Cocaine Detoxification

The term detoxification (rehabilitation) implies a clearing of toxins. However, for individuals with drug dependence, detoxification (rehabilitation) is usually related to withdrawal syndrome, that is, the predictable constellation of signs and symptoms following abrupt discontinuation of, or rapid decrease in, intake of a substance that has been used consistently for a period of time.

In fact, the withdrawal syndrome is the main obstacle for a recovery from an addiction. That is because for persons who are severely dependent on cocaine, abrupt, untreated cessation of consumption may result in severe discomfort and central nervous system changes. But risks to the patient and society are not limited to the severity of the patient's physical disturbance, particularly when the detoxification is conducted in an outpatient setting. Outpatients experiencing withdrawal symptoms give up treatment more often, may self-medicate, and the interaction between prescribed medication and self-administered drugs may result in an overdose or brain damage.

Symptoms of cocaine withdrawal are related primarily to CNS changes. Common symptoms involve depression, insomnia, anorexia, fatigue, irritability, and restlessness. REM sleep may be affected for weeks after last use. Patients frequently experience an intense drug craving that can last for weeks. Patients may have concomitant major psychiatric disorders. Moreover, the risk of relapse is high during the early withdrawal period, in part because drug craving is easily triggered by encounters with or thinking of drug-associated stimuli.

When the cocaine arrives in the brain reward system, it blocks the dopamine transport sites, which are responsible for the reuptake of dopamine in dopaminergic synapeses in this region. Therefore, dopamine is not removed from the synaptic gap, and it remains free there, in ever increasing amounts, because successive nervous stimuli continue to arrive and to release dopamine. The effect remains until the cocaine is removed from the presynaptic terminals. It is believed that the abnormally long presence of dopamine in the brain is responsible for the pleasure effects associated to the use of cocaine. The prolonged use of cocaine makes the brain to adapt to it, and the overall synthesis of dopamine by the neurons is decreased. Between cocaine doses, or when the use of cocaine is interrupted, the drug user experiences the opposite of pleasure, due to the low levels of dopamine: fatigue, depression and altered moods.

For these reason, detoxification treatment without an appropriate medical management and level of care constitutes a great risk for health of patients.

To avoid the risk of brain damage: Ultrarapid detoxification without withdrawal

As it has been remarked, withdrawal symptoms are a fundamental obstacle for cocaine detoxification/rehabilitation treatment. This is because withdrawal from consumption of cocaine is not sufficient to eliminate the serious alterations that cocaine produces in brain cells. Moreover, current medications used in detoxificationtreatment do not restore damaged areas, but mask symptoms.

Once in the brain, drugs affect chemicals called neurotransmitters. These are the chemicals that control the flow of information within the brain between the neurons or brain cells, forming a synapse. Neurotransmitters also alter people's moods and feelings.

To avoid withdrawal syndrome, it is necessary to restore brain functions that have been damaged by cocaine addiction. But this is not possible only by detoxification. Neurons must be recovered, so they can maximize use of available oxygen and neural membrane metabolism is normalized. Only this pharmacological intervention, to recuperate the normal neural functioning of the brain structures harmed by cocaine, allows a detoxification without withdrawal symptoms and without craving. Moreover, it allows the recovery of higher cognitive and affective processes as attention, reading abilities, conciousness or serenity.

Because there is a risk of serious adverse consequences for most patients who undergo withdrawal, it is necessary an advanced pharmacological treatment in a medically-monitored inpatient detoxification. This is an organized service delivered by medical and nursing professionals, which provides for 24-hour medically supervised evaluation and recovery management in a permanent facility with inpatient beds. Services are delivered under a defined set of physician-approved policies and physician-monitored procedures or clinical protocols.

Advantages of inpatient detoxification are that (1) the patient is in a protected setting where access to substances of abuse is restricted, (2) the management and monitoring of neural recovery eliminates craving, and allows a detoxification without withdrawal, and (3) detoxification can be accomplished more rapidly than it can in an outpatient setting. Besides, detoxification with hospitalization prepares the patient for ongoing treatment of his or her dependence on drugs. During detoxification, patients may form therapeutic relationships with treatment staff or other patients, and may become aware of alternatives to a drug-using lifestyle. Detoxification is an opportunity to offer patients information and to motivate them for longer-term treatment.

According to these needs, cocaine detoxification involves several procedures

First, treatment/rehabilitation of patients who are under the influence of, or experiencing withdrawal from, substance-related disorders requires an understanding of the natural history and variants of such syndromes; a complete assessment of the patient's individual medical, psychiatric, and social issues. Detailed clinical exploration is necessary, as well as psycho-diagnostic and psychopathological examinations, to establish the characteristics of the addiction and its intensity, the existence of associated psychological illnesses, and the repercussions on the patient family, work, and friendships.  This medical assessment is important in order to determine the need for medication and medical management, and the patient assessment should identify coexisting medical and psychiatric conditions and cocaine-related medical complications. Besides, this information is necessary to design the psychotherapeutic strategy during hospitalization which is later continued on an out-patient basis after the patient's release.

Afterwards, oral and intravenous pharmacological interventions are performed to recuperate the normal neural functioning of the brain structures harmed by cocaine (dopaminergic and serotonergic neuro-receptor systems, for example).  The goal of pharmacological management is to provide the amount of medication necessary to ensure safe and comfortable detoxification (rehabilitation), as these interventions allow a detoxification without withdrawal symptoms and without craving; by increasing the ability of the treated neurons to take advantage of available oxygen, neural membrane functions are normalized in a short period of time.

General management also includes maintaining adequate fluid balance, correction of electrolyte deficiencies, and attendance to the patient's nutritional needs. Brain nutrition involves enriching the patient's diet with salts, oligo-elements, and amino acids essential for neural recuperation and correcting nutritional deficiencies which frequently accompany this illness.

At the same time, a personalized psychotherapy action plan is designed, based on the psycho-diagnostic examinations, to restore the harmony between personal and familial psychological functioning, clarify erroneous concepts regarding the illness, and promote attitude and lifestyle changes, all of which incorporate the patient as an active participant in his/her own rehabilitation process.  This psychotherapy, as well as pharmacological control, are process of ambulatory follow-up phase, after the patient leaves hospital.

Under these conditions, cocaine detoxification/rehabilitation has four immediate goals: (1) to provide a safe withdrawal from cocaine dependence and enable the patient to become free of non-prescribed medications; (2) to provide a withdrawal that is humane and and that protects the patient's dignity; (3) to provide a recovery of higher cognitive and affective processes, and (4) to prepare the patient for ongoing treatment of his or her new life.

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