Withdrawal Management

Alcohol Withdrawal - The Trembling Tide

Onset: 6-24 hrs post-last drink; peaks 24-48 hrs; can last days.

• Symptoms: Autonomic hyperactivity (tachycardia, HTN, tremors, sweating), anxiety, insomnia, N/V.
  • Severe: Seizures (12-48 hrs), hallucinations (visual, tactile, auditory; 12-48 hrs), Delirium Tremens (DTs; 48-96 hrs).
• Assessment: CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) scale.
  • Score <8-10: Mild, supportive care.
  • Score 10-18: Moderate, medication.
  • Score >18-20: Severe, inpatient, medication.
• Management:
  • Benzodiazepines (BZDs): Diazepam, Lorazepam (safer in liver disease). Symptom-triggered preferred.
  • Supportive: IV fluids, electrolytes, nutrition.

  ⭐ Prophylactic thiamine administration (IV/IM 100-250mg) before or with glucose in suspected alcohol dependent individuals is crucial to prevent Wernicke's Encephalopathy.

  • Refractory DTs: Phenobarbital, propofol.

Opioid Withdrawal - Agony Unbound

• Onset: Heroin: 6-12 hrs; Methadone: 24-72 hrs. Peak: 2-3 days. Duration: 7-10+ days.
• Symptoms (📌 "SICK FANS MYalgia"): Sweating, Insomnia, Cramps (abd.), Kicking movements, Fever, Agitation, Nausea/Vomiting, Salivation/Lacrimation/Rhinorrhea, Mydriasis, Yawning, Myalgia, Piloerection.
• Assessment: Clinical Opioid Withdrawal Scale (COWS).
  • Mild: 5-12
  • Moderate: 13-24
  • Moderately Severe: 25-36
  • Severe: >36
• Management:
  • Supportive care.
  • Medication-Assisted Treatment (MAT): Buprenorphine (±Naloxone), Methadone.
  • Alpha-2 agonists: Clonidine, Lofexidine (for autonomic symptoms).
  • Symptomatic Rx (NSAIDs, antiemetics).

⭐ Mydriasis (dilated pupils) is a characteristic sign of opioid withdrawal, contrasting with miosis (constricted pupils) seen in opioid intoxication. 📌 Remember: "Opioids Off = Open Pupils".

Sedative-Hypnotic Withdrawal - Rebound Rampage

• Agents: Benzodiazepines (BZDs), Barbiturates, Z-drugs (e.g., zolpidem).
• Pathophysiology: Chronic use → ↓GABA-A receptor activity → CNS hyperexcitability on cessation.
• Onset (Varies by drug half-life):
  • Short-acting (e.g., lorazepam, alprazolam): 12-24 hours; peak 24-72 hours.
  • Long-acting (e.g., diazepam): 2-7 days; peak 5-8 days.
• Clinical Features: Anxiety, insomnia, restlessness, tremors, sweating, ↑HR, ↑BP. Severe: Seizures (can be life-threatening), delirium, hallucinations, hyperthermia.
• Management:
  • Symptom-triggered or fixed-schedule tapering using a long-acting BZD (e.g., diazepam, chlordiazepoxide).
  • Phenobarbital for severe BZD or barbiturate withdrawal, or if refractory to BZDs.
  • Supportive care (IV fluids, thiamine). ⚠️ Avoid flumazenil (can precipitate seizures).
• 

⭐ Abrupt withdrawal from chronic high-dose, short-acting benzodiazepines (e.g., alprazolam, lorazepam) can be life-threatening, potentially causing seizures and delirium; gradual tapering is essential.

Stimulant & Other Withdrawals - Crash & Crave

• Stimulants (Cocaine, Amphetamines):
  • "Crash": Intense dysphoria, anhedonia, fatigue, hypersomnia, vivid dreams, ↑ appetite.
  • Peaks 2-4 days, resolves in 1 week.
  • Management: Supportive care.
• Cannabis:
  • Symptoms: Irritability, anxiety, insomnia, ↓ appetite, restlessness, mood swings.
  • Onset 1-2 days, duration 1-2 weeks.
  • Management: Supportive.
• Nicotine:
  • Symptoms: (📌 CRAVING) Intense craving, irritability, anxiety, difficulty concentrating, ↑ appetite/weight gain, restlessness, depressed mood.
  • Management: NRT (patch, gum, lozenge), bupropion, varenicline.

⭐ Stimulant (cocaine, amphetamine) withdrawal is characterized by a "crash" with severe dysphoria, fatigue, and hypersomnia, but is typically not physically life-threatening, unlike alcohol or sedative withdrawal.

High‑Yield Points - ⚡ Biggest Takeaways

• Alcohol withdrawal: Benzodiazepines (e.g., lorazepam) are mainstay; use CIWA-Ar scale. High risk of delirium tremens (DTs).
• Opioid withdrawal: Clonidine for autonomic symptoms; methadone/buprenorphine for substitution. Use COWS scale.
• Benzodiazepine withdrawal: Requires slow tapering to prevent severe complications like seizures.
• Delirium Tremens (DTs): Medical emergency in alcohol withdrawal; treat with IV benzodiazepines, thiamine.
• Wernicke's Encephalopathy: Thiamine BEFORE glucose is critical in chronic alcohol users to prevent neurological damage.
• Naltrexone: For relapse prevention in detoxified alcohol/opioid dependent patients; blocks opioid effects.