What is the recommended protocol for cocaine detox?

Cocaine Detoxification Protocol

Cocaine withdrawal is best managed in a supportive environment with symptomatic treatment only—no specific medication is recommended for the withdrawal syndrome itself, but benzodiazepines should be used short-term (7-14 days) to control agitation, anxiety, and insomnia. 1

Immediate Assessment and Monitoring

• Monitor vital signs closely, particularly in patients with cardiovascular complications, as cocaine can cause hypertension, tachycardia, and coronary vasospasm 2
• Screen for acute medical emergencies including chest pain, seizures, stroke, myocardial infarction, and severe hypertension that require immediate intervention before focusing on detoxification 3
• Assess for psychiatric comorbidities including depression, anxiety, bipolar disorder, and personality disorders, which are extremely common in cocaine users and require concurrent treatment 4, 1

Symptomatic Pharmacologic Management

Benzodiazepines (First-Line for Symptom Control)

• Diazepam or clonazepam at low doses are the foundation for managing acute withdrawal symptoms including agitation, anxiety, insomnia, and craving 4, 1
• Limit duration to 7-14 days maximum to prevent benzodiazepine dependence 4, 1
• Benzodiazepines have demonstrated efficacy in alleviating cocaine-induced and cocaine withdrawal-induced anxiety in controlled studies 5

Medications to AVOID

• Never use beta-blockers within 72 hours of cocaine use as they can potentiate coronary vasospasm through unopposed alpha-adrenergic stimulation 4, 1
• If beta-blockade is absolutely necessary for severe hypertension or tachycardia, use combined alpha- and beta-blocking agents (e.g., labetalol) only after a vasodilator (nitroglycerin or calcium channel blocker) has been given within the previous hour 2
• Do NOT offer dexamphetamine for treatment of cocaine use disorders 1

Post-Acute Phase Management (After Initial Withdrawal)

• Naltrexone 50 mg/day may be introduced after the acute withdrawal phase (after 7-14 days) to reduce craving and prevent relapse 4, 1
• Gradually taper benzodiazepines while introducing naltrexone for ongoing craving management 4

Management of Psychiatric Complications

• Depression or psychosis can emerge during withdrawal—monitor closely and seek specialist consultation when these develop 1
• Antidepressants (TCAs or MAOIs) may help relieve depressive symptoms that emerge when chronic cocaine use is discontinued, particularly in patients with significant mood disturbance 6
• Patients with borderline or narcissistic personality disorders require long-term psychodynamic psychotherapy in addition to addiction treatment 6

Essential Psychosocial Interventions

• Pharmacological treatment alone is insufficient—it must be combined with psychosocial and behavioral interventions for optimal outcomes 2, 4, 1
• Offer short-duration psychosocial support modeled on motivational principles, including brief intervention, individualized feedback, advice on reducing or stopping use, and follow-up 1
• Implement strategies to ensure abstinence such as contingency contracts, regular urinalysis, family intervention, assignment of financial control to others, or hospitalization when necessary 6

Critical Pitfalls to Avoid

• Do not use buspirone, dimenhydrinate, or diphenhydramine for cocaine-induced anxiety—these agents have not shown consistent efficacy and may be anxiogenic 5
• Avoid prolonged benzodiazepine use beyond 2 weeks as this creates secondary dependence without addressing the underlying cocaine addiction 4, 1
• Do not rely solely on medication—cocaine addiction treatment requires comprehensive psychosocial intervention as pharmacologic approaches alone have been largely unsuccessful 7
• Recognize that relapse is probable—establish long-term follow-up and support systems from the outset 8