Basics
Description
- Neuroexcitation is the hallmark of benzodiazepine, barbiturate, and opiate withdrawal
- Benzodiazepine and barbiturate withdrawal can be life threatening
- Opiate withdrawal can be extremely uncomfortable but is not typically life threatening
- Cocaine and amphetamine withdrawal are similarly not life threatening
Etiology
- Chronic exposure to certain drugs cause adaptive changes in the CNS
- Withdrawal syndromes occur when the constant presence of drug is removed or reduced and the adaptive changes persist
- Tolerance occurs when increasing amounts of drug are required to achieve a given response
- Withdrawal and tolerance are distinct entities
Diagnosis
Signs and Symptoms
- Benzodiazepines and barbiturates:
- Anxiety
- Agitation
- Irritability
- Tremor
- Sleep disturbance
- Tachycardia
- Hypertension
- Hyperthermia
- Autonomic instability
- Seizures
- Opiates:
- Restlessness
- Irritability
- Drug craving
- Yawning
- Piloerection
- Mydriasis
- Nausea
- Vomiting
- Diarrhea
- Abdominal pain
- Tachycardia
- HTN
- Cocaine:
- Depressed mood
- Fatigue
- Vivid dreams
- Sleep disturbance
- Psychomotor retardation or agitation
- Amphetamines:
- Fatigue
- Irritability
- Sleep disturbance
- Anxiety
History
- Obtain substance abuse history
- Time of last substance use
- History of previous withdrawal
Physical Exam
A thorough physical exam is necessary
Essential Workup
Thorough history and physical exam with attention to the vital signs
Diagnosis Tests & Interpretation
Lab
- Electrolytes, BUN, creatinine, glucose
- CBC
- Urine drug screening rarely alters management
Imaging
If the clinical situation is not straightforward for withdrawal, CNS or plain radiograph imaging may be indicated depending on the clinical presentation.
Differential Diagnosis
- Ethanol withdrawal
- Intracerebral hemorrhage
- CNS infection
- Encephalopathy
- Hypoglycemia
- Hyperthyroidism
- Sepsis
- Psychosis
- Electrolyte disorder
- Drug intoxication
Treatment
Pre-Hospital
- Assess vital signs
- Assess capillary glucose
Initial Stabilization/Therapy
- Attention to ABCs
- Obtain IV access
- IV fluid administration
- Cardiopulmonary monitoring
Ed Treatment/Procedures
- Benzodiazepine and barbiturate withdrawal:
- Aggressive supportive care
- Begin long-acting agent of the same class causing the withdrawal
- Opiate withdrawal:
- Supportive care
- Antiemetics for nausea and vomiting
- Clonidine to reduce severity of signs and symptoms
- Opiate therapy if withdrawal is complicating other disease states
- Cocaine and amphetamine withdrawal:
Medication
- Clonidine: 0.1 " 0.3 mg PO q4 " 6h
- Diazepam: 5 " 20 mg PO for mild signs and symptoms; 5 " 10 mg IV in repeated doses as necessary for severe symptoms and signs
- Lorazepam: 1 " 2 mg PO for mild symptoms and signs; 2 mg IV in repeated doses as necessary for severe symptoms and signs
- Phenobarbital: 30 " 60 mg PO for mild symptoms and signs; 15 " 20 mg/kg slow IV administration for severe symptoms or status epilepticus.
- Ondansetron: 4 " 8 mg PO/IV
Follow-Up
Disposition
Admission Criteria
- Moderate-to-severe withdrawal symptoms
- Persistent withdrawal symptoms
- Psychosis with withdrawal
- Autonomic instability
- Concomitant medical condition that may complicate withdrawal
- Suicidal ideation or otherwise psychiatrically unstable
Discharge Criteria
- Mild symptoms responsive to therapy
- Psychiatrically stable
Followup Recommendations
Referral to detox program or facility
Pearls and Pitfalls
- Misdiagnosis of medical disease as withdrawal syndrome
- Misunderstanding the relationship between withdrawal syndromes and comorbid medical illness
- Important to administer sufficient quantities of benzodiazepines for patient in benzodiazepine withdrawal states.
Additional Reading
- Hamilton RJ. Withdrawal principles. In: Nelson LS, ed. Goldfranks Toxicologic Emergencies. 9th ed. New York, NY: McGraw-Hill, 2010.
- Leikin JB. Substance-related disorders in adults. Dis Mon. 2007;53(6):313 " 335.
- Tetrault JM, O 'Connor PG. Substance abuse and withdrawal in the critical care setting. Crit Care Clin. 2008;24:767 " 788.
Codes
ICD9
292.0 Drug withdrawal
ICD10
- F11.23 Opioid dependence with withdrawal
- F15.23 Other stimulant dependence with withdrawal
- F19.239 Oth psychoactive substance dependence with withdrawal, unsp
- F13.239 Sedatv/hyp/anxiolytc dependence w withdrawal, unsp
SNOMED
- 363101005 Drug withdrawal (disorder)
- 87132004 Opioid withdrawal (disorder)
- 428370001 Psychostimulant withdrawal (disorder)
- 23601000119102 Sedative withdrawal (disorder)
- 425339005 barbiturate withdrawal (disorder)