Sedative, Hypnotic, or Anxiolytic Withdrawal 559
Associated Features Supporting Diagnosis
The timing and severity of the withdrawal sy ndrome will differ depending on the specific
substance and its pharmacokinetics and ph armacodynamics. For example, withdrawal
from shorter-acting substances that are rapidl y absorbed and that have no active metabo-
lites (e.g., triazolam) can begi n within hours after the subs tance is stopped; withdrawal
from substances with long-acting metabolites  (e.g., diazepam) may not begin for 1–2 days
or longer. The withdrawal syndrome produced by substances in this class may be charac-
terized by the development of a delirium that  can be life-threatening. There may be evi-
dence of tolerance and withdr awal in the absence of a diagnosis of a substance use
disorder in an individual who has abruptly discontinued benzodiazepines that were taken
for long periods of time at prescribed and therapeutic doses. Howe ver, ICD-10-CM codes
only allow a diagnosis of seda tive, hypnotic, or anxiolytic withdrawal in the presence of
comorbid moderate to severe sedative, hypnotic, or anxiolytic use disorder.
The time course of the withdr awal syndrome is generally predicted by the half-life of
the substance. Medications whose actions typica lly last about 10 hours or less (e.g., loraz-
epam, oxazepam, temazepam) produce withdr awal symptoms within 6–8 hours of de-
creasing blood levels that peak in intensity on the second day and improve markedly by
the fourth or fifth day. For substances with  longer half-lives (e .g., diazepam), symptoms