FFinalistSouthampton · 2027
Psychiatry
AKT · Psychiatry/Substance & behavioural

Alcohol withdrawal and opioid withdrawal

Overview

Physiological withdrawal on stopping/reducing in dependence. Alcohol withdrawal: 6–12h tremor/anxiety/sweating, 12–24h seizures, 24–48h+ delirium tremens. Opioid withdrawal: distressing but rarely life-threatening.

Recognise

  • Alcohol: tremor, sweating, tachycardia, anxiety, nausea (6–12h); seizures (~36h); delirium tremens — confusion, hallucinations, autonomic storm (48–72h)
  • Wernicke’s: ataxia, ophthalmoplegia, confusion (thiamine deficiency)
  • Opioid: dilated pupils, lacrimation, rhinorrhoea, yawning, myalgia, GI upset, piloerection

Red flags

  • Delirium tremens and withdrawal seizures are medical emergencies; suspected Wernicke’s → immediate parenteral thiamine

Differentials & how to tell them apart

Delirium of other cause (sepsis, hypoglycaemia)exclude — coexists with DTs
Hepatic encephalopathyliver failure, asterixis, ↑ammonia
Wernicke’s encephalopathythe classic triad — give thiamine BEFORE glucose

Investigations

CIWA-Ar to guide alcohol detox; bloods (FBC, LFTs, U&E, glucose, magnesium), consider alcohol level. Opioid: clinical (COWS), urine drug screen.

Management

  1. 1Alcohol: benzodiazepine detox (chlordiazepoxide, reducing regimen, often CIWA-guided) + parenteral thiamine. Admit if DTs, seizures, or high risk.Gate: Give parenteral thiamine BEFORE any IV glucose to avoid precipitating Wernicke’s
  2. 2Alcohol relapse prevention: acamprosate or naltrexone (+ psychosocial); disulfiram if preferred.
  3. 3Opioid: substitution with methadone or buprenorphine; lofexidine for withdrawal symptoms; naloxone take-home for overdose.
Chlordiazepoxide (or diazepam) — reducing benzodiazepine regimen for alcohol detox
Pabrinex (IV thiamine) — prophylaxis/treatment of Wernicke’s — give before carbohydrate
Methadone / buprenorphine — opioid substitution; lofexidine for symptomatic withdrawal
Naltrexone / acamprosate — relapse prevention after alcohol detox

Key points

Pregnancy: opioid substitution maintained; do not detox abruptly. Offer naloxone to opioid users and carers.

Monitor & prognosis

CIWA/COWS scores, electrolytes (esp. magnesium), neurological status, hydration.

Detox is the start — relapse prevention and psychosocial support determine outcome.

Source: NICE CG100/115; CKS Alcohol-problem-drinking (2025)