Acute Drug Withdrawal

Basics

Drug withdrawal is a physiologic response to an effectively lowered drug concentration in a patient with tolerance to that drug.
Withdrawal results in a predictable pattern of symptoms that are reversible if the drug in question or another appropriate substitute is reintroduced.
Sedative-hypnotic withdrawal is the most common life-threatening withdrawal syndrome in children. This includes withdrawal from barbiturates, benzodiazepines, baclofen, as well as γ-hydroxybutyrate and similar substances.
Other substances that are associated with withdrawal syndromes include nicotine, opioids, selective serotonin reuptake inhibitors (SSRIs), and caffeine.

The most common life-threatening withdrawal syndrome, alcohol withdrawal, rarely occurs in children.
Neonates born to alcohol-dependent mothers are at risk.

Patients receiving sedatives or analgesics capable of causing tolerance are at risk.
Any inpatient use of sedative or opioids >5 days is a risk factor for withdrawal.
This risk is particularly important to consider with infusions or high doses of such substances in previously naive patients.

Clinician familiarity with tolerance and withdrawal associated with prescribed medications allows appropriate drug tapering.
Drug abuse prevention is appropriate for all children.

Altered CNS neurochemistry is the most important and clinically relevant aspect of withdrawal pathophysiology.
Under normal conditions, the CNS maintains a balance between excitation and inhibition. Although there are several ways to achieve this balance, excitation is constant and actions occur through removal of inhibitory tone.
Relative to adults and younger children, adolescents are more prone to develop dependence and withdrawal syndrome due to immaturity of their prefrontal cortex.

Neonates
- Maternal alcohol, caffeine, opioid, sedative-hypnotic, or SSRI use may result in a neonatal abstinence syndrome.
- Treatment with caffeine, opioids, or sedative-hypnotics and subsequent discontinuation may result in subsequent development of an abstinence syndrome.
Older children
- Subsequent to treatment with opioids, or sedative-hypnotics, an abstinence syndrome may result.
- Substance abuse, particularly opioids, γ-hydroxybutyrate, or other sedative-hypnotics, may result in an abstinence syndrome.
- Frequent caffeine or nicotine use may lead to an abstinence syndrome.
Use of opioid antagonists such as naloxone, naltrexone, and nalmefene is associated with development of opioid withdrawal.

There's more to see -- the rest of this topic is available only to subscribers.