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Protracted Withdrawal in Addiction

 

Acute Withdrawal

What most of us think of as drug withdrawal is more accurately known as acute withdrawal; it begins when an addictive substance is stopped abruptly, or its dose reduced. Acute withdrawal is significant distress that occurs at the beginning of a withdrawal syndrome. It is typically more acutely distressful than later stages of withdrawal that may occur. Withdrawal is defined by the American Society of Addiction Medicine as “the onset of a predictable constellation of signs and symptoms following the abrupt discontinuation of, or rapid decrease in, dosage of a psychoactive substance” (1).

Onset of Acute Withdrawal

Each addictive substance has its own time frame for the onset of acute withdrawal symptoms. These begin relatively soon after the regular dose is stopped or reduced. Such symptoms can be stopped with resumed use. In fact, it is the beginning of withdrawal symptoms, or the fear of them, that prompts continued use during addiction.

Some estimated times of withdrawal onset are listed below for various classes of substances. Please note that these are estimates. Individual differences occur. Factors vary among people who use the same addictive substance. The amount and frequency of use, co-occurring health complications, historical extent of use, and other substances used determine the severity of withdrawal.

Also, some specific substances in a class of drugs may stay in the body longer and affect the time it takes for withdrawal to begin after a change in use. For example, the opioid class of drugs is typically thought to cause acute withdrawal symptoms 4-10 days after reduced or stopped use. Methadone, however, which is an opioid, can have delayed acute withdrawal symptoms that take up to 2 weeks to occur. Additionally, there are individual differences that may prolong acute withdrawal such as the need for tapering, or a gradual lowering of dosage, over a longer period for some.

Typical time frames for acute withdrawal from commonly abused substances are:

  • Alcohol 5–7 days
  • Benzodiazepines 1–4 weeks
  • Cannabis 5 days
  • Nicotine 2–4 weeks
  • Opioids 4–10 days
  • Stimulants 1–2 weeks

Protracted Withdrawal

Protracted withdrawal is a prolonged period of distress caused by substance withdrawal. It is sometimes called PAWS or Post-acute Withdrawal Syndrome. It is typically less intense than acute withdrawal and is often likened to a lingering low-level distress. A comparison of acute and protracted withdrawal is much like the difference between an acute episode of flu followed by a prolonged period of lowered immunity, fatigue, overall poor health and vulnerability to another infection (2). It is aptly described in the following statement:

Most clients in treatment for substance use disorders (SUDs) do not immediately feel better after stopping their substance use. In a pattern unique to each client, symptoms related to substance abuse may be felt for weeks, months, and sometimes years. Clients may be affected by less intense versions of the acute signs and symptoms of withdrawal as well as by other conditions such as impaired ability to check impulses, negative emotional states, sleep disturbances, and cravings. These symptoms may lead clients to seek relief by returning to substance use, feeding into the pattern of repeated relapse and return to treatment (2).

Negative Impact of Protracted Withdrawal

Protracted withdrawal can significantly impact the quality of one’s life overall. The chief risk of protracted withdrawal, however, is a return to active addiction. Withdrawal symptoms are a primary cause of relapse.

A return to substance use ‘resolves’ distress at least temporarily. When substances are re-introduced, there is typically a sense of relief in intoxication, however, the addiction progresses, and any relief is temporary, or simply a perception caused by intoxication.

Common Symptoms of Protracted Withdrawal

It is impossible to list all the possible symptoms of protracted withdrawal and its expected course. Individual differences in use history, co-occurring conditions and concurrent life stressors that would exacerbate any distress are important. However, symptoms do fall into discrete categories. Symptoms from various categories may occur simultaneously, or at various times, and in various combinations throughout a period of protracted withdrawal. Symptoms of protracted withdrawal are:

Physical Signs and Symptoms

The brain’s attempts to return to its own regulation without the substance. A simple way to think of this is that neurons are rejuvenating and re-wiring. There is a long list of possible physical symptoms. Some of the most common are tremors, insomnia, fatigue, aches, headaches, night sweats, poor coordination, and poor fine and gross motor skills.

