14 detoxification and management of withdrawal

In many instances effective detoxification can be performed in the home supported by the local doctor and other health workers. This should be considered when:

• there is no evidence of severe withdrawal, eg tremor, hallucinations, disorientation
• where there is no past history of delirium tremens or of fits
  
• in the presence of supportive relatives who elect to stay with the patient during the period of detoxification
• where there is no evidence of a medical illness such as pneumonia or pancreatitis
  
• when no previous history or evidence of suicide is contemplated
• where the patient does not have any access to the drug from which they are being withdrawn.

  These criteria mainly relate to detoxification from alcohol.

Should detoxification be medicated?

That is, assisted by the use of controlled sedatives, or non-medicated in which no sedation is required.

• Non-medicated detoxification is quite appropriate for patients who have no coexisting medical disorders and when only a mild withdrawal can be anticipated.

Non-medicated detoxification

This process should be carried out in a safe environment, ideally in a quiet and comfortable home environment.

• The therapist involved must take a very low key and empathetic approach to the patient, and all guidelines should be explained very clearly both to the patient and his or her family. It is important to avoid confrontation and arguments during this management process.
• The therapist should regularly assess the orientation of the patient and his or her relationship with their environment.
  
• It is necessary to explain the illusions or hallucinations and when they occur to assist in controlling the anxiety produced by them.
• A balanced diet with daily use of oral thiamine is advised in all cases.

Medicated detoxification from alcohol

In the more severe cases medication is important and sedative treatment should be titrated against the severity of the patients withdrawal symptoms and signs. At no time should drug therapy be given to those patients who are still intoxicated.

There are two main approaches:

Tapering withdrawal regimen

• During mild withdrawal:
  • sedate the patient for the first 24 hours
    
  • administer 5-10 mg of diazepam every 6-8 hours as required
    
  • reduce this dosage over 5-7 days.
    
  • In more severe cases:
  • 10-20 mg of diazepam, 6 hourly, reduced over a 5-7 day period.

    Loading dose
    

• The principle of this form of management is to use a loading dose in the first 48 hours and follow that with a reduction over the next 5-10 days.
• In mild withdrawal 5-10 mg of diazepam should be given every 6-8 hours as required by the patient's symptoms. In more severe cases a loading dose of 20 mg of diazepam may be given every two hours until sedation is achieved.
  
• No further medication is then given and the patient's signs reviewed on a four-hourly basis. No more than 120 mg should be given in the first 12 hours. On subsequent days 5-10 mg every six hours may be required but in most cases this is unnecessary.
  
• Diazepam is the drug of choice because both it and its metabolites have a long half-life:
  
  • diazepam has a half-life of 18-40 hours
    
  • active metabolites have a half-life of 2 to 5 days.
    Because of this a sufficient loading dose will usually be enough to cover the whole withdrawal period.
    
• Barbiturates and major tranquillisers should not be used in the management of alcohol withdrawal. There is also little value in the use of beta-adrenergic blocking drugs such as propranolol. Although these do produce some sedation there is a definite risk of inducing hyperglycemia and hypertension.

Other aspects of management

Vitamin therapy

All patients treated for withdrawal from alcohol should receive thiamin to prevent the onset of Wernicke's Encephalopathy. An intravenous or intramuscular dose of 100 mg of thiamin immediately should be given and then orally 100 mg two to three times a day for two weeks.

Electrolyte and fluid balance

The fluid state of patients should be carefully assessed and a watchful eye kept for fluid depletion or fluid overload.

Withdrawal of benzodiazepines can be performed on an outpatient basis. This would need to occur over six weeks but in some cases this may be increased to 10-15 weeks.

