147 - Substance withdrawal

Substance withdrawal

479 Disorders due to substance use or addictive behaviours Substance withdrawal Available categories by substance class 6C40.4 Alcohol withdrawal 6C41.4 Cannabis withdrawal 6C42.4 Synthetic cannabinoid withdrawal 6C43.4 Opioid withdrawal 6C44.4 Sedative, hypnotic or anxiolytic withdrawal 6C45.4 Cocaine withdrawal 6C46.4 Stimulant withdrawal, including amfetamines, methamfetamine and methcathinone 6C47.4 Synthetic cathinone withdrawal 6C48.3 Caffeine withdrawal 6C4A.4 Nicotine withdrawal 6C4B.4 Volatile inhalant withdrawal 6C4C.4 MDMA or related drug withdrawal, including MDA 6C4E.4 Other specified psychoactive substance withdrawal 6C4F.4 Multiple specified psychoactive substances withdrawal 6C4G.4 Withdrawal due to unknown or unspecified psychoactive substances Essential (required) features • The presentation is characterized by a clinically significant cluster of symptoms, behaviours and/or physiological features that occurs upon cessation or reduction in the use of a substance in individuals who have developed dependence on that substance, or have used the substance for a prolonged period or in large amounts. Note: substance withdrawal can occur when prescribed psychoactive medications (e.g. opioids, anxiolytics, stimulants) have been used in standard therapeutic doses. • The specific features of substance withdrawal depend on the pharmacological properties of the specified substance (see Table 6.16, p. 484), and are consistent with those recognized as occurring upon cessation or reduction of the particular substance or other members of the same pharmacological group of substances. The symptoms also vary in degree of severity and duration, depending on the substance and the amount and pattern of prior use. • The symptoms are not better accounted for by another medical condition or another mental disorder. Note: substance withdrawal is only applicable for some substances or substance classes (see the list above and Table 6.13, p. 450). Table 6.16 (p. 484) lists the most common symptoms, behaviours and physiological features for each substance class. Diagnostic requirements for disorders due to substance use | Substance withdrawal

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Specifiers for clinical presentation of substance withdrawal Because of clinically important variation in their withdrawal syndromes, the following specifiers can be applied to alcohol withdrawal (6C40.4) and sedatives, hypnotics or anxiolytics withdrawal (6C44.4), as well as the withdrawal syndrome for other specified (6C4E.4), multiple (6C4F.4) and unspecified (6C4G.4) psychoactive substance categories. The x below corresponds to the fourthcharacter code indicating the substance class (0 for alcohol, 1 for cannabis and so on). Substance withdrawal, uncomplicated All diagnostic requirements for substance withdrawal are met, and the withdrawal state is not accompanied by perceptual disturbances or seizures. Substance withdrawal, with perceptual disturbances All diagnostic requirements for substance withdrawal are met, and the withdrawal state is accompanied by perceptual disturbances (e.g. visual or tactile hallucinations or illusions) with intact reality testing. There is no evidence of confusion, and other diagnostic requirements for delirium are not met. The withdrawal state is not accompanied by seizures. Substance withdrawal, with seizures All diagnostic requirements for substance withdrawal are met, and the withdrawal state is accompanied by seizures (i.e. generalized tonic-clonic seizures) but not by perceptual disturbances. Substance withdrawal, with perceptual disturbances and seizures All diagnostic requirements for substance withdrawal are met, and the withdrawal state is accompanied by both seizures (i.e. generalized tonic-clonic seizures) and perceptual disturbances (e.g. visual or tactile hallucinations or illusions) with intact reality testing. Diagnostic requirements for delirium are not met. Substance withdrawal, unspecified 6C4x.40 6C4x.41 6C4x.42 6C4x.43 6C4x.4Z Diagnostic requirements for disorders due to substance use | Substance withdrawal

