eMedicine Specialties > Emergency Medicine > Toxicology

Withdrawal Syndromes: Follow-up

Author: Nathanael J McKeown, DO, Assistant Professor, Oregon Health and Science University; Medical Toxicologist, Oregon Poison Center; Attending Physician, Emergency Medicine, Portland Veteran Affairs Medical Center, Oregon Health and Science University
Coauthor(s): Patrick L West, MD, Clinical Instructor, Medical Toxicology Fellow, Department of Emergency Medicine, Oregon Health and Sciences University; Staff Physician, Department of Emergency Medicine, Portland Veterans Affairs Medical Center
Contributor Information and Disclosures

Updated: Oct 27, 2009

Follow-up

Further Inpatient Care

  • Symptoms of alcohol withdrawal are often mild or absent in the ED and may manifest only after the patient is admitted to the hospital for other reasons (eg, multiple trauma).
  • Patients already manifesting advanced stages of withdrawal in the ED (eg, seizure, DT) require admission.
  • Patients with DT require admission to the ICU because their hemodynamic picture can change rapidly and because appreciable mortality is associated with DT.
  • Patients may require admission for associated conditions (eg, GI bleed, pancreatitis). In these cases, use of sedatives may be more complex if the patient is hypotensive from blood or third-space fluid losses. 
  • In uncomplicated cases of withdrawal, the sedative regimen can be continued until the patient is calm and vital signs are normalized. At that point, decreasing the dose or increasing the dosing interval over 3-4 days can taper the administration of sedatives.

Further Outpatient Care

  • Referral of patients with chronic alcoholism or intravenous drug use to ongoing treatment programs is worthwhile, even if a minority of these patients maintain sobriety for long periods. Numerous agencies offer inpatient and outpatient treatment programs; the most successful groups appear to be Alcoholics Anonymous and Narcotics Anonymous.
  • The following options are available for people addicted to heroin:
    • Methadone is a long-acting opiate that prevents occurrence of somatic withdrawal symptoms but does not produce sedation or euphoria equivalent to heroin.
    • Buprenorphine is a μ-opioid agonist/antagonist and is prescribed in a manner that is similar to methadone.
    • Both treatment programs require patient compliance and motivation. This appears to be the limiting factor in their success rates.
  • Patients withdrawing from chronic stimulant abuse are best cared for under medical supervision; refer these patients to appropriate institutions or agencies.

Transfer

  • Because of the risk of seizures, patients in active withdrawal from alcohol are unstable for transfer until they have received adequate sedation.
  • Decisions about when to transfer largely depend on underlying associated conditions that may have stabilization requirements of their own (eg, pancreatitis, acute MI).
  • Patients in opiate withdrawal are generally stable for transfer unless underlying conditions render them unstable.

Complications

  • Numerous complications are associated with long-term alcohol and intravenous drug abuse. Complications are more common and more serious in alcohol withdrawal than in opiate or stimulant withdrawal.
  • Alcohol withdrawal
    • Metabolic complications
    • GI complications
      • Pancreatitis
      • Gastrointestinal bleeding (eg, peptic ulcer, esophageal varices, gastritis)
      • Hepatic cirrhosis
    • Infectious complications
      • Pneumonia
      • Meningitis
      • Cellulitis
    • Neurologic complications

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to report patients who have seizures and who are likely to experience repeated loss of consciousness in the future is a pitfall. State laws commonly require reporting of these patients to the state vehicular agencies.
  • Failure to recognize and treat Wernicke-Korsakoff syndrome is a pitfall.
  • Failure to recognize and adequately treat patients in alcohol withdrawal is a pitfall.
  • Failure to recognize and treat associated medical conditions (eg, gastrointestinal bleeding in an alcoholic, sepsis in someone who is opioid dependent) that may have precipitated withdrawal by making a patient unable or unwilling to continue further substance abuse.
  • Failure to recognize a patient's use of ethanol alternatives (eg, methanol, ethylene glycol, cough syrup containing significant amounts of acetaminophen) that may cause significant morbidity or mortality if untreated.
  • Attributing an altered mental status, hyperthermia, or seizures to opioid withdrawal is a pitfall. Patients in opioid withdrawal, though dysphoric, should have a clear sensorium without signs of delirium. An appropriate workup should be initiated if an altered mental status is present. Hyperthermia is not part of the clinical picture of opioid withdrawal, and its presence should prompt an investigation for the cause of the fever. Seizures are also not a part of the clinical picture of opioid withdrawal, except in neonates, in whom seizures may occur. Again, an appropriate workup is indicated if seizures occur in this setting.
 
Acknowledgments




More on Withdrawal Syndromes

Overview: Withdrawal Syndromes
Differential Diagnoses & Workup: Withdrawal Syndromes
Treatment & Medication: Withdrawal Syndromes
Follow-up: Withdrawal Syndromes
Multimedia: Withdrawal Syndromes
References
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References

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Further Reading

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Keywords

withdrawal syndrome, drug withdrawal, alcohol withdrawal, alcoholism, alcohol tolerance, alcohol-withdrawal syndrome, alcohol withdrawal syndrome, AWS, drug abuse, drug tolerance, intravenous drug abuse, IV drug abuse, IVDA, opiate abuse, opiate withdrawal

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Contributor Information and Disclosures

Author

Nathanael J McKeown, DO, Assistant Professor, Oregon Health and Science University; Medical Toxicologist, Oregon Poison Center; Attending Physician, Emergency Medicine, Portland Veteran Affairs Medical Center, Oregon Health and Science University
Nathanael J McKeown, DO is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Patrick L West, MD, Clinical Instructor, Medical Toxicology Fellow, Department of Emergency Medicine, Oregon Health and Sciences University; Staff Physician, Department of Emergency Medicine, Portland Veterans Affairs Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Theodore J Gaeta, DO, MPH, FACEP, Clinical Associate Professor, Department of Emergency Medicine, Joan and Sanford Weill Medical College at Cornell University; Vice Chairman and Program Director of Emergency Medicine Residency Program, Department of Emergency Medicine, New York Methodist Hospital; Academic Chair, Adjunct Professor, Department of Emergency Medicine, St George's University School of Medicine
Theodore J Gaeta, DO, MPH, FACEP is a member of the following medical societies: Alliance for Clinical Education, American College of Emergency Physicians, Clerkship Directors in Emergency Medicine, Council of Emergency Medicine Residency Directors, New York Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

Michael J Burns, MD, Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center
Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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