Drug Withdrawal; Symptoms and Treatments
Drug Withdrawal Definition: group of symptoms that occur as a result of a decrease or stopping intake of a medication, recreational drugs or substances, to which the individual has become dependent.
To experience withdrawal, a mental or physical dependence to the substance of use must be present. Different substances have differing symptoms and different timelines of withdrawal (how long withdrawal lasts).
Addictive substances change the way the brain regulates mood and processes emotions. This change causes a rapid increase of dopamine (what is dopamine?) and serotonin neurotransmitters (types of neurotransmitters) in the brain, creating artificial feelings of euphoria or pleasure, a.k.a, the ‘high’. We experience withdrawal symptoms after our body has developed a dependence on the substance and subsequent “high”
Different substances and drugs have different symptoms of drug withdrawal and different drug withdrawal timelines. The severity of the symptoms and the duration of the symptoms, is influenced by several factors:
- Level of dependency – how often the individual needs to get their ‘fix’.
- Length of time abusing the substance – how long has the individual been dependent / addicted? (months/years)
- Type of substances abused – illegal drugs such as heroin, cocaine, prescription drugs such as codeine, alcohol, nicotine.
- Method of abuse – smoking, injecting, swallowing, snorting
- Dose taken each time
- Family history
- Medical history
- Mental health history
Drug Withdrawal: Why do we become addicted?
Certain drugs and substances trigger an increase of the ‘feel good’ neurotransmitter, dopamine, in the brains reward system, which makes taking the drug pleasurable, leading to addiction.
Drug Withdrawal: Changeset point model (Koob and LeMoal 2001)
According to this model, the mesolimbic pathway (brain’s reward system) is naturally calibrated to release enough dopamine into one of the brain parts, the nucleus accumbens, to produce normal levels of pleasure. Drugs and addictive substances re-calibrate the brain’s reward pathway, leading to a reduction in the release of dopamine and an increase in the release of nor adrenaline, in the absence of the drug.
Drug Withdrawal: Cognitive deficits model
Individuals who develop an addiction have abnormalities in the prefrontal cortex (PFC), making them more susceptible to dependency. This is because the normal functioning PFC helps us to overcome the impulse for immediate reward by sending inhibitory signals to the ventral tegmental area’s dopamine releasing neurons in the mesolimbic system. In those with addiction, this inhibitory mechanism is defective as a result of abnormalities in the PFC.
Drug Withdrawal: Neuroscience of Addiction
Opiates travel through the bloodstream, crossing the blood brain barrier, and attach to receptors on opiod sensitive neurons.
Cocaine binds to dopamine reuptake transporters, increasing levels of dopamine in the synapses. This increase in dopamine is what results in the ‘high’.
The binding of these chemicals to receptors triggers the biochemical process that causes us to feel pleasure. Opiods and other drugs activate the mesolimbic reward system. This in turn generates a signal in the ventral tegmental area, which triggers a release of dopamine in the nucleus accumbens. This sequence of brain activity is what gives rise to the feelings of pleasure drug user’s experience.
The hippocampus creates long-lasting memories of good feelings experienced when taking drugs, also known as conditioned associations. The creation of these memories is what lead to cravings of the drug/substances when in situations associated with these memories. For example, when a recovering alcoholic walks past a bar, they may experience an intense craving for a drink, as result of a memory that associates drinking to feeling relaxed.
Drug Withdrawal: Opiates
Increases feelings of pleasure and reduces feelings of pain. Heroin and prescription drugs such as Oxycodone, Vicodin, morphine, codeine and Methadone all belong to the opiate family. Opiate based substances all highly addictive. Drug withdrawal from opiates produces both physical and psychological symptoms. Withdrawal from opiates occurs in two phases; early and late.
Early phase: Symptoms in this phase, include flu-like symptoms such as muscle aches. Other symptoms in this phase are insomnia, agitation, anxiety (generalized anxiety disorder), and excessive sweating.
Late phase: In this phase individuals are likely to experience nausea, vomiting, chills, diarrhea, abdominal cramps, and also likely to have dilated pupils. Withdrawal from opiates can last as little as weeks long.
