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Drug and Alcohol Withdrawal

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Many substances of abuse can lead to the development of physiological dependence—especially if they are taken in large amounts and for a long period of time. When a person becomes dependent on a substance and then decides to stop using it, they may be at risk of experiencing unpleasant withdrawal symptoms.1

If you are a loved one are struggling with substance use and want to get help, it’s important to understand how withdrawal can affect you. This page will help you learn more about:

  • Withdrawal symptoms.
  • Causes of withdrawal.
  • Treatment for withdrawal symptoms.
  • Detoxification.
  • Medication-assisted treatment (MAT).21
  • Effectiveness of addiction treatment.

What is Drug or Alcohol Withdrawal?

Drug or alcohol withdrawal involves the physical, mental, and behavioral changes that can occur after suddenly cutting back on or stopping prolonged use of substances.1, 2, 3 The character and severity of withdrawal can vary in association with different substances, but symptoms may be quite pronounced when people are attempting to quit alcohol and other substances such as opioids, benzodiazepines, and sedatives.3

Substances like opioids, alcohol, and sedatives, can carry significant risks when going through withdrawal. These withdrawal symptoms can range from mild to potentially dangerous. Medical detox can be a safe way to help manage withdrawal under the care of treatment professionals.3, 4

Causes of Withdrawal

The human body strives to be in a state of balance, known as homeostasis, and actively works to restore any imbalances that arise.5 Drinking and using drugs can greatly alter certain types of brain activity to disrupt normal homeostasis. Over time, when you use a substance regularly, your brain may make its own adjustments (i.e., neuroadaptations) to counter the chemical changes brought about by that specific substance.6

However, once you cut back or stop using, your brain may temporarily struggle to reach homeostasis again. It is this period of adjustment, which may involve a rebalancing of a number of chemical messengers known as neurotransmitters, that is thought to lead to withdrawal symptoms for several types of substances.5, 6

In other terms, these neuroadaptations resulting from continued drug or alcohol use lead to the development of physiological dependence. Dependent individuals grow so accustomed to the presence of a substance that they essentially rely on its continued use to feel and function normally.6, 7, 8 People with substance dependence are likely to experience some degree of withdrawal when attempts are made to slow or altogether stop their substance use.

Types of Withdrawal Symptoms

Withdrawal symptoms can range from mild to severe, depending on the substance being used.1, 3, 4 They also depend on how long and how heavily you’ve been using.1, 5 Withdrawal symptoms can be difficult to deal with and may lead people back to using the substance in an effort to alleviate the discomfort.3

You can experience withdrawal symptoms for various types of substances.3 Significantly severe withdrawal syndromes are associated with substances such as alcohol, benzodiazepines, and opioids. Stimulants and marijuana are other substances that are associated with potentially uncomfortable withdrawal syndromes, though symptoms are often relatively less pronounced than those experienced during opioid, alcohol, and benzodiazepine withdrawal.3 The following sections give more detail about substance-specific withdrawal symptoms.

Alcohol Withdrawal

Alcohol withdrawal symptoms can start between 6 to 24 hours after heavy, prolonged drinking is stopped. Symptoms can progressively worsen over the next 2-3 days, then slowly improve until they are resolved by about the 10th day.3, 4 Some potential symptoms of alcohol withdrawal include:3, 4

  • Anxiety.
  • Irritability.
  • Restlessness.
  • Insomnia.
  • Nightmares.
  • Sweating.
  • Rapid heart rate.
  • Increased blood pressure.
  • Nausea or vomiting.
  • Hand tremors.

Acute alcohol withdrawal can be dangerous and potentially life-threatening.4 Severe symptoms can include agitation, seizures, and delirium tremens, which involves difficulty regulating body temperature and blood pressure, sweating, hallucinations, and confusion.3, 4, 5, 10 Some of the symptoms of alcohol withdrawal can be dangerous and could require immediate medical attention.4 Medical detox and withdrawal management can help keep people as safe and comfortable as possible during this difficult period of early recovery.

Benzodiazepine Withdrawal

Benzodiazepines are central nervous system depressants commonly prescribed to manage anxiety, panic disorder, and certain seizure disorders.4, 8 Some examples of benzodiazepines include: 3, 4, 8, 11

  • Alprazolam (Xanax).
  • Diazepam (Valium).
  • Lorazepam (Ativan).
  • Clonazepam (Klonopin).

Mixing benzodiazepines with opioids or other CNS depressants such as alcohol, can lead to dangerous levels of sedation and respiratory depression, increasing the side effects and the risk of a fatal overdose.8, 11, 12

Though the time of onset may vary, withdrawal symptoms following prolonged benzodiazepine abuse can appear within hours to days after stopping relatively short-acting benzodiazepines such as Ativan, or within several days to a week after you stop taking longer-acting benzodiazepines such as Valium.3

Shorter-acting benzodiazepine withdrawal symptoms might take a few days to peak in intensity, with many symptoms then resolving within 4-5 days. Longer-acting benzos might lead to withdrawal symptoms that peak in the 2nd week and largely resolve by the third or fourth week, though lower-intensity symptoms may linger in some individuals for several months and take up to 8 weeks to resolve.3 Potential symptoms of benzodiazepine withdrawal include:3, 4, 6

  • Anxiety.
  • Insomnia.
  • Agitation.
  • Restlessness.
  • Irritability.
  • Difficulty concentrating or remembering.
  • Achy or tense muscles.
  • Rapid pulse.
  • Sweating.
  • Hallucinations.
  • Delirium.
  • Increased sensitivity to light, smells, and sounds.
  • Rapid pulse.
  • Sweating.
  • Tremors.
  • Seizures.

