The Stages of Withdrawal: Understanding the Process and Managing Symptoms

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Addiction seriously impairs a person’s power to choose. Even after addiction has caused job loss, housing loss, and the loss of important relationships, saying no to a substance of choice can feel downright impossible. Substance abuse alters brain chemistry and brain functioning in ways that make prolonged abstinence unbearable.

Failed efforts to go “cold turkey” aren’t the result of insufficient motivation, effort, or commitment. Relapsing addicts aren’t lazy or inconsiderate. Instead, they’re fighting the long and difficult battle of withdrawal and facing its many physical, mental, and emotional challenges. Find out about the stages of withdrawal, the symptoms it entails, and the best strategies for clearing this all-important hurdle in recovery.

Understanding Withdrawal

Underestimating the duration and intensity of withdrawal is one of the biggest and most common mistakes that people make when starting recovery. Many people assume that if they can just make it through the first day, they’ll be fine in about a week. Unfortunately, alcohol, opiates, benzodiazepine drugs, and other habit-forming substances radically alter the brain’s dopamine pathways and its chemical messengers.

Neutrotransmitters: Mood-Boosting Chemical Messengers and Their Burnout

When people use drugs or alcohol, they artificially trigger the release of mood-boosting, “feel-good” chemicals by activating the reward pathway in the central nervous system (CNS). This is what creates the relaxed, euphoric feelings that people experience when “high”. The chemical messengers or neurotransmitters activated during this process are eventually worn out by repeated substance use. Even when people are still actively using substances, the affected neurotransmitters might misfire or perform abnormally in other ways.

These changes in chemical brain functioning can cause depression, anxiety, aggression, and the desire to use again. This is why people often need to use more of their preferred substances to create the same effects they once experienced. Worse still, many of the neurotransmitters, neural pathways, and brain functions affected by substance abuse have an impact on basic physiological functions as well, including:

• Smooth muscle control
• Temperature regulation
• Nausea regulation
• Balance
• Coordination
• Memory and cognition

When people in withdrawal feel poorly, it’s not simply because they want their drugs of choice. It’s because their brains and bodies no longer know how to function without them. At its most basic, withdrawal is a prolonged state of extreme physiological and psychological distress.

The Physiological and Psychological Mechanisms Behind Withdrawal

Misfiring neurotransmitters are hardly the only cause of withdrawal and withdrawal symptoms. Artificially activating the reward pathway to trigger the release of dopamine and other “feel-good” chemicals changes how this pathway works.

Drug use conditions both the individual and their brain to expect immediate relief. For some drugs, complex changes in the reward pathway can also intensify a person’s perception of pain in instances in which elevated pain responses aren’t required. Weeks, months, or even years of triggering the reward pathway can additionally result in diminished impulse control, lowered pain tolerance, and a decreased ability to feel good without artificial stimulation.

The Physiological and Psychological Effects of Different Substances

Although there are similarities across nearly all types of substance withdrawal, withdrawal can look different for each drug and person.

Alcohol

Two neurochemicals contribute to both the heightened euphoria that people experience when drinking alcohol and the development of alcohol withdrawal symptoms. These are glutamate and gamma-aminobutyric acid (GABA). GABA has a naturally calming effect on the body and plays a major role in relieving fear, stress, and anxiety. It does this by inhibiting communication between nerve cells. Decreased levels of this inhibitory neurotransmitter are associated with various mental health conditions. Decreased levels of GABA during alcohol detox are commonly associated with breathing troubles.

Physiologically, GABA also functions as an:

• Antidiabetic
• Diuretic
• Natural tranquilizer
• Respiratory modulator

In alcohol withdrawal, these and many other GABA-dependent functions are affected.

Glutamate is an excitatory neurotransmitter. Where GABA inhibits nerve activity, glutamate triggers it. It’s the most abundant excitatory neurotransmitter within the brain and it’s heavily associated with learning and memory. During alcohol withdrawal, glutamate can misfire. Too much glutamate causes problems like excitability, aggression, anger, and intensified feelings of emotional and physical pain.

