Prepared by J. Mabbutt & C.

Maynard
NaMO
September 2008
8.2: Managing
Benzodiazepine,
Cannabis, Nicotine
and other Withdrawal
1. During the session nurses & midwives will learn how to identify, assess
& manage a patient in benzodiazepine, cannabis, nicotine & other drug
withdrawal
2. At the end the session, nurses will have a basic understanding
& knowledge to safely & effectively identify, monitor & manage
benzodiazepine, cannabis, nicotine & other drug withdrawal
8.2: Managing other drug withdrawal:
Objectives
This presentation gives general guidelines for managing withdrawal.
Refer to Section 9 for specific details of withdrawal symptoms and
management for the most commonly used substances
For further information, refer to the New South Wales Drug and
Alcohol Withdrawal Clinical Practice Guidelines (2007)
http://www.health.nsw.gov.au/policies/gl/2008/GL2008_011.html

8.2: Managing drug withdrawal
Present the post natal case study for benzodiazepine and other drug
withdrawal from Guidelines CD Rom Section 01
Discuss each section in small groups or as a large group and feedback
8:2 Indications and guidelines
Benzodiazepine Withdrawal
Option Case Study
Onset of withdrawal depends on the half-life of the particular benzodiazepine
used by the person
Withdrawal from short-acting benzodiazepines generally occurs earlier & is
more severe
Withdrawal symptoms do not necessarily decrease steadily from a peak,
but can follow a fluctuating course with good & bad periods
Eventually the good periods will last longer & become more frequent
8:2 Indications and guidelines
Benzodiazepine withdrawal Onset &
duration of benzodiazepine withdrawal
* Based on manufacturers product information.
Elimination half-life: time for the plasma drug concentration to decrease by 50%.
Equivalent dose: approximate dose equivalent to diazepam 5 mg.
Generic name Trade name Time to peak
concentration
Elimination half life Equivalent
dose
Diazepam Antenex
Ducene
Valium
Valpam
30-90 min Biphasic: rapid phase
half-life, 3 hours;
elimination half-life,
20-48 hours
5 mg
Alprazolam Alprax
Xanax
Kalma
1 hour 6-25 hours 0.5-1.0 mg
Bromazepam Lexotan 0.5-4 hours 20 hours 3-6 mg
Clobazam Frisium 1-4 hours 17-49 hours 10 mg
Clonazepam Paxam
Rivotril
2-3 hours 22-54 hours 0.5 mg
Flunitrazepam Hypnodorm 1-2 hours 20-30 hours 1-2 mg
Table 9.9: Absorption rates, half-life, & equivalent daily doses
of common benzodiazepines**
* Based on manufacturers product information. Elimination half-life: time for the plasma drug concentration to decrease by 50%.
Equivalent dose: approximate dose equivalent to diazepam 5 mg.
Generic name Trade name Time to peak
concentration
Elimination half life Equivalent
dose
Lorazepam Ativan 2 hours 1216 hours 1 mg
Nitrazepam Alodorm
Mogadon
2 hours 1648 hours 2.55 mg
Oxazepam Alepam
Murelax
Serepax
23 hours 415 hours 1530 mg
Temazepam Euhypnos
Normison
Temaze
Temtabs
3060 min after
tablets, 2 hours
after capsules
515 hours 1020 mg
Triazolam Halcion 13 hours Biphasic: rapid phase
half-life, 2.53.5 hours;
elimination half-life, 6
9 hours
0.25 mg
Zolpidem Stilnox 0.53 hours 2.5 hours Not known
Table 9.9: Absorption rates, half-life, & equivalent daily doses
of common benzodiazepines**
Subjective symptoms with few observable signs of withdrawal are a feature,
particularly of low dose withdrawal
Individuals may report feeling extremely mentally distressed (as though they
are going mad), although they may not have any obvious signs of physical
discomfort
This may result in the person not receiving the care that would be appropriate
during this time
8:2 Indications and guidelines
Benzodiazepine withdrawal Signs &
symptoms of benzodiazepines withdrawal
NSW Health (2007)
Common symptoms Less common symptoms Uncommon symptoms
Anxiety Nightmares, agoraphobia Delusions
Insomnia Feelings of unreality Paranoia
Restlessness Depersonalisation Hallucinations
Agitation Panic attacks Seizures
Irritability Nausea, dry retching,
decreased
Persistent tinnitus

Poor concentration Increased sensory perception, Confusion

Poor memory Increased temperature, ataxia
Depression Gastrointestinal unrest
Muscle tension, aches
and twitching
Menstrual changes