Opioid Withdrawal

Opioids are a class of drugs that include illicit drugs such as heroin, as well as prescription painkillers such as morphine, hydrocodone (Vicodin), and oxycodone (Percocet, OxyContin).4, 13

Opioid addiction is commonly associated with opioid withdrawal symptoms when use is stopped.3 While opioid withdrawal isn’t typically life-threatening, there may be some dangerous complications. For example, aspirating vomit into the lungs can lead to infection, and ongoing vomiting and diarrhea can cause dehydration and electrolyte imbalances.4, 13 Symptoms of opioid withdrawal include:3, 4, 5, 6, 13

  • Dysphoria.
  • Anxiety.
  • Insomnia.
  • Dilated pupils.
  • Chills.
  • Goosebumps.
  • Excessive yawning.
  • Runny nose.
  • Watery eyes.
  • Sweating and fever.
  • Increased pain sensitivity.
  • Achy muscles and joints.
  • Nausea or vomiting.
  • Diarrhea.

Stimulant Withdrawal

Stimulant abuse often occurs in patterns of heavy use (known as binges) followed by crashes, where use is stopped, and withdrawal symptoms arise.3 Illicit central nervous system stimulants include crystal methamphetamine, cocaine, or crack. Some prescription stimulant medications such as methylphenidate (Ritalin) and dextroamphetamine (Adderall) are also subject to abuse.3, 4, 14

Stimulant withdrawal is typically not dangerous. Though rare, serious depression with suicidal thoughts or behaviors can be present during detox and should be monitored closely.6, 14 Symptoms of stimulant withdrawal can include:3, 4, 6, 14

  • Agitation.
  • Irritability.
  • Depression or dysphoria.
  • Fatigue.
  • Increased appetite.
  • Changes in sleep patterns—either excessive sleep or insomnia.
  • Nightmares.
  • Restlessness.
  • Moving faster or slower than usual.
  • Aching muscles.
  • Strong cravings for the substance.

Marijuana Withdrawal

Marijuana comes from dried parts of the Cannabis plant containing tetrahydrocannabinol (THC) and other psychoactive compounds.15 If you suddenly stop long-term, heavy use of marijuana, even if it is medical marijuana, it’s possible you may experience withdrawal symptoms for as long as 1 to 2 weeks,
such as:3, 4, 6, 16, 17, 18

  • Irritability.
  • Anger.
  • Aggression.
  • Nervousness.
  • Anxiety.
  • Depressed mood.
  • Restlessness.
  • Cravings for marijuana.
  • Insomnia.
  • Upsetting dreams.
  • Loss of appetite.
  • Abdominal pain.
  • Headache.
  • Sweating.
  • Tremors or shakiness.

Treatment for Withdrawal

Professional detoxification and withdrawal management can provide medical and mental health care for people who are going through withdrawal.4, 19 Medical and psychiatric support and monitoring are available so that any physical and mental health symptoms can be addressed as needed.4, 9, 19 In some cases, medications may be used to ease symptoms of withdrawal and prevent complications from arising during medically-managed withdrawal.9

Withdrawal symptoms, potential risks, and available treatments vary by substance, so the type of withdrawal management you receive will differ accordingly.9 If you are planning to cut back or stop using a substance, you should consult with your doctor or a treatment professional to discuss the risks and determine the safest and most effective form of withdrawal management for you.

Detox

Detoxification programs primarily focus on getting you through the withdrawal process safely and comfortably. Though an important step, detox often does little to address the underlying psychological, behavioral, and social issues that contribute to addiction.2 Detox is only the first stage in the recovery process and should be followed up with additional forms of treatment to be most effective.2, 4

Types of Drug and Alcohol Addiction Treatment

Continuing addiction treatment after withdrawal management, or detox, is an important step toward long-term recovery.9, 13 As you get close to completing detox, your treatment team will discuss a longer-term treatment plan that best suits your needs and will help facilitate your entry into additional treatment, whether it be in the same location as the detox program or elsewhere.

