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23.10 Withdrawal from Substance of Abuse

Table of Contents

23.10.1. Heroin

Heroin addiction, is a chronic, relapsing brain disease that is characterized by compulsive substance seeking and use, despite harmful consequences. When your body has become dependent on heroin, a number of unpleasant withdrawal symptoms will arise when the drug hasn’t been used for a certain amount of time.

Diagnostic Criteria Features include:

  • Myalgia
  • Gooseflesh
  • Diarrhoea
  • Rhinorrhoea
  • lacrimation
  • Agitation
  • Anxiety
  • Insomnia
  • Sweating
  • Yawning
  • Abdominal cramping
  • Dilated pupils
  • Nausea and Vomiting

Pharmacological Treatment

D: Methadone (PO) 30mg daily as minimum dose, up to 120mg daily max. dose for 1 to 2 years or more.


S: Buprenorphine (Sublingual) 2mg daily as minimum dose, up to 8mg daily max. dose for 1 to 2 years.



S: Naltrexone (PO) 25mg daily as minimum dose, up to 50mg daily as max. dose for 6 months.


Symptomatic Treatment

C: Diazepam 5–20 mg (PO) once daily or in divided doses only as inpatient, taper off over 5–7 days 6


A: Promethazine 50mg (PO) once daily at sleeping time


A: Chlorpromazine 50–00mg (PO) once daily at sleeping time


For abdominal cramps give:

A: Hyoscine butyl bromide 20 mg (O) up to 3 times daily as required


C: Diclofenac tablets 50mg (O) 8hourly


For diarrhoea give:

B: Loperamide 4 mg (O) immediately, then 2 mg after each loose stool


23.10.2. Alcohol

For an individual with alcohol use disorder, abstinence from alcohol usually leads to withdraw symptoms. Alcohol detoxification requires the use of medication to prevent the symptoms which could become severe and potentially lead to mortality.

Diagnosis Criteria

Withdrawal symptoms include:

  • Insomnia
  • Tremors
  • Chills
  • Anxiety


Non-Pharmacological Treatment

  • Support group that encourage abstinence
  • Inpatient rehabilitation programme where necessary


Pharmacological Treatment

C: Thiamine 300 mg I.M every 24 hours


For the CNS symptoms

A: Diazepam 10 mg (PO) every 4–6 hours on the first 24 and reduce by 20% over 3–5 days (only in inpatient care)


S: Chlordiazepoxide tablets 20–60mg (PO) daily in divided doses and taper over month


Relapse prevention following detoxification

S: Naltrexone 50mg (PO) daily decreases the craving for alcohol

23.10.3. Alcohol Withdrawal Delirium (Delirium Tremens)

It is an acute episode of delirium that is usually caused by withdrawal from alcohol. Although the typical delirium occurs 2–3 days following cessation of prolonged alcohol intake, reaching a peak at around 5 days, some withdrawal symptoms such as tremor may start within 12 hours.

Diagnosis Criteria

  • Visual hallucinations
  • Disorientation
  • Fluctuating level of consciousness
  • Agitation
  • Tachycardia
  • Hypertension
  • A low-grade fever may be present
  • Withdrawal tonic-clonic seizures may occur between 24 and 48 hours following cessation of alcohol intake

Note: It is important to consider alternative causes, when making the diagnosis. This is especially true for cases with an atypical presentation.

Emergency Care

  • Secure airway
  • Ensure breathing
  • Circulation
  • Give IV fluid (Dextrose Normal Saline) to prevent hypoglycaemia and hypotension
  • Monitor for respiratory depression


Pharmacological Treatment

A: Diazepam IV 10 mg


C: Lorazepam IM/IV, 2 mg for immediate sedative or hypnotic action. If no response give a second dose.


Do not administer at a rate over 5 mg/minute
Switch to oral once containment is achieved



S: Chlordiazepoxide 20–60mg taper over one month


C: Thiamine IM 300mg daily


A: Vitamin B Complex 1 ampoule in half litre of 5% Dextrose

12. 10.4. Cocaine

Non-Pharmacological Treatment

These patients usually do not require admission, however beware of depression and assess suicide risk

Pharmacological Treatment

  • No substitute drug available for detoxification
  • For severe anxiety, irritability and insomnia
    A: Diazepam 5–10mg (PO) 8hourly times daily for 5–7 days

Referral: Refer patients to specialized clinic

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