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14 detoxification and management of withdrawal

Detoxification can be defined as the means by which the drug-dependent person may withdraw from the effects of that drug in a supervised way in order that withdrawal symptoms and the risks relating to withdrawal are minimised.

Should detoxification occur at home or in the hosptipal?

In many instances effective detoxification can be performed in the home supported by the local doctor and other health workers. This should be considered when:


Should detoxification be medicated?

That is, assisted by the use of controlled sedatives, or non-medicated in which no sedation is required.

Non-medicated detoxification

This process should be carried out in a safe environment, ideally in a quiet and comfortable home environment.

Medicated detoxification from alcohol

In the more severe cases medication is important and sedative treatment should be titrated against the severity of the patients withdrawal symptoms and signs. At no time should drug therapy be given to those patients who are still intoxicated.

There are two main approaches:

Tapering withdrawal regimen

Other aspects of management

Vitamin therapy

All patients treated for withdrawal from alcohol should receive thiamin to prevent the onset of Wernicke's Encephalopathy. An intravenous or intramuscular dose of 100 mg of thiamin immediately should be given and then orally 100 mg two to three times a day for two weeks.

Electrolyte and fluid balance

The fluid state of patients should be carefully assessed and a watchful eye kept for fluid depletion or fluid overload.


Withdrawal of benzodiazepines can be performed on an outpatient basis. This would need to occur over six weeks but in some cases this may be increased to 10-15 weeks.


The doctor's role in the community is firstly to prevent dependence by judicious and limited prescribing of sedatives and hypnotics for specific clinical situations on a short-term basis, and to manage the detoxification of those who have established dependence on these drugs.


The most common opiate in use today is heroin.


Because of the complexities of the pharmacology involved in polydrug use and abuse it is unwise to contemplate withdrawal except in an inpatient environment.


There is not a lot of evidence to support the idea that there is a cannabis withdrawal syndrome. This does not mean that it is easy for some people to stop using cannabis.

Cessation of use may be situationally determined to a large degree. The presence of particular cues may lead to cannabis use. Cues may be internal or external. External cues may include mixing with a cannabis using group, a joint being shared or cannabis smoke at a party. Feeling bored, despondent or unhappy are all examples of internal cues which may lead to cannabis use.


Management should follow the general principles of detoxification:


Nicotine is one of the most addictive substances known (see Chapter 5, Tobacco). Any person smoking 20 or more cigarettes per day will experience nicotine withdrawal. This physical withdrawal is one aspect of relapse in smoking cessation.


The recommendations of Richmond and Webster (1988) present a very useful approach to assisting patients to quit. There are a number of important principles:

Various approaches

The 'happy user'

These people should be informed about the risks to which they expose themselves and others. Provide written material to reinforce the information you have told them.

Those thinking about quitting

These people can be assisted by encouraging them to:

Staying stopped

These people can be assisted by:


Detoxification from psychostimulants is generally effective using non-pharmacological management techniques. While abstinence is the preferred treatment goal, there is no evidence to suggest that tapered withdrawal is any less effective in the cessation of psychostimulant use. All patients undertaking detoxification should be encouraged to abstain from the use of other mind-altering drugs, such as alcohol or marijuana, which may act as triggers or conditioned cues for the use of psychostimulant drugs or reduce the ability of the individual to cope with cravings experienced during withdrawal.

While most patients can undertake detoxification in an outpatient program, inpatient treatment may be more appropriate in the following circumstances:

Non-pharmacological treatments

There are a number of options available, all of which will not be appropriate for all patients.

Pharmacological interventions in psychostimulant use

Pharmacologic interventions are used to achieve and sustain abstinence through the reduction of withdrawal symptoms. While most cases do not require drug treatment, where necessary, pharmacological interventions should be tailored to the needs of the individual and used in addition to a comprehensive treatment program.

Note: The treatments outlined below have been extrapolated from cocaine management data and therefore it is not known how effective they will be in the management of amphetamine detoxification.

Desipramine is the drug of choice. When used in conjunction with bromocriptine or amantadine (both dopamine agonists), reduced craving and dysphoria are reported during cocaine withdrawal.

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