1.3 Intoxication and Withdrawal Syndromes
Key Takeaways
- Alcohol, benzodiazepine, and barbiturate withdrawal can be fatal; opioid and stimulant withdrawal are usually not.
- The CIWA-Ar scale uses 10 items, scores 0-67, and guides medical management of alcohol withdrawal — a score above 8-10 typically warrants benzodiazepine treatment.
- Delirium tremens (DTs) typically appears 48-96 hours after the last drink, has up to ~5% mortality when treated, and is a medical emergency.
- The COWS scale has 11 items, scores 0-48, and guides buprenorphine induction; 5-12 mild, 13-24 moderate, 25-36 moderately severe, 37-48 severe withdrawal.
- Opioid withdrawal is miserable but rarely fatal; the real danger is post-withdrawal overdose because tolerance drops within days.
Why This Section Is Tested Heavily
Intoxication and withdrawal questions appear on every administration of the ADC exam because counselors are often the first professional to observe symptoms and decide whether to refer the client to medical detox. Two messages anchor the section:
- Three withdrawals can kill: alcohol, benzodiazepines, barbiturates. All three involve GABA-system rebound, central nervous system hyperexcitability, and seizure risk.
- Opioid and stimulant withdrawals feel devastating but are rarely fatal in healthy adults. The real risk after opioid withdrawal is overdose on relapse, because tolerance drops within 3-7 days.
A useful exam rule: the danger of withdrawal mirrors the direction of intoxication. Drugs that depress and sedate (alcohol, benzodiazepines) produce a dangerous, excitatory rebound on withdrawal; drugs that excite (stimulants) produce a depressive crash.
Comparison Table: Intoxication vs. Withdrawal by Class
| Drug Class | Intoxication Signs | Withdrawal Signs | Onset of Withdrawal | Peak | Medical Danger |
|---|---|---|---|---|---|
| Alcohol | Slurred speech, ataxia, disinhibition, nystagmus, blackouts at high BAC | Tremor, sweating, anxiety, tachycardia, nausea, hallucinations, seizures, DTs | 6-24 hr | 24-72 hr (DTs 48-96 hr) | HIGH — seizures, DTs, mortality up to ~5% treated |
| Benzodiazepines | Sedation, ataxia, slurred speech, amnesia, paradoxical disinhibition | Anxiety, tremor, insomnia, perceptual disturbances, seizures | 1-4 days (longer for long-acting) | Up to several weeks | HIGH — seizures; taper required |
| Opioids | Pinpoint pupils, sedation, respiratory depression, slurred speech, nodding, constipation | Lacrimation, rhinorrhea, yawning, dilated pupils, piloerection, GI cramps, diarrhea, muscle aches, dysphoria | 8-12 hr (heroin), 24-48 hr (methadone) | 36-72 hr (heroin) | LOW directly; HIGH for post-detox overdose |
| Stimulants (cocaine, meth) | Pupillary dilation, tachycardia, hypertension, agitation, paranoia, hyperthermia | The "crash": fatigue, hypersomnia, increased appetite, vivid dreams, dysphoria, anhedonia | Hours | 1-3 days, dysphoria may last weeks | Suicide risk during crash; cardiac risk during intoxication |
| Cannabis | Conjunctival injection, dry mouth, tachycardia, slowed reaction time, increased appetite, anxiety/paranoia at high doses | Irritability, anxiety, sleep disturbance, decreased appetite, restlessness | 24-72 hr | First week | LOW |
| Hallucinogens | Perceptual distortion, depersonalization, mydriasis, tachycardia | No formal withdrawal syndrome | n/a | n/a | Bad trips, HPPD, accidents |
| Inhalants | Slurred speech, dizziness, euphoria, ataxia, chemical odor on breath/clothes | Mild irritability, sleep problems (not a formal syndrome) | n/a | n/a | Sudden Sniffing Death; chronic neurotoxicity |
Note the opioid mnemonic: opioid intoxication produces pinpoint (constricted) pupils, while opioid withdrawal produces dilated pupils — pupil size is one of the fastest field discriminators.
