Alcohol and Drug Withdrawal Management

The physical and mental health risks of substance use are not limited to active use. Distressing symptoms and health risks may also occur once someone quits. The set of symptoms that arise when someone cuts back significantly or quits is referred to as withdrawal.

The fact that withdrawal may result in some distressing symptoms should not deter you if you need help for addiction, as the risks of continuing to live in active addiction will likely far outweigh the withdrawal risks; however, in order to stay safe, you’ll need to make sure you find the right level of support as you detox.

What Is Withdrawal Management?

The management of the symptoms and complications of substance withdrawal is referred to as “withdrawal management” (WM), also called “detoxification.”¹ Withdrawal management (WM) encompasses all of the professional medical and psychological care a person receives after reducing or ending their substance use.²

Specific substances are associated with a cluster of symptoms that occur when the drug is discontinued/reduced called the “withdrawal syndrome” or “discontinuation syndrome.” The timeframe of the withdrawal syndrome—when symptoms will peak and subside—is relatively predictable as well.^1,3

In some cases, the predicted withdrawal syndrome will be relatively minor, while in others the syndrome may be potentially life-threatening. For example, withdrawal from marijuana is unlikely to result in serious health risks; however, withdrawal from alcohol or sedatives can cause seizures or delirium tremens (DTs).^1,2

Which Drugs Require Withdrawal Management?

Withdrawal syndromes vary widely depending on the substance. Professional medical detox is recommended for the drugs that have known medical risks. The most hazardous withdrawal symptoms come from the discontinuation of:²

• Alcohol.
• Sedatives.
• Opioids.
• Stimulants.

Alcohol, opioids, sedatives, and stimulants carry the reputation for having the most problematic withdrawal symptoms, but withdrawal management may be needed for other drugs as well. If you have questions about whether you need professional withdrawal management, speak to a doctor or addiction treatment provider.

Alcohol Withdrawal Symptoms

When someone is physically dependent on alcohol, their body needs the drug to function normally, so withdrawal symptoms will begin between 6 and 24 hours after the last use, with the onset of the most uncomfortable symptoms between 36 and 72 hours.²

The acute withdrawal symptoms from alcohol can last for up to 10 days and include:²

• Anxiety.
• Sweating.
• Shakiness.
• Dehydration from vomiting and diarrhea.
• Higher blood pressure and heart rate.
• Sleeping problems.
• Seizures.
• Hallucinations and delusions.

Approximately 5% of patients in alcohol withdrawal will experience delirium tremens (DTs), an intense and severe condition characterized by agitation, tremor, disorientation, persistent hallucinations and large increases in pulse, breathing rate and blood pressure. DTs usually appear 2-4 days after the patient’s last drink.⁴

Sedative Withdrawal Symptoms

Withdrawal from sedatives such as benzodiazepines and sleep medications (e.g., Ambien) is associated with symptoms that are very similar to those of alcohol withdrawal. The withdrawal symptoms from short-acting sedatives (e.g., oxazepam, alprazolam and temazepam) typically starts 1-2 days after the last dose and can last for 4 weeks, while symptoms from long-acting versions (e.g., diazepam and nitrazepam) begin 2-7 days after the last dose and can last for about 8 weeks.²

Sedative withdrawal symptoms include:³

• Hand tremor and restlessness.
• Nausea and vomiting.
• Severe anxiety.
• Insomnia.
• Hallucinations.
• Seizures.

Opioid Withdrawal Symptoms

Like sedatives, the specific type of opioid will determine the approximate timeline of withdrawal. Quitting a short-acting opioid like heroin can result in a quick onset of withdrawal (symptoms arising just hours after the last use and resolving by day 10).² Withdrawal symptoms associated with longer-acting opioids such as methadone may not come on until 2 days after the last use, and symptoms may persist for up to 20 days.³

Regardless of the type of opioid, the symptoms will be the same. They include:³

• Low mood.
• Insomnia.
• Goose bumps.
• Runny nose and teary eyes.
• Aching muscles.
• Nausea, vomiting and diarrhea.
• Sweating.
• Fever.

Withdrawal from opioids is not considered life-threatening in the same way as withdrawal from alcohol and sedatives; however, serious medical complications such as dehydration and electrolyte imbalance may result from vomiting and diarrhea.  Individuals with underlying cardiac conditions may also suffer medical complications during withdrawal due to withdrawal symptoms such as increased blood pressure and pulse rate.

