Substance Withdrawal - Clinical Tree

Substance withdrawal is commonly encountered in both psychiatric and medical patients. The psychiatrist on call is asked to evaluate and treat patients who are behaviorally difficult, have comorbid psychiatric diagnoses, suffer clinical stigmata of withdrawal, and/or complain of various subjective discomforts related to the substance(s) from which they are withdrawing.

Primary concerns for substance withdrawal include medical and psychiatric stability, and identification of the specific substance(s) and most recent use. Although many symptoms (e.g., distress, irritability, dysphoria) are mild and self-limited, others may progress to life-threatening situations, such as delirium tremens (DTs) and seizures. When the patient is stable, a complete history will include usage patterns including query of prescription monitoring database (if available), prior withdrawal symptoms, comorbid medical conditions, and other data specific to the substance(s), outlined as follows. As substance use disorders are chronic and relapsing in nature, complete care for withdrawal should ideally include referral to appropriate aftercare.

Phone call

Questions

1.
What are the patient’s vital signs?
2.
What is the patient’s level of consciousness (e.g., comatose, obtunded but responsive, disoriented with clouded sensorium)?
3.
Does the patient appear dangerous to himself or herself, or to others?
4.
Are there obvious signs concerning for withdrawal (e.g., autonomic arousal, piloerection, lacrimation, vomiting, diarrhea, dilated or pinpoint pupils)?
5.
Is there a history of drug use or evidence of drug use (e.g., alcohol on breath, needle tracks)?
6.
If the patient admits to drug use or abuse, what substances were used, when was the last use, how much was used, and by what route was it administered?
7.
What medications is the patient taking?

Orders

If the patient is severely agitated, violent, or suicidal, one-to-one observation should be started immediately.

Inform RN

“Will arrive in … minutes.”

1.
If any of the above information is lacking (e.g., vital signs), ask the nurse to obtain it while you are on your way.
2.
If indicated, ask the nurse to prepare intramuscular (IM) medications—for example, lorazepam (Ativan) 2 mg and/or haloperidol (Haldol) 5 mg.

Elevator thoughts

What causes substance withdrawal?

Prolonged and repeated exposure to drugs of abuse is associated with receptor downregulation in the central nervous system (CNS), and substance dependence is defined physiologically by the presence of craving and withdrawal as a result of these changes. Withdrawal syndromes result from the discontinuation or decrease of the substances (or their analogues) responsible for this habituation. The signs and symptoms of withdrawal are often opposite those of intoxication, and the severity of withdrawal is directly proportional to the severity of dependence. In severely dependent patients, withdrawal may occur when intoxicants are still detected, but at a relatively lower level than those at which the patient has been habituated.

Substance-Specific Syndromes

1.
Alcohol withdrawal, including withdrawal delirium (DTs) ^a

a Indicates a potentially lethal withdrawal syndrome.
2.
Sedative, hypnotic, or anxiolytic withdrawal ^a
3.
Opioid withdrawal
4.
CNS stimulant (cocaine and amphetamine) withdrawal
5.
Nicotine withdrawal
6.
Antidepressant withdrawal
7.
Anticholinergic withdrawal
8.
Marijuana withdrawal
9.
Synthetic cannabinoid receptor agonist (SCRA) withdrawal ^a

In addition to these syndromes, be alert for:

1.
Multiple concurrent intoxication and withdrawal syndromes
2.
The presence of withdrawal symptoms despite concurrent evidence of intoxication (e.g., alcohol on breath)
2.
Medical sequelae of substance use, including trauma associated with altered states, endocarditis, septic shock, or hepatitis C virus/human immunodeficiency virus (HCV/HIV) associated with intravenous (IV) drug use
3.
Malnutrition
4.
Malingering for secondary gain of substance treatment (e.g., methadone), food, shelter, or avoidance of court appearances

Initial assessment

Level of consciousness, airway, and vital signs: Is the patient stable and able to protect his or her airway in the event of emesis? Is he or she agitated or distressed?

Mental status exam (MSE): While you may choose to defer a complete MSE until the patient is stable and withdrawal is being managed, use the initial assessment to look for evidence of substance use (e.g., track marks, alcohol on breath, jaundice), evidence of trauma (e.g., head trauma that might be the result of sudden loss of consciousness), evidence of acute physical pain, evidence of withdrawal (e.g., diaphoresis, dilated pupils, tremor), evidence of recent seizure (e.g., incontinence, tongue lacerations), psychosis (e.g., internal preoccupations, disorganized thought), suicidal ideation, and homicidal ideation; perform a basic cognitive assessment if possible.