Table 9.10: Symptoms of benzodiazepine withdrawal
The major complications of withdrawal are:
Progression to severe withdrawal
Delirium with risk of injury (to self or others)
Risk of dehydration or electrolyte imbalance
Potential for seizures
Presence of concurrent illness, which masks or mimics withdrawal
Orthostatic hypotension
8:2 Indications and guidelines
Benzodiazepine withdrawal
Major complications of withdrawal
Withdrawal from short-acting benzodiazepines (e.g. oxazepam, temazepam,
alprazolam, & lorazepam) typically produces a faster and more severe onset
of symptoms
Withdrawal from long-acting benzodiazepines (e.g. diazepam, nitrazepam)
may be more difficult to undergo and complete
8:2 Indications and guidelines
Benzodiazepine withdrawal
Course of withdrawal
Adapted from Frank L, Pead J . New concepts in drug withdrawal: a resource handbook
1995 State of Victoria. Reproduced with permission.
Figure 9.3: Withdrawal from short and long-acting benzodiazepines
Undertake nursing observations to identify & manage withdrawal symptoms
& prevent the progression to severe withdrawal
In particular, offer:
Reassurance regarding distorted sensory stimuli
Heat & massage for muscle aches
Symptomatic management to reduce the severity of symptoms
8:2 Indications and guidelines
Managing benzodiazepine withdrawal
There is no validated tool for recording benzodiazepine withdrawal symptoms
in an inpatient setting
The symptoms previously listed in Table 9.10 need to be monitored
8:2 Indications and guidelines
Managing benzodiazepine withdrawal
Monitoring
Initial stabilisation of dose (preferably with a long-acting benzodiazepine)
a gradual dose reduction preferably as an outpatient
In hospital: patients taking high doses, or polydrug users, should be stabilised
on a long-acting benzodiazepine (preferably, diazepam), at a dose about 40%
of their regular intake prior to admission (or 80 mg/day, whichever is lower)
Reduction & withdrawal should follow once their other medical condition has
been dealt with
From the New South Wales Drug and Alcohol
Withdrawal Clinical Practice Guidelines (2007)
8:2 Indications and guidelines
Managing benzodiazepine withdrawal
Pharmacological treatment (1)
Referral to Drug & Alcohol outpatient services or supportive GPs needs to be
arranged well in advance of discharge to organise a continued outpatient reduction
regime
Please contact a specialist Drug & Alcohol medical officer/nurse practitioner/
senior clinical nurse for advice & support
If patients stabilise on a dose in the range 4080 mg of diazepam daily, withdrawal
should be at the rate of at least 5 mg per week until the dose reaches 40 mg, then
2.5 mg/week
A maximal rate of withdrawal would be to reduce the dose by 10 mg at weekly
intervals until 40 mg, then by 5mg at weekly intervals this will take 12 weeks as
an outpatient
New South Wales Drug and Alcohol Withdrawal
Clinical Practice Guidelines (2007)
8:2 Indications and guidelines
Managing benzodiazepine withdrawal
Pharmacological treatment (2)
Most symptoms commence on day 1, peaking at day 2-3, returning to baseline
after a week or two
Can be an onset of aggression (day 4) often peaking after 2 weeks of abstinence
and anger (day 6) also being particularly significant
There is a National Cannabis Prevention and Information Centre (NCPIC) with
has a range of resources and information regarding cannabis withdrawal, for
the workforce, users & families, http://ncpic.org.au/ 1800 30 40 50
8:2 Indications and guidelines
Managing cannabis withdrawal Onset
& duration of cannabis withdrawal (1)
Special considerations include:
Patients with a comorbid mental health condition as there may be
unmasking of the mental illness during withdrawal
Appropriate assessment & management is required
Patients who use cannabis for chronic pain may require assessment
for adequate pain management & referral to specialist pain services
Patients with a history of aggression may require closer monitoring
and a higher dose of benzodiazepine
8:2 Indications and guidelines
Managing cannabis withdrawal Onset
& duration of cannabis withdrawal (2)
Common symptoms Less common symptoms/equivocal
symptoms
Anger or aggression Chills
Decreased appetite or weight loss Depressed mood
Irritability Stomach pain
Nervousness/anxiety Shakiness
Restlessness Sweating
Sleep difficulties, including
strange dreams
Table 9.13 Cannabis withdrawal symptoms (Budney et al., 2004:1975)

