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Withdrawal Syndromes

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Critical Care Toxicology

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Abstract

The use of mind-altering substances predates written history. As a consequence, so do the withdrawal syndromes associated with the abrupt cessation of these substances. The discussion of withdrawal requires defining the following terms: narcotic, tolerance, dependence, addiction, withdrawal, and cross-tolerance. Defining these words not only allows for better understanding but also enables the appropriate application of these terms. Narcotic literally means any drug that induces sleep, although it also has the socio-legal implication of an illegal substance. For the purpose of maintaining clarity, drugs should be referred to by their clinical class (i.e., opioids, sedative-hypnotics, and stimulants [e.g., cocaine and amphetamines]). Tolerance is the process by which increasing drug dosages are required to obtain a desired effect and can be represented graphically by a shift in the dose-response curve to the right. This effect is exemplified by heroin tolerance, in which a tolerant person’s routine dose would be lethal to a naïve user. Tolerance can be mediated via receptor modulation (opioids), induced metabolism (barbiturates), or both (ethanol). Dependence implies that cessation of the drug leads to withdrawal symptoms. Withdrawal can be physical (i.e., autonomic instability, nausea, vomiting, diarrhea, hyperactivity, or altered mentation), psychological (i.e., emotional symptoms and craving), or both. Withdrawal is a response to lowered drug concentrations resulting in a predictable constellation of symptoms (e.g., tremor, hypertension, nausea, vomiting, and diarrhea). These symptoms are reversible if the drug in question is reintroduced. Not all withdrawal symptoms are negative or unpleasant. Piloerection, yawning, and lacrimation are associated with opioid withdrawal, but most patients do not perceive these symptoms as negative compared with their drug craving, nausea, and vomiting. When continued use of a drug induces socially unacceptable behavior (theft) or results in unacceptable outcomes (a driving-while-intoxicated conviction), the user of the drug is considered addicted.

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Author information

Authors and Affiliations

  1. Medical Affairs, South Nassau Communities Hospital, Healthy Way, Oceanside, NY, USA

    Adhi N. Sharma

  2. Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Langone Medical Center, New York, NY, USA

    Robert S. Hoffman

  3. Emergency Medicine, Hofstra Northwell School of Medicine, Hempstead, NY, USA

    Adhi N. Sharma

Authors
  1. Adhi N. Sharma
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  2. Robert S. Hoffman
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Corresponding authors

Correspondence to Adhi N. Sharma or Robert S. Hoffman .

Editor information

Editors and Affiliations

  1. University of Colorado School of Medicine, Toxicology Associates, Denver, Colorado, USA

    Jeffrey Brent

  2. Office of New Drugs Drug Evaluation and Research, FDA, Silver Spring, Maryland, USA

    Keith Burkhart

  3. Clinical Toxicology, St Thomas' Hospital, London, United Kingdom

    Paul Dargan

  4. University of Colorado School of Medicine, Toxicology Associates, Denver, Colorado, USA

    Benjamin Hatten

  5. Med & Toxicological Intensive Care Unit, Lariboisière Hospital Paris-Diderot University, Paris, France

    Bruno Megarbane

  6. University of Colorado School of Medicine, Toxicology Associates, Denver, Colorado, USA

    Robert Palmer

Grading System for Levels of Evidence Supporting Recommendations in Critical Care Toxicology, 2nd Edition

Grading System for Levels of Evidence Supporting Recommendations in Critical Care Toxicology, 2nd Edition

  1. I

    Evidence obtained from at least one properly randomized controlled trial.

  2. II-1

    Evidence obtained from well-designed controlled trials without randomization.

  3. II-2

    Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

  4. II-3

    Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.

  5. III

    Opinions of respected authorities, based on clinical experience, descriptive studies and case reports, or reports of expert committees.

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Sharma, A.N., Hoffman, R.S. (2016). Withdrawal Syndromes. In: Brent, J., Burkhart, K., Dargan, P., Hatten, B., Megarbane, B., Palmer, R. (eds) Critical Care Toxicology. Springer, Cham. https://doi.org/10.1007/978-3-319-20790-2_97-1

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  • DOI: https://doi.org/10.1007/978-3-319-20790-2_97-1

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