Cocaine Rehabilitation

The myth that cocaine was not addictive was widely accepted throughout the medical profession and by society at large for a long time. Some accepted this notion as late as the seventies and eighties despite the knowledge that regular cocaine users experience intense and irresistible craving. In fact, the compulsive drug-seeking is the behavioral hallmark of cocaine addiction. The confusion arose because the existence of cocaine addiction was measured against withdrawal symptoms associated with heroin. But each drug has its own unique physical effects, which in the case of cocaine and crack are very powerful (“crack" is the street name given to cocaine that has been processed from cocaine hydrochloride to a free base for smoking, and it is almost instlantly addictive).

Thus, cocaine is, perhaps, the most addictive drug, and it has been an enormous increase in the number of people seeking cocaine detox (and rehabilitation) from addiction during the 1980s and 1990s.

Withdrawal syndrome: the main obstacle for cocaine detox and rehabilitation

The term detoxification implies a clearing of toxins. However, for individuals with drug dependence, detoxification 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.

Once the user stops, which can prove very difficult for a regular or chronic cocaine user, they will very quickly start to feel withdrawal symptoms. But in contrast to withdrawal from opiates and alcohol, the cocaine withdrawal syndrome is not dramatic, obvious, and physical, but primarily behavioral. The immediate “crash” upon exhausting the drug supply is followed by depression, anxiety, agitation, and suspiciousness (sometimes actual paranoia). As the abstinence continues, there is extreme boredom, lack of motivation, and depression. Recalling what the “high” was like provokes intense craving, as do numerous conditioned cues (people, objects, and situations associated with cocaine or amphetamine use). Often these conditioned association triggers provoke a new binge, and vulnerability to relapse probably persists for a lifetime.

For these reason, cocaine detoxification treatment and rehabilitation without an appropriate medical management and level of care constitutes a great risk for patients' health. On the other hand, the harshness of the methadone withdrawal syndrome leads to a very high risk of relapse during the early withdrawal period, in part because drug craving is easily triggered by encounters with or thinking of drug-associated stimuli.

Summing up, the withdrawal syndrome is the main obstacle for a recovery from cocaine 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 detox/rehab 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.

Damages in the brain caused by cocaine abuse and problems to rehabilitation

As it has been remarked, withdrawal symptoms are a fundamental obstacle for cocaine rehabilitation treatment. This is because withdrawal from use of cocaine is not sufficient to eliminate the serious alterations that cocaine produces in brain cells. Moreover, current medications used in detox treatment 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 mood and feelings. When the cocaine arrives at 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 subsequently release dopamine. The effect remains until 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.

To avoid brain damage risk: ultra rapid detoxification without withdrawal

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

It is necessary, thus, an advanced pharmacological treatment in a medically-monitored inpatient detoxification. This is an organized service delivered by medical and nursing professionals, who provide 24-hour medically supervised evaluation and recovery management in a permanent facility with inpatient beds. services that is delivered under a defined set of physician-approved policies and physician-monitored procedures or clinical protocols.

Advantages of inpatient rehabilitation 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 detox without withdrawal, and (3) detoxification can be accomplished more rapidly than in an outpatient setting. Besides, detox with hospitalization prepares the patient for ongoing treatment of his or her dependence on drugs. During cocaine rehabilitation, patients may form therapeutic relationships with treatment staff or other patients, and may become aware of alternatives to a drug-using lifestyle. Cocaine rehabilitation period is an opportunity to offer patients information and to motivate them for longer-term treatment.

According to these needs, cocaine detox 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 detox, as these interventions allow a rehabilitation 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 detox 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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