage their cravings without significant effort. Depression, anxiety, and other issues with mood often appear to wax and wane over the course of an individual’s recovery.

Individuals with a history of chronic substance use disorders are always at an increased risk for relapse. Many individuals recovering from chronic cocaine abuse may find themselves alternating between periods of abstinence, relapse and binges, complete abstinence for a while, and then issues with relapse.

Although the actual withdrawal syndrome associated with cocaine abuse is not generally considered to be potentially dangerous, some of the symptoms can place individuals at risk. For instance, people who become dehydrated as a result of significant appetite loss, depression, or lethargy are at risk for serious health issues. Individuals who are emotionally distraught due to depression, apathy, or anxiety are at risk for harm due to poor decision-making or even suicidal ideations.

It is generally recommended that individuals who are attempting to recover from chronic cocaine usage become involved in a formal substance use disorder treatment program to assist them. The formal recovery program should include some form of withdrawal management, or medical detox.

How Medical Detox Helps

The withdrawal management or medical detox portion of a recovery program helps the individual in the initial stages of their recovery. According to professional sources such as the American Society of Addiction Medicine (ASAM), the largest organization of physicians who specialize in treating addictions, there are certain things to be considered.

  • Relapse rates are highest early in recovery, particularly when individuals experience withdrawal symptoms. Medical detox can reduce the risk of relapse.
  • The urge to use becomes very powerful during withdrawal. Overdose rates are extremely high for people who relapse during the withdrawal phase. Medical detox can reduce the risk of relapse.
  • The foundation to a successful recovery program is early success and direction. Medical detox allows an individual to establish a sense of control over their behavior.
  • Many individuals have co-occurring mental health disorders along with their cocaine abuse. These disorders can lead to an increased risk for relapse. Such disorders can be identified, and treatment can begin during the medical detox protocol.
  • Becoming involved in a withdrawal management program can also boost confidence in someone in recovery. This can help make their long-term recovery smoother.

There are no specific medications that have been formally approved to treat the withdrawal syndrome associated with cocaine abuse or any other type of stimulant abuse. Instead, the protocol typically uses what can be best described as a symptom management approach.

The physician will attempt to manage the specific symptoms that occur to the individual. Cravings can be addressed with the use of certain medications, but the long-term treatment approach to dealing with cravings is best achieved by behavioral methods, such as substance use disorder therapy. Medications can be given to help people who are feeling uneasy, jittery, or lethargic, and who have issues with sleep.

Depending on the specific circumstances, the medical detox protocol may be best delivered in an inpatient program, although in some cases, individuals can benefit from outpatient medical detox. The determination of an inpatient or outpatient program is made by the observations of the physician in charge of the protocol, therapists, and the individual. Certainly, people who have had numerous unsuccessful attempts at recovery, who have toxic environments, or who have complicated co-occurring disorders would respond best to an inpatient program initially. However, at some point, everyone will transition to outpatient treatment.

Finally, the treatment of the withdrawal syndrome is only the very beginning of an individual’s recovery program. According to ASAM and other sources, individuals who do not engage in comprehensive treatment following medical detox relapse at rates that approach 100%. Relapse rates are high even in individuals who are in structured treatment programs. The recovery from a substance use disorder is a long-term endeavor, and simply getting through the withdrawal syndrome is not sufficient for a successful long-term recovery.