481 Disorders due to substance use or addictive behaviours Additional clinical features for substance withdrawal • For some substances, characteristic features of substance withdrawal are opposite to the acute pharmacological effects of that substance (see Table 6.15, p. 475, and Table 6.16, p. 484). • Substance withdrawal symptoms become more severe with repeated episodes of withdrawal (termed “kindling”), with ageing, or in the presence of comorbid medical conditions. • A diagnosis of substance withdrawal due to unknown or unspecified psychoactive substances can be assigned if the substance consumed is initially unknown. As more information becomes available (e.g. laboratory results, report from a collateral informant) the diagnosis should be changed to indicate the substance responsible for the withdrawal symptoms. Boundary with normality (threshold) • Substance withdrawal should only be diagnosed when symptoms are consistent with those recognized as occurring upon cessation or reduction in use of the particular substance or pharmacologically related group of substances (see Table 6.16, p. 484). Recent cessation or reduction of use and the presence of various nonspecific transient symptoms is not sufficient to make the diagnosis of substance withdrawal. • Withdrawal symptoms should be differentiated from the transient physiological aftereffects of intoxication (“hangover effect”). For example, if low mood and reduction in energy are reported following use of alcohol; sedatives, hypnotics or anxiolytics; stimulants; or MDMA or related drugs, and other characteristic features of substance withdrawal are not present, a diagnosis of substance withdrawal should not be assigned. The presence of a set of associated symptoms specific to different classes of psychoactive substances (see Table 6.16, p. 484) – as well as the frequency, amount and duration of its use and presence of substance dependence – should be considered in distinguishing substance withdrawal from a “hangover effect”. • Some individuals who have previously had substance dependence may experience symptoms similar to those of substance withdrawal months after the last use of the substance, particularly when the individual encounters stimuli (e.g. drug paraphernalia) and contexts (e.g. location where use was frequent) previously associated with past substance use. These symptoms are more transient than those observed during substance withdrawal, and occur exclusively when in contact with associated stimuli and contexts. A diagnosis of substance withdrawal should not be assigned under these circumstances. Diagnostic requirements for disorders due to substance use | Substance withdrawal

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Course features • Substance withdrawal is time-limited. Factors that influence the features and time course of substance withdrawal include the severity of substance dependence (if present); the dose, frequency of use and duration of use of the substance prior to cessation or reduction of that use; the half-life and duration of action of the substance; and the presence of comorbid medical conditions (e.g. metabolic disturbances). Culture-related features • Symptoms of withdrawal depend largely on the psychotropic characteristics of the substance. • However, specific cultures may emphasize certain symptoms of withdrawal over others, making it more difficult to conduct a differential diagnosis. In addition, vernacular terms for withdrawal vary greatly. Boundaries with other disorders and conditions (differential diagnosis) Boundary with substance dependence Depending on the substance, many individuals with substance dependence develop substance withdrawal upon cessation or reduction in the amount of the substance. In such cases, both substance dependence and substance withdrawal should be diagnosed. However, substance withdrawal can be diagnosed in the absence of a diagnosis of substance dependence – for example, in response to cessation of medically appropriate treatment with opioid analgesics that is not accompanied by the other essential features of substance dependence. Boundary with substance intoxication The onset of substance intoxication occurs immediately or shortly after the consumption of a substance. In contrast, substance withdrawal occurs upon cessation or reduction in the amount of a substance in the context of substance dependence, or when a substance has been taken for a prolonged period or in large amounts. For a particular substance, the intoxication and withdrawal syndromes are typically distinct. See Table 6.15 (p. 475) for a description of the substance-specific features of substance intoxication and Table 6.16 (p. 484) for a description of the substancespecific features of substance withdrawal. Boundary with substance-induced delirium Delirium is characterized by disturbances in attention, orientation and awareness that develop within a short period of time, with symptoms that are transient and may fluctuate depending Diagnostic requirements for disorders due to substance use | Substance withdrawal