Both heavy and long-term drinkers should always seek medical and mental health support when detoxing. If the earliest symptoms of alcohol withdrawal are not properly managed, they can lead to a potentially fatal set of withdrawal symptoms known as delirium tremens.

Opioids

The human body naturally mutes pain receptors by releasing endorphins. Endorphins are opioid neuropeptides or natural opioids. Prescription and illicit opioid drugs take the process further by docking on opioid receptors and stopping all electrical impulses from traveling through them. When these drugs make their way into the brain’s locus ceruleus, they decrease alertness, cause constipation, slow respiration, and more. When heightened, many of these same physiological effects are associated with overdose.

Unfortunately, when opioids are taken away, formerly suppressed neurons fire extensively. The effects are felt across many basic physiological functions and in significantly reduced pain tolerance and mood balance. Without the benefits of medical and mental health support, opioid withdrawal can prove deadly. Problems like persistent diarrhea and vomiting can lead to severe dehydration and a condition known as hypernatremia. In hypernatremia, blood sodium levels soar and may cause heart failure.

Benzodiazepine Drugs

Benzodiazepine drugs or benzos are highly addictive. Benzos increase firing of the dopamine neurons and artificially trigger the release of GABA. Like alcohol, when too much are used or when benzos are suddenly taken away, they can affect smooth muscle control, respiration, and many other essential functions. People in unmanaged benzo withdrawal can experience intense anxiety and panic attacks, hallucinations, and seizures. Rapid withdrawal from benzos can also lead to psychotic episodes, convulsions, and a higher likelihood of protracted or post-acute withdrawal symptoms (PAWS). Due to GABA’s impact on respiration, unmanaged benzo detox can also have fatal consequences.

Stimulants

Stimulants increase brain activity by disrupting, increasing, or modifying normal communication between the brain and neurons. As with all other addictive substances, stimulants also trigger the reward pathway. Stimulants activate norepinephrine and dopamine. Dopamine incites feelings of euphoria that make people want to use stimulants again. Norepinephrine gears the body for action.

Stimulant withdrawal-induced anxiety has strong ties to relapse. This intense anxiety is the result of changes in the amygdala wrought by overstimulation of norepinephrine.

Taking stimulants away suddenly by going “cold turkey” can also cause:

• Uncontrollable drug cravings
• Erratic sleep
• Severe anxiety
• Unstable emotions

When detoxing or crashing from stimulants, people often experience lethargy.

The Stages of Withdrawal

Withdrawal occurs in several distinct stages. Although acute, early withdrawal symptoms often last just several days or weeks, post-acute withdrawal symptoms could continue a year or more.

The Anticipatory State

When people make commitments to quitting drugs, they’re often terrified of how their bodies will feel when substances leave their systems. They may have experienced withdrawal symptoms before due to limited drug or alcohol access or during prior, spontaneous efforts to quit.

During the anticipatory stage, overwhelming fear and anxiety are paired with strong cravings. The anticipatory stage often occurs just before a substance has completely exited a person’s body. Entering a detox facility while the resolve to quit remains stronger than the desire to use works best. Clients can get medical and mental health support for their discomfort. Secure, closed campuses also greatly limit access to substances.

The Acute Withdrawal Stage

Acute withdrawal starts shortly after drugs or alcohol exit a person’s system. Acute withdrawal symptoms may begin within just hours of cessation. Common symptoms include:

• Nausea
• Sweating
• Shaking
• Anxiety
• Insomnia
• Mood swings

For some substances, acute withdrawal symptoms last just two to four days. For others, acute withdrawal symptoms could last between one and three weeks. In addition to substance type, the duration of symptoms for acute withdrawal is also affected by factors like age, gender, general health, and the health of the filter organs.

The Early Withdrawal Stage

In early withdrawal, acute symptoms like nausea, vomiting, and dizziness largely abate. For most people, acute symptoms are either gone or increasingly less severe. Early withdrawal typically begins within seven to 14 days of abstinence and can last for several weeks.

