Sedative Withdrawal and Detoxification
When someone has been taking central nervous system depressants for a long time and the use is no longer medically indicated, or when there are signs of abuse or addiction (such as a pattern of increasing use, periods of intoxication, psychoactive prescriptions from multiple doctors, functional impairment and unsuccessful attempts to decrease or discontinue the dose), detoxification may be necessary. Sedatives associated with withdrawal include alcohol, both short–and long–acting benzodiazepines, barbiturates, glutethimide, chloral hydrate and meprobamate.
The prototypic withdrawal syndrome occurs with cessation of alcohol use; the patterns seen with other sedatives represent small variations on alcohol withdrawal. Minor (stage 1) withdrawal is characterized by restlessness, anxiety, sleeping problems, agitation and tremor; other signs include tachycardia, low–grade fever, diaphoresis and elevated blood pressure. Major (stage 2) withdrawal involves the signs and symptoms associated with minor withdrawal plus visual or auditory hallucinations. Whole-body tremor, pulse exceeding 100 per minute, diastolic pressure exceeding 100 mm Hg, pronounced diaphoresis and vomiting may also be present. Delirium tremens (stage 3) may be accompanied by a temperature exceeding 37.8 degC (100 degF) and disorientation to time, place and person, as well as global confusion and inability to recognize familiar objects or persons. This is a medical emergency, with a mortality of 2 to 5 percent [38] and should prompt a thorough medical evaluation for other physical problems.
Alcohol withdrawal seizures may occur 12 to 48 hours after the last drink; seizures from barbiturates usually occur within 72 hours after the last use. Withdrawal from long-acting benzodiazepines may not manifest for up to a week or more.
Detoxification of patients dependent on sedatives should be done with extreme care, because abrupt withdrawal may be associated with potentially life-threatening effects. Detoxification involves either supervised stepwise dose reduction or substitution with a cross-tolerant, longer-acting substance (such as diazepam or phenobarbital) that has less risk of severe withdrawal symptoms. The cross-tolerated drug is given in gradually tapering doses. The goals of treatment are to relieve symptoms, prevent stage 2 or 3 withdrawal, prevent seizures, minimize the chance of a new dependency on the medication used for withdrawal and minimize the toxicity of the medication. It should be noted that the triazolobenzodiazepines (e.g., triazolam [Halcion] and alprazolam [Xanax]) may not be completely cross-tolerant with other sedatives. Patients dependent on alprazolam require a particularly gradual tapering from their initial dosage.
Benzodiazepine Detoxification Programme
In order to be included in Benzodiazepine Abuse or Misuse Detoxification Programme, patients should have suffered at least two of recognisable symptoms of benzodiazepines withdrawal: restlessness, anxiety, insomnia, tremor, fits, impaired memory and/or concentration .
Assessment of liver and kidney functions is essential. LFT, proteins, hepatic enzymes, cholesterol, LDL, HDL, vitamin K tests, and urine analysis will be performed.
If the patient has any of the withdrawal symptoms mentioned above (excluding fits), he should be given diazepam 5 – 30 mg BD according to clinical criteria, plus sleeping medications other than barbitates.
Diazepam could be given OD because of his long half-life (19 – 50 hours).It should be considered dose accumulation.
This benzodiazepine dose will be reduced by 10 mg per week. This is a 1 to 4 weeks process that could be adjusted on individual necessities.
If the patient has any of the withdrawal symptoms mentioned above including fits related to, or not related benzodiazepines withdrawal, the patient should also receive: Valproate 300 mg tds, Gabapentin 300 mg tds or another appropriate antiepileptic medication.
Valproate or Gabapentin should be prescribed for not less than a month, or until a normal EEG has been obtained, and other causes of convulsion have been ruled out.
If the patient is abusing alcohol as well as benzodiazepines, they should be included in an Alcohol Detoxification Programme, particularly if this is the primary addictive disease. The Benzodiazepine Detoxification Programme will be adapted to the patient’s clinical condition. This may mean that the patient will remain medicated with Benzodiazepines for a longer period than was established for the formal Benzodiazepine Detox Programme.
If the patient is using benzodiazepines to control stimulant excitement or to cope with opiates withdrawal, they should be included onto an Opiate or Stimulant Detoxification Programme, particularly if these are the primary addictive diseases.
