What is the management protocol for a patient presenting with restlessness, body aches, and anxiety after 10 days of abstinence from heroin, cocaine, alcohol, LSD, and other recreational drug abuse?

Management of Polysubstance Withdrawal After 10 Days of Abstinence

This patient presenting with restlessness, body aches, and anxiety after 10 days of abstinence from multiple substances (heroin, cocaine, alcohol, LSD) is likely experiencing protracted withdrawal symptoms that require symptomatic management in a supportive environment, with benzodiazepines for residual anxiety/agitation, non-opioid analgesics for body aches, and immediate psychosocial support to prevent relapse.

Initial Assessment and Risk Stratification

At 10 days post-abstinence, the acute withdrawal phase from most substances has passed, but protracted symptoms persist 1, 2:

• Heroin/opioid withdrawal: Acute phase (5-7 days) is complete; protracted symptoms (anxiety, body aches, restlessness) can persist for weeks 3
• Alcohol withdrawal: Most dangerous phase (seizures, delirium tremens) occurs within 48-72 hours and should have resolved by day 10 1, 4
• Cocaine/stimulants: Withdrawal peaks at 2-4 days; residual depression and anxiety may persist 1
• Cannabis/LSD: Minimal physical withdrawal; psychological symptoms predominate 2

Critical pitfall: Do not assume the patient is still in acute withdrawal requiring aggressive medical management—at 10 days, focus shifts to managing protracted symptoms and preventing relapse 1, 5.

Symptomatic Management Protocol

For Anxiety and Restlessness

• Benzodiazepines (short-term only, 7-14 days maximum to avoid iatrogenic dependence): Lorazepam 0.5-1 mg every 6-8 hours as needed for breakthrough anxiety 1, 6
• Avoid long-term benzodiazepine use given polysubstance history 6

For Body Aches and Myalgia

• Non-opioid analgesics: NSAIDs (ibuprofen 400-600 mg every 6-8 hours) or acetaminophen 3
• Avoid opioids entirely—the patient is 10 days into opioid abstinence and reintroduction risks relapse 1, 3

For Sleep Disturbance

• Trazodone 50-100 mg at bedtime or mirtazapine 15-30 mg at bedtime (non-addictive alternatives) 1
• Avoid benzodiazepine hypnotics beyond the initial 1-2 weeks 6

Psychosocial Intervention (Primary Treatment)

Short-duration psychosocial support based on motivational principles is the cornerstone of treatment at this stage 1, 2:

• Brief intervention (5-30 minutes) incorporating individualized feedback on progress, reinforcement of abstinence, and strategies to prevent relapse 1, 2
• Motivational enhancement therapy to address ambivalence and strengthen commitment to recovery 1
• Offer follow-up appointments within 1 week to monitor symptoms and adjust treatment 2

Relapse Prevention Strategies

For Alcohol Dependence

• Acamprosate (666 mg three times daily) is the only intervention with high-quality evidence for maintaining abstinence 1, 4, 6
• Alternative: Naltrexone 50 mg daily (contraindicated if liver disease present) 1, 4, 6
• Disulfiram 250 mg daily (requires patient motivation and monitoring) 1, 4

For Opioid Dependence

• Consider medication-assisted treatment (MAT) with buprenorphine/naloxone (Suboxone) or naltrexone (Vivitrol) to reduce relapse risk 1, 5
• Critical timing: Buprenorphine can only be initiated when patient is in mild opioid withdrawal; at 10 days abstinent, naltrexone is the safer option 1

For Stimulant Use

• No FDA-approved medications; psychosocial support is primary treatment 1
• Monitor for depression and consider antidepressants only after 2+ weeks of complete abstinence 6

Essential Adjunctive Treatment

Thiamine supplementation (oral 100 mg daily or parenteral if malnourished) to prevent Wernicke's encephalopathy, given polysubstance use and likely nutritional deficiency 1, 4, 6

Monitoring and Follow-Up

• Weekly visits for the first month to assess symptom resolution, medication adherence, and relapse risk 2
• Screen for depression or psychosis (can emerge during protracted withdrawal) and obtain psychiatric consultation if present 1, 2
• Mutual help groups (Alcoholics Anonymous, Narcotics Anonymous) should be strongly encouraged 1, 4

When to Refer for Specialist Care

Refer immediately if 1, 2:

• Symptoms do not improve with brief psychosocial intervention
• Severe depression or suicidal ideation emerges
• Psychotic symptoms develop
• Patient relapses to substance use

Common Pitfalls to Avoid

• Prescribing opioids for body aches—this will trigger relapse in a patient 10 days abstinent from heroin 1, 3
• Prolonged benzodiazepine prescriptions (>14 days) creating new dependence 6
• Delaying psychosocial intervention while focusing solely on medications—psychosocial support is the primary evidence-based treatment at this stage 1, 2
• Overlooking co-occurring psychiatric disorders that complicate recovery 4, 6
• Failing to initiate relapse prevention medications (acamprosate, naltrexone) once acute symptoms resolve 1, 4, 6