Abuse of cocaine is fueled by very potent euphoric sensations that result from massive release of the neurotransmitters dopamine and norepinephrine in the brain when the drug is taken. Cocaine is a central nervous system stimulant drug, and its use results in an increased firing rate in the neurons in the brain and spinal cord.
Continued use of cocaine produces significant tolerance to the drug. Tolerance to cocaine and other central nervous stimulants can develop very rapidly. It is a complex physiological and psychological event that is triggered by the system attempting to maintain a state of balance. Use of a central nervous stimulant like cocaine on a regular basis disrupts the body’s natural state of balance, and the system will attempt to restore balance by increasing levels of neurotransmitters, hormones, and other substances that counteract the stimulating effects of cocaine. When this new set point is reached, and the person continues to use more cocaine to increase their chances of experiencing the euphoric effects of the drug, the body again readjusts itself.
Eventually, the individual no longer gets the same level of euphoria from use of the drug. They will often continue to use the drug just to maintain the new level of balance the system has initiated. The desired intensity of the euphoria decreases with continued use of cocaine, and individuals will often binge on the drug in an attempt to obtain the same types of psychoactive feelings of euphoria they achieved when they began using it. This behavior results in the further development of increased tolerance and the need for more of the drug to get the type of effects that maintain this new set point.
Once the person stops using cocaine, levels of the drug in the system are quickly reduced through the normal process of metabolism, which is mostly accomplished by the liver. As levels of the drug in the person’s bloodstream and tissues decrease, the system again becomes unbalanced because it is now operating at a different set point. The adjustments the system made to account for the presence of cocaine in the bloodstream produce a new level of imbalance. This results in the experience of withdrawal symptoms.
When an individual begins to experience withdrawal symptoms from any drug, they have developed some level of physical dependence on the drug. With many central nervous system stimulants, it was once believed that the withdrawal symptoms people experienced were primarily emotional or psychological in nature.
Is Withdrawal from Cocaine Primarily Psychological or Physical?
The designation of a withdrawal syndrome as primarily psychological or physical in nature is a false dichotomy because even an individual experiencing primarily psychological symptoms, such as depression, apathy, cravings, etc., is experiencing events that have a physiological basis. The depression that occurs when individuals who have developed a stimulant use disorder as a result of cocaine abuse stop using the drug is an emotional symptom that most likely has a very strong physiological component to it.
The massive release of dopamine and other excitatory neurotransmitters that occurs with use of cocaine is counterbalanced by a massive depletion of these neurotransmitters when the person stops using the drug. This cycle of massive neurotransmitter release followed by massive neurotransmitter depletion is most likely the main component that contributes to the apathy, depression, and other emotional symptoms that many individuals refer to as the crash.
Moreover, the American Psychiatric Association (APA) lists the diagnostic symptoms for withdrawal from stimulants, including cocaine. These diagnostic criteria consist of a combination of psychological and physical symptoms. There is a sudden stop in use of cocaine or significant reduction in the amount of cocaine used. Negative mood states and at least two physiological changes occur within several hours to a few days after stopping cocaine. Issues include:
- Insomnia or increased sleeping
- Increased appetite
- Very vivid and disturbing dreams
- Changes in motor behavior, such that the person either becomes restless and irritable (psychomotor agitation) or moves very slow (psychomotor retardation)
Over the long run, chronic use of stimulant drugs like cocaine leads to changes in neurobiology that result in long-term issues experiencing pleasure, satisfaction, and other positive mood states without use of the drug. Other symptoms that may occur during withdrawal from cocaine are listed in the timeline below.
All diagnoses of a withdrawal syndrome from cocaine would need to rule out other potential causes that could better explain the above symptoms and require that the above symptoms are causing significant distress. Thus, as can be observed from the diagnostic symptoms for withdrawal from cocaine and other stimulants, there is both a psychological and physiological component to the withdrawal syndrome.
An Average Cocaine Withdrawal Timeline
Recognized withdrawal syndromes will typically have an onset phase, an acute phase, and a longer-lasting phase where the symptoms have peaked and then begin to wane. Cocaine is a drug that has a very short half-life, meaning that it does not stay in the system very long and is metabolized very quickly. This means that the onset of withdrawal symptoms can occur very rapidly once a person stops using the drug. The brief half-life of cocaine and the rapid onset of negative withdrawal symptoms often contribute to the practice of bingeing on the drug that many abusers engage in.
The withdrawal syndrome from cocaine and its timeline have been clinically described.
