What are the mental health issues related to cocaine addiction and withdraw?

Cocaine-induced Disorders with Onset During Withdraw:
Mental Health Informed Addiction Information 
Brandon Bruce Dellario LMSW LASAC

     This is a report on cocaine-induced disorders with onset during withdraw.  Cocaine is known to elicit a very strong psychological dependency.  There are many symptoms of post-acute withdraw from cocaine.
  To examine the forms of depression, anxiety and psychosis that come of it, we will take a general overview of the cocaine dependent population with and without previous mental illness.  We will also look at some treatment modalities available for those in recovery from this substance use disorder.

Etiologies
“Regular users of stimulants seem to experience withdraw symptoms upon cessation, but they do not have a clear cut, easily observable syndrome as can be seen with opioid, sedative, or alcohol withdraw.  The typical symptoms include dysphoria, fatigue, insomnia and psychomotor agitation . . . Cocaine users may develop a variety of psychiatric symptoms including anxiety, agitation, paranoia, and psychosis.  Cocaine-induced psychosis and paranoia appear to be a relatively common experience for users, . . . As with other substances, those who abuse or are dependent on stimulants are at increased risk of a variety of psychiatric illnesses including depression, bipolar disorder, anxiety disorders, personality disorders, and schizophrenia, though a cause and effect relationship has not been established.”(Rastegar, 2005 pgs. 147 & 150)

     Detoxification from cocaine dependence is best done through an inpatient program at a drug rehabilitation treatment facility.  Yet many of those addicted to cocaine go in and out of withdraw regularly when they run out of drugs and money to buy them.  This is observable in the devastating effects of people going through cocaine-induced withdraw who trade or sell all their possessions, sell their bodies, live homeless, live well below poverty, steal (sometimes by force), and so on.  These are some of the easily recognizable effects of drug addiction on society, but what about the finer, psychological symptoms of someone going through this painful process.  The DSM-IV TR describes three diagnostic criteria for drug withdraw: 

“(a) development of a substance-specific syndrome as a consequence of cessation of (or reduction in) substance use that has been heavy and prolonged; (b) the substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and (c) the symptoms are not a result of a general medical condition and are not better accounted for by another medical or mental disorder.”(DSM-IV TR, 200?) 

Characteristics
     There are several specific diagnostic categories within individual substance use disorders.  There is also a range of dual-diagnosis categories, some with the mental disorder being the primary diagnosis and some with the substance-related disorder being the primary diagnosis.  Understandably, these are confused from time to time.  The ways these disorders are determined have many dimensions.  Firstly, if a psychiatric disorder was present before the substance related disorder, the psychiatric disorder is considered the primary, and vice versa.  If the patient is still using drugs when seen by a psychiatrist, it is not viable to diagnose the psychiatric disorder until there has been a period of abstinence.  However, it is proven that if there is the possibility of a dual diagnosis, it is effective to prescribe the proper medications right away to aid the person in their recovery.  So, many doctors will diagnose prematurely in order to lubricate the recovery process, affording the patient with all of the services available to them, including medications necessary.
     I was personally invested in a similar situation as a young man with a substance abuse history, along with a new psychiatric diagnosis in 1996.  Through the years, I have discovered some things about my dual-disorder diagnosis.  I had emotional and behavioral issues as a youngster, which I now view as symptoms of my vulnerability to mental illness.  This predisposition caused onset of mental conditions once I experienced times of physical and emotional trauma in my adult life.  Also, my social and self-medicating drug abuse spiraled into exacerbated mental health challenges thereafter.  
     For whatever reasons, I was determined to drink and use drugs even from the early age of 10.  It could have been “the gene,” the nature theory people argue for in the (medical) disease-model of addiction, which does exist in my family.  It may have been the traumatic environmental stressors I experienced, or a combination of both.  In any case, the drugs gradually exacerbated my mental symptoms over the years, while also exacerbating the addiction itself.  Cocaine itself made me crazy, during and after using it.  It has been a long, hard road in my recovery from substance abuse, mental disorders and the difficulties that come from the combination.
     Cocaine, like any drug of abuse, is sometimes used to self-medicate.  This is a topic of dispute in research.  Some findings show that certain populations are self-medicating in some situations, and not in others.  Whether or not someone starts off using cocaine to self-medicate or not, it is my opinion that with prolonged use, addicts eventually get to the point of self-medicating with cocaine to kill the pain of addiction.  Though cocaine-induced disorders are plenty and varied, the disorders that come with onset of withdraw (cocaine withdraw syndrome), comes in three phases:

Table 1.  The first phase of cocaine abstinence

First Step:  Agitation, Dysphoria Depression, Anorexia, Craving
      
Second Step:  Fatigue, Depression, Hypersomnia
      
Third Step:  Strong fatigue, Somnolence, Hyperfagia   

Table 2.  The second phase of cocaine abstinence

First and Second Step:  Normalization of sleep and of mood, Anxiety, Irritability       

Third Step:  Anhedonia, Strong Anxiety and Craving   

     “The third begins several weeks or months after cessation and it is dominated by an intense craving.  The withdraw syndrome in cocaine addicts is characterized by a hedonic dysregulation . . . clinical evidence has shown that hedonic dysregulation in cocaine-dependent patients is responsible of dysphoria, apathy, irritability, depression, and suicidality.”(Barbaro, 2007 pg. 37)  These disorders occurring upon withdraw are the opposite effects that a cocaine user seeks in using the drug.  This is known as “reflective withdraw,” where the natural states the person is trying to relieve by using the drug are reversed and magnified during withdraw.  Another cocaine-induced disorder which is common among stimulant abuse is known as “crack bugs” or “meth bugs.”  This is a form of psychosomatic dermatitis, or more specifically, a skin allergy developed with abuse of cocaine or methamphetamine, where the addict actually feels as though they are covered with bugs.  Although these states “are not medically dangerous,”(Barbaro, 2007 pg. 40) they are intense and can be overwhelming for the cocaine-dependent person beginning their recovery.  Some have found relief from the itching sensations with use of the over-the-counter allergy medication Cetirizine.  Though there are serious side effects involved with use of allergy medications, and any use of medication should be concurrent with doctors orders.

Psychosocial Considerations
     One Spanish study on “psychiatric co-morbidity in young cocaine users: induced versus independent disorders,”(Herrero, 2008 pg. 2) discovers some psychosocial demographics of young cocaine users (18 – 30 year olds).  Of the 139 subjects studies, 85% had never been married, almost 93% were schooled beyond primary education, 14.4% were university students, around 45% were employed, nearly 54% lived with friends (23.7% of whom were squatters), 32.4% were living with their parents, 11% lived with their significant other, 3% lived by themselves, About 22% of them had been to jail or prison.  More men were single, lived with their parents and had a criminal record.  This study also found that this large population of cocaine using young people with psychiatric co-morbidity “never sought treatment for their substance abuse nor for associated psychopathology.”(Herrero, 2008 pg. 7)
     A Yale study on mood disorders among cocaine using-methadone patients found that treatment completion could be loosely associated with ethnicity.  In their sample of 67 patients with a mean age of 37 years old, they found that African-American ethnicity was a positive predictor of treatment success.  Also, those who were not able to speak English fluently in this U.S. study (i.e. Hispanics) “participated less in group discussions.  Perhaps these patients were consequently less engaged in the treatment and more likely to drop out.”(Rosenblum, 1999 pg. 8)
(This article is continued in the posting below)

Barbaro, G., Nava, F., Barbarini, G., Lucchini, A. (2007). Management of Medical Disorders Associated with Drug Abuse and Addiction, Nova Science Publishers, Inc., New York, NY.

Herrero, M.J., Domingo-Salvany, A., Torrens, M., TeresaBrugal, M. (2008). Psychiatric comorbidity in young cocaine users: induced versus independent disorders. Addiction, 103 (2), 284-293.

Inaba, D., Cohen, W. E., (2007). Uppers, Downers and All Arounders, CNS Productions Inc., Medford, OR.

Rastegar, D.A. (2005). Addiction Medicine: An Evidence-Based Handbook, Lippincott Williams & Wilkins, Philadelphia, PA.

Rosenblum, A., Fallon, B., Magura, S., Handelsman, L., Foote, J., Bernstein, D. (1999). The Autonomy of Mood Disorders Among Cocaine-Using Methadone Patients. The American Journal of Drug and Alcohol Abuse, 25 (1), 67-80.