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KAP KEYS Based on TIP 19
Detoxification From Alcohol and Other
Drugs
        CSATs
Knowledge Application Program
KAP Keys
For Clinicians
Based on TIP 19
Detoxification from Alcohol
and Other Drugs
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
www.samhsa.gov
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KAP KEYS Based on TIP 19
Detoxification From Alcohol and Other Drugs
These Kap Keys were developed to accompany the Treatment
Improvement Protocol (TIP) Series published by the Center for
Substance Abuse Treatment (CSAT), Substance Abuse and
Mental Health Services Administration. These KAP Keys are
based entirely on TIP 19 and are designed to meet the needs
of the busy clinician for concise, easily accessed "how-to" infor
mation.
For more information on the topics in these KAP Keys, readers
are referred to TIP 19.
Introduction
TIP 7, Screening and Assessment for Alcohol and Other Drug
 Abuse Among Adults in the Criminal Justice System (1994)
 BKD138
TIP 8, Intensive Outpatient Treatment for Alcohol and Other
 Drug Use (1994) BKD139
TIP 9, Assessment and Treatment of Patients With Coexisiting
 Mental Illness and Alcohol and Other Drug Abuse (1994)
 BKD134
TIP 22, LAAM in the Treatment of Opiate Addiction (1995)
 BKD170
TIP 24, A Guide to Substance Abuse Services for Primary Care
 Clinicians (1997) BKD234
TIP 28, Naltrexone and Alcoholism Treatment (1998) BKD268
TIP 31, Screening and Assessing Adolescents for Substance
 Use Disorders (1999) BKD306
TIP 32, Treatment of Adolescents With Substance Abuse
 Disorders (1999) BKD307
TIP 33, Treatment for Stimulant Use Disorders (1999)
BKD289
Other Treatment Improvement Protocols (TIPs)
that are relevant to these KAP Keys:
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Signs and Symptoms of the Acute
Phase of Alcohol Abstinence Syndrome
1
KAP KEYS Based on TIP 19
Detoxification From Alcohol and Other Drugs
 Restlessness, irritability, anxiety, agitation
 Anorexia, nausea, vomiting
 Tremor, elevated heart rate, increased blood pressure
 Insomnia, intense dreaming, nightmares 
 Impaired concentration, memory, and judgment
 Increased sensitivity to sounds, alteration in tactile sensations
 Delirium (disorientation to time, place, situation)
 Hallucinations (auditory, visual, or tactile)
 Delusions (usually paranoid)
 Grand mal seizures
 Elevated temperature
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Signs and Symptoms of
Opiate Abstinence
2
KAP KEYS Based on TIP 19
Detoxification From Alcohol and Other Drugs
Early Signs
 Anxiety
 Increased respiratory rate
 Sweating
 Lacrimation (tearing or crying)
 Yawning
 Rhinorrhea (runny nose)
 Piloerection (goosebumps)
 Restlessness 
 Anorexia
 Irritability
 Dilated pupils
Advanced Signs
 Insomnia
 Nausea and vomiting
 Diarrhea
 Weakness
 Abdominal cramps
 Tachycardia
 Hypertension
 Muscle spasms
 Muscle and bone pain
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Withdrawal From Benzodiazepines
and Other Sedative-Hypnotics
3
KAP KEYS Based on TIP 19
Detoxification From Alcohol and Other Drugs
For therapeutic use, barbiturates and the older sedative-hyp
notics have been largely replaced by the benzodiazepines. The
withdrawal syndromes from benzodiazepines and other seda
tive-hypnotics are similar, and the pharmacotherapy treatment
strategies apply to both. 
High-Dose Sedative-Hypnotic 
Withdrawal Syndrome
Signs and Symptoms of High-Dose Sedative-Hypnotic
Withdrawal Syndrome
 anxiety
 tremors
 nightmares
 insomnia
 anorexia
 nausea
 vomiting
 orthostatic hypotension
 seizures
 delirium
 hyperpyrexia
The syndrome is qualitatively similar for all sedative-hypnotics;
however, the time course of symptoms depends upon the par
ticular drug.
