Based on TIP 19

Detoxification from Alcohol

and Other Drugs

KAP Keys

For Clinicians

CSAT’s

Knowledge Application Program

KAP KEYS 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
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" information.

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:
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

Signs and Symptoms of the Acute

Phase of Alcohol Abstinence Syndrome

1
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

Signs and Symptoms of

Opiate Abstinence

2
KAP KEYS Based on TIP 19

Detoxification From Alcohol and Other Drugs

Withdrawal From Benzodiazepines

and Other Sedative-Hypnotics

3

For therapeutic use, barbiturates and the older sedative-hypnotics have been largely replaced by the benzodiazepines. The

withdrawal syndromes from benzodiazepines and other sedative-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 particular drug.

Low-Dose Benzodiazepine 

Withdrawal Syndrome

In the literature of addiction medicine, low-dose benzodiazepine 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.
KAP KEYS Based on TIP 19

Detoxification From Alcohol and Other Drugs

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

Withdrawal From Other Drugs 5

Marijuana

There is no acute abstinence syndrome associated with withdrawal 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 exposure 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 prevent 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 chlordiazepoxide), 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 withdrawn. Finally, the sedative-hypnotic is withdrawn. 
Easy Ways to Obtain Free Copies 

of All TIP Products

1. Call SAMHSA’s National Clearinghouse for Alcohol and

Drug Information (NCADI) at 800-729-6686, 

TDD (hearing impaired) 800-487-4889.

2. Visit CSAT’s Website at www.csat.samhsa.gov

Do not reproduce or distribute this publication for a fee without specific, written authorization from the Office of

Communications, Substance Abuse and Mental Health

Services Administration, U.S. Department of Health and

Human Services.

Ordering Information

TIP 19

Detoxification from Alcohol 

and Other Drugs

DHHS Publication No. (SMA) 01-3574

Printed 2001