Management of substance abuse

Withdrawal state

Definition

A group of symptoms of variable clustering and degree of severity which occur on cessation or reduction of use of a psychoactive substance that has been taken repeatedly, usually for a prolonged period and/ or in high doses. The syndrome may be accompanied by signs of physiological disturbance. A withdrawal syndrome is one of the indicators of a dependence syndrome. It is also the defining characteristic of the narrower psycho-pharmacological meaning of dependence.

The onset and course of the withdrawal syndrome are time-limited and are related to the type of substance and dose being taken immediately before cessation or reduction of use. Typically, the features of a withdrawal syndrome are the opposite of those of acute intoxication.

The alcohol withdrawal syndrome is characterized by tremor, sweating, anxiety, agitation, depression, nausea, and malaise. It occurs 6-48 hours after cessation of alcohol consumption and, when uncomplicated, abates after 2-5 days. It may be complicated by grand mal seizures and may progress to delirium (known as delirium tremens).

Sedative withdrawal syndromes have many features in common with alcohol withdrawal, but may also include muscle aches and twitches, perceptual distortions, and distortions of body image.

Opioid withdrawal is accompanied by rhinorrhoea (running nose), lacrimation (excessive tear formation), aching muscles, chills, gooseflesh, and, after 24-48 hours, muscle and abdominal cramps. Drug-seeking behaviour is prominent and continues after the physical symptoms have abated.

Stimulant withdrawal (the ''crash") is less well defined than syndromes of withdrawal from central nervous system depressant substances; depression is prominent and is accompanied by malaise, inertia, and instability.

ICD-10 Clinical description

A group of symptoms of variable clustering and severity occurring on absolute or relative withdrawal of a substance after repeated, and usually prolonged and/or high-dose, use of that substance. Onset and course of the withdrawal state are time-limited and are related to the type of substance and the dose being used immediately before abstinence. The withdrawal state may be complicated by convulsions.

ICD-10 Diagnostic criteria for research

Withdrawal state is one of the indicators of dependence syndrome and this latter diagnosis should also be considered.

Withdrawal state should be coded as the main diagnosis if it is the reason for referral and sufficiently severe to require medical attention in its own right.

Physical symptoms vary according to the substance being used. Psychological disturbances (e.g. anxiety, depression, and sleep disorders) are also common features of withdrawal. Typically, the patient is likely to report that withdrawal symptoms are relieved by further substance use.

It should be remembered that withdrawal symptoms can be induced by conditioned/learned stimuli in the absence of immediately preceding substance use. In such cases a diagnosis of withdrawal state should be made only if it is warranted in terms of severity.

Differential diagnosis. Many symptoms present in drug withdrawal state may also be caused by other psychiatric conditions, e.g. anxiety states, and depressive disorders. Simple 'hangover' or tremor sue to other conditions should not be confused with the symptoms of a withdrawal state.

The diagnosis of withdrawal state may be further specified by using the following five-character codes:

F1x.30 - Uncomplicated

F1x.31 - With convulsions