Alcohol Withdrawal Timeline
| Time After Last Drink | Symptoms |
|---|---|
| 6-12 hours | Tremor, anxiety, nausea, sweating, headache, insomnia |
| 12-24 hours | Alcoholic hallucinosis (usually visual, sensorium intact) |
| 24-48 hours | Generalized tonic-clonic withdrawal seizures |
| 48-96 hours | Delirium tremens (DTs) — disorientation, autonomic instability, agitation, hallucinations, fever |
DTs mortality is approximately 1-5% with treatment and historically up to 15-20% untreated. Risk factors include prior DTs, prior withdrawal seizures, heavy daily drinking, co-occurring medical illness, and electrolyte abnormalities. Distinguish brief alcoholic hallucinosis (clear sensorium) from DTs (clouded sensorium plus autonomic storm) — only the latter is a true medical emergency.
CIWA-Ar (Clinical Institute Withdrawal Assessment, Alcohol — Revised)
Counselors do not prescribe benzodiazepines, but they must understand the scale used to guide medical management.
- 10 items — nausea/vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache, and orientation/clouding of sensorium.
- Score range 0-67. Nine items scored 0-7; orientation scored 0-4.
- Cutoffs: under 8 minimal/mild then supportive care; 8-15 moderate; over 15 severe then high risk of complications. Symptom-triggered or fixed-schedule benzodiazepine treatment is typically indicated when scores exceed roughly 8-10. Symptom-triggered dosing reduces total benzodiazepine exposure compared with fixed schedules.
COWS (Clinical Opioid Withdrawal Scale)
- 11 items — resting pulse, sweating, restlessness, pupil size, bone/joint aches, runny nose/tearing, GI upset, tremor, yawning, anxiety/irritability, gooseflesh skin.
- Score range 0-48.
- Cutoffs: 5-12 mild, 13-24 moderate, 25-36 moderately severe, 37-48 severe.
- Buprenorphine induction usually begins when COWS is roughly 8-13 or higher to avoid precipitated withdrawal — the abrupt, intense withdrawal that occurs if buprenorphine displaces a full agonist while it is still on the receptor.
Benzodiazepine Withdrawal — Special Warning
Unlike opioid withdrawal, benzodiazepine withdrawal can be fatal because of seizure risk. A client on therapeutic alprazolam for two years cannot safely stop abruptly. Standard practice is a slow taper — often diazepam substitution because of its long half-life — over weeks to months. Counselors should never advise a client to discontinue benzodiazepines without physician oversight.
Stimulant Crash
After a stimulant binge, clients experience profound fatigue, hypersomnia, hyperphagia, vivid unpleasant dreams, and severe dysphoria with anhedonia. There is no FDA-approved medication for stimulant withdrawal; supportive care, sleep, hydration, and suicide-risk assessment are the priorities.
The ASAM Levels of Care
The American Society of Addiction Medicine (ASAM) Criteria define a continuum of withdrawal-management and treatment settings, and the ADC exam expects you to match a client's risk to the right level:
| Level | Setting | Example Fit |
|---|---|---|
| 1-WM | Ambulatory withdrawal management, no extended monitoring | Mild alcohol withdrawal, stable support at home |
| 2-WM | Ambulatory with extended on-site monitoring | Moderate withdrawal needing daily check-ins |
| 3.7-WM | Medically monitored inpatient | High CIWA-Ar, prior DTs or seizures |
| 4-WM | Medically managed intensive inpatient | Active DTs, unstable vitals, severe co-occurring illness |
A counselor's job is not to prescribe, but to screen, recognize danger, and refer to the correct level. Sending a client with prior withdrawal seizures to unsupervised home detox is a classic wrong-answer scenario.
Counselor Red Flags Requiring Immediate Medical Referral
- Any sign of clouded sensorium, fever, or autonomic instability after alcohol or benzodiazepine cessation.
- History of prior withdrawal seizures or DTs (kindling raises risk each time).
- Pregnancy with any substance use — withdrawal management must be physician-directed.
- Suspected overdose: pinpoint pupils plus slowed breathing calls for naloxone and 911, not counseling.
A 52-year-old client with a 20-year history of daily heavy drinking presents 60 hours after her last drink with confusion, fever of 101.5 F, heart rate 130, BP 168/104, profuse sweating, and visual hallucinations. The MOST appropriate counselor action is to:
Which of the following withdrawal syndromes is MOST likely to be fatal if not medically managed?
A client in early opioid withdrawal scores 14 on the COWS. This indicates:
Why is the risk of fatal overdose HIGHEST in the days immediately following opioid detox?