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Institutes of Health.

Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence
in Closed Settings. Geneva: World Health Organization; 2009.

CLINICAL GUIDELINES FOR WITHDRAWAL MANAGEMENT AND TREATMENT OF DRUG DEPENDENCE
IN CLOSED SETTINGS.

Show details
Geneva: World Health Organization; 2009.
* Contents

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< PrevNext >

4WITHDRAWAL MANAGEMENT

Go to:

4.1. INTRODUCTION

Withdrawal management (WM) refers to the medical and psychological care of
patients who are experiencing withdrawal symptoms as a result of ceasing or
reducing use of their drug of dependence.5

People who are not dependent on drugs will not experience withdrawal and hence
do not need WM. Refer to the patient's assessment to determine if he or she is
dependent and requires WM.

Patients who are opioid dependent and consent to commence methadone maintenance
treatment do not require WM; they can be commenced on methadone immediately (see
opioid withdrawal protocol for more information).

It is very common for people who complete withdrawal management to relapse to
drug use. It is unrealistic to think that withdrawal management will lead to
sustained abstinence. Rather, withdrawal management is an important first step
before a patient commences psychosocial treatment.

Providing withdrawal management in a way that reduces the discomfort of patients
and shows empathy for patients can help to build trust between patients and
treatment staff of closed settings.

Go to:

4.2. STANDARD CARE FOR WITHDRAWAL MANAGEMENT

Patients in withdrawal should be accommodated away from patients who have
already completed withdrawal. Healthcare workers should be available 24 hours a
day. Workers should include:

* A doctor who sees patients on admission and is on call to attend to the
patient in case of complications;
* Nurses, who are responsible for monitoring patients in withdrawal, dispensing
medications as directed by the doctor and providing the patient with
information about withdrawal.

The WM area should be quiet and calm. Patients should be allowed to sleep or
rest in bed if they wish, or to do moderate activities such as walking. Offer
patients opportunities to engage in meditation or other calming practices.

Patients in withdrawal should not be forced to do physical exercise. There is no
evidence that physical exercise is helpful for WM. Physical exercise may prolong
withdrawal and make withdrawal symptoms worse.

Patients in withdrawal may be feeling anxious or scared. Offer accurate,
realistic information about drugs and withdrawal symptoms to help alleviate
anxiety and fears.

Do not try to engage the patient in counselling or other psychological therapy
at this stage. A person in withdrawal may be vulnerable and confused; this is
not an appropriate time to commence counselling.

During withdrawal some patients may become disruptive and difficult to manage.
There may be many reasons for this sort of behaviour. The patient may be scared
of being in the closed setting, or may not understand why they are in the closed
setting. The patient may be disoriented and confused about where they are. In
the first instance, use behaviour management strategies to address difficult
behaviour (Table 2).

TABLE 2

Strategies for managing difficult behaviour.

Withdrawal symptoms vary according to the drug of dependence and severity of
dependence, but often include nausea, vomiting, diarrhoea, anxiety and insomnia.
Table 3 provides guidance on medications for alleviating common withdrawal
symptoms.

TABLE 3

Symptomatic medications in withdrawal management.

Go to:

4.3. WITHDRAWAL MANAGEMENT FOR OPIOID DEPENDENCE

Opioids are drugs such as heroin, opium, morphine, codeine and methadone. Opioid
withdrawal can be very uncomfortable and difficult for the patient. It can feel
like a very bad flu. However, opioid withdrawal is not usually life-threatening.

There are some patients who should NOT complete opioid withdrawal:

* Pregnant women: It is recommended that pregnant women who are opioid
dependent do not undergo opioid withdrawal as this can cause miscarriage or
premature delivery. The recommended treatment approach for pregnant, opioid
dependent women is methadone maintenance treatment.
* Patients commencing methadone maintenance treatment do not need to undergo
withdrawal before commencing treatment.

