Acute Drug Withdrawal



  • 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.

Risk Factors

  • 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.

General Prevention

  • 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.

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