Physical exam: Likewise, a complete physical exam may be deferred at this time. However, a targeted exam can yield important information. In addition to the general observations included in the MSE, perform a focused neurologic exam with special attention to pupil size, extraocular movements, tendon reflexes, cerebellar function, and gait. If there is suspicion of alcohol use history, look for stigmata of liver failure. If there is suspicion of IV drug use, look for evidence of infective endocarditis, liver injury (HCV), and opportunistic infections associated with AIDS.

History/Chart Review

1.
Is there a history of substance abuse? What have the most recent patterns of use been (amounts, routes)? Has the patient ever had withdrawal symptoms, including DTs, seizures, or prior hospitalizations for withdrawal? Is there any history of IV drug use?
2.
Has the patient been enrolled in detoxification or rehabilitation programs or methadone clinics? If the patient is enrolled in a methadone maintenance program, contact the program and obtain the daily maintenance dosage and date of last dose administered.
3.
Is there a psychiatric history of a mood or psychotic disorder? Has the patient been hospitalized or taken psychotropic medications? Has the patient followed up with treatment?
4.
Is there a history of suicide attempts or violence?
5.
Is there a family history of substance abuse or other psychiatric illness?
6.
Is the patient in pain? Ask about the localization and quality of pain. Has the patient been prescribed pain medication (e.g., opiates), and for what duration?

Labs: The patient needs a careful medical evaluation to rule out a possible life-threatening condition. The autonomic instability and delirium of severe alcohol withdrawal can mimic an infectious process, and confusion and agitation could be due to CNS injury. A medical evaluation may include some or all of the following, depending on what pathology is suspected: complete blood count, blood chemistry and possibly fingerstick glucose, liver function tests, thyroid function tests, rapid plasma reagin, vitamin B12, folate, hepatitis panel, HIV test, blood cultures, chest x-ray, electrocardiogram, lumbar puncture, and head computed tomography scan.

Confirm or rule out suspected substances of abuse by obtaining urine toxicology and blood alcohol levels, if they have not already been obtained. Some emergency rooms are equipped with dipstick urine toxicology kits. However, note that not all substances of abuse are detected by these screens (i.e., synthetic opiates such as buprenorphine, short-acting benzodiazepines such as alprazolam).

Specific withdrawal conditions

Alcohol Withdrawal

Signs and Symptoms

1.
Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm, elevated blood pressure)
2.
Increased hand tremor
3.
Insomnia
4.
Nausea or vomiting
5.
Transient visual, tactile, or auditory hallucinations or illusions
6.
Psychomotor agitation
7.
Anxiety
8.
Generalized tonic-clonic seizures

See the following for discussion of withdrawal seizures, DTs, and Wernicke encephalopathy.

Time course: Tremors usually begin within 5 to 10 hours after alcohol use has been stopped or reduced. They are related to a hyperadrenergic state. Symptoms peak in intensity during the second day of abstinence and usually remit by the third to fifth day in uncomplicated withdrawal. Alcohol withdrawal seizures usually occur within the first 24 to 48 hours of withdrawal, and DTs may occur within 3 to 5 days.

N.b.: If the patient has a history of concomitant cocaine dependence or is taking beta blockers, vital sign elevation may not be a reliable indication of withdrawal, because large amounts of cocaine may result in adrenergic depletion, and beta blockers may suppress adrenergic response. In this case, alterations in mental status may be the best indication of withdrawal, and presumptive prophylaxis should be initiated.

Immediate Steps

Consider admission if the patient presents with fever, autonomic instability, seizures, protracted nausea, vomiting, diarrhea, or signs of Wernicke encephalopathy.

1.
Assess and treat withdrawal symptoms. Evidence of autonomic arousal by vital signs (increasing heart rate or blood pressure) or CIWA (Clinical Institute Withdrawal Assessment) score > 8 indicates the need for treatment. The CIWA scale asks the patient or the treating clinician to assign a rating from 0 to 15, with 15 being more severe, to the patient’s agitation, anxiety, auditory disturbances, clouding of sensorium, headache, nausea/vomiting, paroxysmal diaphoresis, tactile disturbances, tremor, and visual disturbances. CIWA > 15 has been shown to have a relative risk of 3.72 for severe alcohol withdrawal.