OPIOID WITHDRAWAL SYNDROME

Short-acting opioids (e.g. heroin): Onset of opioid withdrawal symptoms 8-24
hours after last use; duration 4-10 days.

Long-acting opioids (e.g. methadone): Onset of opioid withdrawal symptoms 12-48
hours after last use; duration 10-20 days.

Symptoms include:

* Nausea and vomiting
* Anxiety
* Insomnia
* Hot and cold flushes
* Perspiration
* Muscle cramps
* Watery discharge from eyes and nose
* Diarrhoea

OBSERVATION AND MONITORING

Patients should be monitored regularly (3-4 times daily) for symptoms and
complications. The Short Opioid Withdrawal Scale (SOWS, p.37) is a useful tool
for monitoring withdrawal. It should be administered 1-2 times daily. Use the
SOWS score to select an appropriate management strategy.

SHORT OPIOID WITHDRAWAL SCALE7

View in own window

SymptomNot presentMildModerateSevereFeeling sick0123Stomach cramps0123Muscle
spasms or twitching0123Feeling cold0123Heart pounding0123Muscular
tension0123Aches and pains0123Yawning0123Runny/watery eyes0123Difficulty
sleeping0123

Gossop M. The development of a short opiate withdrawal scale. Addictive
Behaviors. 1990;15:487–490. [PubMed: 2248123]

Add scores for total score:

Compare total score to table below to guide withdrawal management

View in own window

ScoreSuggested withdrawal management0-10Mild withdrawal; symptomatic medication
only10-20Moderate withdrawal; symptomatic or opioid medication20-30Severe
withdrawal; opioid medication

MANAGEMENT OF MILD OPIOID WITHDRAWAL

Patients should drink at least 2-3 litres of water per day during withdrawal to
replace fluids lost through perspiration and diarrhoea. Also provide vitamin B
and vitamin C supplements.

Symptomatic treatment (see Table 3) and supportive care are usually sufficient
for management of mild opioid withdrawal.

MANAGEMENT OF MODERATE TO SEVERE OPIOID WITHDRAWAL

As for management of mild withdrawal, but with the addition of clonidine or
opioid medications such as buprenorphine, methadone or codeine phosphate:

OPIOID WITHDRAWAL MANAGEMENT USING CLONIDINE

Clonidine is an alpha-2 adrenergic agonist. It can provide relief to many of the
physical symptoms of opioid withdrawal including sweating, diarrhoea, vomiting,
abdominal cramps, chills, anxiety, insomnia, and tremor. It can also cause
drowsiness, dizziness and low blood pressure.

Clonidine should be used in conjunction with symptomatic treatment as required.
It should not be given at the same time as opioid substitution.

Measure the patient's blood pressure and heart rate before administering
clonidine (Figure 2). Dose according to Table 4. Continue to monitor blood
pressure and cease clonidine if blood pressure drops below 90/50mmHg.

FIGURE 2

Procedure for administering clonidine for moderate/severe opioid withdrawal.

TABLE 4

Clonidine dosing for moderate/severe opioid withdrawal.

OPIOID WITHDRAWAL MANAGEMENT USING BUPRENORPHINE

Buprenorphine is the best opioid medication for management of moderate to severe
opioid withdrawal. It alleviates withdrawal symptoms and reduces cravings.

Because of its pharmacological action (partial opiate agonist), buprenorphine
should only be given after the patient begins to experience withdrawal symptoms
(i.e. at least eight hours after last taking heroin).

Buprenorphine should be used with caution in patients with:

* Respiratory deficiency
* Urethral obstruction
* Diabetes

The dose of buprenorphine given must be reviewed on daily basis and adjusted
based upon how well the symptoms are controlled and the presence of side
effects. The greater the amount of opioid used by the patient, the larger the
dose of buprenorphine required to control symptoms. A suggested dosing protocol
is shown in Table 5. Symptoms that are not satisfactorily reduced by
buprenorphine can be managed with symptomatic treatment as required (see Table
3).