Low-Dose Benzodiazepine 
Withdrawal Syndrome
In the literature of addiction medicine, low-dose benzodi
azepine withdrawal may be referred to as "therapeutic-dose
withdrawal," or benzodiazepine-discontinuation syndrome. 
Signs and symptoms of patients treated with benzodiazepine
 anxiety
 insomnia
 muscle tension
Note: These symptoms may reappear when the patients stop
taking the benzodiazepine.
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Withdrawal From Stimulants (Cocaine, Crack
Cocaine, Amphetamines, and Methamphetamine)
4
The two most commonly abused stimulants are cocaine and
methamphetamine. Intermittent binge use of both agents is
common. The withdrawal symptoms of both agents is common.
The withdrawal symptoms that occur after a 2- to 3-day binge
are different than those that occur after chronic, high-dose
use. The withdrawal syndromes are similar. 
Following regular use, the withdrawal syndrome consists of
 dysphoria
 irritability
 difficulty sleeping
 intense dreaming
Often stimulant abusers experience signs and symptoms of the
abuse of multiple drugs. The symptoms subside over 2 to 4
days of drug abstinence.
KAP KEYS Based on TIP 19
Detoxification From Alcohol and Other Drugs
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Withdrawal From Other Drugs 5
Marijuana
There is no acute abstinence syndrome associated with with
drawal from marijuana. Some patients are irritable and have
difficulty sleeping for a few days when they discontinue chronic
use of marijuana. Persons withdrawing from marijuana, like
those withdrawing from cocaine, benefit from a supportive
environment during detoxification. 
Nicotine
Two issues regarding tobacco smoking merit consideration by
staff of substance abuse detoxification programs. The first is
the program management's desire to establish a smoke-free
treatment environment to comply with workplace ordinances
and to safeguard the health and comfort of patients from expo
sure to second-hand smoke. The second issue is the patient's
dependence on nicotine as a drug of abuse.
Drugs that do not produce a withdrawal syndrome
Chronic use of PCP can cause a toxic psychosis that takes days
or weeks to clear; however, PCP does not have a withdrawal
syndrome. LSD, DMT, and ecstasy do not produce physical
dependence.
Polydrug Use
Addicts rarely use just one substance. Typical combinations
and the preferred modes of treatment are as follows:
 Alcohol and stimulant: Treat alcohol abuse.
 Alcohol and benzodiazepine: Treat with phenobarbital.
 Cocaine and benzodiazepine: Treat benzodiazepine withdrawal.
 Cocaine and opiate: Treat opiate dependence.
 Cocaine and amphetamine: No detoxification protocol is known.
Opiate-Barbiturate Dependence
Symptoms of withdrawal from opiates and barbiturates have
some common features, making it difficult to assess the
patient's clinical condition when both drugs are withdrawn at
the same time. Many clinicians prefer to gradually withdraw the
sedative-hypnotic first, while administering methadone to pre
vent opiate withdrawal. When the patient is barbiturate-free,
the methadone is withdrawn at a level of 5 mg per day. If the
sedative-hypnotic was a benzodiazepine (diazepam or chlor
diazepoxide), some clinicians prefer to begin with a partial
reduction of the sedative-hypnotic. While the patient is still
receiving a partial dosage of the sedative, methadone is with
drawn. Finally, the sedative-hypnotic is withdrawn. 
KAP KEYS Based on TIP 19
Detoxification From Alcohol and Other Drugs
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Ordering Information
       TIP 19
Detoxification from Alcohol 
and Other Drugs
Easy Ways to Obtain Free Copies 
of All TIP Products
1.  Call SAMHSAs National Clearinghouse for Alcohol and
Drug Information (NCADI) at 800-729-6686, 
TDD (hearing impaired) 800-487-4889.
2.  Visit CSATs Website at www.csat.samhsa.gov
Do not reproduce or distribute this publication for a fee with
out specific, written authorization from the Office of
Communications, Substance Abuse and Mental Health
Services Administration, U.S. Department of Health and
Human Services.
DHHS Publication No. (SMA) 01-3574
Printed 2001