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Symptoms can last for more than 4 weeks and typically resolve within a day of restoring the medication.
Antidepressants, including SSRIs, can cross the placenta and have the potential to affect the fetus and newborns, presenting a dilemma whether pregnant women should take antidepressants at all, and if they do, whether tapering them near the end of pregnancy could have a protective effect for the newborn.
Postnatal adaptation syndrome (PNAS) (originally called “neonatal behavioral syndrome”, “poor neonatal adaptation syndrome”, or "neonatal withdrawal syndrome") was first noticed in 1973 in newborns of mothers taking antidepressants; symptoms in the infant include irritability, rapid breathing, hypothermia, and blood sugar problems. The symptoms usually develop from birth to days after delivery and usually resolve within days or weeks of delivery.
According to the British National Formulary, it is better to withdraw too slowly rather than too quickly from benzodiazepines. The rate of dosage reduction is best carried out so as to minimize the symptoms' intensity and severity. Anecdotally, a slow rate of reduction may reduce the risk of developing a severe protracted syndrome.
Long half-life benzodiazepines like diazepam or chlordiazepoxide are preferred to minimize rebound effects and are available in low potency dose forms. Some people may not fully stabilize between dose reductions, even when the rate of reduction is slowed. Such people sometimes simply need to persist as they may not feel better until they have been fully withdrawn from them for a period of time.
The condition gradually improves over a period of time which can range from six months to several years in more severe cases.
Flumazenil was found to be more effective than placebo in reducing feelings of hostility and aggression in patients who had been free of benzodiazepines for 4–266 weeks. This may suggest a role for flumazenil in treating protracted benzodiazepine withdrawal symptoms.
Acamprosate has been found to be effective in alleviating some of the post acute withdrawal symptoms of alcohol withdrawal. Carbamazepine or trazodone may also be effective in the treatment of post acute withdrawal syndrome in regards to alcohol use. Cognitive behavioral therapy can also help the post acute withdrawal syndrome especially when cravings are a prominent feature.
For a diagnosis of benzodiazepine dependence to be made, the ICD-10 requires that at least 3 of the below criteria are met and that they have been present for at least a month, or, if less than a month, that they appeared repeatedly during a 12-month period.
- Behavioral, cognitive, and physiological phenomena that are associated with the repeated use and that typically include a strong desire to take the drug.
- Difficulty controlling use
- Continued use despite harmful consequences
- Preference given to drug use rather than to other activities and obligations
- Increased tolerance to effects of the drug and sometimes a physical withdrawal state.
These diagnostic criteria are good for research purposes, but, in everyday clinical practice, they should be interpreted according to clinical judgement. In clinical practice, benzodiazepine dependence should be suspected in those having used benzodiazepines for longer than a month, in particular, if they are from a high-risk group. The main factors associated with an increased incidence of benzodiazepine dependence include:
- Dose
- Duration
- Concomitant use of antidepressants
Benzodiazepine dependence should be suspected also in individuals having substance use disorders including alcohol, and should be suspected in individuals obtaining their own supplies of benzodiazepines. Benzodiazepine dependence is almost certain in individuals who are members of a tranquilizer self-help group.
Research has found that about 40 percent of people with a diagnosis of benzodiazepine dependence are not aware that they are dependent on benzodiazepines, whereas about 11 percent of people judged not to be dependent believe that they are.
When assessing a person for benzodiazepine dependence, asking specific questions rather than questions based on concepts is recommended by experts as the best approach of getting a more accurate diagnosis. For example, asking persons if they "think about the medication at times of the day other than when they take the drug" would provide a more meaningful answer than asking "do you think you are psychologically dependent?". The Benzodiazepine Dependence Self Report Questionnaire is one questionnaire used to assess and diagnose benzodiazepine dependence.
In severe cases, the withdrawal reaction or protracted withdrawal may exacerbate or resemble serious psychiatric and medical conditions, such as mania, schizophrenia, agitated depression, panic disorder, generalised anxiety disorder, and complex partial seizures and, especially at high doses, seizure disorders. Failure to recognize discontinuation symptoms can lead to false evidence for the need to take benzodiazepines, which in turn leads to withdrawal failure and reinstatement of benzodiazepines, often to higher doses. Pre-existing disorder or other causes typically do not improve, whereas symptoms of protracted withdrawal gradually improve over the ensuing months. For this reason at least six months should have elapsed after benzodiazepines cessation before re-evaluating the symptoms and updating a diagnosis.
Symptoms may lack a psychological cause and can fluctuate in intensity with periods of good and bad days until eventual recovery.
