What is the management for substance withdrawal?

From the Guidelines

Management of substance withdrawal should prioritize medication-assisted treatment, with buprenorphine being a highly effective option for opioid withdrawal, as it alleviates withdrawal symptoms and has a higher treatment completion rate compared to clonidine or lofexidine 1. For opioid withdrawal, the use of buprenorphine is recommended, with a typical starting dose of 4-8mg on day one, increased to 12-16mg daily 1. Methadone is also an option, starting at 20-30mg daily, titrated as needed 1. Clonidine can be used to manage autonomic symptoms, at a dose of 0.1-0.2mg every 4-6 hours 1. In addition to medication-assisted treatment, supportive care, hydration, electrolyte replacement, nutritional support, and treatment of comorbid conditions are essential for managing substance withdrawal. For alcohol withdrawal, benzodiazepines, such as diazepam or lorazepam, are the mainstay of treatment, administered on a fixed schedule or symptom-triggered basis for 3-7 days, along with thiamine supplementation to prevent Wernicke's encephalopathy 1. Benzodiazepine withdrawal requires gradual tapering, typically reducing the dose by 10-25% every 1-2 weeks. Stimulant withdrawal primarily involves supportive care and addressing psychiatric symptoms with antidepressants if needed. Following acute withdrawal management, patients should transition to long-term addiction treatment, including counseling, support groups, and sometimes maintenance medications to prevent relapse.

Some key points to consider in managing substance withdrawal include:

• The use of buprenorphine for opioid withdrawal, due to its effectiveness in alleviating withdrawal symptoms and improving treatment completion rates 1
• The importance of supportive care, hydration, electrolyte replacement, nutritional support, and treatment of comorbid conditions in managing substance withdrawal
• The need for gradual tapering in benzodiazepine withdrawal, to minimize the risk of seizures and other complications
• The importance of transitioning patients to long-term addiction treatment, including counseling, support groups, and maintenance medications, to prevent relapse and improve outcomes. It is essential to prioritize the most recent and highest quality study, which in this case is the 2020 study published in the Annals of Emergency Medicine 1, when making decisions about substance withdrawal management.

From the FDA Drug Label

To reduce the risk of withdrawal reactions, use a gradual taper to discontinue lorazepam or reduce the dosage If a patient develops withdrawal reactions, consider pausing the taper or increasing the dosage to the previous tapered dosage level. The continued use of benzodiazepines, including lorazepam may lead to clinically significant physical dependence. The risks of dependence and withdrawal increase with longer treatment duration and higher daily dose. Abrupt discontinuation or rapid dosage reduction of lorazepam after continued use may precipitate acute withdrawal reactions, which can be life-threatening Withdrawal may be precipitated through the administration of drugs with opioid antagonist activity (e.g., naloxone), mixed agonist/antagonist analgesics (e.g., pentazocine, butorphanol, nalbuphine), or partial agonists (e.g., buprenorphine). Physical dependence may not occur to a clinically significant degree until after several days to weeks of continued use. Buprenorphine hydrochloride should not be abruptly discontinued in a physically-dependent patient [see DOSAGE AND ADMINISTRATION] If buprenorphine hydrochloride is abruptly discontinued in a physically-dependent patient, a withdrawal syndrome may occur, typically characterized by restlessness, lacrimation, rhinorrhea, perspiration, chills, myalgia, and mydriasis

Management for substance withdrawal includes:

• Gradual taper to discontinue the substance or reduce the dosage
• Pausing the taper or increasing the dosage to the previous tapered dosage level if withdrawal reactions occur
• Avoiding abrupt discontinuation of the substance in physically-dependent patients
• Monitoring for signs and symptoms of withdrawal reactions, such as restlessness, lacrimation, rhinorrhea, perspiration, chills, myalgia, and mydriasis 2, 3, 2

From the Research

Management of Substance Withdrawal

The management of substance withdrawal, particularly alcohol withdrawal, involves a combination of supportive care, pharmacotherapy, and individual support.

• The symptoms of alcohol withdrawal syndrome can range from mild to severe and may include anxiety, agitation, tremor, excessive sweating, altered consciousness, and hallucinations 4.
• The main risk factors for severe withdrawal syndrome are chronic heavy drinking, a history of generalized seizures, and a history of delirium tremens 4.

Pharmacotherapy

• Oral benzodiazepines are the best-assessed drugs for preventing a severe alcohol withdrawal syndrome, particularly the risk of seizures 4.
• Diazepam is a commonly used benzodiazepine for the treatment of moderate to severe alcohol withdrawal, with a shorter time to peak effect and a longer elimination half-life compared to other benzodiazepines 5.
• The use of diazepam has been shown to be safe and effective in patients with liver disease and elderly patients when administered using a simple symptom-based approach 5.
• Other medications, such as phenytoin, phenothiazines, barbiturates, paraldehyde, and antihistamines, have no role in the treatment of withdrawal due to their toxicity or lack of efficacy 6.

Supportive Care

• Individual support and effective communication seem to reduce the risk of severe withdrawal syndrome 4.
• Patients who are attempting to stop drinking alcohol need close personal support and communication, and a reassuring environment, as well as regular monitoring for early signs of a withdrawal syndrome 4.
• Supportive nursing care and, if necessary, benzodiazepines can usually prevent progression to serious withdrawal reactions and provide the patient with sufficient symptomatic relief 6.

Treatment Settings

• Patients with severe symptoms or medical complications should be admitted to a hospital for treatment 7, 8.
• Patients with milder withdrawal symptoms can be managed effectively and safely on an outpatient basis or with nonmedical treatment 8.
• The need for pharmacotherapy should be determined on an individual basis, and the management of alcohol withdrawal includes offering and initiating long-term treatment to reduce alcohol consumption 8.