SN10 SHORT NOTE 5M

Write a short note on withdrawal syndromes.

General Medicine · Final Professional

Definition

A withdrawal syndrome is the predictable cluster of symptoms that follows reduction or cessation of a substance on which the body has become physically dependent. Features are characteristically opposite to the acute effects of the drug, because neuroadaptation has occurred during chronic use.

ALCOHOL WITHDRAWAL — the most important

Chronic alcohol enhances inhibitory GABA and suppresses excitatory NMDA transmission. On withdrawal, the adapted brain is left in a state of unopposed excitation.

Time after last drink	Features
6–12 hours	Tremor, anxiety, sweating, nausea, palpitations, insomnia
12–24 hours	Alcoholic hallucinosis — usually visual, with intact orientation and insight
24–48 hours	Withdrawal seizures — generalised tonic-clonic, usually few and self-limiting
48–72 hours (up to 5 days)	Delirium tremens — coarse tremor, clouded consciousness, disorientation, vivid visual hallucinations (classically insects or small animals), agitation, fever, marked autonomic overactivity

Delirium tremens is a medical emergency with mortality up to 5–15% if untreated, from arrhythmia, hyperthermia, seizures and cardiovascular collapse.

Management:

Benzodiazepines are the cornerstone — chlordiazepoxide or diazepam in a tapering regimen; lorazepam is preferred in significant liver disease because it is not oxidatively metabolised. Symptom-triggered dosing guided by the CIWA-Ar scale is more effective than fixed schedules.
Parenteral thiamine before any glucose — see the danger box below.
Correct fluids, electrolytes (especially magnesium and potassium), and treat intercurrent infection.
Nurse in a calm, well-lit environment; haloperidol may be added for severe agitation or hallucinations, but never as a substitute for benzodiazepines, since it lowers the seizure threshold.
After detoxification, offer relapse prevention: acamprosate, naltrexone or disulfiram, plus counselling and Alcoholics Anonymous.

DANGER / REMEMBER

Always give parenteral thiamine BEFORE any glucose-containing fluid in a chronic alcohol user. Glucose administration consumes the last thiamine reserves as a cofactor and can precipitate Wernicke's encephalopathy — the classic triad of confusion, ophthalmoplegia and ataxia — which becomes irreversible Korsakoff psychosis if untreated.

Opioid Withdrawal

Onset depends on half-life — 6–12 hours after heroin, 24–48 hours after methadone. Features: lacrimation, rhinorrhoea, yawning, mydriasis, piloerection ("cold turkey"), muscle and joint aches, abdominal cramps, vomiting, diarrhoea, insomnia and intense craving.

Distressing but rarely life-threatening in adults (unlike alcohol withdrawal) — a favourite examination contrast. Management: substitution with methadone or buprenorphine, with symptomatic support (clonidine or lofexidine for autonomic symptoms, loperamide, NSAIDs), followed by long-term maintenance therapy and psychosocial support. Naltrexone is used after detoxification for relapse prevention.

Benzodiazepine Withdrawal

Follows chronic use, especially of short-acting agents. Features: rebound anxiety and insomnia, tremor, sweating, perceptual disturbance, depersonalisation, and — as with alcohol — seizures, which may be fatal. Management is gradual dose reduction, usually after conversion to a long-acting agent such as diazepam, tapered over weeks to months. Never stop abruptly.

Nicotine Withdrawal

Craving, irritability, anxiety, poor concentration, increased appetite and insomnia; peaks at 2–3 days and settles over 3–4 weeks. Managed with nicotine replacement, varenicline or bupropion with behavioural support.

STIMULANT WITHDRAWAL ("crash")

After cocaine or amphetamine: dysphoria, hypersomnia, hyperphagia, psychomotor retardation, intense craving and suicidal ideation. There is no specific pharmacotherapy; management is supportive with monitoring of suicide risk.

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