Acute Drug Withdrawal
Acute Drug Withdrawal: Excerpt from The 5-Minute Pediatric Consult
Robert J. Hoffman, MD
Acute Drug Withdrawal - BASICS
Acute Drug Withdrawal - description
- 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, as well as gamma hydroxybutyrate and similar substances.
- Other substances that are associated with withdrawal syndromes include opioids, selective serotonin reuptake inhibitors, and caffeine.
Acute Drug Withdrawal - general prevention
- Clinician familiarity with tolerance and withdrawal associated with prescribed medications allows appropriate drug tapering.
- Drug abuse prevention is appropriate for all children.
Acute Drug Withdrawal - epidemiology
- The most common life-threatening withdrawal syndrome, alcohol withdrawal, rarely occurs in children.
- Neonates born to alcohol-dependent mothers are at risk.
Acute Drug Withdrawal - risk factors
Patients receiving sedatives or analgesics capable of causing tolerance are at risk. This is particularly true with infusions or high doses of such substances in previously naïve patients.
Acute Drug Withdrawal - pathophysiology
- 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. While there are several ways to achieve this balance, excitation is constant and actions occur through removal of inhibitory tone.
Acute Drug Withdrawal - etiology
- Neonates:
- Maternal alcohol, caffeine, opioid, sedative-hypnotic, or selective serotonin reuptake inhibitor use may result in a neonatal abstinence syndrome.
- Treatment with caffeine, opioids, or sedative-hypnotics may result in an abstinence syndrome.
- Older children:
- Subsequent to treatment with caffeine, opioids, or sedative-hypnotics, an abstinence syndrome may result.
- Substance abuse, particularly gamma 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 nalmephene are associated with opioid withdrawal.
Acute Drug Withdrawal - DIAGNOSIS
Acute Drug Withdrawal - signs & symptoms
- Drug withdrawal is a clinical diagnosis.
- Patients should be evaluated for associated diagnoses such as traumatic injury, pneumonia, etc.
Acute Drug Withdrawal - history
- Typically, a history of substance exposure, either direct exposure or maternal use, will be elicited.
- Exposure may be to prescribed medication or abusable substances.
- Substance use by the mother or child might intentionally be concealed.
- The timing of withdrawal varies depending on the half-life of the substance involved.
- The shorter the half-life, the sooner the onset of withdrawal and typically the more severe withdrawal symptoms.
- Alcohol or sedative-hypnotics:
- Withdrawal from these may result in tremulousness, diaphoresis, agitation, insomnia, altered mental status, or withdrawal seizures.
- Baclofen withdrawal is more frequently severe or life-threatening relative to benzodiazepine withdrawal. History of pump manipulation or malfunction should be sought.
- Caffeine:
- Withdrawal may result in dysphoria, headache, behavioral changes, or agitation.
- Opioids:
- Nausea, vomiting, diarrhea, irritability, yawning, sleeplessness, diaphoresis, lacrimation, tremor, and hypertonicity may result.
- Neonates can also have seizures, a high-pitch cry, skin mottling, and excoriation. These latter signs and symptoms are more typical of opioid withdrawal and rarely occur with neonatal alcohol withdrawal.
- Nicotine:
- Dysphoria, agitation, behavioral changes, and increased appetite may all occur.
- SSRIs:
- Neonatal withdrawal from SSRIs may result in jitteriness, agitation, crying, shivering, increased muscle tone, breathing and sucking problems, as well as seizure.
- Children withdrawing from SSRIs may have jitteriness, agitation, dysphoria, behavioral changes, shivering, increased muscle tone, and seizure.
Acute Drug Withdrawal - physical exam
- Vital signs including temperature should be evaluated regularly. For sedative-hypnotic withdrawal, frequent monitoring of vital signs is indicated.
- Technology-dependent patients, such as children with an intrathecal baclofen pump, should have evaluation of the machine to determine if it is working properly.
- Most cases of substance withdrawal only result in behavioral changes.
- Opioid withdrawal may be accompanied by diaphoresis, mydriasis, yawning, and lacrimation.
