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Table 1 provides general guidance on onset and duration of withdrawal symptoms Drug Approximate time to onset of withdrawal symptoms Opioids Heroin 24-48 hours; duration of withdrawal up to 8-10 days; earlier shorter withdrawal compared to prescription opioids Opioids 36-72 hours; duration of withdrawal up to 10-30 days Buprenorphine 36-60 hours; duration of withdrawal up to 28 or more days; onset maybe delayed especially with higher doses Methadone 48-72 hours; duration of withdrawal up to 30 or more days; later onset and longer withdrawal Nonopioids Alcohol 3-12 hours Methamphetamines 24 hours; duration of withdrawal up to 7-10 days; can see immediate withdrawal TCAs 24-48 hours; duration of withdrawal up to 2-6 days SSRIs 24-48 hours; duration of withdrawal up to 2-6 days Inhalants 24-48 hours; duration of withdrawal up to 2-7 days Neonate Clinical Signs Consistent with Withdrawal · Central nervous system o High pitched cry, irritability, unexplained/excessive jitteriness, hypertonia, disorganized sleep, sneezing, hiccups, unexplained seizures, CVA or other vascular accident, NEC in full-term newborn o Seizures occur in 2 to 11 percent and are a serious manifestation of withdrawal. These should be treated immediately (Kocherlakota, 2014). · Autonomic nervous system o Unexplained apnea, unexplained SGA based on gestational age, diaphoresis, fever, mottling, temperature instability, mild elevations in respiratory rate and blood pressure · Gastrointestinal o Drooling, diarrhea, vomiting, poor feeding, poor weight gain, uncoordinated and constant sucking · Other o Congenital abnormalities suspected to be related to maternal drug use or excessive substance use such as alcohol Assessment of Neonate Assessment Tool Description Validation Finnegan Neonatal Abstinence Severity Score (NASS) 32 items; each assigned a weight from 1 to 5 points based on potential for clinically adverse effects. Infants are scored two hours after birth, and then every four hours for the first five days of life, or until symptoms abate. It is recommended that pharmacologic treatment be initiated if the neonate scores eight or more on three consecutive scorings. Evaluated in two different groups of neonates with NAS. Treatment time and length were found to decrease in the NAS scoring group and significantly fewer of these neonates required drug treatment. Inter-rater reliability ranged from 0.75 to 0.96. Modified Finnegan Neonatal Abstinence Severity Score 21 items from the original Finnegan organized within three categories (central nervous system, gastrointestinal, and metabolic).