483 Disorders due to substance use or addictive behaviours on the underlying etiology. Delirium often includes disturbance of behaviour and emotion, and may include impairment in multiple cognitive domains. Disturbance of the sleep-wake cycle may also be present. Delirium may occur as an aspect of substance withdrawal, particularly during later stages of withdrawal. In such cases, diagnoses of both substance withdrawal and substanceinduced delirium should be assigned. Note: substance-induced delirium is only applicable for some substances or substance classes (see Table 6.14, p. 454). Boundary with other substance-induced mental disorders Mental or behavioural symptoms that arise during substance withdrawal should only be used as a basis for diagnosing a substance-induced mental disorder if the intensity or duration of the symptoms is substantially in excess of those that are characteristic of the substance withdrawal due to the specified substance (see Table 6.16, p. 484), and the symptoms are sufficiently severe to warrant specific clinical attention. In such cases, if the withdrawal syndrome is ongoing, diagnoses of both substance withdrawal and a substance-induced mental disorder may be assigned. Boundary with other mental disorders Various symptoms associated with substance withdrawal overlap with those that are characteristic of other mental disorders (e.g. depressive and anxiety symptoms). Symptoms of substance withdrawal occur in specific temporal relationship to the cessation of use of a specific substance, and diminish with the passage of time. Evidence supporting a mental disorder diagnosis would include the symptoms preceding the onset of the substance use, the symptoms persisting for a substantial period of time after cessation of the substance or medication use or withdrawal (e.g. 1 month or more, depending on the substance), or other evidence of a pre-existing mental disorder (e.g. a history of prior episodes not associated with substance use). Boundary with other medical conditions It may be difficult to distinguish between various symptoms associated with substance withdrawal (e.g. nausea, retching or vomiting, seizures, abdominal cramps, diarrhoea, perspiration, postural hypotension, decreased or increased heart rate, cough, sleep disruption) and those that are characteristic of other medical conditions. Symptoms of substance withdrawal occur in specific temporal relationship to the cessation of use of a specific substance and diminish with the passage of time. Boundary with fetus or newborn affected by maternal use of tobacco, alcohol, or other drugs of addiction Chapter 19 on certain conditions arising during the perinatal period contains a category of fetus or newborn affected by maternal use of tobacco, alcohol and other drugs. A neonate exhibiting signs of substance withdrawal related to a specific substance may also be assigned the appropriate substance withdrawal diagnosis in order to guide treatment together with appropriate diagnosis from Chapter 19. Substance withdrawal is a cluster of symptoms, behaviours and physiological features, varying in degree of severity and duration, that occur upon cessation or reduction of use of a psychoactive substance in individuals who have developed dependence on that substance, or who have taken the substance for a prolonged period or in large amounts. The diagnosis of substance withdrawal is applicable only to certain substances and substance groups (see Table 6.13, p. 450). Specific presenting features that may occur as a part of substance withdrawal for each applicable class of psychoactive substances in the grouping of disorders due to substance use are listed in Table 6.16. Diagnostic requirements for disorders due to substance use | Substance withdrawal

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Table 6.16. Common substance-specific features of substance withdrawal Substance Substance-specific features of withdrawal Alcohol Presenting features of alcohol withdrawal may include autonomic hyperactivity (e.g. tachycardia, hypertension, perspiration), increased hand tremor, nausea, retching or vomiting, insomnia, anxiety, psychomotor agitation, depressed or dysphoric mood, transient visual, tactile or auditory illusions or hallucinations, and distractibility. Less commonly, alcohol withdrawal is complicated by seizures. Additional features • Onset of alcohol withdrawal typically occurs within 6–12 hours after last use, as blood alcohol concentrations decline. Symptoms vary in type, severity, onset and duration, according to the duration and intensity of alcohol use prior to cessation or reduction of use. • Features of mild or moderate withdrawal typically last for 3–7 days after cessation of alcohol use, and include autonomic hyperactivity, increased hand tremor, anxiety, insomnia, nausea, vomiting and headache. Features of moderate withdrawal may also include transient visual, tactile or auditory illusions or hallucinations, distractibility and psychomotor agitation. • In 1–3% of cases, alcohol withdrawal is complicated by seizures of a tonic-clonic type. When seizures occur, they are usually single seizures with onset within 6–48 hours after last use. Evidence of a premorbid seizure disorder, other intracranial pathology or co-occurring use of other substances does not preclude a presumptive alcohol withdrawal diagnosis. • Approximately 2% of cases of alcohol withdrawal progress to a very severe syndrome sometimes referred to as “delirium tremens” (or DTs), characterized by confusion and disorientation, delusions and prolonged visual, tactile or auditory hallucinations. When delirium is present, a separate diagnosis of 6C40.5 Alcohol-induced delirium should also be assigned. The presence of seizures during withdrawal represents a risk factor for development of delirium. If unrecognized or untreated, delirium during alcohol withdrawal is associated with substantially increased mortality compared to alcohol withdrawal without co-occurring delirium. • Some symptoms associated with alcohol withdrawal – such as autonomic hyperactivity, anxiety and insomnia – can recur or persist for several months after abstinence, particularly when the person is exposed to alcohol-associated cues (a conditioned withdrawal state). The presence of such persisting symptoms is not sufficient to meet diagnostic requirements for alcohol withdrawal. Cannabis Presenting features of cannabis withdrawal may include irritability, anger or aggressive behaviour, shakiness, insomnia, restlessness, anxiety, depressed or dysphoric mood, decreased appetite and weight loss, headache, sweating or chills, abdominal cramps and muscle aches. Additional features • The occurrence, severity and duration of cannabis withdrawal vary according to the type and potency of the cannabis preparation, as well as the amount, frequency and duration of use before cessation or reduction of use. • Onset of cannabis withdrawal typically occurs at some point between 12 hours and 3 days after cessation or reduction of use. Symptom severity typically peaks at 4–7 days and may last for 1–3 weeks after cessation of use. However, cannabis withdrawal may also be briefer, in some cases lasting only a few days. • When cannabis withdrawal occurs in the context of a co-occurring mental disorder, the features of the other disorder (e.g. fluctuation of mood) may be exacerbated. Diagnostic requirements for disorders due to substance use | Substance withdrawal