The Substance Abuse and Mental Health Services Administration counts opioids among the drug types whose withdrawal syndrome is severe enough to warrant some form of inpatient detoxification because of the suffering the symptoms can cause.¹ Opioid withdrawal is commonly described as a terrible flu but worse.⁵

Stimulant Withdrawal Symptoms

Stimulants cover a wide range of drugs including methamphetamine, cocaine, and medications for attention-deficit/hyperactivity disorder.⁶

Other withdrawal syndromes create much more significant physical health issues, but stimulant withdrawal has the potential to create significant mental health risks. In some cases, stimulant withdrawal may cause paranoia, delusions, and hallucinations that may result in the detoxing person acting violently toward themselves or others.²

What About Marijuana?

While cannabis withdrawal is typically considered to be one of the more mild drug withdrawal syndromes, it does still produce a number of symptoms which may benefit from some form of withdrawal support. Symptoms of cannabis withdrawal typically begin about 24 hours after last use and can last for up to 2 weeks. Symptoms may  include:⁷

• Irritable mood.
• Anxiety.
• Problems sleeping and/or very vivid dreams.
• Cravings.
• Appetite loss.
• Headache.
• Stomach pain.
• Tremors.
• Sweating/night sweats.
• Chills.
• Fever.

Though there are no medications approved for cannabis withdrawal, certain medications may be given to alleviate specific symptoms, such as tremors or insomnia.⁸

There have been some reported cases of psychotic symptoms arising during cannabis withdrawal. Psychotic symptoms may be treated with antipsychotic medications during the acute withdrawal period.^8,9

Polysubstance Withdrawal Management

When multiple drugs are involved, withdrawal management may be more complicated, and an inpatient detoxification may be a requirement for your safety. For example, you might be able to detox from marijuana on your own, but if you’re also dependent on alcohol, withdrawal could become much more serious and merit the care of a professional medical staff.¹

When a person is withdrawing from than one substance, it not always possible to predict the withdrawal syndrome with the same kind of accuracy as when only one drug is involved. Being in a supervised detoxification program allows you to receive immediate care for unexpected symptoms that may arise. ¹

During managed withdrawal, medical professionals will prioritize each substance, and address the ones with the most serious withdrawal syndrome first. For example, a patient detoxing off both benzodiazepines and opioids may first undergo a taper off the benzodiazepine and then detoxification from opioids can begin. ¹

If you’re abusing more than one drug and you’re unsure if you need medical detox, ask a physician or addiction treatment provider. For questions about Laguna’s withdrawal management program, call 949-565-2377.

Phases of  Withdrawal Management

According to SAMHSA, the 3 main phases of detox, or withdrawal management, include:¹

1. Evaluation: Assessing the person’s status and symptoms.
2. Stabilization: Treating the condition to maintain their health.
3. Fostering readiness for treatment: Encouraging continued substance abuse treatment after detox ends.

Evaluation

When you are entering a treatment program to detox from drugs and/or alcohol, your providers will assess your physical and mental health and try to determine how at-risk you are of suffering severe symptoms or life-threatening complications. They will determine a treatment plan to manage your symptoms and keep you as comfortable as possible.^10,11

Based on the findings, the evaluator will recommend withdrawal management at a level of care suitable for the client’s needs. Possible treatment levels from least intense to most intense include:¹

• Outpatient detox without additional onsite monitoring.
• Outpatient detox with additional monitoring.
• Clinically managed (nonmedical) residential detox.*
• Medically monitored inpatient detox in a freestanding detox center.
• Medically managed inpatient detox in an acute care hospital.

