DRUG(S) OF DEPENDENCE WITHDRAWAL

• Withdrawal syndromes are specific to:
• type of drug involved
• route of administration
• frequency of use
• quantity used
• individual variation in sensitivity
• psychological state
• Mild symptoms occurring after withdrawal of a drug do not require routine medical intervention
• explaining to patient likely course of withdrawal reduces severity of withdrawal symptoms
• If treatment may be required suggest TAP
• Test (investigations) Assess (as described below) and Phone (drug agency that will continue input following discharge acute hospital)

Investigations

• Obtain witnessed urine sample or mouth swab for drug screen
• contact alcohol liaison team for screening tests
• Check patient’s prescribed medications with GP when surgery open
• if patient states they are taking opiate substitute, contact prescriber
• Pregnancy test, if indicated 

Pregnancy

• Very detailed assessment and close management of withdrawal because of risks to fetus
• Refer to appropriate drug service and contact on-call obstetric team. See Management of a pregnant woman with a non-obstetric problem guideline

Symptoms and signs

• Nausea, vomiting
• Diarrhoea
• Restlessness, anxiety
• Irritability, insomnia
• Muscle and bone pains
• Running eyes and nose
• Sneezing, yawning
• Sweating, flushing
• Dilated pupils, pilo-erection
• In a hospital setting assess opiate withdrawal severity

Immediate treatment

• Where withdrawal symptoms are of sufficient severity to warrant medical treatment, several options are available

Symptomatic treatment

• Nausea, vomiting and insomnia: promethazine hydrochloride 25 mg oral 12-hrly
• Somatic anxiety: propranolol 40 mg oral 8-hrly
• Diarrhoea: loperamide 4 mg single oral dose. Do not give loperamide if infective diarrhoea suspected
• Stomach cramps: hyoscine butylbromide 10–20 mg oral 6-hrly
• Pain: paracetamol 1 g oral 6-hrly or ibuprofen 400 mg oral 8-hrly if required

Opiate substitution

• Discuss initiation of opiate substitution with drug agency (based on geography) that will continue input following discharge from acute hospital
• Do not give substitutes unless a screening test confirms presence of opiates
• Drug of choice is methadone mixture (1 mg/1 mL)
• do not use injectable or tablet forms of methadone
• do not give alternative forms of opiate unless discussed with relevant drug agency

Initial dose

• Measure withdrawal symptoms at 6-hrly intervals for 24 hr
• if score >5, give methadone 1 mg per point (i.e. score of 5 = no dose, score of 7 = 7 mg)
• Following first four 6-hrly assessments, add up doses administered at these assessments
• sum will be the daily dose on which patient should continue
• If significant withdrawal symptoms persist and patient remaining in hospital, give the new daily dose and perform a further 24 hr cycle of 6-hrly assessments
• in order to decide dose to be given on day 3, add any extra methadone given on day 2 to the sum obtained from day 1

Maintenance dose

• Once stable dose has been achieved, give methadone as single daily dose
• with amount calculated from initial doses as described above
• Maximum dose in 24 hr should not exceed 50 mg without specialist advice

Subsequent management

• Aim to allow patient to stabilise on the dose of methadone reached by titration with any reductions arranged by continuing care teams once discharged
• On discharge, continuing prescription should be via local community services

Monitoring treatment

• Complete withdrawal table 6-hrly

Discharge and follow-up

• Contact agency that has agreed to continue prescribing
• allow as much warning as possible in order for necessary arrangements to be made
• relevant agency will confirm arrangements for prescription and appointment
• Do not write methadone prescription as a TTO
• Notify GP

• Benzodiazepines and other sedative hypnotic drugs
• Alcohol. See Alcohol withdrawal guideline

Symptoms and signs

• Confusion
• Nystagmus
• Tremor
• Agitation, irritability
• Insomnia
• Pyrexia
• Hyperreflexia
• Weakness
• Convulsions

Immediate treatment

• In initial stages, treatment of sedative withdrawal is similar to that for alcohol. See Alcohol withdrawal guideline
• Once symptoms controlled, change to long-acting benzodiazepine (chlordiazepoxide, diazepam) in an equivalent dose (Table) to maintain clinical state
• Discuss a longer-term strategy with either Local drug management service or patient’s GP

• GHB is a ‘party’ drug used for its euphoric effects. It may interact with other illicit or prescribed drugs (e.g. anti-convulsants or anti-psychotics)

Serious side effects

• Headaches
• Hallucinations
• Dizziness
• Confusion
• Nausea
• Vomiting
• Drowsiness
• Agitation
• Diarrhoea
• Sexual arousal
• Numbing of legs
• Vision problems
• Tightness of chest
• Mental changes
• Combativeness
• Memory loss
• Serious breathing and heart problems
• Seizures
• Coma
• Death
• Long-term use may lead to withdrawal symptoms

Management

• Patients may present to A&E in an intoxicated or comatose state
• most wake up within a few hours, but some require ventilation
• Due to short half-life, withdrawal symptoms require active management – use diazepam as indicated in Alcohol withdrawal guideline using CIWA-Ar assessment chart, Higher doses may be required
• Refer to local community drug and alcohol service

• There are no acute symptoms of stimulant withdrawal that need medical treatment as a matter of urgency. Insomnia and anxiety can be treated symptomatically
• Advice and support are valuable
• Depressive symptoms sometimes occur as a later withdrawal effect and can be treated with an antidepressant
• Refer to local community services

• Commonly misused are butane, toluene, glues, petrol
• As there are no physical withdrawal syndromes, it is best to discontinue use abruptly
• Treatment of intoxication involves general supportive measures
• Refer to local community services

• Treat anxiety and insomnia symptomatically