Cognitive Alterations

The cognitive, or intellectual signs and symptoms of protracted withdrawal, can include slowed processing of information, difficulties concentrating, poor retention of newly learned information, impaired decision-making and problem-solving, slowed retrieval of words, usual perceptions and difficulty with abstract thinking.

Memory Disturbances

Memory disturbances are common in protracted withdrawal. Some are what we typically think of as a ‘black out’ phenomenon during addiction. One simply doesn’t recall events that occurred during a period of active substance use. Other types include overall poor short and long term memory as well as fabricated or confused memory.

Mood Disturbances

Mood disturbances in protracted withdrawal can cover the range of all mood disturbances–depression, anxiety, anger, tearfulness and excitement or euphoria, for example. Mood swings are common. There may also be what are known as incongruent moods. These are emotional reactions that seem inappropriate to the context in which they occur.

Sexual Disturbances

Sexual problems are also common. These typically are an inability to become aroused or sustain arousal. Difficulty achieving orgasm is also relatively common.Sexual problems can be related to brain chemistry and neuronal impairments, but also commonly arise overall poor health and from ongoing stress. At times they are related to sexual activity during addiction that cause guilt and remorse in abstinence.

Interactional Problems

Social issues are common during protracted withdrawal, too. There is often a persisting sense of loneliness and a tendency to be withdrawn, isolated and apathetic toward interaction and intimacy. Anxiety and a heightened self-consciousness are typical and can make social situations particularly uncomfortable. Some experience suspicious and paranoia. Guilt, shame, feelings of inadequacy and the fear of judgment and rejection are also common.

Spiritual Problems

Spiritual problems in protracted withdrawal may involve religious conflicts, but they typically manifest in a broader sense. A felt sense of meaningless, having no purpose, feeling empty and disconnected from others and the world are more common.

Common Symptoms and Specific Drugs

Some common protracted symptoms are given below for specific substances. These findings are from research and anecdotal evidence reported by clinicians.

Alcohol

  • irritability
  • anxiety
  • depression
  • hostility
  • mood swings
  • fatigue
  • insomnia
  • poor concentration
  • body aches and pains

Opioids

  • anxiety
  • depression
  • sleep disturbances
  • fatigue
  • irritability
  • emotional flatness
  • poor concentration

Stimulants

  • poor impulse control
  • poor emotional regulation

Marijuana

  • sleep disturbances

Benzodiazepines

  • anxiety
  • panic
  • agitation
  • depression

–above information adapted from references 4-9.

Treatment of Protracted Withdrawal

Acute withdrawal is commonly treated with a variety of support therapies and medical supervision. Gradual withdrawal and the use of medications to ease withdrawal symptoms are common practice. Treatment of protracted withdrawal has remained difficult in mainstream addiction treatment. Chinese Medicine has proven to be effective, however. Particularly the use of Chinese herbalism has been documented as efficacious.

Louisville acupunctureIf you have become abstinent from an addictive substance in the last year to 18 months and have any of the symptoms above, you may benefit from Chinese Medicine. In the Louisville area, you can contact Jeffrey Russell at 502 299-8900 to explore treatment options.

 

