Posted March 2009

A. Alcohol

1. Manifestations of Alcohol Withdrawal Symptoms

Although more than 95% of alcohol withdrawal cases are uncomplicated and self-limited, intoxication and withdrawal can be fatal. Alcohol withdrawal symptoms are characterized by autonomic hyperreactivity and neuropsychiatric alterations (see Table 1). Withdrawal symptoms do not always progress from mild to severe in a predictable manner, and patients can progress quickly into delirium tremens (DTs), hallucinosis, or generalized seizures. The possibility of alcohol withdrawal should be seriously considered in any patient with persistent sinus tachycardia and elevated blood pressure.

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2. Management Goals of Alcohol Withdrawal

The standard treatment of alcohol withdrawal is with benzodiazepines. Depending on the patient’s severity of symptoms, and on the protocols of the institution, different benzodiazepine treatment modalities may be used.

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B. Opioids

1. Manifestations and Assessment of Opioid Withdrawal Symptoms

The following factors may affect the time of onset, intensity, and duration of opioid withdrawal symptoms:

• Specific substance used


• Total daily dose


• Interval between doses


• Duration of use


• Individual sensitivity

Refer to Table 1 in Care of the Hospitalized HIV-Infected Substance User for the signs and symptoms of opioid withdrawal, including withdrawal from buprenorphine and methadone.

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2. Management Goals of Opioid Withdrawal

The two primary goals in the management of opioid withdrawal are:

1. To minimize the severity of discomfort in a safe environment


2. To help the patient develop a realistic treatment plan

Opioid withdrawal in the hospital setting should be managed according to the institution’s protocols, which may include either methadone or buprenorphine. For patients who were receiving buprenorphine treatment or who were enrolled in a methadone maintenance program before hospitalization, the same dose of buprenorphine or methadone at the same time of day is generally indicated in the hospital setting. The dose and time of dose may be altered over the course of the hospitalization as clinically indicated; however, rapid tapering of methadone is not advisable, particularly if such tapering is against the patient’s wishes. Opioid-dependent patients who are not in treatment but want to participate after discharge should be referred for treatment with a methadone maintenance program or buprenorphine provider. Optimally, an established referral system should be in place between the hospital and providers who treat opioid dependence.

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C. Benzodiazepines

1. Manifestations and Assessment of Benzodiazepine Withdrawal

Benzodiazepine withdrawal syndrome presents similarly to alcohol withdrawal, but the time course and severity of benzodiazepine withdrawal will vary depending on the amount and type of benzodiazepine used (short- or long-acting), as well as the chronicity of the patient’s use. In general, onset of withdrawal symptoms occurs within 1 to 7 days and includes agitation, tachycardia, insomnia, and nightmares. Severe withdrawal can cause fevers, seizures, and psychosis and can be potentially fatal. Some individuals develop a protracted withdrawal syndrome that can fluctuate in intensity over several months.

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2. Management Goals of Benzodiazepine Withdrawal

Members of the inpatient clinical team will inquire about the types and amounts of pills that the patient uses. A patient with a high level of benzodiazepine dependence requires a lengthy tapering period that he/she will likely be unable to complete while hospitalized. A realistic goal is to change to a longer-acting benzodiazepine, such as clonazepam or chlordiazepoxide, and provide the primary care clinician with an appropriate regimen for continuing the detoxification on an outpatient basis. Ensuring patient comfort and ability to adhere to outpatient treatment is an important consideration when switching to a longer-acting benzodiazepine and tapering after discharge. In general, the drug of addiction should not be the drug used for withdrawal treatment.

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D. Stimulants

Cocaine and methamphetamine are the most commonly abused stimulants. Intermittent binge use of both is common.

1. Manifestations and Assessment of Stimulant Withdrawal

The withdrawal symptoms from stimulant use that occur after a 2- to 3-day binge are slightly different from those that occur after chronic high-dose use (see Table 2). The typical clinical features of the cocaine withdrawal syndrome that may occur after the acute cessation of or reduction in heavy and prolonged cocaine use can be characterized as progressing through three phases:

1. An acute withdrawal phase (crashing), which may include intense depression and fatigue, sometimes accompanied by suicidal ideation
2. A period of more gradual withdrawal
3. An extinction phase lasting 1 to 10 weeks

Table 2 lists withdrawal symptoms associated with cocaine use.

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2. Management Goals of Generalized Stimulant Intoxication and Withdrawal

The treatment of stimulant intoxication is symptomatic and supportive. In the case of cocaine, which is quickly metabolized and cleared, most individuals recover within hours and often do not require treatment. However, treatment of acute cocaine and methamphetamine toxicity is required when symptoms of paranoid delusions, severe excessive aggravation, hypertension, or tachycardia are present. Short-acting benzodiazepines, such as lorazepam, may be helpful in selected patients who develop agitation or sleep disturbance. Treatment for paranoid psychosis may include haloperidol or thioridazine.

The risk of relapse for patients who use stimulants (e.g., crack, cocaine, and methamphetamine) is high during the early withdrawal period. A patient’s exposure to environments or people associated with his/her stimulant use can trigger drug craving.

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E. Nicotine

1. Manifestations and Assessment of Nicotine Withdrawal

Nicotine withdrawal can manifest as:

• Depressed mood


• Insomnia


• Irritability or anger


• Impaired concentration


• Restlessness


• Anxiety


• Increase in appetite or weight gain


• Decreased heart rate

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2. Management Goals of Nicotine Withdrawal Symptoms

Pharmacotherapy for nicotine dependence is important (patch, gum, inhaler) for avoiding withdrawal symptoms in smokers. Because hospitalization is a time when smokers have increased contact with health professionals who can provide detailed and personalized advice on abstaining from tobacco, all patients who use tobacco should receive counseling. It should not be assumed that actively using patients are unreceptive to learning about how to reduce or stop smoking.

Treatment for nicotine cessation includes several forms of nicotine replacement therapy and non-nicotine therapy, such as bupropion. If the smoker has severe withdrawal symptoms, cravings, or difficulty maintaining abstinence, a general treatment approach is to start with one agent and add a second. The nicotine patch may be particularly suitable in the hospital setting because of its ease of application and dosing schedule.¹ Bupropion can also manage nicotine withdrawal; however, because it takes approximately 1 week to achieve effective levels in the blood,¹ the earlier bupropion is administered, the more likely it is to be effective. A complete description of the drugs used for smoking cessation is provided in Appendix VIII.

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Reference

1. Lewis SF, Piasecki TM, Fiore MC, et al. Transdermal nicotine replacement for hospitalized patients: A randomized clinical trial. Prev Med 1998;27:296-303. [Abstract]

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