How do you manage symptoms of cocaine intoxication vs withdrawal?

Management of Cocaine Intoxication vs Withdrawal Symptoms

Benzodiazepines are the mainstay of initial management for both cocaine intoxication and withdrawal, with additional targeted interventions based on specific symptoms and complications. 1

Cocaine Intoxication Management

Initial Approach

• First-line treatment: Benzodiazepines for psychomotor agitation, hypertension, and tachycardia 1
• Rapid external cooling for life-threatening hyperthermia using evaporative or immersive cooling methods (highest priority for preventing mortality) 1

Cardiovascular Complications

• For wide-complex tachycardia or cardiac arrest:
  • Sodium bicarbonate (hypertonic solution) 1
  • Lidocaine (reasonable alternative) 1
• For coronary vasospasm or hypertensive emergencies:
  • Vasodilators: nitrates, phentolamine, calcium channel blockers 1
  • Avoid β-blockers as their use in cocaine toxicity is controversial with studies showing both benefit and harm 1

Neurological Complications

• For seizures: Benzodiazepines (first-line) 1
• For severe agitation unresponsive to benzodiazepines: Consider low-dose antipsychotics 2

Cocaine Withdrawal Management

Initial Approach

• Supportive care in a supportive environment with symptomatic medication for specific symptoms 2
• Monitor closely for depression or psychosis during withdrawal 2

Symptom-Specific Management

• Agitation: Short-acting benzodiazepines 2
• Sleep disturbance: Non-benzodiazepine sleep aids 2
• Psychotic symptoms: Low-dose antipsychotics 2
• Pain and respiratory distress: Opioids titrated to symptoms 1
  • Start with bolus doses of 2 mg IV morphine in opioid-naïve patients
  • Follow with infusion if needed

Medication Dosing Guidelines

• Benzodiazepines:
  • Start with 2 mg IV midazolam in benzodiazepine-naïve patients 1
  • Follow with 1 mg/h infusion if needed
  • For breakthrough agitation: bolus dose of 1-2× hourly infusion rate every 5 minutes
  • If patient requires 2 bolus doses in an hour, double the infusion rate 1

Key Differences Between Intoxication and Withdrawal

Feature	Intoxication	Withdrawal
Primary symptoms	Tachycardia, hypertension, hyperthermia, seizures, diaphoresis	Agitation, sleep disturbance, fatigue, depression, anxiety, cravings
Priority interventions	Benzodiazepines + cardiovascular support	Supportive care + symptomatic treatment
Cardiac concerns	Wide-complex tachycardia, coronary vasospasm	Generally less severe
Duration	Hours to days	Days to weeks
Monitoring focus	Vital signs, cardiac rhythm, temperature	Psychiatric symptoms, sleep patterns

Long-term Recovery Planning

• Brief interventions (5-30 minutes) with individualized feedback 2
• Cognitive Behavioral Therapy for better retention 2
• Contingency Management combined with Community Reinforcement Approach shows strongest evidence for effectiveness 2
• Mutual help groups such as Narcotics Anonymous 2

Common Pitfalls to Avoid

• Failing to monitor for psychiatric complications during withdrawal 2
• Using medications without evidence of efficacy 2
• Focusing only on short-term withdrawal without addressing long-term recovery 2
• Neglecting adequate psychosocial support (increases relapse risk) 2
• Delaying treatment for hyperthermia in intoxication (can be rapidly fatal) 1
• Using β-blockers for cocaine-induced cardiovascular effects (controversial safety profile) 1

Remember that cocaine intoxication represents an acute medical emergency requiring immediate intervention, while withdrawal management focuses on supportive care and symptom control over a longer period.