The most common symptoms in the early withdrawal stage include:

• Persistent anxiety
• Irritability
• Mild physical symptoms
• Emotional instability

Muscle pain and intense hunger or appetite loss are also common symptoms of early withdrawal.

The Protracted Withdrawal Stage

Post-Acute withdrawal symptoms or PAWS are the withdrawal symptoms experienced during the protracted withdrawal phase. This phase can last for several months or several years.

People who successfully complete the first one to six months of recovery often wonder why they feel so poorly and if they’ll ever feel good or happy again. This stage is evidence of substance abuse’s significant impact on brain health. Fortunately, PAWS symptoms are manageable and possible to mitigate with the right lifestyle choices and mental health support.

Symptoms of the protracted withdrawal phase include:

• Periodic drug cravings
• Mood swings
• Fatigue
• Anxiety
• Insomnia

The protracted withdrawal stage is also often a time of low motivation.

Withdrawal Symptoms for Common Substance Types

Detoxing from alcohol can feel very different from detoxing from methamphetamine. For each substance type, there are different symptoms and different medical and mental health risks involved.

Alcohol Withdrawal

Early symptoms of alcohol withdrawal can start within just six to 12 hours of stopping or limiting consumption. They include:

• Excessive sweating
• Restlessness
• Shaking
• Loss of appetite
• Nausea
• Headache

Peak symptoms begin within 24 to 48 hours of cessation and may include:

• Heart palpitations
• Increased heart rate
• Elevated blood pressure
• Vomiting
• Hypothermia or poor temperature regulation

When the early symptoms of alcohol withdrawal are unmanaged or poorly managed, people can develop delirium tremens or the DTs. These dangerously severe symptoms of alcohol detox include visual and auditory hallucinations, extreme agitation, seizures, and respiratory distress.

Opioid Withdrawal

The early symptoms of opioid withdrawal start within just six to 12 hours of stopping short-acting opioids and within 30 hours of stopping long-acting opioids. They include:

• Yawning
• Runny nose
• Sneezing
• Agitation
• Headache
• Intense craving

Peak symptoms of opioid withdrawal typically manifest within 72 hours of cessation. They include:

• Sweating
• Shaking
• Hot and cold flashes
• Nausea
• Vomiting
• Diarrhea
• Watery eyes

People typically experience intense muscle and joint pain throughout this time along with heightened pain sensitivity.

The prolonged systems of opioid withdrawal include:

• Focusing and memory difficulties
• Lack of motivation
• Mood swings
• Depression
• Anxiety
• Drug cravings

Benzodiazepine Withdrawal

Benzodiazepine drugs are often unsafe to detox without medical support. People are safest when using replacement medications that gradually step their doses down.

The early symptoms of benzodiazepine withdrawal manifest within just one to four days of cessation and include:

• Headaches
• Heart palpitations
• Muscle pain
• Intense anxiety
• Tremors
• Nausea
• Panic attacks

In unmanaged detox and with total cessation rather than “stepped-down” dosing, seizures and breathing trouble may occur.

Peak symptoms of benzodiazepine detox occur within one to two weeks of cessation and include difficulty concentrating, insomnia, memory challenges, depression, and lack of motivation. The prolonged or post-acute withdrawal symptoms of benzo withdrawal can last months or years.

Managing Withdrawal Symptoms

For alcohol, opioids, stimulants, and benzodiazepine drugs, medical supervision for detox is highly advised. With around-the-clock medical and mental health support, there’s little risk of having potentially dangerous withdrawal symptoms spiral out of control.

Medical Supervision

Medically assisted treatment (MAT) offers timely interventions for severe withdrawal symptoms without exposing patients to potentially habit-forming medications. For people detoxing from benzodiazepine drugs and opioids, alternative medications can ease the brain and body off substances and limit physiological and psychological distress. In medically supervised detox, patients receive ongoing monitoring of their vital signs and interventions to prevent or mitigate common problems such as dehydration, elevated blood pressure, and breathing difficulties.

Psychological Support

Mental health support eases symptoms such as heightened anxiety and depression. Both medical and mental support also leverage tools for minimizing common challenges with insomnia and other sleep troubles.

