Acute and protracted cocaine abstinence in an outpatient population: A prospective study of mood, sleep and withdrawal symptoms
Introduction
In general, the phenomenon of drug withdrawal has proven to be a robust syndrome that has been observed in drug-dependent individuals following cessation of drug consumption. Withdrawal syndromes have been observed with both licit and illicit drug use (Farrell, 1994, Hughes et al., 1994, Pétursson, 1994, West and Gossop, 1994). In contrast to withdrawal from other drugs of abuse, a withdrawal syndrome following abrupt discontinuation of cocaine has received only mixed support within the research literature. According to DSM-IV (American Psychiatric Association, 1994), cocaine withdrawal requires dysphoric mood and at least two of the following symptoms: fatigue, vivid and unpleasant dreams; sleep disturbance; increased appetite and psychomotor retardation or agitation. These symptoms must follow cessation of heavy and prolonged cocaine use and must be severe enough to be clinically significant.
A number of studies have attempted to characterize and quantify cocaine withdrawal with mixed success. Gawin and Kleber (1986) describe cocaine withdrawal using a triphasic model. However, subsequent studies have failed to support the phasic nature of Gawin and Kleber’s model of cocaine withdrawal. Weddington et al. (1990) examined cocaine withdrawal over 28 days in male inpatients and found a linear decrease in symptom reporting on measures of dysphoria and craving. Cocaine-dependent patients did not differ from controls on measures of sleep disturbance except that the cocaine-dependent patients reported more difficulty falling asleep throughout the study and reported significant improvement in clearheadedness upon waking. These authors concluded that abrupt cocaine abstinence does not produce a ‘classic withdrawal pattern’ as seen in other drugs of abuse and, more appropriately should be referred to as ‘short-term abstinence’ or ‘short-term cessation’ rather than ‘cocaine withdrawal’ (Weddington et al., 1990, Weddington, 1992). Satel et al. (1991) examined cocaine withdrawal symptoms for 21 days within an inpatient sample and found results similar to Weddington et al. (1990). Satel et al. reported mild symptoms of cocaine craving, anxiety, depression, physical discomfort, and drug withdrawal which decreased over the course of the study, but did not follow a triphasic model as proposed by Gawin and Kleber (1986).
One explanation for the failure of these investigations to support the model of cocaine withdrawal proposed by Gawin and Kleber (1986) is that both Weddington et al. (1990) and Satel et al. (1991) enlisted inpatient samples to examine cocaine withdrawal symptomatology. Individuals on inpatient units typically have limited exposure to numerous conditioned cues which may illicit withdrawal symptoms. It has been hypothesized that this contrived environment may inhibit a full presentation of the withdrawal syndrome described by Gawin and Kleber.
Cottler et al. (1993) examined symptomatology following cocaine cessation in two large outpatient samples of men and women in the St. Louis, MO area. One sample consisted of individuals who only used cocaine while the second sample consisted of individuals who used both cocaine and heroin. Cocaine dependence or abuse was not a necessary inclusion criteria for the study, only cocaine use. Through a structured interview, participants retrospectively endorsed symptoms they had experienced following cocaine use. In order of frequency, the most common symptoms following cessation of cocaine use in the cocaine-only group were depression, anxiety/restless/irritability, tired/sleepy/weak, difficulty sleeping, trouble concentrating, increased appetite, and fast heart rate. The issue of symptom duration and change over time was not addressed in this study.
In addition to the limitation of inpatient samples, previous studies have focused primarily or exclusively on male cocaine addicts (Gawin and Kleber, 1986, Brower et al., 1988, Satel et al., 1991, Weddington, 1992). As stated above, Cottler et al. (1993) addressed the limitation of inpatient samples and examined cocaine withdrawal symptoms in both men and women, however, not all participants were cocaine-dependent, withdrawal symptoms were measured retrospectively, and symptom change over time was not addressed. More recently, cocaine abstinence symptomatology was examined over time in methadone-maintained outpatient cocaine addicts (Margolin et al., 1996). Male and female patients were asked to recall an instance of cocaine use followed by cocaine abstinence that lasted at least 2 weeks. Patients then rated the intensity of 18 symptoms at six different time points over that 2-week period. Symptom intensity steadily decreased over the 2 weeks similar to Weddington et al. (1990) and Satel et al. (1991).
In conclusion, there remains some controversy in the literature concerning the signs and symptoms and, in particular, the time course of cocaine withdrawal. Differences in methodology (e.g. inpatient vs. outpatient; retrospective vs. prospective) in studies to date may account for this lack of consensus. In an attempt to address some of these issues, a group of male and female cocaine-dependent outpatients were periodically assessed during a period of monitored cocaine abstinence. Abstinence-related symptoms including mood, anxiety, sleep, concentration, and craving, were monitored at 2, 5, 10, 14, 21, and 28 days following last cocaine use.
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Participants
A total of 82 cocaine-dependent patients were recruited from several local substance abuse treatment programs. All participants met DSM-III-R (American Psychiatric Association, 1987) criteria for cocaine dependence and 43 subjects were also dependent on alcohol. Patients who were dependent on any drug(s) other than cocaine, alcohol, or nicotine were excluded from the study. Average age for the total sample was 34 years (S.D.=6.8). Of the 82 patients in the sample, 24 patients (12
Results
Patient characteristics are given for the total sample and the sample of completers in Table 1. Study completers are those patients who provided data during all three assessment time blocks. Patients’ cocaine and alcohol use prior to study entry was measured retrospectively with the TLFB (Sobell and Sobell, 1992). The month prior to study entry, patients completing the study used an average of $987 worth of cocaine (S.D.=$959) and reported using cocaine an average of 13 days (S.D.=9.5). The
Discussion
This study examined cocaine-dependent outpatients prospectively during short-term abstinence from cocaine. The 24 patients who provided data during each of the three assessment blocks exhibited significant changes in mood, as measured by the POMS, across the three time blocks including reductions in confusion, depression, anxiety, and vigor. A significant linear reduction in anger and depression and a significant linear increase in the ability to concentrate were identified by the CAWQ. A
Acknowledgements
This research was supported by a scientist development grant from the National Institute on Drug Abuse (K21-DA00243) awarded to Bonnie S. Dansky, Ph.D. with Kathleen T. Brady, M.D., Ph.D. serving as mentor, and by National Institute on Drug Abuse grants DA10595 and T32 07288. We wish to thank Research Assistant Stephanie Mamay-Gentilin for her invaluable contributions to this project.
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