These multiple withdrawal management levels exist because no one treatment is appropriate for everyone. People with a severe addiction, numerous mental and medical issues, and a lack of support in their home environment may need the structure, supervision, and support of an inpatient detox. Alternatively, a person with a mild substance use disorder and no co-occurring mental health issues who is detoxing from a drug with a minor withdrawal syndrome could make good progress in an outpatient setting.¹

* Some detox programs offer only nonmedical “social detox,” or supervised, supportive care with no use of medications. These programs may be appropriate for those withdrawing from substances where the symptoms are unlikely to require medical attention. Attempting to detox from substances such as alcohol and sedatives in a social detox program can be physically dangerous. A doctor or addiction specialist can discuss with you the appropriate level of withdrawal management for you.¹

Stabilization

The practical management of your withdrawal syndrome will then begin. You may be given certain medications such as methadone or buprenorphine (for opioid withdrawal), anticonvulsants (for seizures associated with alcohol or sedative withdrawal), or over-the-counter medications to address minor symptoms such as insomnia.¹

Medical staff will be on-hand to address emergencies, either providing immediate care or arranging for effective transfer to a more intensive treatment environment, such as an emergency room.¹

Fostering Readiness for Treatment

There is more to addiction treatment than detoxification. Withdrawal management includes helping the patient feel ready to continue on in treatment.^1,11

According to the American Society of Addiction Medicine (ASAM), the current standard of care for the treatment of those recovering from substance use disorders involves a multistep approach that consists of 6 phases, of which withdrawal management is only the second.¹¹ The broader treatment approach includes all of the following:¹¹

1. Comprehensive Assessment and Diagnosis: Taking a comprehensive medical history, performing a physical examination, and conducting appropriate diagnostic testing to inform the right course of treatment.
2. Withdrawal Management: Providing treatment as the individual overcomes physical dependence on one or more drugs.
3. Treatment Planning: Developing comprehensive treatment plans to assist the individual in recovery.
4. Treatment Management: Implementing treatment plans ensuring quality of care.
5. Care Transitions and Care Coordination: Providing regular reassessments of how well the treatment is working and making necessary adjustments, taking action to coordinate with other treatment providers, helping the patient transition to other forms of care when appropriate, and ensuring that privacy and confidentiality is maintained throughout.
6. Continuing Care Management: Following acute treatment, making efforts to ensure that the individual continues to engage in a proactive treatment program and receive support.

Medications to Manage Cravings

While medications may be used to stave off withdrawal symptoms during detox, some medications may also be used after detox to support recovery. The use of medications in combination with therapy is called medication-assisted treatment (MAT).¹²

MAT medications include:¹²

• For opioid addiction:
  • Methadone.
  • Buprenorphine.
  • Suboxone (buprenorphine/naloxone).
  • Naltrexone.
• For alcohol addiction:
  • Acamprosate (Campral).
  • Disulfiram (Antabuse).
  • Naltrexone.

Withdrawal management is only the beginning of the treatment process. Alone, a period of detox rarely results in long-term abstinence from substances, which is why therapy is so critical.¹³

Therapy can help a person to:¹³

• Increase their motivation for change.
• Provide incentives and rewards for abstinence from drugs.
• Build new skills to avoid substance use.
• Substitute drug use with healthier activities.
• Improve their ability to solve problems and manage intense feelings.
• Foster better relationships and communication with loved ones.

Not every person will need withdrawal management, but every person should receive a thorough evaluation to determine if detox is right for them. If you are thinking about ending your substance use, consider calling to safely begin the treatment process today.

References:

1. Substance Abuse and Mental Health Services Administration. (2015). Detoxification and Substance Abuse Treatment.
2. World Health Organization. (2009). Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings.
3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
4. Myrick, H., & Anton, R. F. (1998). Treatment of Alcohol Withdrawal, 22(1), 38–43.
5. National Institute on Drug Abuse. (n.d.). Mind Matters: The Body’s Response to Opioids.
6. Scholastic. (2009). Health Effects of Stimulants.
7. Bonnet, U., & Preuss, U. W. (2017). The cannabis withdrawal syndrome: current insights. Substance abuse and rehabilitation, 8, 9–37.
8. Government of South Australia. (n.d.). Cannabis Withdrawal Syndrome.
9. Joseph, C., Ojo, O., Popoola, O., Azizi, H., Khan, T., Pramanik, O., … Jolayemi, A. (2018). A case of brief psychosis upon cannabis withdrawal. MOJ Addiction Medicine & Therapy, 5(6).
10. Beacon Health Options. (2015). An Introduction to the ASAM Criteria For Patients and Families.
11. American Society of Addiction Medicine. (2014). The ASAM Standards of Care For the Addiction Specialist Physician.
12. National Institute on Drug Abuse. (2019). DrugFacts: Treatment Approaches for Drug Addiction.
13. National Institute on Drug Abuse. (2018). Principles of Drug Addiction Treatment: A Research-Based Guide.