Drug Withdrawal: Benzodiazepines
These include prescription drugs they used to treat anxiety panic disorders and seizures (overcoming anxiety and panic attacks with medication). Benzodiazepines are often used to relax an overactive fight or flight to reflex in individuals with anxiety or stress. These types of drugs are also used as muscle relaxants and to aid sleep. Benzodiazepines activate GABA neurotransmitters which act as natural sedatives. Once dependency to benzodiazepines has been established, withdrawal can cause a major drop in GABA neurotransmitters, which can increase levels of anxiety and insomnia whilst the brain tries to regain its balance. Symptoms and benzodiazepines withdrawal include:
- Panic attacks
- Difficulty concentrating
- Short term memory loss
- Disturbed sleep
- Muscle pain and stiffness
- Irregular heart rate
More serious side-effects include:
- Extreme confusion
In most cases, symptoms last for a few months. However, in more severe cases symptoms can last a number of years.
Drug Withdrawal: Cocaine
When taken, this substance increase heart rate, body temperature, blood pressure, energy levels and confidence. It also creates an extreme state of euphoria, which is extremely short lived.
Withdrawal from cocaine has 3 phases:
- Phase 1 – The ‘crash’. This phase lasts for about 4 days. Withdrawal symptoms included increased appetite, sleeping more than usual, and feeling extremely depressed and agitated.
- Phase 2 – Acute withdrawal. This phase lasts around 3 weeks and is characterised by irritability, fatigue, depression, insomnia, anxiety and intense cravings for the substance.
- Phase 3 – Extinction period. During this phase, cocaine cravings and depression are still present. This phase can last for several months.
Drug Withdrawal: Alcohol
Withdrawal symptoms from alcohol include:
- Nausea and vomiting
- Muscle aches
- Clammy skin
- Trouble concentrating
- Loss of appetite
- Elevated heart rate
- Mood swings
Treating withdrawal symptoms
The most common way of tackling withdrawal symptoms is to use medicine or behavioural therapies.
Medication based therapies – Medication based therapies fall into three categories.
- Substitution therapy involves, swapping the drug of abuse for a less harmful alternative. Individuals addicted to heroin are often placed on highly controlled methadone or buprenorphine medication regimes. In smoking cessation programs, nicotine patches can be used to manage withdrawal symptoms. Furthermore, anxiety medication and antidepressants are often prescribed to patients recovering from cocaine addiction, in order to reduce the associated depressive and anxiety related symptoms. The use of drug substitution therapies can be successful in preventing relapse, by relieving physiological withdrawal symptoms.
- Inducing an aversive state using medication. To treat alcoholism, disulfiram is often used to induce aversive symptoms when alcohol is consumed. When alcohol is consumed, the medication speeds up the hangover state, so that within 5 -10 minutes of drinking, the individuals begins to experience hangover symptoms. The medication induced rapid hangover can last for hours, thus acting as a punishment for consuming alcohol.
Drug therapies are far from the perfect answer for treatment of addiction and drug withdrawal. Although successful, they require long-term commitment in order to be effective. Furthermore, as with any medication, treatment can have negative side effects.
- Contingency management – Recovering addicts are rewarded for maintaining their abstinence. With this kind of therapy, the addict is positively rewarded when they test negative for drugs in their system. The individual may receive a number of incentives and rewards, like meal or shopping vouchers. This technique is useful for short term withdrawal management, as it can motivate individuals to sustain between drug tests. However, long-term contingency management is much more difficult because the cost of these rewards can become significant. Nevertheless, this type of therapy has been moderately successful in managing addiction and withdrawal.
- CBT (Cognitive behavioural therapy) – This method of behavioural therapy can aid recovering addicts to recognise and cope with situations in which they are more likely to use drugs. This type of therapy teaches individuals to be more conscious of their behaviour, so as to prevent automatic drug taking behaviour. By acknowledging and avoiding situations that elicit cravings (and activate brain circuits involved in addiction), CBT has the same effect as antidepressants on the limbic circuitry (are antidepressants for you?).
Drug withdrawal is extremely complex and can be affected or altered by a number of different factors. Although there are treatments are available, their efficacy is highly dependent on the addict’s commitment to their sobriety. Nevertheless, with the right combination of treatments and willpower, drug dependency can be overcome.
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Milton, A. L., & Everitt, B. J. (2012). The persistence of maladaptive memory: addiction, drug memories and anti-relapse treatments. Neuroscience & Biobehavioral Reviews, 36(4), 1119-1139.