References

  1. Ries, R. K., Miller, S. C., Fiellin, D. A., & Saitz, R. (Eds.). (2009). Appendix 1: ASAM addiction terminology. In Principles of addiction medicine (4th ed.). Chevy Chase, MD: American Society of Addiction Medicine.
  2. Scott, C., Foss, M., & Dennis, M. (2005). Pathways in the relapse–treatment–recovery cycle over 3 years. Journal of Substance Abuse Treatment, 28, S63–S72.
  3. Substance Abuse Treatment ADVISORY News for the Treatment Field, Protracted Withdrawal. July 2010 Volume 9 Issue 1
  4. Brower, K. J. (2001). Alcohol’s effects on sleep in alcoholics. Alcohol Research & Health, 25(2), 110–125. 22 Satel, S. L., Kosten, T. R., Schuckit, M. A., & Fischman, M. W. (1993).
  5. Prosser, J., London, E. D., & Galynkera, I. I. (2009). Sustained attention in patients receiving and abstinent following methadone maintenance treatment for opiate dependence: Performance and neuroimaging results. Drug and Alcohol Dependence, 104, 228–240.
  6. Baicy, K., & London, E. D. (2007). Corticolimbic dysregulation and chronic methamphetamine abuse. Addiction, 102(Suppl 1), 5–15.
  7. Fox, H. C., Axelrod, S. R., Paliwal, P. J., Sleeper, J., & Sinha, R. (2007). Difficulties in emotion regulation and impulse control during cocaine abstinence. Drug and Alcohol Dependence, 89, 298–301.
  8. Li-ping, F., Guo-hua, B., Zhi-tong, Z., Yan, W., En-mao, Y., Lin, M., et al. (2008). Impaired response inhibition function in abstinent heroin dependents: An fMRI study. Neuroscience Letters, 438, 322–326.
  9. Budney, A. J., Hughes, J. R., Moore, B. A., & Vandrey, R. G. (2004). Review of the validity and significance of cannabis withdrawal syndrome. American Journal of Psychiatry, 161(11), 1967–1977.

Resources

Chu M. (1996a). Progress of studying acupuncture for drug abstinence. Chinese Journal of Information on Traditional Chinese Medicine 3(1):9.

Chu M. (1996b). Progress of studying acupuncture for drug abstinence (II). Chinese Journal of Information on Traditional Chinese Medicine 3(2):16-17.

Chu M. (1996c). Progress of studying acupuncture for drug abstinence (III). Chinese Journal of Information on Traditional Chinese Medicine 3(3):21-23.

Clinical Toxicology Task Force for Chinese Medicine, Hospital Authority, Hong Kong. 6(2002).

Handbook on Toxicological Aspect of Chinese Medicines. pp 1-6. Goldstein A & Herrera J. (1995). Heroin addicts and methadone treatment in Albuquerque: a 22-year follow-up. Drug Alcohol Depend 40: 139-150.

Guo S, Liang ZN, Wang YD, Hu GC, Wu YM, Huang MS. (1995). A comparative study of Chinese herbal medicine Fukang Pian with clonidine hydrochloride on opiate withdrawal symptoms. Chin Bull Drug Depend 4(4):210-216. Hou JY (Ed). (2002).

Mo QZ, Hu J. (1999). History and current status of traditional Chinese medicine treatment for drug detoxification. Shanghai Journal of Traditional Chinese Medicine (10):45-48. Zhan SY (Ed). (2002). Evidence-based medicine & evidence-based healthcare. Beijing: Beijing Medical University Press. pp 140.

Mo ZX, Ou ZJ, Li M, Zeng YS, Yu LZ. (1999). Experimental studies of Qigong on drug abstinence. Chinese Journal of Somatic Science (1):18-21.

Mo ZX, Wang CY, Luo XY, Zhang XF, Huang YH. (2002). A study on the efficacy of Qingfeng capsules on protracted withdrawal syndrome of detoxified heroin addicts. Chinese Journal of Clinical Rehabilitation 6(23):3588-3589. Part 5: Advances in drug abuse research 395

Shong XG. (2001). The progress of studying on traditional Chinese medicine treatment in drug detoxification. Journal of Anhui College of Traditional Chinese Medicine 20(4):60-62.

Ward J, Hall W, Mattick RP. (1999). Role of maintenance treatment in opioid dependence. Lancet 353:221-226.

Wyshak G & Modest GA. (1996). Violence, mental health, and substance abuse in patients who are seen in primary care settings. Arch Fam Med 5:441-447. Xin YH, Lu Y,

Zhang JP & Zhou M. (1995). Clinical observation of Antidrug II on protracted abstinence syndrome. Neimenggu Journal of Traditional Chinese Medicine 14(4):4. Literature collection Electronic databases Hand search Literature translation Data management system Data computerisation Fig. 1 Flow chart on the establishment of a database of TCM treatment for drug addiction P