TABLE 5

Buprenorphine for opioid withdrawal management.

OPIOID WITHDRAWAL MANAGEMENT USING METHADONE

Methadone alleviates opioid withdrawal symptoms and reduces cravings. Methadone
is useful for detoxification from longer acting opioids such as morphine or
methadone itself.

Methadone should be used with caution if the patient has:

* Respiratory deficiency
* Acute alcohol dependence
* Head injury
* Treatment with monoamine oxidase inhibitors (MAOIs)
* Ulcerating colitis or Crohn's disease
* Severe hepatic impairment

The dose must be reviewed on daily basis and adjusted based upon how well the
symptoms are controlled and the presence of side effects. The greater the amount
of opioid used by the patient the greater the dose of methadone required to
control withdrawal symptoms. A suggested dosing protocol is presented in Table
6. If symptoms are not sufficiently controlled either reduce the dose of
methadone more slowly, or provide symptomatic treatment (see Table 3).

TABLE 6

Methadone for opioid withdrawal management.

To avoid the risk of overdose in the first days of treatment methadone can be
given in divided doses, for example, give 30mg in two doses of 15mg morning and
evening.

OPIOID WITHDRAWAL MANAGEMENT USING CODEINE PHOSPHATE

Codeine phosphate alleviates opioid withdrawal symptoms and reduces cravings.
Codeine has no effect for 2–10% of people.

Codeine phosphate should be used with caution if the patient has:

* Respiratory deficiency
* Severe hepatic impairment

The dose must be reviewed on daily basis and adjusted based upon how well the
symptoms are controlled and the presence of side effects. The greater the amount
of opioid used by the patient the greater the dose of codeine phosphate required
to control withdrawal symptoms. A suggesting dosing protocol is shown in Table
7. Symptoms that are not satisfactorily reduced by codeine phosphate can be
managed with symptomatic treatment as required (see Table 3).

TABLE 7

Codeine phosphate for opioid withdrawal management.

FOLLOW-UP CARE

Acute opioid withdrawal is followed by a protracted withdrawal phase that lasts
for up to six months and is characterised by a general feeling of reduced
well-being and strong cravings for opioids. This craving often leads to relapse
to opioid use. To reduce the risk of relapse, patients should be engaged in
psychosocial interventions such as described later in these guidelines. Patients
who repeatedly relapse following withdrawal management are likely to benefit
from methadone maintenance treatment or other opioid substitution treatment.

All opioid dependent patients who have withdrawn from opioids should be advised
that they are at increased risk of overdose due to reduced opioid tolerance.
Should they use opioids, they must use a smaller amount than usual to reduce the
risk of overdose.

Go to:

4.4. WITHDRAWAL MANAGEMENT FOR BENZODIAZEPINE DEPENDENCE

Benzodiazepines are central nervous system depressants. They are used to treat
anxiety and sleeping disorders. When used appropriately they are very effective
in treating these disorders. However, when used for an extended period of time
(e.g. several weeks), dependence can develop.

BENZODIAZEPINE WITHDRAWAL SYNDROME

Benzodiazepines can have short or long durations of action. This affects the
onset and course of withdrawal.

Short-acting benzodiazepines include oxazepam, alprazolam and temazepam.
Withdrawal typically begins 1-2 days after the last dose, and continues for 2-4
weeks or longer.

Long-acting benzodiazepines include diazepam and nitrazepam. Withdrawal
typically begins 2-7 days after the last dose, and continues for 2-8 weeks or
longer

Symptoms include:

* Anxiety
* Insomnia
* Restlessness
* Agitation and irritability
* Poor concentration and memory
* Muscle tension and aches

These symptoms tend to be subjective, with few observable signs.

OBSERVATION AND MONITORING

Patients in benzodiazepine withdrawal should be monitored regularly for symptoms
and complications.

The severity of benzodiazepine withdrawal symptoms can fluctuate markedly and
withdrawal scales are not recommended for monitoring withdrawal. Rather, the
healthcare worker should regularly (every 3-4 hours) speak with the patient and
ask about physical and psychological symptoms. Provide reassurance and
explanation of symptoms as necessary.