485 Disorders due to substance use or addictive behaviours Substance Substance-specific features of withdrawal Synthetic cannabinoids Presenting features of synthetic cannabinoid withdrawal may include irritability, anger, aggression, shakiness, insomnia and disturbing dreams, restlessness, anxiety, depressed or dysphoric mood and appetite disturbance. In the early phase, synthetic cannabinoid withdrawal may be accompanied by residual features of intoxication from the drug, such as paranoid ideation and auditory and visual hallucinations. Additional features • The occurrence, severity and duration of synthetic cannabinoid withdrawal vary according to the type and potency of the synthetic cannabinoid used, as well as the amount, frequency and duration of use before cessation or reduction of use. • Synthetic cannabinoid withdrawal typically lasts for 1–3 weeks after cessation of use. Opioids Presenting features of opioid withdrawal may include depressed or dysphoric mood, craving for an opioid, anxiety, nausea or vomiting, abdominal cramps, muscle aches, yawning, perspiration, hot and cold flushes, hypersomnia (typically in the initial phase) or insomnia, diarrhoea, piloerection and pupillary dilation. Additional features • The severity and time course of opioid withdrawal is influenced by many factors that include the type of opioid taken, its half-life and duration of action, the amount, frequency and duration of opioid use before cessation or reduction of use, prior experience of opioid withdrawal, and expectations of the severity of the syndrome. • Opioid withdrawal from short-acting opioids such as injected heroin or morphine typically begins within 4–12 hours of cessation of use and lasts for 4–10 days. • Opioid withdrawal from longer-acting opioids such as codeine, oxycodone and similar pharmaceutical agents may not be evident for 2–4 days and may last for 1–2 weeks. • The withdrawal state from long-acting drugs such as methadone may persist for up to 2 months after cessation of use. • Opioid withdrawal occurs in phases. The early phase typically includes lacrimation, rhinorrhoea and yawning. This is followed by hot and cold flashes, muscle aching and abdominal cramps, nausea and vomiting and diarrhoea; piloerection and pupillary dilatation may also occur. The later phase is dominated by craving for opioids. • Recurrence or worsening of pain may occur if the opioid was used to manage chronic pain. • Serious medical complications of opioid withdrawal are rare. Fluid depletion may occasionally lead to renal impairment. Death during opioid withdrawal is very uncommon. Table 6.16. contd Diagnostic requirements for disorders due to substance use | Substance withdrawal

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Substance Substance-specific features of withdrawal Sedatives, hypnotics or anxiolytics Presenting features of sedative, hypnotic or anxiolytic withdrawal may include anxiety, psychomotor agitation, insomnia, increased hand tremor, nausea or vomiting, and transient visual, tactile or auditory illusions or hallucinations. There may be signs of autonomic hyperactivity (e.g. tachycardia, hypertension, perspiration) or postural hypotension. The withdrawal state may be complicated by seizures. Additional features • The severity and time course of sedative, hypnotic or anxiolytic withdrawal is related to the particular substance taken, its half-life and duration of action, and the amount, frequency and duration of use before cessation or reduction of use. • The withdrawal state associated with short-acting drugs typically has its onset within 12–24 hours after cessation of use and has a course of up to 14 days. Withdrawal onset may be delayed by 3–5 days with longer-acting drugs and may persist for several weeks. • Sedative, hypnotic or anxiolytic withdrawal may be complicated by seizures, which are of a tonic-clonic type and may be single or multiple. • Sedative, hypnotic or anxiolytic withdrawal, especially when untreated, may progress to a very severe form of delirium, characterized by confusion and disorientation, delusions, and more prolonged visual, tactile or auditory hallucinations. In such cases, a separate diagnosis of 6C44.5 Sedative, hypnotic or anxiolytic-induced delirium should also be assigned. • Medical sequelae of complicated withdrawal include status epilepticus, respiratory compromise and renal failure. • Some features of sedative, hypnotic or anxiolytic withdrawal – such as anxiety, transient illusions or hallucinations, and derealization – may persist for several months after cessation of use. Cocaine Presenting features of cocaine withdrawal may include depressed or dysphoric mood, irritability, fatigue, psychomotor agitation or retardation, vivid unpleasant dreams, insomnia or hypersomnia, increased appetite, anxiety and craving for cocaine. Additional features • Initial symptoms of cocaine withdrawal include a dysphoric and low energy state manifested in depressed or dysphoric mood, irritability, fatigue, inertia and hypersomnia. This typically occurs within 6–24 hours of cessation of cocaine use. • The withdrawal state may last up to 7 days. Craving for cocaine is prominent in the later stages. • Suicidal ideation may occur, especially when dysphoric mood is marked. • At the onset of cocaine withdrawal there may be features that persist from the intoxicating effects of cocaine, such as hyperactivity, paranoid ideation and auditory hallucinations. Stimulants, including amfetamines, methamfetamine and methcathinone Presenting features of stimulant withdrawal may include depressed or dysphoric mood, irritability, fatigue, insomnia or (more commonly) hypersomnia, vivid and unpleasant dreams, increased appetite, psychomotor agitation or retardation, and craving for amfetamine and related stimulants. Additional features • Stimulant withdrawal typically occurs within 24 hours to 4 days of cessation of stimulant use, and is characterized by a dysphoric and low energy state manifested in depressed or dysphoric mood, irritability, fatigue, inertia and hypersomnia. • The severity and duration of the withdrawal state is widely variable based on the type of stimulant taken and the amount, frequency and duration of such use prior to its cessation. • In the first phase of stimulant withdrawal, which typically lasts for 7–14 days, low mood, lethargy and hypersomnia predominate. After this phase, irritability and craving for stimulants are prominent and may persist for 6–8 weeks. • At the onset of stimulant withdrawal there may be features that persist from the intoxicating effects of the stimulant, such as hyperactivity, paranoid ideation and auditory hallucinations. Table 6.16. contd Diagnostic requirements for disorders due to substance use | Substance withdrawal

