Withdrawal Management for GHB, Methamphetamine, and Cocaine

General Principles

• Provide supportive care in a monitored environment for methamphetamine and cocaine withdrawal, as no specific pharmacological treatment has demonstrated efficacy, using symptom-targeted medications rather than attempting to treat withdrawal with specific agents 1
• Offer brief psychosocial intervention (5-30 minutes) incorporating individualized feedback and advice on reducing or stopping methamphetamine or cocaine use, with follow-up, and provide short-duration psychosocial support based on motivational principles 2

Methamphetamine Withdrawal Management

• Administer benzodiazepines for short-term management of agitation and sleep disturbance in methamphetamine withdrawal 1
• Monitor closely for depression or psychosis during methamphetamine withdrawal, which require specialized psychiatric consultation if severe 1
• Do NOT use dexamphetamine for treatment of stimulant use disorders 2

Cocaine Withdrawal Management

• Manage cocaine withdrawal in a supportive environment with symptomatic treatment only, as no specific medication is recommended 3
• Monitor closely for depression or psychosis, which occur less commonly but require specialist consultation when present 3

Documentation and Medication Management

• Document the rationale for each medication dose administered during withdrawal management 4
• Avoid missing polysubstance use, particularly concurrent benzodiazepine dependence, which requires its own gradual taper over 8-12 weeks with conversion to long-acting benzodiazepines 3

GHB Withdrawal Management

Primary Pharmacological Management

• The American Society of Addiction Medicine recommends starting with lorazepam 2-4 mg IV/PO every 4-8 hours as initial dosing, with aggressive titration based on symptom severity, and using long-acting benzodiazepines (diazepam, chlordiazepoxide) for better seizure protection and smoother symptom control 5
• Administer doses every 4-6 hours initially, with more frequent dosing for breakthrough agitation, and monitor continuously for autonomic instability, neurological symptoms, and respiratory status 5
• Use validated withdrawal scales to guide dosing, though these must be interpreted in clinical context, and document rationale for each medication dose administered 5

Monitoring and Assessment

• Monitor continuously for autonomic instability: tachycardia, hypertension, diaphoresis, fever, and neurological symptoms: tremor, agitation, altered mental status, delirium, seizures 5
• Use validated withdrawal scales (similar to CIWA for alcohol withdrawal) to guide dosing, though these must be interpreted in clinical context 5