Withdrawal symptoms

Disease Description (Causes and Symptoms)

Withdrawal phenomenon is a group of physical and psychological symptoms that occurs when a person stops or rapidly reduces the dose of a specific substance (e.g., alcohol, opioids, benzodiazepines, nicotine, central nervous system stimulants) or behavior (e.g., gambling, gaming, internet use, shopping) after prolonged or repeated use or engagement.
The main pathophysiological mechanism is the nervous system’s adaptation to the substance (receptor regulation and changes in neurotransmitter balance), resulting in an excessive response in the opposite direction when use is stopped.

Main Symptoms (Examples)

• Autonomic nervous system hyperactivity: sweating, tremor, tachycardia, hypertension, fever
• Central nervous system symptoms: anxiety, agitation, insomnia, headache, confusion, anxiety and panic, hallucinations and auditory hallucinations, seizures (especially with alcohol)
• Localized symptoms: diplopia, dizziness, gastrointestinal symptoms (nausea, vomiting, abdominal pain)
• Long-term and psychological symptoms: depression, intense cravings (urges), decreased concentration

The pattern of onset varies depending on the causative substance and the speed of discontinuation (e.g., nicotine within several days, alcohol within several hours to several days, benzodiazepines within several days to several weeks).

Treatment

Goal: Prevent life-threatening complications (seizures, delirium, cardiovascular instability), relieve symptoms, and prevent relapse and reuse

General Principles

• In severe cases (delirium, persistent hallucinations, risk of seizures), inpatient treatment (intensive care unit/examination room) is required
• Combine symptom-based treatment with cause-specific treatment
• Basic tests (blood electrolytes, liver function, blood glucose, CBC) and, when necessary, CT, electrocardiography, and other tests are performed

Summary of Treatment by Cause

• Alcohol
  • Warning: Risk of seizures and delirium tremens → Consider hospitalization
  • Medication: Use long-acting benzodiazepines (e.g., chlordiazepoxide, diazepam) to suppress symptoms and take advantage of cross-tolerance. For older adults and patients with liver disease, consider half-life and metabolism, using lorazepam or other appropriate medications.
  • Supportive treatment: Administer vitamin B1 (thiamine) (to prevent Wernicke encephalopathy), provide fluids and electrolyte correction, and supplement nutrition
  • Appropriate emergency treatment for acute delirium and seizures (anticonvulsants, anxiolytics, etc.)
  • Assessment tool: Adjust medication dosage using CIWA-Ar (assessment of symptom severity)
• Nicotine
  • Smoking cessation therapy: Nicotine replacement therapy (NRT: patches, gum, etc.) and medications (bupropion, varenicline)
  • Behavioral therapy: Cognitive behavioral therapy and smoking cessation counseling
  • Symptom management: Symptomatic treatment for sleep and anxiety symptoms
• Benzodiazepines and sedative-hypnotics
  • Gradual dose reduction (tapering) is recommended. Consider hospitalization and monitoring for users of high doses or long-term users, or when the dose is unknown
  • Standard method: Switch to a long-acting benzodiazepine and then gradually reduce the dose (e.g., diazepam)
  • Short-term symptomatic treatment for acute anxiety and insomnia, combined with definitive treatment for anxiety disorders to prevent relapse
• Opioids
  • Symptom relief and replacement therapy: Methadone or buprenorphine maintenance therapy (depending on the medical situation), with nonpharmacological support
  • Symptomatic treatment (for vomiting, diarrhea, pain, etc.)
• Other substances (glue, inhalants, stimulants, etc.)
  • Symptomatic treatment (sedatives, anxiolytics, antidepressants, etc.)
• Behavioral addictions (gambling, gaming, etc.)
  • Psychotherapy (cognitive behavioral therapy); medication treatment is determined according to symptoms and comorbid conditions (e.g., antidepressants for depression and anxiety)

Precautions, Risk of Complications, and Self-Care

• Alcohol withdrawal can be life-threatening, so be sure to visit a medical institution if severe symptoms are expected
• Abrupt discontinuation of benzodiazepines carries risks of seizures, severe anxiety, and relapse → Gradually reduce the dose
• Nicotine withdrawal commonly causes anxiety, sleep disturbances, and decreased concentration, but the risk to life is low; check for medication side effects when taking smoking cessation aids
• If symptoms worsen during self-discontinuation, consult a healthcare professional immediately
• Hydration and nutritional supplementation, regular sleep, stress management (relaxation and deep breathing), and participation in support groups are beneficial

Outpatient Visit Checklist (Including Example Questions)

Items and Records to Prepare

• A list of currently taken medications (including prescription and nonprescription medications, herbal medicines, and health functional foods), along with recent doses and duration of use
• Records of the amount, frequency, and time of last use of the substance causing the problem (alcohol, nicotine, medications, etc.)
• Previous withdrawal experiences (symptoms, severity, and whether hospitalization was required)
• Medical history: history of epilepsy (seizures), heart disease, liver or kidney disease, and mental illness (depression, anxiety, suicidal thoughts)
• Recent test results (liver function, electrolytes, CBC, etc.) or the possibility of scheduling tests
• Symptom diary (when symptoms occur, what symptoms occur, duration, and triggering factors)

Key Information to Submit to the Doctor During an Outpatient Visit

• Type, amount, and duration of substance use
• Time of last intake
• Current symptoms (including autonomic and psychiatric symptoms)

Example Questions (To Prepare in Advance)

• A paper or photograph listing recently taken medications
• A timeline of symptoms (when symptoms started and how they changed)

Examples of General Questions to Ask the Doctor

• Could this condition be life-threatening? Do I need inpatient treatment?
• What treatment (medication or nonmedication) is recommended for my withdrawal symptoms? What are the expected effects and side effects?
• What long-term treatment or counseling is needed to prevent relapse (reuse)?
• What should I be careful about in daily life (driving, work, etc.)?
• Are there any interactions with other medications I am taking or with my underlying conditions?

Examples of Condition-Specific Questions

• Alcohol-related withdrawal:
  • "If I have previously experienced seizures (or delirium) due to drinking, do I need to be hospitalized this time as well?"
• Benzodiazepine and sedative withdrawal:
  • "How can I safely reduce the medication I am currently taking (medication name and dose)? Can you provide an alternative medication or a tapering schedule?"

Additional Information

• If severe anxiety, hallucinations, persistent vomiting, fever, decreased consciousness, or seizures occur, an immediate visit to the emergency room is recommended
• Withdrawal management is safest under medical supervision, and combining medication with psychosocial treatment tailored to the individual’s condition is important for improving the prognosis.