• Withdrawal syndromes are specific to:
• type of drug involved
• route of administration
• frequency of use
• quantity used
• individual variation in sensitivity
• psychological state
• Mild symptoms occurring after withdrawal of a drug do not require routine medical intervention
• explaining to patient likely course of withdrawal reduces severity of withdrawal symptoms
• If treatment may be required suggest TAP
• Test (investigations), Assess (as described below) and Phone (drug agency that will continue input following discharge acute hospital)

Investigations

• Obtain witnessed urine sample or mouth swab for drug screen
• contact alcohol liaison team for screening tests
• Check patient's prescribed medications with GP when surgery open
• If indicated, Pregnancy test

Pregnancy

• Very detailed assessment and close management of withdrawal because of risks to fetus
• Refer to appropriate drug service and contact on-call obstetric team. See Management of a pregnant woman with a non-obstetric problem guideline

Symptoms and signs

• Nausea, vomiting
• Diarrhoea
• Restlessness, anxiety
• Irritability, insomnia
• Muscle and bone pains
• Running eyes and nose
• Sneezing, yawning
• Sweating, flushing
• Dilated pupils, pilo-erection ("Goosebumps")
• In a hospital setting assess opiate withdrawal severity every 6 hr

Immediate treatment

• Where withdrawal symptoms are of sufficient severity to warrant medical treatment, several options are available
  • principally either managing the withdrawals symptomatically or by using a substitute drug (which would normally be methadone)

Symptomatic treatment

• Nausea, vomiting and insomnia: promethazine hydrochloride 25 mg oral 12-hrly
• Somatic anxiety: propranolol 40 mg oral 8-hrly (contraindicated if has COPD/Asthma)
• Diarrhoea: loperamide 4 mg single oral dose and if further loose stools, 2mg (dose to be taken after each loose stool) (maximum dose 16 mg/day)
  • if infective diarrhoea suspected, do not give loperamide
• Stomach cramps: hyoscine butylbromide 10-20 mg oral 6-hrly
• Pain: paracetamol 1 g oral 6-hrly or ibuprofen 400 mg oral 8-hrly if required

Opiate substitution prior checks

• Check with local drug service if already on a script
• Obtain drug test (mouth-swab or urine test)
• If Methadone >80mg/day, ECG (Methadone may prolong QTc)
  • if QTc 451-500 undertake cardiac risk assessment
  • if QTc greater than 500 discuss with Cardiology
• Undertake LFTs & FBC (unless tests done in last 3 months)

Patient states they are taking opiate substitute

• Contact community pharmacy being used to clarify
  • drug prescribed, dose, route, frequency
  • whether it's supervised or unsupervised
  • last collection date, whether they collect daily, or a few days at a time e.g. Sat collection for Sat & Sun doses and if any recent doses missed
• Contact the prescriber. Clarify management plan and ask for name of key worker
• Do not make increases to dose without discussion with the prescriber
  • if they have been taking the medication regularly and not using additional heroin or other opiates, then no change in the dose will be required

Initiation of opiate substitution

• If patient is not on methadone or buprenorphine or has missed their community doses for >72 hr, discuss initiation of opiate substitution with drug agency (based on geography) that will continue input following from discharge acute hospital
• Do not give substitutes unless a screening test confirms presence of opiates
• Drug of choice is methadone mixture (1 mg/1 mL)
  • do not use injectable or tablet forms of methadone
  • do not give alternative forms of opiate unless discussed with relevant drug agency
  • where patient is already on buprenorphine rather than methadone, discuss with community drug team

Initial dose

• Measure withdrawal symptoms at 6-hrly intervals for 24 hr
• if score >5, give methadone 1 mg per point (i.e. score of 5 = no dose, score of 7 = 7 mg)
• Following first four 6-hrly assessments, add up doses administered at these assessments
• sum will be the daily dose on which patient should continue
• If significant withdrawal symptoms persist and patient remaining in hospital, give the new daily dose and perform a further 24 hr cycle of 6-hrly assessments
• in order to decide dose to be given on day 3, add any extra methadone given on day 2 to the sum obtained from day 1

Maintenance dose

• Once stable dose has been achieved, give methadone as single daily dose
• with amount calculated from initial doses as described above
• Maximum dose in 24 hr should not exceed 50 mg without specialist advice

Subsequent management

• Aim to allow patient to stabilise on the dose of methadone reached by titration with any reductions arranged by continuing care teams once discharged
• On discharge, continuing prescription should be via local community services
  • opiate substitution methadone or buprenorphine will not be issued by UHNM on discharge

Monitoring treatment

• Complete withdrawal table 6-hrly
  • usually be for 48 hr but may need a further 24 hr for some patients

Discharge and follow-up

• Contact agency that has agreed to continue prescribing
• give details of the ward phone numbers
• allow as much warning as possible in order for necessary arrangements to be made before the day of discharge and note the drug service closes at 1600 hr, and is not open over the weekends
• relevant agency will confirm arrangements for prescription and appointment
• Do not write methadone prescription as a TTO
• Notify GP and drug service

• Benzodiazepines and other sedative hypnotic drugs
• Alcohol. See Alcohol withdrawal guideline

Symptoms and signs

• Confusion
• Nystagmus
• Tremor
• Agitation, irritability
• Insomnia
• Pyrexia
• Hyperreflexia
• Weakness
• Convulsions

Immediate treatment

• In initial stages, treatment of sedative withdrawal is similar to that for alcohol. See Alcohol withdrawal guideline
• Once symptoms controlled, change to long-acting benzodiazepine (chlordiazepoxide, diazepam) in an equivalent dose (Table) to maintain clinical state
• Discuss a longer-term strategy with either local drug management service or patient's GP

• GHB is a 'party' drug used for its euphoric effects. It may interact with other illicit or prescribed drugs (e.g. anti-convulsants or anti-psychotics)

Serious side effects

• Headaches
• Hallucinations
• Dizziness
• Confusion
• Nausea
• Vomiting
• Drowsiness
• Agitation
• Diarrhoea
• Sexual arousal
• Numbing of legs
• Vision problems
• Tightness of chest
• Mental changes
• Combativeness
• Memory loss
• Serious breathing and heart problems
• Seizures
• Coma
• Death
• Long-term use may lead to withdrawal symptoms

Management

• Patients may present to A&E in an intoxicated or comatose state
• most wake up within a few hours, but some require ventilation
• Due to short half-life, withdrawal symptoms require active management - use diazepam as indicated in Alcohol withdrawal guideline using CIWA-Ar assessment chart, higher doses may be required
• Refer to local community drug and alcohol service

• There are no acute symptoms of stimulant withdrawal that need medical treatment as a matter of urgency. Insomnia and anxiety can be treated symptomatically
• Advice and support are valuable
• Depressive symptoms sometimes occur as a later withdrawal effect and can be treated with an antidepressant
• Refer to local community drug and alcohol service

• Commonly misused are butane, toluene, glues, petrol
• As there are no physical withdrawal syndromes, it is best to discontinue use abruptly
• Treatment of intoxication involves general supportive measures
• Refer to local community drug and alcohol service

• Treat anxiety and insomnia symptomatically