courtesy of DIVISION ON ADDICTIONS, Cambridge Health Alliance,
Early Signs (8-12 hrs): Diaphoresis, nausea, yawning, lacrimation, an affiliate of Harvard Medical School
tremor, rhinorrhea, irritability, dilated pupils, resp. rate, pulse>90 Severe Signs (12-48 hrs): Insomnia, elevated T,P,R,& BP, nausea, CAGE Test (adapted) to screen for Alcoholism/Drug Addiction:
vomiting, abdominal cramps, chills, diarrhea, muscle twitching, 1 + = high risk for addiction; full assessment recommended.
Have you ever:

Cut back or Changed your drinking or (drug use) pattern?
Course: (1) Heroin: onset in 8-12 hrs, lasting 5-10 d, untreated.
felt Annoyed if people criticized your or (drug use) drinking?
(2) Methadone: onset in 24-48 hrs., lasting 2-4 wks.
felt Guilty about drinking or (drug use)?
needed a drink Early in the day to steady yourself?
Methadone-maintained pt - confirm dose w/methadone clinic.
(Eye opener)
Analgesics: pt is tolerant to opioids - analgesic Rx required for painmanagement. Methadone maintenance pts. may require higher ALCOHOL WITHDRAWAL
than conventional doses or increased frequency to attain analgesia.
Early Sxs (6-12 hrs.): Tremor, anorexia, nausea/vomiting, insomnia, anxiety, Expect coping problems: Don’t dwell on dosage with pt.
irritability, diaphoresis, tachycardia, fever, mild hypertension, hallucino- Monitor pulse, respiration, pupil size.
Later Sxs. (7-96 hrs): Seizures, Delirium Tremens Timing: Earliest onset 6-8 hrs. after abstinence. Can be immediate or up 5 - 7 days. Some may present sxs. with a decrease in amount of use) Untreated street addict: @ signs of w/drawal. Rx 20 mg po.
Rx: 1) Benzos to eleviate sxs.: Acute Medical Settings: lorazepam (ativan) at Known heavy use: 30 mg po: Increase 5-10 mg q 2-4 hrs. to least 1 mg q 4-6 hrs IV; titrate up or down holding the interval steady stabilize. No more than 40 mg in 1st 24 hrs.
depending on patient status aiming for calm, but not oversedation .
Avoid doses >40 mg qd. unless enrolled in a licensed methadone Dosage requirements vary widely. Decrease by no more than 10-20% May use Clonidine 0.1mg. po tid with methadone or alone for Note: Lorazepam preferred in acute medical settings (greatest flexibility); Detox Setting: Chlordiazepoxide (Librium) 50-100 mg. po;titrate up and down as indicated If NPO: ½ daily dose IM, divided q 12 hrs & restart prior full po 2) Thiamine 100 mg IM or IV qd x 3d; Folate 1 mg po qd.
3) Haloperidol (Haldol) .5-2.0 mg po or IM for severe agitation or Course: Onset 30-60 m: peak levels 2-6 hrs: duration 24-36 hrs.
Side Effects: Reduce 5-10 mg prn lethargy: Taper: If 1-14 d s/p admission, 10-20% qd. Expect distress.
DTs: Marked hypertension, tachycardia, fever, hallucinosis, agitation, Discharge planning: initiate as quickly as possible.
confusion, combativeness, and seizures.
Timing: 24-72 hrs. after abstinenceRx: ICU monitoring, restraints, IV fluids, IV benzos, antipyretics if AVAILABLE RESOURCES:
needed. Diazepam 5-10 mg or lorazepam (if liver disease) 1-2 mg slowly IV q 15-20 min. until stabilized. Then q 2h prn.
Sx: Ataxia, nystagmus, ophthalmoplegia, confusion Outpatient Programs:
Prevention: Thiamine 100 mg IM or IV prior to any glucose Security guards present; Don’t show anger; Haloperidol 5 mg po or IM; Add lorazepam 1-2 mg if needed; restraints if violent.
Problem Gambling:
Sx: Generalized (focal gets a workup); often 2-6 closely spaced; status rare.
Timing: 7-48 hrs. after abstinence (late onset gets a workup).
DDX: R/O Trauma, metabolic causes (incl low Mg++), infection.
Rx: Benzos best. Protect from falls.
This resource is intended solely for the use of medical This resource is intended solely for the use of medical professionals and should not be used by the lay public. professionals and should not be used by the lay public.


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