Withdrawal is managed by using a long-acting benzodiazepine such as diazepam in a dose relevant to that of the drug in question. The following guidelines should be followed:


• a detailed history of total daily benzodiazepine use should be accurately determined
  
• the equivalent dose of diazepam should be calculated
  
• substitute diazepam (which has a long half-life) for other benzodiazepines
  
• maintain this dose for one week (ie stabilise the patient on this dosage)
  
• after stabilisation gradually withdraw the patient by 2.5-5 mg per week
  
• regular review and advice must be given to the patient at this difficult time
  
• cessation of the last few milligrams of diazepam can be very difficult for the patient. They may require support and encouragement particularly at this time
  
• refer to the NHMRC booklet on benzodiazepine dependence for more information (Brayley, Bradshaw and Pols, 1991).

The doctor's role in the community is firstly to prevent dependence by judicious and limited prescribing of sedatives and hypnotics for specific clinical situations on a short-term basis, and to manage the detoxification of those who have established dependence on these drugs.

• The withdrawal syndrome from the effect of barbiturates and other sedative hypnotics ranges in severity from mild anxiety, weakness, sweating and insomnia to an acute syndrome resembling delirium tremens. The latter may include convulsions, hallucinations and gross tremor and sweating.

  Such a withdrawal state may occur in those who are taking short-acting barbiturates, but often may be delayed several days in those who are taking longer-acting preparations such as phenobarbitone. Other symptoms and signs that may occur are hypertension, abdominal cramps, and anorexia.

  It is necessary to withdraw such patients on long-term sedation. At the outset a decision should be made whether formal detoxification is required.

• Formal detoxification from high dose barbiturates is potentially dangerous and should be carried out in a hospital setting. Phenobarbitone equivalents should be calculated, and withdrawal proceeded with a reduction in dose of 10-15% daily. Anticonvulsant cover may be indicated.
• In patients taking therapeutic doses of hypnotics at night it is usually safe to stop the drug and for a few days replace it with an equivalent dose of a long acting benzodiazepine, similar to that used for withdrawal from benzodiazepine dependence. The principle is to then wean the patient on a gradual basis. In the base of barbiturates, help should be sought from a drug and alcohol specialist before attempting detoxification.

  Such detoxification can be achieved in the home, but in patients with more severe dependence hospitalisation in a detoxification unit is advised.

The most common opiate in use today is heroin.

• Withdrawal from heroin occurs within 4-6 hours of the last administered dose.

  Symptoms include nasal stuffiness and rhinorrhoea, sweating and lacrimation. Anxiety, restlessness and irritability follow, and over the next 36 hours chills and muscle cramps, particularly intestinal cramps, may occur. Vomiting and diarrhoea are also common at this stage.

• The 'cold turkey' withdrawal without any medication will usually run a course of between 5-10 days depending upon the size of the patient's habit.

  In general the withdrawal syndrome from opiates is much less severe than withdrawal from sedative drugs or alcohol.

• Outpatient management of detoxification can be successfully used but should take place over 10-14 days. Patients need to be seen each day and be given only a 24 hour supply of their medication; this should be reviewed on a daily basis.

  A combination of clonidine and diazepam is recommended.

  • Clonidine (Catapres) 150-130 micrograms 6 hourly up to 8 days.
    
  • Diazepam (eg Valium) six hourly for 4 days should be given.
    
  • Hourly review is required to check on withdrawal symptoms and blood pressure (daily review for outpatients).
    
  • On day 4 the patient should be reassessed and the dose of each drug may be able to be gradually reduced over the following 10-14 days.
    
  • When the withdrawal is more severe inpatient management is required.

Because of the complexities of the pharmacology involved in polydrug use and abuse it is unwise to contemplate withdrawal except in an inpatient environment.

There is not a lot of evidence to support the idea that there is a cannabis withdrawal syndrome. This does not mean that it is easy for some people to stop using cannabis.

Cessation of use may be situationally determined to a large degree. The presence of particular cues may lead to cannabis use. Cues may be internal or external. External cues may include mixing with a cannabis using group, a joint being shared or cannabis smoke at a party. Feeling bored, despondent or unhappy are all examples of internal cues which may lead to cannabis use.

Management

Management should follow the general principles of detoxification:

• help to assess patient motivation
• weigh up the costs and benefits of stopping
  
• identify the cues which lead to cannabis use
• devise a management plan for change.