MANAGEMENT OF BENZODIAZEPINE WITHDRAWAL

The safest way to manage benzodiazepine withdrawal is to give benzodiazepines in
gradually decreasing amounts. This helps to relieve benzodiazepine withdrawal
symptoms and prevent the development of seizures.

The first step in benzodiazepine withdrawal management is to stabilise the
patient on an appropriate dose of diazepam. Calculate how much diazepam is
equivalent to the dose of benzodiazepine that the patient currently uses, to a
maximum of 40mg of diazepam (Table 8).

TABLE 8

Calculating diazepam equivalent doses.

This dose of diazepam (up to a maximum of 40mg) is then given to the patient
daily in three divided doses. Even if the patient's equivalent diazepam dose
exceeds 40mg, do not give greater than 40mg diazepam daily during this
stabilisation phase.

Allow the patient to stabilise on this dose of diazepam for 4-7 days. Then, for
patients taking less than the equivalent of 40mg of diazepam, follow the
low-dose benzodiazepine reducing schedule (Table 9). For patients taking the
equivalent of 40mg or more of diazepam, follow the high-dose benzodiazepine
reducing schedule (Table 10).

TABLE 9

Low-dose benzodiazepine reducing schedule.

TABLE 10

High-dose benzodiazepine reducing schedule.

The length of time between each dose reduction should be based on the presence
and severity of withdrawal symptoms. The longer the interval between reductions,
the more comfortable and safer the withdrawal. Generally, there should be at
least one week between dose reductions.

Generally, benzodiazepine withdrawal symptoms fluctuate; the intensity of the
symptoms does not decrease in a steady fashion as is the case with most other
drug withdrawal syndromes. It is not recommended to increase the dose when
symptoms worsen; instead, persist with the current dose until symptoms abate,
then continue with the dose reduction schedule.

Symptomatic treatment can be used in cases where residual withdrawal symptoms
persist (Table 3).

FOLLOW-UP CARE

Withdrawal management alone is unlikely to lead to sustained abstinence from
benzodiazepines. The patient should commence psychosocial treatment as described
in these guidelines.

Patients may have been taking benzodiazepines for an anxiety or other
psychological disorder; following withdrawal from benzodiazepines, the patient
is likely to experience a recurrence of these psychological symptoms. Patients
should be offered psychological care to address these symptoms.

Go to:

4.5. WITHDRAWAL MANAGEMENT FOR STIMULANT DEPENDENCE

Stimulants are drugs such as methamphetamine, amphetamine and cocaine. Although
these drugs vary in their effects, they have similar withdrawal syndromes.

STIMULANT WITHDRAWAL SYNDROME

Symptoms begin within 24 hours of last use of stimulants and last for 3-5 days.

Symptoms include:

* Agitation and irritability
* Depression
* Increased sleeping and appetite
* Muscle aches

People who use large amounts of stimulants, particularly methamphetamine, can
develop psychotic symptoms such as paranoia, disordered thoughts and
hallucinations. The patient may be distressed and agitated. They may be a risk
of harming themselves or others. These symptoms can be managed using
anti-psychotic medications and will usually resolve within a week of ceasing
stimulant use.

OBSERVATION AND MONITORING

Patients withdrawing from stimulants should be monitored regularly. Because the
mainstay of treatment for stimulant withdrawal is symptomatic medication and
supportive care, no withdrawal scale has been included.

During withdrawal, the patient's mental state should be monitored to detect
complications such as psychosis, depression and anxiety. Patients who exhibit
severe psychiatric symptoms should be referred to a hospital for appropriate
assessment and treatment.

MANAGEMENT OF STIMULANT WITHDRAWAL

Patients should drink at least 2-3 litres of water per day during stimulant
withdrawal. Multivitamin supplements containing B group vitamins and vitamin C
are recommended. Symptomatic medications should be offered as required for
aches, anxiety and other symptoms.

