Substance abuse withdrawal

Diazepam is used primarily in the treatment of mental anxiety. In addition, it acts as a muscle relaxant for a variety of medical conditions. It may also be used as a sedative-hypnotic and anticonvulsant (e.g., for status epilepticus and drug-induced seizures). Diazepam may also be used to alleviate some of the symptoms associated with the following cholinesterase poisoning, substance abuse withdrawal, antihistamine overdose. Black Widow spider envenomation, and chloroquine overdose. As an anesthetic, diazepam may be used alone or in combination with other drugs for conscious sedation. 

Hypertropic obstructive cardiomyopathy Hyperthyroidism Migraine prophylaxis Acute panic symptoms Substance abuse withdrawal... 

Several controlled studies appear to support the use of certain herbal preparations in rational detoxification treatment programs. Exhibit 3 displays findings of selected studies on natural products with apparent efficacy in treating syndromes of substance abuse, withdrawal or addiction. 

Medications will prevent all side effects of substance abuse withdrawal. 

Benzodiazepines and other anxiolytics. Although benzodiazepines are widely used in the treatment of acute alcohol withdrawal, most nonmedical personnel involved in the treatment of alcoholism are opposed to the use of medications that can induce any variety of dependence to treat the anxiety, depression, and sleep disturbances that can persist for months following withdrawal. Researchers have debated the pros and cons of the use of benzodiazepines for the management of anxiety or insomnia in alcoholic patients and other substance abuse patients during the postwithdrawal period (Ciraulo and Nace 2000 Posternak and Mueller 2001). 

A dramatically different pattern is found in surveys of drug abuse treatment facilities. Substance abuse treatment centers have reported that more than 20% of patients use benzodiazepines weekly or more frequently, with 30%— 90% of opioid abusers reporting illicit use (Iguchi et al. 1993 Stitzer et al 1981). Methadone clinics reported that high proportions ofurine samples are positive for benzodiazepines (Darke et al. 2003 Dinwiddle et al. 1996 Ross and Darke 2000 Seivewright 2001 Strain et al. 1991 Williams et al. 1996). The reasons for the high rates of benzodiazepine use in opioid addicts include self-medication of insomnia, anxiety, and withdrawal symptoms, as well as attempts to boost the euphoric effects of opioids. 

Harper MH, Winter PM, Johnson BH, et al Withdrawal convulsions in mice following nitrous oxide. Anesth Analg 59 19—21, 1980 Hasin D,Nunes E, MeydanJ Comorbidity of alcohol, drug, and psychiatric disorders epidemiology, in Dual Diagnosis and Psychiatric Treatment Substance Abuse and Comorbid Disorders, 2nd Edition. Edited by Kranzler HR, Tinsley JA. New York, Marcel Dekker, 2004, pp 1-34... 

The treatment goals for withdrawal from ethanol, cocaine/ amphetamines, and opioids include (1) a determination if pharmacologic treatment of withdrawal symptoms is necessary, (2) management of medical manifestations of withdrawal such as hypertension, seizures, arthralgias, and nausea, and (3) referral to the appropriate program for substance abuse treatment. 

A number of medications have been studied to alleviate symptoms of stimulant withdrawal and the intense craving that may accompany it, but inconsistent results across controlled trials preclude any recommendations for their routine use. Patients with stimulant use disorders should be referred to substance abuse treatment because of the high risk for continued use either during or immediately following stimulant withdrawal. 

Delirium is characterized by a disturbance of consciousness and a change in cognition that develops over a short period of time, usually hours or days. The course can fluctuate over the course of the day, usually worsening in the evening. Underlying medical problems such as urinary tract infections in the elderly, substance abuse, or withdrawal symptoms in adults may precipitate delirium.1... 

Mood disorders, hypochondriasis, personality disorders, alcohol/ substance abuse, alcohol/substance withdrawal, other anxiety disorders... 

Benzodiazepines are used commonly in SAD however, there are limited data supporting their use. Clonazepam has been effective for social anxiety, fear, and phobic avoidance, and it reduced social and work disability during acute treatment.58 Long-term treatment is not desirable for many SAD patients owing to the risk of withdrawal and difficulty with discontinuation, cognitive side effects, and lack of effect on depressive symptoms. Benzodiazepines may be useful for acute relief of physiologic symptoms of anxiety when used concomitantly with antidepressants or psychotherapy. Benzodiazepines are contraindicated in SAD patients with alcohol or substance abuse or history of such. 

Fig. 22.1 Mechanisms underlying substance abuse. Addictive behavior is seen as a cyclical process where anticipation of the pleasure resulting from use of the drug leads to failure of the psychological mechanisms that usually control consumption. Excess quantities of drug are taken and an unpleasant withdrawal state arises when drug levels fall. This leads to...

After the acute psychotic episode has resolved, the patient typically has residual features (e.g., anxiety, suspiciousness, lack of volition, lack of motivation, poor insight, impaired judgment, social withdrawal, difficulty in learning from experience, and poor self-care skills). Patients often have comorbid substance abuse and are nonadherent with medications. 

Anxiety disorders (e.g., generalized anxiety disorder, obsessive-compulsive disorder) Substance abuse (alcohol or sedative-hypnotic withdrawal)... 

Cannabis carries some potential for dependence and addiction. Compared to cocaine, heroin, alcohol, and nicotine, cannabis has lesser addictive potential and withdrawal effects, but some users do develop compulsive and maladaptive use patterns that require treatment (Taylor 1998). Individuals with underlying psychopathology or tendencies for substance abuse should be particularly leery of using cannabis in the interests of avoiding compulsive use patterns. 

In this chapter, we will focus primarily on treatments for the substance use disorders. However, because detoxification during a substance-induced withdrawal is often the first step in treating a substance use disorder, we will discuss withdrawal states to some extent. The substance use disorders include both substance abuse and the more serious substance dependence. Substance abuse consists of a pattern of misuse that causes recurring problems in at least one aspect of life. This can be a failure to fulfill responsibilities at home or work, reckless use of the substance such as drunken driving, repeated substance-related arrests, and ongoing substance use despite resulting problems in family relationships. See Table 6.1 for the diagnostic criteria for substance abuse. 

Exposure to toxicants can vary, producing what is known as acute or chronic poisoning. Poisoning can also be classified according to the intent of use. Poisoning can either be suicidal (non-accidental) or accidental in nature. Recreational poisoning, such as substance abuse, can be a source of harmful intoxication and, in some cases, can lead to addiction and withdrawal symptoms. Intentional harm is observed when there is criminal doping with sedative-hypnotic medicines, often associated with robberies. 

Within this Held, most of the research and results have been focused on the effects of drug therapy on the disorders induced by alcohol, and by the abuse of opiates. For a broader discussion of substance abuse see Chapter 18. In all instances of alcohol or drug abuse the first objective is to wean the patients from the addictive substance, treating or preventing the effects of withdrawal for those substances which cause physical dependence (alcohol, nicotine, opiates, caffeine, certain psychotropic agents such as benzodiazepines, possibly antidepressants). The second phase is the prevention of recurrence or relapse, which relies on a combination of social support, psychotherapy, and pharmacotherapy where available. In this respect, alcoholism is exemplary. 

Psychotic symptoms may also occur with the withdrawal of alcohol, sedatives, hypnotics, and anxiolytics The following symptoms may occur persecutory delusions, perceptual distortions, and vivid hallucinations in any modality, most classically visual and tactile hallucination of insects crawling under the skin (formication) Substance abuse history may be elicited from the history and confirmed by finding urinary metabolites Confirmation of schizophrenia can only be made if the psychotic symptoms persist for at least a month following drug withdrawal... 

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