In follow-up treatment programs, you can learn coping skills and relapse prevention techniques, improve your communication skills, and receive medication treatment, if needed.9

Treatment that may include withdrawal can occur in a variety of settings, depending on your needs and the intensity of your withdrawal symptoms.2, 8 There is a continuum of treatment settings where detox and rehab services are available including:2, 22

  • Outpatient: A person can live at home and continue working while receiving treatment. This typically involves less than 9 weekly hours of treatment.
  • Intensive outpatient: A person can live at home and continue working while receiving treatment for complex needs such as co-occurring mental health conditions. This type of treatment typically involves 9 or more weekly hours of treatment.
  • Partial hospitalization: A person can live at home and continue working while receiving treatment for multidimensional instabilities. This typically involves at least 20 weekly hours of outpatient treatment.
  • Residential treatment: A person lives at the treatment facility to receive 24-hour support from medical, mental health, and addiction treatment professionals. This typically involves a minimum of 5 weekly hours of clinical care.
  • Medically-managed Inpatient treatment: A person receives 24-hour nursing care and daily care from a physician to address severe and/or unstable problems. This level of care involves 24/7 medical monitoring plus availability of counseling staff up to 16 hours a week.

As you move through recovery, your treatment plan may need to be reevaluated and adjusted to meet your needs, as they may change.9 Additionally, longer periods of any form of treatment (3 months or more) may be most helpful in reducing drug or alcohol use and improving treatment outcomes.9

Dealing with substance use and withdrawal is difficult and can be overwhelming. You may have questions about withdrawal management and treatment and American Addiction Centers is here to help. Our compassionate admissions navigators are available 24/7 to help you understand treatment options, including where you can receive withdrawal management. Call us at (877) 905-7590 learn more and verify your benefits.

Sources

  1. National Institute on Drug Abuse. Frequently asked questions.
  2. Center for Substance Abuse Treatment. (2015). Detoxification and substance abuse treatment. Treatment Improvement Protocol (TIP) Series, No. 45. HHS Publication No. (SMA) 15-4131. Rockville, MD: Center for Substance Abuse Treatment.
  3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  4. World Health Organization. (2009). Clinical guidelines for withdrawal management and treatment of drug dependence in closed settings. Geneva: World Health Organization.
  5. Gupta, M., Gokarakonda, S.B., & Attia, F.N. (2021). Withdrawal syndromes. Treasure Island, FL: StatPearls.
  6. Lerner, A., & Klein, M. (2019). Dependence, withdrawal and rebound of CNS drugs: An update and regulatory considerations for new drugs development. Brain Communications, 1(1).
  7. National Institute on Drug Abuse. (2017). Tolerance, dependence, addiction: What’s the difference?
  8. National Institute of Drug Abuse. (2020). Misuse of prescription drugs research report.
  9. National Institute of Drug Abuse. (2018). Principles of drug addiction treatment: A research-based guide (Third edition).
  10. S. National Library of Medicine. (2021). Alcohol withdrawal.
  11. Department of Justice/Drug Enforcement Agency. (2020). Benzodiazepines.
  12. National Institute of Drug Abuse. (2021). Benzodiazepines and opioids.
  13. S. National Library of Medicine. (2021). Opiate and opioid withdrawal.
  14. Center for Substance Abuse Treatment. (1999). Treatment for stimulant use disorders. Rockville, MD: Substance Abuse and Mental Health Services Administration.
  15. National Institute of Drug Abuse. (2019). Marijuana drugfacts.
  16. Coughlin, L.N., Ilgen, M.A., Jannausch, M., Walton, M.A., & Bohnert, K.M. (2021). Progression of cannabis withdrawal symptoms in people using medical cannabis for chronic pain. Addiction.
  17. Livne, O., Shmulewitz, D., Lev-Ran, S., & Hasin, D.S. (2019). DSM-5 cannabis withdrawal syndrome: Demographic and clinical correlates in U.S. adults. Drug and Alcohol Dependence, 195, 170-177.
  18. Bahji, A., Stephenson, C., Tyo, R., Hawken, E.R., & Seitz, D.P. (2020). Prevalence of cannabis withdrawal symptoms among people with regular or dependent use of cannabinoids: A systematic review and meta-analysis. JAMA Network Open, 3(4).
  19. American Society of Addiction Medicine. (2020). The ASAM clinical practice guideline on alcohol withdrawal management.
  20. Substance Abuse and Mental Health Services Administration. (2020). MAT medications, counseling, and related conditions.
  21. Center for Substance Abuse Treatment. (2005). Medication-assisted treatment for opioid addiction treatment in opioid treatment programs. Rockville, MD: Substance Abuse and Mental Health Services Administration.
  22. American Society of Addiction Medicine. (2015). What are the ASAM levels of care?

 

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Dr. Thomas received his medical degree from the University of California, San Diego School of Medicine. During his medical studies, Dr. Thomas saw firsthand the multitude of lives impacted by struggles with substance abuse and addiction, motivating him to seek a clinical psychiatry preceptorship at the San Diego VA Hospital’s Inpatient Alcohol and Drug Treatment Program. In his post-graduate clinical work, Dr. Thomas later applied the tenets he learned to help guide his therapeutic approach with many patients in need of substance treatment. In his current capacity as Senior Medical Editor for American Addiction Centers, Dr. Thomas, works to provide accurate, authoritative information to those seeking help for substance abuse and behavioral health issues.
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