MANAGEMENT OF SEVERE AGITATION

A minority of patients withdrawing from stimulants may become significantly
distressed or agitated, presenting a danger to themselves or others.

In the first instance, attempt behavioural management strategies as shown in
Table 2 (page 33). If this does not adequately calm the patient, it may be
necessary to sedate him or her using diazepam. Provide 10-20ng of diazepam every
30 minutes until the patient is adequately sedated. No more than 120mg of
diazepam should be given in a 24-hour period. The patient should be observed
during sedation and no more diazepam given if signs of respiratory depression
are observed.

If agitation persists and the patient cannot be adequately sedated with oral
diazepam, transfer the patient to a hospital setting for psychiatric care.

FOLLOW-UP CARE

Acute stimulant withdrawal is followed by a protracted withdrawal phase of 1-2
months duration, characterised by lethargy, anxiety, unstable emotions, erratic
sleep patterns and strong cravings for stimulant drugs. These symptoms may
complicate the patient's involvement in treatment and should be taken into
account when planning treatment.

The preferred treatment for stimulant dependence is psychological therapy that
focuses on providing patients with skills to reduce the risk of relapse (see
Part 5: Psychosocial approaches to drug dependence treatment).

Go to:

4.6. WITHDRAWAL MANAGEMENT FOR ALCOHOL DEPENDENCE

Alcohol withdrawal can be very difficult for the patient. In rare cases, alcohol
withdrawal can be life-threatening and require emergency medical intervention.
Hence, it is extremely important to assess patients for alcohol dependence and
monitor alcohol dependent patients carefully.

ALCOHOL WITHDRAWAL SYNDROME

Alcohol withdrawal symptoms appear within 6-24 hours after stopping alcohol, are
most severe after 36 – 72 hours and last for 2 – 10 days.

Symptoms include:

* Anxiety
* Excess perspiration
* Tremors, particularly in hands
* Dehydration
* Increased heart rate and blood pressure
* Insomnia
* Nausea and vomiting
* Diarrhoea

Severe withdrawal may involve complications:

* Seizures
* Hallucinations
* Delirium
* Extreme fluctuations in body temperature and blood pressure
* Extreme agitation

OBSERVATION AND MONITORING

Patients should be monitored 3-4 times daily for symptoms and complications. The
Alcohol Withdrawal Scale (AWS, p.49) should be administered every four hours for
at least three days, or longer if withdrawal symptoms persist. A patient's score
on the AWS should be used to select an appropriate management plan from below.

ALCOHOL WITHDRAWAL SCALE8

View in own window

DateTimePERSPIRATIONNo abnormal sweating0Moist skin1Localised beads of sweat
e.g. on face and chest2Whole body wet from sweat3Profuse maximum sweating –
clothes, sheets are wet4TREMORNo tremor0Slight tremor upper extremities1Constant
light tremor upper extremities2Constant marked tremor upper
extremities3ANXIETYNo apprehension or anxiety0Slight apprehension1Apprehension
or understandable fear2Anxiety occasionally accentuated to state of
panic3Constant panic-like anxiety4AGITATIONRests normally no sign of
agitation0Slight restlessness, cannot sit or lie still, awake when others
sleep1Moves constantly, looks tense, wants to get out of bed but obeys requests
to stay into bed2Constantly restless, gets out of bed for no obvious reason,
returns to bed if taken3Maximally restless, aggressive, ignores requests to stay
in bed4TEMPERATURE37.0°C or less037.1 – 37.5°C137.6 – 38.0°C238.1 – 38.5°C3above
38.5°C4HALLUCINATIONSNo evidence of hallucinations0Distortion of real objects,
aware these are not real if this is pointed out1Appearance of totally new
objects or perceptions, aware that these are not real if this is pointed
out2Believes hallucinations are real but still orientated in place and
person3Believes himself to be in a totally non-existent environment, preoccupied
and cannot be diverted or reassured4ORIENTATIONFully orientated in time place
and person0Orientated in person but not sure where he is or what time it
is1Orientated in person but not time and place2Doubtful personal orientation
disoriented in time and place; there maybe short bursts of lucidity3Disoriented
in time, place and person, no meaningful contact can be obtained4Total score

Nowak H, editor. Nursing education and nursing management of alcohol and other
drugs. Sydney: CEIDA; 1989. .

