I recently participated in a Webinar entitled “Managing Alcohol Withdrawal in the Correctional Setting.” During the question and answer section of the Webinar, a question was posed about how to manage the patient withdrawing from both alcohol and heroin at the same time. I have been thinking about this question since. In all my years of practice in correctional settings, I personally have never seen a patient who was simultaneously withdrawing from both alcohol and narcotics. Is such a thing even possible?
After thinking about it, I have decided that this question this question has two answers: a theoretical answer and a practical answer. The theoretical answer first:
Theoretically, if a patient was truly suffering from both alcohol withdrawal and heroin withdrawal at the same time, our primary concern would be alcohol withdrawal rather than heroin withdrawal. The reason for this is that patients die from alcohol withdrawal; it is a potentially lethal problem. Heroin withdrawal, on the other hand, can be a serious medical problem, but does not tend to be lethal. I was an emergency physician before I came to corrections, and this principle was drilled into us over and over–you deal with the life threatening concern first.
It would be theoretically possible to treat both at the same time–give Valium, say for alcohol withdrawal and clonodine for heroin withdrawal, but you would have to be careful of the potential drug interactions between these two medications. Perhaps I would treat the alcohol withdrawal like I usually do with symptom driven Valium but not use as much clonodine as I normally would for heroin withdrawal.
But, again, all of this is theoretical because though I have treated literally hundreds of patients for alcohol withdrawal and hundreds more for narcotic withdrawal, I personally have never seen a patient who withdrew from both at the same time.
This brings us to the practical answer to the question. The practical answer is that, as a very strong general rule, patients do not withdraw from both alcohol and heroin at the same time. It takes many years of dedicated daily heavy drinking to cause the brain receptor changes that result in alcohol withdrawal. That is why most alcohol withdrawal patients we see are middle-aged. Young people usually have not been at the business of dedicated drinking long enough to lead to withdrawal (there are exceptions to this, but as a general rule, the younger the patient, the less likely they are to go through alcohol withdrawal, even if they are a heavy drinker). Heroin addicts are more interested in heroin than alcohol. They may drink, but not enough to lead to true alcohol withdrawal.
However, it is not uncommon for heroin addicts to say that they are going to withdraw from alcohol as well as heroin. Especially if they have been through the system before, they know that alcohol withdrawal is treated with a benzodiazepine like Valium. What they are doing is trying to score a little Valium. I usually view such claims with suspicion.
So if a patient presents in the jail and says that he is going to withdraw from alcohol as well as heroin, I usually will treat him according to our narcotic withdrawal protocol. We will also do an alcohol withdrawal score, but it is unlikely that he will get any Valium.
Any thoughts? Has anyone seen simultaneous withdrawal from alcohol and narcotics?
I agree with your statements. I have worked in corrections for 23 years and have not seen a duel withdrawl. I’m not saying that the two substances are not used together but from what I have seen there is a preference of one over the other.
We follow our protocol for alcohol withdrawl this involves a CWIA assessment which is a great tool for alcohol withdrawl.
I agree that withdrawling from alcohol is more life threating and should be treated as such.
And yes they will do and say anything if they think they can get a fix from something.
Thank you for your thoughts.
Working in an addictions unit prior to corrections, I have commonly seen people go through withdrawal for both opiates and either alcohol or sed-hypnotics. Unfortunately, we have young people who pummel their bodies with not milligrams of opiates, but GRAMS of opiates. This is in addition to either drinking or taking another GABAnergic substance.
So in those cases, it becomes an exercise in clinical prioritization and applying what we know about withdrawal. Remember the basics: First, Sed-Hypnotic and alcohol withdrawal will kill your patient. Opiate withdrawal makes you want to kill your patient, but outside of that they will generally be fine (remember the medically compromised and pregnant don’t fall under this however). Secondly, benzo’s are not indicated in the treatment of opiate withdrawal. There is really no good “cure” for opiate withdrawal. Everything should be focused on maintaining fluid volume and ameliorating symptoms like diarrhea.
So my advice is to treat the highest risk factor first and adequately. Then focus on keeping their fluid volume maintained and you should be golden.
Well said Jeremy!
I’m having trouble w/ Jeremy’s viewpoints because in correctional detox:
1. The history most often has secondary gain (to become intoxicated over the first week) and thus
2. Which active symptom do you acribe to which reported substance?
So “dual” withdrawal syndromes isn’t, for this viewpoint, helpful. Instead, I suggest enhanced focused upon the objective stuff and focus upon the timelines for the reported substances. Starting a benzo (because of a worrisome reported history for etoh) when there’s no autonomic irritability is just plain dangerous, particularly when there’s a dependency pattern for opioids.
It may be an oversimplification, but folks won’t exaggerate opioid use, they will their etoh use. I uniformly ask which would they want now: a drink or a dime bag? The answer usually is the leading diagnosis – as Dr. Osler once said.
I would tend to disagree with a dual withdrawal from alcohol and heroin. I have known this person for many years and he has been drinking since the age of 14. He was currently up to at least 2 pints of 100 proof Captain Morgan in an 8 to 10 hr period. Would easily consume that, if he couldn’t get his well over 2 gram a day heroin addiction. So if he couldn’t have one he would settle with alcohol. .His addiction we feel began after numerous car accidents which lead to much brain trauma however was never confirmed and truly needs to be if he is going to get the help he needs. The current withdrawal state for him after 10 days is really bad. He has constant thoughts and visions that make him worried about himself and family. His thoughts are consuming him and making him easily agitated, obviously uncomfortable and in need to be transferred to a rehabilitation facility asap. Not to mention the agonizing discomfort of the heroin withdrawal. Yes with alcohol withdrawal it can lead to death but with heroin I can honestly say the shock that is does to your body and the stress very well could lead to a hard attack if not monitored. Not to mention, the pain and thoughts that you deal with make you wish you were dead and can easily make someone suicidal. i understand these symptoms first hand.