Cannabis withdrawal can be monitored by using a withdrawal assessment scale
such as the Cannabis Withdrawal Assessment Scale (see Appendix 5)
Not all patients will require medication for withdrawal
The following table lists medications for symptomatic relief of cannabis withdrawal
8:2 Indications and guidelines
Managing cannabis withdrawal
Monitoring
(NSW Health 2007)
Symptom Medication
Sleep problems benzodiazepines, zolpidem zopiclone,
promethazine
Restlessness, anxiety, diazepam
irritability
Stomach pains buscopan, atrobel
Physical pain, headaches paracetamol, non-steroidal anti-
inflammatory agents
Nausea promethazine, metoclopramide
Table 9.14 Medications for relief of cannabis withdrawal
Given the wide interpersonal variability, dosages and prescribing schedules
will most effectively be decided upon only after a thorough exploration of the
individual patients symptom profile and circumstances.
Outpatient regimens might be:
7 days of diazepam 5 mg four times daily, zopiclone 7.5 mg at night, NSAIDs
/ buscopan as needed, or
7 days of zolpidem 7.5 mg at night
From the New South Wales Drug and Alcohol
Withdrawal Clinical Practice Guidelines (2007)
8:2 Indications and guidelines
Managing cannabis withdrawal
Pharmacological Treatment
Onset of withdrawal is usually within a few hours of the last cigarette
& withdrawal symptoms peak at 24-72 hours
Withdrawal symptoms vary, but can include the following:
Irritability
Cravings
Increased nervousness and tension
Sleep disturbance
Stomach upsets
8:2 Indications and Guidelines
Nicotine withdrawal signs & symptoms (1)
Bowel disturbance
Loss of concentration
Muscle spasm
Changes in taste
Headaches
Cough
Increased appetite
8:2 Indications and Guidelines
Nicotine withdrawal signs & symptoms (2)
There is generally no indication for admission into a Drug & Alcohol inpatient
facility but may be admitted into hospital & experience withdrawal from nicotine
consequently
Patients should be informed of the NSW Health Smoke Free Workplace
Policy (1999) & offered support to stop
NRT should be used when not contraindicated
Refer to NSW Health Guidelines GL2005_036: Nicotine Dependent Inpatients
http://www.health.nsw.gov.au/policies/GL/2005/pdf/GL2005_036.pdf
8:2 Pharmacological treatment
Treatment: Indication for in patient
nicotine withdrawal
A holistic approach to smoking cessation is important and
a pharmacotherapy should be seen as one part of this approach
Pharmacotherapy options are:
Nicotine Replacement Therapy (NRT)
Bupropion
Other options such as clonidine, & nortriptyline
8:2 Nicotine withdrawal
Pharmacological treatment
Pharmacotherapiesc
Type Dose and Duration Side Effects Contraindications
Less than
10 cigs
per day
10-20 cigs
per day
More than
20 cigs
per day
Patches None Nicobate
14 mg
Nicorette
10 mg
Nicobate
21 mg
Nicorette
15 mg
Transient skin
irritation, itching,
dreams, sleep
disturbance,
indigestion,
diarrhoea
Relative:
Ischaemic
heart disease
Absolute:
Recent MI
Serious
arrhythmias
Unstable
angina
Pregnancy
Gum None 2 mg, 8-12
per day
4 mg, 8-12
per day
Jaw discomfort,
nausea, indigestion,
hiccups, excess
saliva, sore throat
Inhaler None Nicorette
6-12
cartridges
per day
Not recommended Mouth and throat
irritation, cough,
nausea and
indigestion
Table 9.16 Pharmacotherapy of nicotine replacement therapies
Type Dose and Duration Side Effects Contraindications
Less
than
10
cigs
per
day
1020
cigs per
day
More than
20 cigs per
day
Bupropion 150 mg for 3 days, then 150 mg
b.d. for 7 weeks
Headaches, dry
mouth, impaired
sleep, seizures,
nausea, anxiety,
constipation and
dizziness
1. seizure disorders or
significant risk of seizure
2. bulimia
3. anorexia nervosa
4. bipolar disorders
From New South Wales Drug and Alcohol Withdrawal Clinical Practice Guidelines (2007)
Table 9.17 Pharmacotherapy of bupropion (Zyban)
These drugs are not usually associated with dependence arising
from long term, high-level use
There is no evidence of a withdrawal syndrome from hallucinogens
even after abrupt cessation or substantial reduction in their use
8:2 Hallucinogen
Dependence and withdrawal
Withdrawal syndrome can occur in some cases, but it is generally mild
Symptoms include:
Anxiety
Depression
Headache
Nausea
Dizziness
8:2 Solvents
Withdrawal (1)
Drowsiness
Chills
Abdominal pains
Muscular cramps
Sometimes, confusion & hallucinations can occur after chronic solvent use
8:2 Solvents
Withdrawal (2)
Abrupt withdrawal can occur after cessation of long-term daily use
(White et al 2002)
There is no validated tool for recording ketamine withdrawal symptoms
Symptoms of withdrawal are:
Fear
Tremors; facial twitches
Craving
Animal studies show seizures, irritability & weight loss during ketamine withdrawal
8:2 Indications and guidelines
Ketamine withdrawal
GHB use should be suspected in particular groups such as clubbers & body
builders who present with signs compatible with alcohol intoxication but record
a breath alcohol level of zero
E.g. nystagmus, ataxia, nausea, vomiting, bradycardia & hypotension)
Withdrawal presents as rapid onset, prolonged alcohol withdrawal picture, with
less autonomic arousal and risk of seizures, but marked confusion, delirium &
hallucinations, waxing & waning over a two week period
8:2 Indications and guidelines
Gamma Hydroxybutyrate (GHB)
Withdrawal (1)
Management may require the use of both short & long acting benzodiazepines
Additional sedation with propofol may be required in some patients
There is no validated tool for recording GHB withdrawal symptoms

8:2 Indications and guidelines
GHB withdrawal (2)
Generally, physical dependence does not appear to occur with steroid use
8:2 Steroids
Withdrawal