Substance Withdrawal Syndromes

Alcohol Withdrawal - Shakes, Sweats & Seizures

• Pathophysiology: Chronic alcohol → ↓GABAergic inhibition, ↑NMDA excitation. Withdrawal reverses this.
• Timeline & Features (post-last drink):
  • 6-12 hrs: Tremor, anxiety, insomnia, autonomic hyperactivity (sweats, tachycardia).
  • 12-24 hrs: Alcoholic hallucinosis (visual/auditory; clear sensorium).
  • 24-48 hrs: Withdrawal seizures (GTCS).
  • 48-96 hrs: Delirium Tremens (DTs) - confusion, agitation, fever, severe autonomic hyperactivity, hallucinations.

    ⭐ Delirium Tremens: medical emergency, up to 15% mortality if untreated. Features: autonomic hyperactivity, confusion, hallucinations. Onset 48-96 hrs post-drink.

• Assessment: CIWA-Ar scale.
  • <10: Mild.
  • 10-18: Moderate (medication).

  • 18: Severe (inpatient, aggressive medication).

• Management:
  • Benzodiazepines (BZD): Lorazepam (liver safe), Diazepam.
  • Thiamine 100mg (IV/IM) before glucose.
  • Supportive: IV fluids, electrolytes.

Opioid Withdrawal - Flu-Like Misery

• Onset: 6-12h (short-acting), peak 2-3d.
• Symptoms: 📌 FINISH + more:
  • Flu-like: Rhinorrhea, lacrimation, chills, myalgia, arthralgia, piloerection ("gooseflesh"), fever.
  • Insomnia, yawning.
  • Nausea, vomiting, diarrhea, abdominal cramps.
  • Irritability, anxiety, dysphoria.
  • Sweating.
  • Hot/cold flashes.
  • Objective signs: Mydriasis, ↑HR, ↑BP, restlessness.
• Assessment: Clinical Opiate Withdrawal Scale (COWS):
  • Mild: 5-12
  • Moderate: 13-24
  • Mod-Severe: 25-36
  • Severe: >36
• Management:

⭐ Mydriasis (dilated pupils) is a characteristic objective sign of opioid withdrawal, contrasting with miosis seen in opioid intoxication.

Sedative-Hypnotic Withdrawal - Anxiety Rebound & Risk

• Abrupt stop of sedative-hypnotics (BZDs, barbiturates).
• Features: Anxiety rebound, insomnia, autonomic dysfunction (↑HR, ↑BP), tremors, perceptual changes.
• ⚠️ Risks: Seizures (can be fatal), delirium, psychosis.
• Manage: Gradual taper with long-acting BZD (e.g., diazepam).
• Benzodiazepine Withdrawal Comparison:

  Type	Onset & Intensity	Key Risk	Examples
  Short	Early, intense	↑ Seizure risk	Lorazepam, Alprazolam
  Long	Delayed, milder	Prolonged course	Diazepam, Chlordiazepoxide

⭐ Withdrawal from short-acting benzodiazepines (e.g., lorazepam, alprazolam) typically begins sooner and is more intense than from long-acting ones (e.g., diazepam), but both can cause seizures.

Stimulants, Cannabis, Nicotine - The Aftermath Trio

High‑Yield Points - ⚡ Biggest Takeaways

• Alcohol withdrawal: Delirium Tremens (DTs) is life-threatening; treat with benzodiazepines. Seizures common (12-48h).
• Opioid withdrawal: Flu-like symptoms (piloerection, mydriasis, diarrhea); not typically life-threatening.
• Benzodiazepine withdrawal: Risk of seizures; requires gradual tapering of the drug.
• Stimulant withdrawal: Characterized by severe dysphoria ("crash"), fatigue, and hypersomnia.
• Wernicke-Korsakoff: Thiamine (B1) deficiency (alcohol use); give thiamine before glucose to prevent precipitation.
• Nicotine withdrawal: Intense craving, irritability, increased appetite, difficulty concentrating.