Many hospitals use the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol in order to assess the level of withdrawal present and therefore the amount of medication needed. When overuse of alcohol is suspected but drinking history is unclear, testing for elevated values of carbohydrate-deficient transferrin or gammaglutamyl transferase can help make the diagnosis of alcohol overuse and dependence more clear. The CIWA has also been shortened (now called the CIWA-Ar), while retaining its validity and reliability, to help assess patients more efficiently due to the life-threatening nature of alcohol withdrawal.
Other conditions that may present similarly include benzodiazepine withdrawal syndrome (a condition also mainly caused by GABA receptor adaptation).
After long-term use of dopamine agonists, a withdrawal syndrome may occur during dose reduction or discontinuation with the following possible side effects: anxiety, panic attacks, dysphoria, depression, agitation, irritability, suicidal ideation, fatigue, orthostatic hypotension, nausea, vomiting, diaphoresis, generalized pain, and drug cravings. For some individuals, these withdrawal symptoms are short-lived and make a full recovery, for others a protracted withdrawal syndrome may occur with withdrawal symptoms persisting for months or years.
ADT tachyphylaxis specifically occurs in depressed patients using SSRIs and MAOIs. Currently, SSRIs are the preferred treatment for depression among clinicians, as MAOIs require the patient to avoid certain foods and other medications due to the potential for interactions capable of inducing dangerous side effects. Provided is a list of medications known to be subject to Poop-out.
Sending a letter to patients warning of the adverse effects of long-term use of benzodiazepines and recommending dosage reduction has been found to be successful and a cost-effective strategy in reducing benzodiazepine consumption in general practice. Within a year of the letter's going out, there was found to be a 17% fall in the number of benzodiazepines being prescribed, with 5% of patients having totally discontinued benzodiazepines. A study in the Netherlands reported a higher success rate by sending a letter to patients who are benzodiazepine-dependent. The results of the Dutch study reported 11.3% of patients discontinuing benzodiazepines completely within a year.
Benzodiazepines are effective for the management of symptoms as well as the prevention of seizures. Certain vitamins are also an important part of the management of alcohol withdrawal syndrome. In those with severe symptoms inpatient care is often required. In those with lesser symptoms treatment at home may be possible with daily visits with a health care provider.
Diagnosis is mainly based on symptoms. In a person with delirium tremens it is important to rule out other associated problems such as electrolyte abnormalities, pancreatitis, and alcoholic hepatitis.
In the United States, cocaine use results in about 5,000–6,000 deaths annually.
Confirming the presence of withdrawal in the neonate can be assessed from obtained a detailed medical history from the mother. In some cases neonatal drug withdrawal can be mistaken for central nervous system disorders. Typically the tests that are ordered are CBC, hair analysis, drug screen (of mother and infant), thyroid levels, electrolytes, and blood glucose. Chest x-rays can confirm or infirm the presence of heart defects. The diagnosis for babies with signs of withdrawal may be confirmed with drug tests of the baby's urine or stool. The mother's urine will also be tested.
There are at least two different scoring systems for neonatal withdrawal syndrome. One difficulty with both is that were developed to assess opiate withdrawal. The Finnegan scoring system is more widely used.
Following a declination or total extinction in response to a previously therapeutic dose of an antidepressant, the issue is clinically addressed as stemming from tolerance development. Several strategies are available, such as exploring drug options from a different drug class used to treat depression. The patient can also choose to switch to another SSRI (or MAOI, if applicable) while maintaining proportionate dose. If tolerance develops in a drug from the same class, the clinician may recommend a regular cycle consisting of all effective treatments within the SSRI or MAOI classes, in order to minimize transitional side effects while maximizing therapeutic efficacy.
Other options include increasing dose of the same medication, or supplementation with another antidepressant. Dual reuptake inhibitors, also known as tricyclic antidepressants have been shown to have lower rates of tachyphylaxis.
The DSM-5 guidelines for diagnosis of opioid use disorder require that the individual has significant impairment or distress related to opioid uses. In order to make the diagnosed two or more of eleven criteria must be present in a given year:
1. More opioids are taken than intended
2. The individual is unable to decrease the amount of opioids used
3. Large amounts of time are spent trying to obtain opioids, use opioids, or recover from taking them
4. The individual has cravings for opioids
5. Difficulty fulfilling professional duties at work or school
6. Continued use of opioids leading to social and interpersonal consequences
7. Decreased social or recreational activities
8. Using opioids despite it being physically dangerous settings
9. Continued use despite opioids worsening physical or psychological health (i.e. depression, constipation)
10. Tolerance
11. Withdrawal
Nicotine withdrawal is a group of symptoms that occur in the first few weeks upon the abrupt discontinuation or decrease in intake of nicotine. Symptoms include cravings for nicotine, anger/irritability, anxiety, depression, impatience, trouble sleeping, restlessness, hunger or weight gain, and difficulty concentrating. A quit smoking program may improve one’s chance for success in quitting nicotine. Nicotine withdrawal is recognized in both the American Psychiatric Association Diagnostic and Statistical Manual and the WHO International Classification of Diseases.
