Withdrawal Management for GHB, Methamphetamine, and Cocaine
For GHB withdrawal, use high-dose benzodiazepines as first-line treatment in a monitored inpatient setting; for methamphetamine and cocaine withdrawal, provide supportive care with symptom-targeted medications in a supportive environment, as no specific pharmacological agents are recommended for stimulant withdrawal.
GHB Withdrawal Management
Setting and Monitoring
- Admit severe cases to an inpatient unit for close monitoring, as GHB withdrawal can rapidly deteriorate into delirium (occurring in 53% of cases) and is potentially life-threatening 1
- Monitor vital signs closely, though they show poor correlation with withdrawal symptom severity and are not suitable as primary withdrawal monitoring tools 2
- Assess for polysubstance use and psychiatric comorbidities (personality disorders, depression, anxiety), as these predict poor treatment outcomes 3
Pharmacological Management
- Administer high-dose benzodiazepines as first-line treatment for GHB withdrawal 1, 4
- Start with lorazepam or diazepam; severe cases may require extremely high doses (one case required 507 mg lorazepam and 120 mg diazepam over 90 hours) 5
- For benzodiazepine-refractory cases, use second-line sedative agents including pentobarbital or chloral hydrate 1
- Consider clomethiazole as an alternative sedative agent 3
- Add atypical or typical antipsychotics if delirium develops 3
- Use beta-blockers for tachycardia and hypertension 3
Key Clinical Features
- Withdrawal symptoms include severe agitation, mental status changes, tremor, tachycardia, hypertension, diaphoresis, insomnia, and anxiety 5, 1, 3
- Symptoms often occur earlier in usage compared to alcohol withdrawal, with delirium associated with more frequent GHB ingestion patterns 1
- Common subjective symptoms include cravings, fatigue, insomnia, sweating, and feeling gloomy 2
- No withdrawal seizures have been documented in published case series, though one death has been recorded 1
Methamphetamine Withdrawal Management
Clinical Approach
- Provide supportive care in a monitored environment, as no specific pharmacological treatment has demonstrated efficacy for methamphetamine withdrawal 6
- Use symptom-targeted medications rather than attempting to treat withdrawal with specific agents 6
Symptom Management
- Administer benzodiazepines for short-term management of agitation and sleep disturbance 6
- Monitor closely for depression or psychosis during withdrawal, which require specialized psychiatric consultation if severe 6
- Track vital signs throughout the withdrawal period 6
Psychosocial Interventions
- Offer brief psychosocial intervention (5-30 minutes) incorporating individualized feedback and advice on reducing or stopping methamphetamine use 7
- Provide short-duration psychosocial support based on motivational principles 7, 6
- Refer patients who do not respond to brief interventions for specialist assessment 7, 6
- Consider referral to mutual help groups when appropriate 6
Critical Warnings
- Do NOT use dexamphetamine for treatment of stimulant use disorders 7, 6
- Assess for co-occurring mental health conditions that may complicate withdrawal management 6
Cocaine Withdrawal Management
Clinical Approach
- Manage withdrawal in a supportive environment with symptomatic treatment only 7
- No specific medication is recommended for cocaine withdrawal 7
Symptom Management
- Provide relief of agitation with symptomatic medications during the withdrawal period 7
- Treat sleep disturbances with appropriate short-term agents 7
- Monitor closely for depression or psychosis, which occur less commonly but require specialist consultation when present 7
Psychosocial Interventions
- Offer brief intervention (5-30 minutes) with individualized feedback and advice on reducing or stopping cocaine use, with follow-up 7
- Provide short-duration psychosocial support modeled on motivational principles 7
- Refer individuals with ongoing problems who do not respond to brief interventions for specialist assessment 7
Common Pitfalls Across All Three Substances
- Avoid missing polysubstance use, particularly concurrent benzodiazepine dependence, which requires its own gradual taper over 8-12 weeks with conversion to long-acting benzodiazepines 7
- Do not abruptly discontinue any co-prescribed benzodiazepines, as this can precipitate severe withdrawal including seizures 6
- Recognize that retention in treatment programs is poor for GHB withdrawal, with only 25% completing detoxification in one case series 3
- Document the rationale for each medication dose administered during withdrawal management 7