487 Disorders due to substance use or addictive behaviours Substance Substance-specific features of withdrawal Synthetic cathinones Presenting features of synthetic cathinone withdrawal may include depressed or dysphoric mood, irritability, fatigue, insomnia or (more commonly) hypersomnia, vivid and unpleasant dreams, increased appetite, psychomotor agitation or retardation, and craving for stimulants, including synthetic cathinones. Caffeine Presenting features of caffeine withdrawal may include headache, marked fatigue or drowsiness, irritability, depressed or dysphoric mood, nausea or vomiting, and difficulty concentrating. Additional features: • The severity and duration of caffeine withdrawal is related to the amount, frequency and duration of caffeine use prior to cessation of use. • Onset of caffeine withdrawal is typically 12–48 hours after the last use and may last up to 7 days. Nicotine Presenting features of nicotine withdrawal may include depressed or dysphoric mood, insomnia, irritability, anger, anxiety, difficulty concentrating, restlessness, bradycardia, increased appetite, and craving for tobacco or other nicotine-containing products. Other physical symptoms may include increased cough and mouth ulceration. Additional features: • The severity and duration of nicotine withdrawal is variable, related to the amount, frequency and duration of tobacco smoked (or otherwise consumed) or of nicotine products taken prior to cessation of use. • Onset of nicotine withdrawal is typically 6–24 hours after cessation or reduction of use. Psychological and physiological features typically last up to 10 days. Physical features such as increased cough and mouth ulceration may persist for 2–3 weeks. • Craving for tobacco (or other nicotine-containing products) is prominent throughout the duration of nicotine withdrawal. Volatile inhalants Presenting features of volatile inhalant withdrawal may include insomnia, anxiety, irritability, depressed or dysphoric mood, shakiness, perspiration, nausea and transient illusions. Additional features: • The severity and duration of volatile inhalant withdrawal is related to the type of inhalant used and to the amount, frequency and duration of use of the specific inhalant. • Volatile inhalant withdrawal may be accompanied by persisting features of volatile inhalant intoxication or its medical complications, such as encephalopathy – especially when the inhalant used is lead-containing petrol/gasoline. MDMA or related drugs, including MDA Presenting features of MDMA or related drug withdrawal may include fatigue, lethargy, hypersomnia or insomnia, depressed mood, anxiety, irritability, craving, difficulty in concentrating and appetite disturbance. Additional features • The above information primarily concerns withdrawal from MDMA. There is insufficient information on the features and course of the withdrawal state from drugs related to MDMA, including MDA, to fully characterize the associated withdrawal states. • MDMA withdrawal is uncommon, reflecting the comparative rarity of MDMA dependence. • Onset of MDMA withdrawal typically occurs within 12–24 hours after last use, as blood concentrations decline. The features vary in type, severity, onset and duration according to the amount, frequency and duration of MDMA use prior to cessation of use. • The duration of MDMA withdrawal may be up to 10 days. Craving for MDMA may be prominent during the later stages. Table 6.16. contd Diagnostic requirements for disorders due to substance use | Substance withdrawal