A withdrawal syndrome, also called a discontinuation syndrome is a set of symptoms occurring in discontinuation or dosage reduction of some types of medications. The risk of a discontinuation syndrome occurring increases with dosage and length of use.
- Alcohol withdrawal syndrome, symptoms seen when an individual reduces or stops alcohol consumption after periods of excessive alcohol intake
- Antidepressant discontinuation syndrome, a syndrome that can occur following the interruption, dose reduction, or discontinuation of SSRI or SNRI medications
- Antipsychotic withdrawal syndrome or dopamine supersensitivity psychosis, symptoms seen when an individual reduces or suddenly stops antipsychotics
- Benzodiazepine withdrawal syndrome, symptoms that appear when a long term user stops taking benzodiazepines or reduces the dosage
- Cannabis withdrawal, a form of withdrawal associated with the substance cannabis
- Drug withdrawal
- Neonatal withdrawal, a withdrawal syndrome of infants, caused by administration of drugs or the prenatal exposure to a substance
- Nicotine withdrawal, the effects felt by a person who is nicotine dependent and suddenly stops or significantly reduces his or her nicotine intake
- Opioid withdrawal, symptoms seen cessation or rapid reduction of intake of opioid class drugs
Most daily cigarette smokers have at least one of the above withdrawal symptoms when they try to stop. Withdrawal can occur in less-frequent users, however heavier users and those with a past or current psychiatric disorder tend to have more severe withdrawal. Genetics also influence the severity of withdrawal.
Kim Janda has been working for years on a vaccination that would treat cocaine use disorders by limiting its rewarding effects.
Transcranial magnetic stimulation (TMS) is being studied as a treatment for cocaine addiction. So far studies have been undertaken by Medical University of South Carolina (MUSC), National Institute on Drug Abuse (NIDA), and Mexican National Institute of Psychiatry.
Physical dependence is a physical condition caused by chronic use of a tolerance forming drug, in which abrupt or gradual drug withdrawal causes unpleasant physical symptoms. Physical dependence can develop from low-dose therapeutic use of certain medications such as benzodiazepines, opioids, antiepileptics and antidepressants, as well as the recreational misuse of drugs such as alcohol, opioids, and benzodiazepines. The higher the dose used, the greater the duration of use, and the earlier age use began are predictive of worsened physical dependence and thus more severe withdrawal syndromes. Acute withdrawal syndromes can last days, weeks or months. Protracted withdrawal syndrome, also known as post-acute-withdrawal syndrome or "PAWS", is a low-grade continuation of some of the symptoms of acute withdrawal, typically in a remitting-relapsing pattern, often resulting in relapse and prolonged disability of a degree to preclude the possibility of lawful employment. Protracted withdrawal syndrome can last for months, years, or depending on individual factors, indefinitely. Protracted withdrawal syndrome is noted to be most often caused by benzodiazepines. To dispel the popular misassociation with addiction, physical dependence to medications is sometimes compared to dependence on insulin by persons with diabetes.
Treatment for physical dependence depends upon the drug being withdrawn and often includes administration of another drug, especially for substances that can be dangerous when abruptly discontinued or when previous attempts have failed. Physical dependence is usually managed by a slow dose reduction over a period of weeks, months or sometimes longer depending on the drug, dose and the individual. A physical dependence on alcohol is often managed with a cross tolerant drug, such as long acting benzodiazepines to manage the alcohol withdrawal symptoms.
A specific blood test to verify toxicity is not typically available. An electrocardiogram (ECG) should be included in the assessment when there is concern of an overdose.
Delirium tremens due to alcohol withdrawal can be treated with benzodiazepines. High doses may be necessary to prevent death. Amounts given are based on the symptoms. Typically the person is kept sedated with benzodiazepines, such as diazepam, lorazepam, chlordiazepoxide, or oxazepam.
In some cases antipsychotics, such as haloperidol may also be used. Older drugs such as paraldehyde and clomethiazole were formerly the traditional treatment but have now largely been superseded by the benzodiazepines.
Acamprosate is occasionally used in addition to other treatments, and is then carried on into long term use to reduce the risk of relapse. If status epilepticus occurs it is treated in the usual way. It can also be helpful to control environmental stimuli, by providing a well-lit but relaxing environment for minimizing distress and visual hallucinations.
Alcoholic beverages can also be prescribed as a treatment for delirium tremens, but this practice is not universally supported.
High doses of thiamine often by the intravenous route is also recommended.
The CAGE questionnaire, the name of which is an acronym of its four questions, is a widely used method of screening for alcoholism.
- Online version of the CAGE questionnaire