CAPÍTULO II: HIPÓTESIS Y VARIABLES
ESPECIFICACIONES DEL TRABAJO COLABORATIVO
Symptoms
Stimulantsareassociatedwithwithdrawal symptomsthatdiffermarkedlyfromthoseseen withopioid,alcohol,andsedativedependence (seeFigure4-7).Whilemostcliniciansbelieve thatalcoholandheroinwithdrawalshouldbe treatedaggressivelywithdetoxification,there hasbeenlittleemphasisontreatingsymptoms ofstimulantwithdrawal.Consequently,no medicationshavebeendevelopedforthispur- pose.Thissituationisunderstandablebecause stimulantwithdrawalusuallydoesnotinvolve medicaldangerorintensepatientdiscomfort. However,ifstimulantwithdrawalpredictspoor outcome,itmaybeareasonabletargetforclin- icalinterventions.
Anoftenoverlookedbutpotentiallylethal “medicaldanger”duringstimulantwithdrawal istheriskofaprofounddysphoria(depres- sion,negativethoughtsandfeelings)thatmay includesuicidalideasorattempts.Thismay be,inpart,aphysiologicalresponsetococaine
oramphetaminewithdrawaland,inpart,a reactiontoindividuals’acuterealizationofthe devastatingpsychosocialconsequencesaftera bingeends.Whilebothcocaineand
amphetamineusersmayexperiencedepression duringwithdrawal,theperiodofdepression experiencedbyamphetamineusersismore prolongedandmaybemoreintense.
Amphetamineusers,inparticular,shouldbe monitoredcloselyduringdetoxificationfor signsofsuicidalityandtreatedfordepressionif appropriate.
Althoughtheliteratureoncocainewithdrawal iscontroversial,reasonableconsensussupports theconstellationofsymptomsdepictedin Figure4-7(Coffeyetal.2000;Cottleretal. 1993).Thesesymptomsoftendisappearafter severaldaysofstimulantabstinencebutcan persistfor3to4weeks(Coffeyetal.2000).In addition,sinceindividualsaddictedtostimu- lantsoftenfailtoachieveabstinence,withdraw- alsymptomscanbeapersistentcomponentof activeaddiction.Inaddition,individuals addictedtostimulantsmayexperienceimpair- mentinhedonicfunction(abilitytoexperience pleasure)thathasbeenascribedtostimulant- induceddisruptionsofendogenousrewardcen- ters(DackisandO’Brien2002).Researchon animalshasfoundthatexposuretohighdoses ofmethamphetamineresultsinchangestoboth thedopaminergicandserotonergicsystemsof thebrain(Nordahletal.2005)anddopamine abnormalitiesamonganimalsandhumanswho hadbeeningestingcocaine(Schuckit2000).
Figure 4-7
Stimulant Withdrawal Symptoms
•Depresion
•Hypersomnia(orinsomnia) •Fatigue •Anxiety •Irritability •Poorconcentration •Psychomotorretardation •Increasedappetite •Paranoia •Drugcraving
Researchershavealsoobservedabnormalities inregionsofthebrainthatgovernattention andmemoryinanimalsthatwereregularly administeredmethamphetamine(Nordahletal. 2005).
Althoughcocainewithdrawalhastraditionally beenviewedasrelativelymild(Sateletal. 1991;Weddingtonetal.1990),evidencesug- geststhatindividualsdependentoncocaine withseverestimulantwithdrawalaremorelike- lytohaveapoorclinicaloutcome(Kampman etal.2001a).Thelevelofwithdrawalsymp- toms,therefore,maybeclinicallysignificant andshouldbemonitoredandrecordedfor futuretreatment(Kampmanetal.2001b). Kampmanreportedsignificantlyhigher dropoutratesinindividualsdependenton cocainewhoscoredhighontheCocaine SelectiveSeverityAssessment(CSSA),areli- ableandvalidstructuredinterviewdesignedto capturecocainewithdrawalsymptoms
(Kampmanetal.1998).Patientswithhigh scoresontheCSSAwerefivetimesmorelikely toleavetreatmentandfourtimesmorelikelyto resumecocaineusethanthosewithlowscores (Mulvaneyetal.1999).TheCSSAisaneasily administered18-itemquestionnaire.Eachitem isa7-pointratingscale,sothatapersoncan scoreanumberofpointsonanygivenques- tion.Scoresinexcessof22indicatethepres- enceofsignificantcocainewithdrawal.See appendixCformoreinformationontheCSSA. Giventhepoorprognosisassociatedwith cocainewithdrawal,itisreasonablethatmore clinicalattentionbedirectedtowardthisphe- nomenon.