Psychological support is a critical element of the detox process for those with undiagnosed and untreated mental health disorders. Mental health disorders that occur simultaneously with either substance use disorder (SUD) or alcohol use disorder (AUD) are called co-occurring disorders. Co-occurring disorders include:

• Bipolar disorder
• General anxiety disorder
• Post-traumatic stress disorder (PTSD)
• Panic disorder
• Major depressive disorder

Many people use drugs or alcohol to self-treat these and other co-occurring disorders. Abstinence can intensify the mental and emotional pain they cause. Untreated co-occurring disorders are a major risk factor for relapse.

Therapy and Counseling

Therapy and counseling provide people in recovery with new tools for managing stress and other discomfort. In private and group therapy, patients learn healthy coping strategies such as deep-breathing, meditation, and mindfulness. They also explore the many underlying causes of addiction, such as early-life trauma, unprocessed guilt or grief, and feelings of low self-worth.

Group therapy provides a sense of camaraderie. It also gives patients a chance to learn from one another and build important social skills, including communication skills and boundary-setting.

Lifestyle and Self-Care

The duration of post-acute withdrawal symptoms is daunting. However, people can improve their quality of life throughout this time and their likelihood of long-term success with the right lifestyle choices and diligent self-care. Among some of the best ways to minimize the effects of PAWS are:

• Staying hydrated
• Eating nutritious foods
• Getting plenty of exercise
• Engaging in positive social activities
• Building and maintaining meaningful relationships
• Developing new hobbies
• Engaging in fulfilling work

Good sleep hygiene is invaluable throughout this time. When insomnia persists, people in recovery should seek appropriate medical care.

Medications

Medically assisted detox uses select medications to support patients throughout the challenges of acute and post-acute withdrawal. Among some of the more commonly used medications in detox facilities are:

• Buprenorphine
• Phenobarbital
• Methadone
• Anti-convulsants
• Sleep aids

When patients have co-occuring disorders, antidepressants, antipsychotics, mood stabilizers, and anxiolytics are prescribed as needed.

The Benefits and Risks of Pharmacological Intervention

Successful pharmacological intervention minimizes the risks of severe withdrawal symptoms without causing new addictions. It makes the withdrawal process easier and helps people in recovery avoid relapse as their brains and bodies heal. However, detox professionals typically limit the distribution of pain-relieving drugs as a way to encourage patients to build their pain tolerance.

Too much medication for relieving either physical or psychological pain does not give the reward pathway opportunity to resume normal functioning. Developing pain tolerance is a key step in learning how to function in the real world without using drugs or alcohol for their pain-muting effects.

Long-Term Recovery and Relapse Prevention

Structured relapse prevention plans greatly minimize the risk of relapse. They also give people in recovery solid strategies for rebounding after relapse occurs. Relapse is so common during the first one to five years of recovery that its’s now considered part of the recovery process.

Developing a Recovery Plan

Establishing balanced and sustainable lifestyles helps people succeed in recovery. After all, issues like homelessness, joblessness, and lack of social support are among the top risk factors for relapse. Sober living facilities, outpatient rehab programs, support groups, and sobriety meetings are all great places to find resources for establishing stability.

Devising formal and structured relapse prevention plans helps people anticipate challenges and devise effective strategies for overcoming them. Relapse prevention plans include strategies for:

• Building multi-pronged support teams
• Setting realistic goals and milestones
• Understanding personal stressors and triggers
• Recognizing the earliest stages of relapse
• Including family, friends, and support groups in long-term recoveries

Relapse prevention plans should additionally include strategies for overcoming cravings and temptation by applying new coping skills.

Conclusion

Withdrawal is far more than abstaining from substances and learning how to live without them. It’s a time of intense physiological and psychological distress and neurological healing. People who start and complete the withdrawal process with adequate medical and mental health support have a much lower risk of relapsing. They can also avoid many serious, detox-related health issues. If you’re battling addiction or if someone you care about needs withdrawal support, get help today!