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Nearly one half of all primary care patients have an alcohol or drug disorder. Each stage of addictive illness can be characterized by types and severity of withdrawal and relapse prevention.
Pharmacotherapy for withdrawal syndromes
Detoxification. Pharmacologic therapies are indicated for use in patients with addictive disorders to prevent life-threatening withdrawal complications such as seizures and delirium tremens.
Alcohol withdrawal. Agents that are commonly recommended include diazepam (Valium), lorazepam (Ativan), chlordiazepoxide (Limbitrol) and clorazepate (Tranxene).
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Signs and Symptoms of Alcohol and Drug Withdrawal |
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Drug |
Peak period |
Duration |
Signs |
Symptoms |
|
Alcohol |
1 to 3 days |
5 to 7 days |
Elevated blood pressure, pulse and temperature, hyperarousal, agitation, restlessness, cutaneous flushing, tremors, diaphoresis, dilated pupils, ataxia, clouding of consciousness, disorientation |
Anxiety, panic, paranoid delusions, illusions, visual and auditory hallucinations |
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Benzodiazepines and other sedative/hypnotics |
Short-acting: 2 to 4 days Long-acting: 4 to 7 days |
Short-acting: 4 to 7 days Long-acting: 7 to 14 days |
Increased psychomotor activity, agitation, muscular weakness, tremulousness, hyperpyrexia, diaphoresis, delirium, convulsions, elevated blood pressure, pulse and temperature, tremor |
Anxiety, depression, euphoria, incoherent thoughts, hostility, grandiosity, disorientation, tactile, auditory and visual hallucinations, suicidal thoughts |
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Stimulants (cocaine, amphetamines and derivatives) |
1 to 3 days |
5 to 7 days |
Social withdrawal, psychomotor retardation, hypersomnia, hyperphagia |
Depression, anhedonia, suicidal thoughts and behavior, paranoid delusions |
|
Opiates (heroin) |
1 to 3 days |
5 to 7 days |
Drug seeking, mydriasis, piloerection, diaphoresis, rhinorrhea, lacrimation, diarrhea, insomnia, elevated blood pressure and pulse |
Intense desire for drugs, muscle cramps, arthralgia, anxiety, nausea, vomiting, malaise |
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PCP/psychedelics |
Days to weeks |
Days to weeks |
Hyperactivity, increased pain threshold, nystagmus, hyperreflexia, hypertension and tachycardia, eyelid retraction (stare), agitation and hyperarousal, dry and erythematous skin, violent and self-destructive behaviors |
Anxiety, depression, delusions, auditory and visual hallucinations, memory loss, irritable and angry mood and affect, suicidal thoughts |
Benzodiazepines and other sedative/hypnotics. The signs and symptoms of benzodiazepine withdrawal are similar to those for withdrawal from barbiturates. Withdrawal is not usually marked by significant elevations in blood pressure and pulse.
Stimulants ( cocaine, amphetamines and derivatives)
Supportive treatment is indicated in patients who are undergoing withdrawal.
For severe withdrawal symptoms with persistent depression, therapy may be initiated with desipramine (Norpramin).
Opiates. Management of withdrawal can be accomplished with clonidine (Catapres) or methadone.
Phencyclidine and other psychedelic agents. Acute symptoms of withdrawal from psychedelic agents may be diminished or reversed by using haloperidol (Haldol), 5 to 10 mg IM or PO every 3-6h prn. Lorazepam, 1 to 2 mg
Medications for relapse prevention
Disulfiram ( Antabuse)
Disulfiram is an aversive agent. The dosage of is 250 mg per day. Disulfiram inhibits acetaldehyde dehydrogenase. An accumulation of acetaldehyde produces an unpleasant reaction when alcohol is consumed.
Before using disulfiram, patients must have a blood alcohol level of zero and must be able to comprehend the risks.
Methadone maintenance is a form of pharmacologic management of opiate addiction performed in programs.
Naltrexone ( ReVia) is an opioid antagonist which inhibits the effect of opiate agonists. Naltrexone is effective.