There is an initial phase (commonly referred to appropriately as phase 1) that consists of the emotional symptoms of anxiety, apathy, depression, fatigue, lethargy, increased appetite, difficulty experiencing pleasure, and significant cravings. This is the phase that is often referred to by users as the crash. Physical symptoms like irregular heartbeat, trembling, and even the potential to develop seizures have been known to occur; however, these are rare. Some individuals may experience confusion and problems concentrating during this phase. Cravings to start using cocaine again are typically very strong.
The second phase is the formal withdrawal phase (phase 2), which can last several weeks or more. It is typically characterized by significant feelings of fatigue, lethargy, irritability, mild issues with concentration, and intermittent cravings. The formal withdrawal phase occurs after the peak of symptoms during the crash.
The extinction phase (phase 3) occurs within a week to several weeks after the initial crash. Individuals will still experience intermittent moods swings and cravings, particularly when they are exposed to some situation that reminds them of their past cocaine use. This can include stressful situations, returning to environments where they used cocaine, watching TV commercials that show people happy and laughing (which works to prime the positive feelings that people may associate with their past cocaine use), and similar events. These specific triggers are often very general in nature and affect many past abusers of the drug, but some triggers are very specific to the individual.
Research has suggested that the specific phases of withdrawal from cocaine are not as discernible as the stages that occur in withdrawal from other drugs, such as alcohol or opiate medications. The progression from the initial crash to the extinction phase is different for different people; it tends to be steady and often does not consist of specific steps or stages.
Relapse probability is high for months following discontinuation. Some individuals may experience extended periods of abstinence followed by a relapse that results from a stressful event or an attempt to occasionally use cocaine on a recreational basis. Because the neurobiological changes associated with cocaine abuse do not completely remit even with years of abstinence, it is very easy for an individual who has a past history of a stimulant use disorder as a result of cocaine abuse to fully relapse after only a few recreational uses of the drug.
The types of factors that determine the length and symptoms that occur in any single person’s withdrawal syndrome include:
- The length of time the person used cocaine
- The amount of cocaine the person typically used
- How they used cocaine (People who smoke or inject cocaine typically have more severe withdrawal syndromes than people who snort it.)
- Personal differences in metabolic rates
- Whether the person typically used cocaine with other drugs of abuse
- The person’s psychological history
Withdrawal Management Issues for Cocaine Abuse
Withdrawal from cocaine is not considered potentially dangerous in most cases, but serious issues may occur as a result of dehydration or in people who have other physical and/or emotional issues, such as heart disease or a severe psychiatric disorder like depression. Of course, relapsing during the withdrawal period is common, and the potential to overdose on cocaine during a relapse is increased, which can lead to serious and even fatal consequences. That is why undergoing withdrawal under a physician’s supervision is also the best course of action.
People who have experienced numerous relapses or who have living conditions that result in significant risk for relapse can initially be treated for their withdrawal symptoms in an inpatient or residential unit; however, many individuals will benefit from outpatient withdrawal management from cocaine as well.
There are no standard protocols or FDA-approved medications that are used specifically for cocaine withdrawal in the same way that there are approved medications for the treatment of withdrawal from alcohol, opiates, and even benzodiazepines. There are different medications that can be used to manage cravings and some of the other symptoms people may experience when undergoing withdrawal from cocaine.
- The anticonvulsant gabapentin (brand name: Neurontin) is useful in reducing cravings and other symptoms that may occur during withdrawal from cocaine.
- Topiramate (brand name: Topamax) is another anticonvulsant medication that may be useful in reducing cravings and treating other symptoms during withdrawal.
- The muscle relaxant bacolfen (brand names: Lioresal or Gablofen) has also been found to reduce some of the effects of withdrawal from cocaine.
- The mild stimulant modafinil (brand name: Provigil) can be used to treat lethargy, sleepiness, and other similar problems during withdrawal from cocaine without any significant side effects.
- There is some evidence to suggest that disulfiram (brand name: Antabuse), which is commonly used to prevent relapse to alcohol abuse, might also be helpful in reducing the relapse probability in individuals who are recovering from cocaine abuse.
Obviously, physicians may address any specific symptoms during withdrawal from cocaine with medications that are designed to formally treat those symptoms.
Recovery from a substance use disorder and successfully going through the withdrawal syndrome are not equivalent concepts. Getting through any withdrawal syndrome, including withdrawal from cocaine, is only the beginning of a recovery program. The stereotypic notion that getting through a withdrawal syndrome is equivalent to being cured from an addiction has long been abandoned. Individuals who successfully get through the early stages of the withdrawal syndrome are at an extremely high risk for relapse even if they seek formal treatment that includes continued medical management, therapy, support group participation, a commitment to abstinence, etc.