- Sedative-hypnotic withdrawal may result in hypertension, tachycardia, hyperthermia, agitation, hallucinations, and seizure.
Acute Drug Withdrawal - tests
- No routine lab tests are indicated for patients with substance withdrawal.
- Tests necessary to rule out differential diagnoses should be obtained when appropriate.
Acute Drug Withdrawal - imaging
Neuroimaging to rule out intracranial pathology may rarely be indicated.
Acute Drug Withdrawal - differencial diagnosis
- Hypoglycemia
- Intoxication with sympathomimetics, anticholinergics, theophylline, caffeine, aspirin, or lithium
- Thyroid storm
- Serotonin syndrome
- Neuroleptic malignant syndrome
- Encephalitis
- Meningitis
- Sepsis
Acute Drug Withdrawal - TREATMENT
Acute Drug Withdrawal - initial stabilization
Initial management is aimed at evaluating and supporting airway, breathing, circulation, serum glucose, and ECG. (A,B,C,D,E)
Acute Drug Withdrawal - general measures
- Supportive care is the most important general principle.
- The illness is managed with intent of close monitoring and addressing issues as they arise.
Acute Drug Withdrawal - special therapy
Acute Drug Withdrawal - iv fluids
- Maintenance IV fluid may be required in patients who are unable to take PO.
- Dehydration was once a leading cause of death among patients with alcohol withdrawal.
Acute Drug Withdrawal - medication
- Symptom-triggered treatment has been demonstrated to be superior to fixed-regimen treatment in terms of patient outcome as well as length of stay.
- Patients experiencing withdrawal from benzodiazepines or barbiturates after treatment in a chronic or intensive care setting may be treated by reinstituting the drug and then tapering.
- Iatrogenic withdrawal induced by use of opioid antagonists should not be treated by opioid administration.
- Withdrawal induced by naloxone should abate rapidly due to the brief half-life of naloxone.
- Withdrawal induced by naltrexone or nalmephene will be much longer lasting. Symptomatic treatment may be indicated.
- There is no fixed quantity of drug to use for any withdrawal syndrome. Each patient requires a unique quantity of drug.
- Repeated dosing should continue until the symptoms are controlled, at which point maintenance and then tapering can occur.
- Sedative-hypnotic withdrawal:
- Ideally, withdrawal is treated with the same class of substance, such as benzodiazepine or barbiturate, if not the precise same drug.
- Benzodiazepines are particularly useful due to the rapid onset of effect.
- Diazepam has active metabolites that assist in tapering the drug.
- Propofol is an outstanding medication for treatment of severe alcohol or sedative-hypnotic withdrawal in adults.
- Propofol may be used in pediatric cases refractory to benzodiazepines and barbiturates.
- Use is associated with respiratory depression.
- Clinicians must be capable of airway management and expect airway support to be necessary when propofol is used.
- Propofol use is safe in children, but rare cases of metabolic acidemia have occurred when prolonged infusions are used. Prolonged use of propofol infusion should be accompanied by close observation for acidemia.
- Opioid withdrawal:
- Heroin (as well as other opioids) withdrawal is best treated with an opioid of similar potency and equal or longer duration of action.
- Methadone is a preferred treatment for withdrawal in adolescents and adults, but most neonatologists have limited or no experience with this drug.
- Paregoric and tincture of opium remain the most commonly used therapies for neonatal withdrawal.
- Patients who experience opioid withdrawal in the setting of chronic or intensive care may be treated by reinstituting infusion or dosing of the drug they were on before withdrawal symptoms and then tapering this, typically by 10% daily.
- Caffeine withdrawal:
- Caffeine as soft drink or tea taken to treat headache or agitation
- Neonatal caffeine abstinence symptoms may be treated by reinstituting 75–100% of the caffeine dosage that was discontinued. This amount is then tapered, typically by 10% daily.
- Nicotine withdrawal is not typically treated in children.
- Use of nicotine patch, gum, or other delivery methods are used to increase success rate of abstinence rather than for medical management of the withdrawal syndrome.