Benzodiazepines relieve the withdrawal symptoms by serving as an alcohol substitute at GABA receptors; they also raise the seizure threshold and provide sedation. Specific benzodiazepines and benzodiazepine administration protocols may vary, but evidence shows that treating symptoms as they arise (“symptom-triggered therapy”) results in shorter duration of treatment and less overall drugs administered than scheduled or tapered-dose therapy. If you suspect the patient may suffer from liver failure, use lorazepam, oxazepam, or temazepam, which are not hepatically metabolized. Suggested symptom-triggered therapy using lorazepam is 2 mg PO for CIWA greater than 8 or vitals indicating withdrawal, or 2 mg IV q2h if vomiting is present. For withdrawal seizures and DTs, see the later discussion. Note that in the absence of other evidence of DTs, hallucinations themselves do not require treatment with benzodiazepines.
2.
Ensure hydration. Encourage fluid intake by mouth (PO) if patient is able to protect his or her airway and not suffering from nausea, vomiting, or diarrhea. In such cases, consider IV fluids. Patients who drink heavily may become volume depleted due to poor PO intake apart from alcohol, which can lead to tachycardia and nausea independent of withdrawal.
3.
Give vitamins and minerals. All patients suspected of chronic alcohol use should receive IV or IM thiamine 100 mg before glucose, as well as 1 mg folate, and 1 tablet vitamin B complex. Mg, Ca, K, and glucose should be corrected if necessary. Continue to replete thiamine, folate, and vitamin B PO daily for the next week if the patient remains hospitalized.
4.
Continue to monitor while treating and repleting. Monitor vitals, level of consciousness, and CIWA regularly, and retreat with benzodiazepines as needed. Remember that heavy drinkers may begin withdrawing while their blood alcohol level remains elevated.

Management of Seizures

Seizures occur in 5% to 15% of patients, are typically tonic-clonic, and are one or two in number. They usually develop within 24 to 48 hours but can also occur as late as 7 days following the cessation of alcohol use. About 30% of patients who have seizures will develop withdrawal delirium. Treat withdrawal seizures with lorazepam 2 mg IV. Diazepam 5 mg IV can also be used, although it is longer-acting and has active metabolites. Call a neurology consultation for all seizures.

Management of Withdrawal Delirium

Withdrawal delirium (DTs) is a medical emergency. It occurs in less than 5% of individuals and usually begins 48 to 96 hours (or rarely 1 week) after cessation or decrease in alcohol intake. It typically occurs in individuals who have been drinking heavily for 5 to 15 years. If seizures also occur, they almost always precede the development of delirium. Withdrawal delirium may last 1 to 5 days. If untreated, mortality may be as high as 20%.

This potentially life-threatening condition includes disturbances in consciousness and cognition (e.g., disorientation, memory impairment), visual, tactile, or auditory hallucinations; agitation; and marked autonomic hyperactivity (e.g., tremulousness, tachycardia, hyperthermia, diaphoresis). It may lead to circulatory collapse, coma, and death. When alcohol withdrawal delirium develops, it is likely that a clinically related general medical condition may be present (e.g., liver failure, pneumonia, gastrointestinal bleeding, sequelae of head trauma, hypoglycemia, pancreatitis, an electrolyte imbalance, or postoperative status).

In addition to the preceding guidelines for the management of uncomplicated withdrawal:

1.
Secure an IV access.
2.
Lorazepam 1 to 4 mg IV q5–15 minutes. Doses should be repeated until symptoms clear. Patients should be calm and lightly sedated. Severely dependent individuals may have high benzodiazepine requirements. If symptoms are not adequately controlled, escalation to barbiturates or propofol may be indicated, which would require ICU-level care.
3.
Haloperidol 2 to 5 mg, IM or IV, every 2 to 4 hours may be used to control severe cases of agitation or psychosis. It should be used with caution, however, because it may lower the seizure threshold and is metabolized hepatically.
4.
Avoid physical restraints, if possible, because the patient may fight them and cause injury. Be alert to the possibility of sharp elevations in creatine phosphokinase level. Adequate sedation with benzodiazepines should be used to avoid the need for restraint.
5.
Observe the patient closely for the development of focal neurologic signs.
6.
Put the patient on a high-calorie, high-carbohydrate diet.

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