Medical
Complications
of
Stimulant
Withdrawal
Aspreviouslynoted,stimulantwithdrawalis notusuallyassociatedwithmedicalcomplica- tions.However,patientswithrecentcocaine usecanexperiencepersistentcardiaccomplica- tions,includingprolongedQTcintervaland vulnerabilityforarrhythmiaandmyocardial infarction(ChakkoandMyerburg1995).QTis anintervaloftimethatcanbemeasuredonan
electrocardiogram(betweentheqwaveandthe twave),whileQTcistherelative(or“correct- ed”)QTinterval.Someconditionsandmany drugs(LAAM,otheropioids,andevenantibi- otics)cancausetheintervaltolengthenand thiscanresultincardiacrhythmdisturbances. Anteriorchestpainorcardiacsymptoms shouldthereforebefullyevaluatedinthese individuals.Seizuresalsomaybeacomplica- tionofstimulantabuseandcanoccurduring detoxification.Persistentheadachescouldrep- resentasubdural,subarachnoid,orintracere- bralbleed(bleedinginoraroundthebrain) andshouldbeappropriatelyevaluated.Italso shouldbeemphasizedthatpeoplewhoabuse stimulantsusuallybecomeaddictedtoother substances,suchasalcohol,sedatives,oropi- oids,andthereforecanexperienceanyofthe complicationsascribedtodetoxificationfrom thesesubstances.Covert(secretive)useof othersubstancesshouldbesuspectedand assessedwithurinetoxicology.
Management
of
Withdrawal
Without
Medications
Themosteffectivemeansoftreatingstimulant withdrawalinvolvesestablishingaperiodof abstinencefromtheseagents.Accesstobrief hospitalization,alevelofcarepreviouslyavail- ableforthosewhoabusestimulants,hasbeen largelyeliminatedbymanagedcareinitiatives. Initsplace,intensiveoutpatienttreatmentcan assistthepatienttoceaseuselongenoughfor withdrawalsymptomstoabateentirely. Rehabilitativeapproachestoachievestimulant abstinencehavebeenreviewedelsewhere (DackisandO’Brien2001).Theavoidanceof cue-inducedcravingisparticularlyimportant intheseindividuals,especiallyinlightof researchthatshowslimbicactivation(activity inacertainpartofthebrain)inresponseto cue-inducedcraving(Childressetal.1999).It alsoisimportantthatindividualsdependenton stimulantsabstainfromotheraddictivesub- stances.
Management
of
Withdrawal
With
Medications
Therearenomedicationswithprovenefficacy totreatstimulantwithdrawal.However, researchershaveinvestigatedsomemedications forcocainedetoxification.Amantadinemay helpreducecocaineuseinpatientswithmore severewithdrawalsymptoms(Kampmanetal. 2000).Modafinil,anantinarcolepsyagentwith stimulant-likeaction,iscurrentlyunderinves- tigationbyoneresearchgroupasacocaine detoxificationagent(DackisandO’Brien 2002).OnesmallstudyinThailandfoundthe antidepressantmirtazapine(Remeron)was effectiveatreducinganumberofthesymptoms associatedwithamphetaminewithdrawal (Kongsakonetal.2005).Noneofthesemedica- tions,however,areapprovedforuseintreating stimulantwithdrawalandfurtherresearchis needed.Gorelickandcolleagues(2004)review thefullrangeofclinicalliteratureonpharma- cologicalinterventionforcocaineaddiction.
Patient
Care
and
Comfort
Sincestimulantwithdrawalisnotassociated withseverephysicalsymptoms,adjunctive medicationsareseldomrequired.These patientsoftenaresleepdeprivedandmightbe unabletobenefitfromtherapeuticactivities duringthefirst24to36hoursofabstinence. Theyoftenarehungryandinneedoflarge mealportionsinitiallyastheirfoodintakemay havebeeninadequateduringactiveaddiction. Stimulantusersalsomaybeirritableandcare shouldbetakentoavoidneedlessconfrontation duringtheinitialwithdrawalphase.Headaches oftenarereportedandcanbetreatedsymp- tomatically.Persistentheadachesshouldbe evaluated,ascocainecanproducecerebrovas- culardisease.Similarly,chestpainofpossible cardiacoriginshouldbeevaluatedmedically withelectrocardiography,cardiacenzymes, andappropriatemedicalattention.Onocca- sion,patientsundergoingwithdrawalfrom cocaineoramphetaminesreportinsomniaand maybenefitfromdiphenhydramine(Benadryl) 50to100mg,trazodone(Desyrel)75to200mg,
orhydroxyzine(Vistaril)25to50mgatbed- time.Benzodiazepinesshouldbeavoidedunless requiredforconcomitantalcoholorsedative detoxification.Asstimulantwithdrawalsymp- tomswane,patientsarebesttreatedwithan activerehabilitativeapproachthatcombines entryintosubstanceabusetreatmentwithsup- port,education,andchangesinlifestyle.
Other
Immediate
Concerns
Centralnervoussystemstimulantsexertmost oftheirtoxiceffectsthroughvasoconstriction (constrictionofthebloodvessels).
Consequently,anumberofmedicalconditions canarisefrom
ischemia(lackof
properbloodsupply)