Compare score to table below for suggested management

View in own window

AWS scoreSuggested withdrawal management1-4Mild withdrawal: Symptomatic
medications5-14Moderate withdrawal: Follow ‘management of moderate alcohol
withdrawal’ protocol15+Severe withdrawal: Follow ‘management of severe alcohol
withdrawal’ protocol

MANAGEMENT OF MILD ALCOHOL WITHDRAWAL (AWS SCORE 1-4)

Patients should drink 2-4 litres of water per day during withdrawal to replace
fluids lost through perspiration and diarrhoea. Multivitamin supplements and
particularly vitamin B1 (thiamine) supplements (at least 100mg daily during
withdrawal) should also be provided to help prevent cognitive impairments9 that
can develop in alcohol dependent patients.

Provide symptomatic treatment (see Table 3) and supportive care as required.

MANAGEMENT OF MODERATE ALCOHOL WITHDRAWAL (AWS SCORE 5-14)

As for management of mild alcohol withdrawal, with diazepam as in Table 11.

TABLE 11

Diazepam for management of moderate alcohol withdrawal.

If the protocol in Table 11 does not adequately control alcohol withdrawal
symptoms, provide additional diazepam (up to 120mg in 24 hours). Monitor the
patient carefully for excessive sedation. Once symptoms are controlled, follow
the protocol as above.

MANAGEMENT OF SEVERE ALCOHOL WITHDRAWAL (AWS SCORE 15+)

As for management of mild alcohol withdrawal, but patients in severe alcohol
withdrawal also require diazepam sedation. This may involve very large amounts
of diazepam, many times greater than would be prescribed for patients in
moderate alcohol withdrawal.

Give 20mg diazepam by mouth every 1-2 hours until symptoms are controlled and
AWS score is less than 5. Monitor the patient regularly during this time for
excessive sedation.

In rare cases, alcohol dependent patients may experience severe complications
such as seizures, hallucinations, dangerous fluctuations in body temperature and
blood pressure, extreme agitation and extreme dehydration. These symptoms can be
life-threatening. As above, provide 20mg diazepam every 1-2 hours until symptoms
are controlled. Be aware that very large doses of diazepam may be needed for
this. In cases of severe dehydration, provide intravenous fluids with potassium
and magnesium salts.

FOLLOW-UP CARE

Withdrawal management rarely leads to sustained abstinence from alcohol. After
withdrawal is completed, the patient should be engaged in psychosocial
interventions such as described in Section 5.

Patients with cognitive impairments as a result of alcohol dependence should be
provided with ongoing vitamin B1 (thiamine) supplements.

Go to:

4.7. WITHDRAWAL MANAGEMENT FOR INHALANT DEPENDENCE

Inhalant dependence and withdrawal is poorly understood. Some people who use
inhalants regularly develop dependence, while others do not. Among heavy users,
only some will experience withdrawal symptoms.

INHALANT WITHDRAWAL SYNDROME

Inhalant withdrawal symptoms can begin anywhere between a few hours to a few
days after ceasing inhalant use. Symptoms may last for only 2-3 days, or may
last for up to two weeks.

Symptoms include:

* Headaches
* Nausea
* Tremors
* Hallucinations
* Insomnia
* Lethargy
* Anxiety and depressed mood
* Irritability
* Poor concentration

OBSERVATION AND MONITORING

Patients withdrawing from inhalants should be observed every three-four hours to
assess for complications such as hallucinations, which may require medication.