The Benzodiazepine Detoxification Programme will be adapted to the patient’s clinical condition. This may mean that the patient will remain medicated with diazepam for a longer period than the one established for the formal Benzodiazepine Detox Programme.
Therapeutic programmes for benzodiazepines detoxification will last no less than 10 days.
The prototypic withdrawal syndrome occurs with cessation of alcohol use; the patterns seen with other sedatives represent small variations on alcohol withdrawal. Minor (stage 1) withdrawal is characterized by restlessness, anxiety, sleeping problems, agitation and tremor; other signs include tachycardia, low–grade fever, diaphoresis and elevated blood pressure. Major (stage 2) withdrawal involves the signs and symptoms associated with minor withdrawal plus visual or auditory hallucinations. Whole-body tremor, pulse exceeding 100 per minute, diastolic pressure exceeding 100 mm Hg, pronounced diaphoresis and vomiting may also be present. Delirium tremens (stage 3) may be accompanied by a temperature exceeding 37.8 degC (100 degF) and disorientation to time, place and person, as well as global confusion and inability to recognize familiar objects or persons. This is a medical emergency, with a mortality of 2 to 5 percent [38] and should prompt a thorough medical evaluation for other physical problems.
Alcohol withdrawal seizures may occur 12 to 48 hours after the last drink; seizures from barbiturates usually occur within 72 hours after the last use. Withdrawal from long-acting benzodiazepines may not manifest for up to a week or more.
Detoxification of patients dependent on sedatives should be done with extreme care, because abrupt withdrawal may be associated with potentially life-threatening effects. Detoxification involves either supervised stepwise dose reduction or substitution with a cross-tolerant, longer-acting substance (such as diazepam or phenobarbital) that has less risk of severe withdrawal symptoms. The cross-tolerated drug is given in gradually tapering doses. The goals of treatment are to relieve symptoms, prevent stage 2 or 3 withdrawal, prevent seizures, minimize the chance of a new dependency on the medication used for withdrawal and minimize the toxicity of the medication. It should be noted that the triazolobenzodiazepines (e.g., triazolam [Halcion] and alprazolam [Xanax]) may not be completely cross-tolerant with other sedatives. Patients dependent on alprazolam require a particularly gradual tapering from their initial dosage.
Benzodiazepine Detoxification Programme
In order to be included in Benzodiazepine Abuse or Misuse Detoxification Programme, patients should have suffered at least two of recognisable symptoms of benzodiazepines withdrawal: restlessness, anxiety, insomnia, tremor, fits, impaired memory and/or concentration .
Assessment of liver and kidney functions is essential. LFT, proteins, hepatic enzymes, cholesterol, LDL, HDL, vitamin K tests, and urine analysis will be performed.
If the patient has any of the withdrawal symptoms mentioned above (excluding fits), he should be given diazepam 5 – 30 mg BD according to clinical criteria, plus sleeping medications other than barbitates.
Diazepam could be given OD because of his long half-life (19 – 50 hours).It should be considered dose accumulation.
This benzodiazepine dose will be reduced by 10 mg per week. This is a 1 to 4 weeks process that could be adjusted on individual necessities.
If the patient has any of the withdrawal symptoms mentioned above including fits related to, or not related benzodiazepines withdrawal, the patient should also receive: Valproate 300 mg tds, Gabapentin 300 mg tds or another appropriate antiepileptic medication.
Valproate or Gabapentin should be prescribed for not less than a month, or until a normal EEG has been obtained, and other causes of convulsion have been ruled out.
If the patient is abusing alcohol as well as benzodiazepines, they should be included in an Alcohol Detoxification Programme, particularly if this is the primary addictive disease. The Benzodiazepine Detoxification Programme will be adapted to the patient’s clinical condition. This may mean that the patient will remain medicated with Benzodiazepines for a longer period than was established for the formal Benzodiazepine Detox Programme.
If the patient is using benzodiazepines to control stimulant excitement or to cope with opiates withdrawal, they should be included onto an Opiate or Stimulant Detoxification Programme, particularly if these are the primary addictive diseases.
The Benzodiazepine Detoxification Programme will be adapted to the patient’s clinical condition. This may mean that the patient will remain medicated with diazepam for a longer period than the one established for the formal Benzodiazepine Detox Programme.
Therapeutic programmes for benzodiazepines detoxification will last no less than 10 days.