What medications are used to manage cocaine withdrawal?

Cocaine Withdrawal Medications

No pharmacologic treatment for cocaine withdrawal can be recommended for use in clinical practice. 1

Evidence-Based Treatment Approach

Primary Treatment: Psychosocial Interventions (Not Medications)

The combination of Contingency Management (CM) plus Community Reinforcement Approach (CRA) is the most effective treatment for cocaine withdrawal and dependence, with a number needed to treat (NNT) of 3.7 (95% CI 2.4–14.2). 2

• Contingency Management provides tangible rewards (vouchers or prizes) contingent upon drug-free urine samples, creating immediate positive reinforcement for abstinence 2, 3
• Community Reinforcement Approach addresses underlying psychological and social factors through functional analysis, coping-skills training, and social/familial/recreational/vocational reinforcements 2, 3
• This combination works because CM alone shows efficacy during treatment but effects are not sustained at long-term follow-up, while CRA provides the sustained support needed for long-term recovery 2, 3

Symptomatic Management Only

Withdrawal from cocaine is best undertaken in a supportive environment with symptomatic medication only for relief of specific symptoms. 1

• Treat agitation with appropriate sedatives as needed 1
• Treat sleep disturbance with appropriate sleep aids as needed 1
• Monitor for depression or psychosis during withdrawal, which occur less commonly but require close monitoring and specialist consultation if they develop 1
• Medication is rarely needed, as withdrawal symptoms (depression, anxiety, lethargy) usually clear within a week 4

What NOT to Do

Do not use dexamphetamine or other stimulant replacement therapy for cocaine withdrawal. 1

• Unlike opioid use disorder where agonist therapy is effective, stimulant replacement has no role in cocaine treatment 5
• No FDA-approved medications exist specifically for cocaine use disorder 2

Do not rely on 12-step programs alone as monotherapy. 5, 2

• 12-step programs show no significant benefit over treatment as usual (OR 0.87, p=0.616) 5
• They may be beneficial as an adjunct but should not be the sole treatment approach 2

Treatment Implementation Algorithm

Step 1: Initial Assessment and Withdrawal Management

• Conduct withdrawal in a supportive environment with regular monitoring 1
• Provide symptomatic medications only for agitation, sleep disturbance, or other specific symptoms 1
• Monitor closely for depression or psychosis, which require specialist consultation 1

Step 2: Initiate Evidence-Based Psychosocial Treatment

• First-line: Implement CM plus CRA immediately upon patient presentation 2
• Begin regular urine drug screening to provide objective evidence for CM rewards 2
• Address barriers to treatment engagement such as lack of motivation 2

Step 3: Alternative if CM+CRA Unavailable

• Second-line: Cognitive Behavioral Therapy (CBT) alone, though it is more acceptable than treatment as usual but not significantly more efficacious for abstinence 2
• CBT demonstrates sustained benefits even after treatment completion (OR 2.29-2.22 for abstinence versus treatment as usual) 5

Step 4: Long-Term Follow-Up

• Provide regular follow-up and support after initial treatment, which is critical for sustained recovery 2, 3
• Continue monitoring for relapse and provide ongoing psychosocial support 2

Critical Pitfalls to Avoid

• Do not prescribe medications as primary treatment for cocaine withdrawal or dependence, as no pharmacologic treatment is recommended 1
• Do not use CM without CRA or similar comprehensive approaches, as this leads to relapse after treatment completion 2, 3
• Do not fail to provide long-term follow-up, which is essential for sustained recovery 2, 3
• Do not overlook co-occurring mental health conditions that may require integrated treatment approaches 2

Special Considerations

• For patients with comorbid psychiatric disorders, ensure psychiatric consultation is available as these patients may require specialized management 5
• For individuals who inject cocaine, address barriers such as lack of motivation and facilitate access to sterile injection equipment and outreach programs 1, 2
• Exercise that produces cardiopulmonary stimulation may be helpful in reducing drug hunger and anxiety during recovery 4