MANAGEMENT OF INHALANT WITHDRAWAL

Patients should drink 2-3 litres of water per day while in withdrawal. Provide a
calm, quiet environment for the patient. Offer symptomatic medication as
required for symptoms such as headaches, nausea and anxiety (Table 3).

FOLLOW-UP CARE

For up to a month after ceasing inhalant use, the patient may experience
confusion and have difficulty concentrating. This should be taken into
consideration in planning treatment involvement.

Go to:

4.8. WITHDRAWAL MANAGEMENT FOR CANNABIS DEPENDENCE

CANNABIS WITHDRAWAL SYNDROME

The cannabis withdrawal syndrome is typically mild, but can be difficult for the
patient to cope with. Symptoms last between one and two weeks.

Symptoms include:

* Anxiety and a general feeling of fear and dissociation
* Restlessness
* Irritability
* Poor appetite
* Disturbed sleep, sometimes marked by vivid dreams
* Gastrointestinal upsets
* Night sweats
* Tremor

OBSERVATION AND MONITORING

Patients should be observed every three to four hours to assess for
complications such as worsening anxiety and dissociation, which may require
medication.

As cannabis withdrawal is usually mild, no withdrawal scales are required for
its management.

MANAGEMENT OF CANNABIS WITHDRAWAL

Cannabis withdrawal is managed by providing supportive care in a calm
environment, and symptomatic medication as required (Table 3).

There is some evidence that lithium carbonate may be an effective medication for
cannabis withdrawal management. However, until further research has established
the efficacy of the medication for this purpose, it is not recommended for use
in closed settings.

FOLLOW-UP CARE

The preferred treatment for cannabis dependence is psycho-social care. Patients
who have been using large amounts of cannabis may experience psychiatric
disturbances such as psychosis; if necessary, refer patients for psychiatric
care.

Go to:

FOOTNOTES

The term ‘withdrawal management’ (WM) has been used rather than
‘detoxification’. This is because the term detoxification has many meanings and
does not translate easily to languages other than English.

Known as Wernicke's Encephalopathy.

* 4.1. INTRODUCTION
* 4.2. STANDARD CARE FOR WITHDRAWAL MANAGEMENT
* 4.3. WITHDRAWAL MANAGEMENT FOR OPIOID DEPENDENCE
* 4.4. WITHDRAWAL MANAGEMENT FOR BENZODIAZEPINE DEPENDENCE
* 4.5. WITHDRAWAL MANAGEMENT FOR STIMULANT DEPENDENCE
* 4.6. WITHDRAWAL MANAGEMENT FOR ALCOHOL DEPENDENCE
* 4.7. WITHDRAWAL MANAGEMENT FOR INHALANT DEPENDENCE
* 4.8. WITHDRAWAL MANAGEMENT FOR CANNABIS DEPENDENCE
* Footnotes

Publications of the World Health Organization can be obtained from WHO Press,
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permission to reproduce WHO publications, in part or in whole, or to translate
them – whether for sale or for noncommercial distribution – should be addressed
to WHO Press, at the above address (fax: +41 22 791 4806; e-mail:
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permission to reproduce should be addressed to Publications Office, World Health
Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000,
Manila, Philippines, fax: +632 521 1036, e-mail: tni.ohw.orpw@snoitacilbup

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* INTRODUCTION
* STANDARD CARE FOR WITHDRAWAL MANAGEMENT
* WITHDRAWAL MANAGEMENT FOR OPIOID DEPENDENCE
* WITHDRAWAL MANAGEMENT FOR BENZODIAZEPINE DEPENDENCE
* WITHDRAWAL MANAGEMENT FOR STIMULANT DEPENDENCE
* WITHDRAWAL MANAGEMENT FOR ALCOHOL DEPENDENCE
* WITHDRAWAL MANAGEMENT FOR INHALANT DEPENDENCE
* WITHDRAWAL MANAGEMENT FOR CANNABIS DEPENDENCE

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Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence
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