Acute Drug Withdrawal - FOLLOW UP
Acute Drug Withdrawal - disposition
- If disposition will be discharge, it is crucial to ensure that the patient’s condition is stable before discharge.
- If there is any question regarding whether the patient can be appropriately managed as an outpatient, initial inpatient management is preferable.
Acute Drug Withdrawal - admission criteria
- Inpatient treatment for alcohol or sedative-hypnotic withdrawal is mandatory.
- Although withdrawal from opioids and selective serotonin reuptake inhibitors is not life-threatening, admission with initial management as an inpatient is preferable.
Acute Drug Withdrawal - discharge criteria
- Inpatients who have been converted from parenteral to oral medications and are controlled with oral medications may be discharged for home tapering.
- Patients who never require parenteral therapy may be discharged with oral replacement medication after consultation with the appropriate specialist.
Acute Drug Withdrawal - issues for referral
- Any patient with substance abuse issues should be referred for appropriate psychiatric or drug counseling.
- Most cases of substance withdrawal are best handled by an addiction specialist, medical toxicologist, intensivist, or other clinician experienced with management of withdrawal.
Acute Drug Withdrawal - prognosis
- With appropriate therapy, withdrawal is well tolerated.
- Poor prognostic factors are primarily related to comorbidities.
Acute Drug Withdrawal - complications
Complications of hypertension, tachycardia, hyperthermia, and CNS agitation or seizure may occur with sedative-hypnotic withdrawal.
Acute Drug Withdrawal - patient monitoring
- Sedative-hypnotic withdrawal or any other withdrawal syndrome with severe symptoms is best cared for with initial cardiopulmonary monitoring until vital sign abnormalities are controlled with appropriate replacement therapy.
- Patients should be closely monitored until vital signs are within acceptable limits.
- Vigilance for agitation or delirium with sedative-hypnotic withdrawal is necessary.
- Vigilance to detect oversedation and respiratory depression is necessary.
Acute Drug Withdrawal - bibliography
- Anon. Neonatal complications after intrauterine exposure to SSRI antidepressants. Prescrire Int. 2004;13:103–104.
- Coffey RJ, Edgar TS, Francisco GE, et al. Abrupt withdrawal from intrathecal baclofen: Recognition and management of a potentially life-threatening syndrome. Arch Phys Med Rehabil. 2002;83:735–741.
- Coles CD, Smith IE, Fernhoff PM, et al. Neonatal ethanol withdrawal: Characteristics in clinically normal, nondysmorphic neonates. J Pediaticsr. 1984;105:445–451.
- Dyer JE, Roth B, Hyma BA. Gamma-hydroxybutyrate withdrawal syndrome. Ann Emerg Med. 2001;37:147–153.
- Nordeng H, Lindeman R, Perminov KV, et al. Neonatal withdrawal syndrome after in utero exposure to selective serotonin reuptake inhibitors. Acta Paediatr. 2001;90:288–291.
- Robe LB, Gromisch DS, Iosub S. Symptoms of neonatal ethanol withdrawal. Curr Alcohol. 1981;8:485–493.
- Scott CS, Decker JL, Edwards ML, et al. Withdrawal after narcotic therapy: A survey of neonatal and pediatric clinicians. Pharmacotherapy. 1998;1308–1312.
- Tobias JD. Tolerance, withdrawal, and physical dependency after long-term sedation and analgesia of children in the pediatric intensive care unit. Crit Care Med. 2000;28:2122–2132.
Acute Drug Withdrawal - CODES
Acute Drug Withdrawal - icd9
- 292.0 Drug withdrawal
- 779.5 Drug withdrawal syndrome in newborn
Acute Drug Withdrawal - PATIENT TEACHING-MED
Patients or parents should be aware of withdrawal symptoms to be vigilant for detecting future events.
Acute Drug Withdrawal - prevent
Drug abuse prevention is appropriate for all children.
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
More About Alcohol Withdrawal
More Medical Textbooks Online about Alcohol Withdrawal
Review other book chapters online related to Alcohol Withdrawal:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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