Why Withdrawal is So Difficult.

“The giant tree grows from a single seed. A journey of a thousand miles starts with the very first step.” Recovery consists of two basic parts: 1) getting “clean” (in the parlance of my twelve-step program)—discontinuing using, becoming abstinent, and halting the vicious obsessive-compulsive circle of active addiction; and 2) staying clean—remaining abstinent by learning how to live without using in an ongoing way. As hard as getting clean can be, this is actually the easy part in that it only has to happen once. Staying clean is much harder because it’s a continuous, daily process. Mark Twain framed this distinction beautifully when he said, “Quitting smoking is easy, I’ve done it thousands of times.” As difficult as going through inpatient treatment can be, in some respects it’s easy compared to the challenges of continuing the recovery process upon one’s return to home and community. Quality treatment provides a sheltered, supportive, supervised, and safe (emotionally, as well as physically) milieu twenty-four/seven. The most arduous work in recovery commences upon one’s re-entry into the “real world,” outside of the protective cocoon of the treatment environment. A common misconception shared by many people, including those with addiction, their loved ones and friends, and even some less savvy medical and behavioral health professionals, is that very soon after the offending substances are out of the body (upon completion of detoxification or acute withdrawal), life will get noticeably better and “normal” functioning will return. If only that were true. There are actually two distinct phases of the withdrawal process. In early abstinence, the brain’s stores of both endorphins and dopamine are severely depleted. Dopamine, the neurotransmitter that floods the brain during drug use to produce titanic highs, is also involved in the regulation of mood, and a certain amount of it is necessary in order to maintain a “normal” mood. The absence of this necessary threshold of dopamine creates a biochemically based depression. It can take weeks to months for the brain to naturally manufacture enough endorphins and dopamine to replenish its inventory of these vital brain chemicals. Depending on the length and intensity of active addiction—that is, how frequently, how much, and for how long an individual has used substances, the second phase of the withdrawal process can last for weeks or even months after someone has stopped using. This exquisite phenomenon is known as post-acute withdrawal (sometimes referred to as protracted withdrawal). Post-acute withdrawal is a constellation of often brutally uncomfortable symptoms that persist after detoxification, after all physical traces of mind- and mood-altering substances have left the body and brain. Post-acute withdrawal is another consequence of the significant changes to brain anatomy and chemistry created by active addiction over the course of—in many cases—decades of using daily. The brain’s reward system is turned on its head, and its natural ability to cope with stress is undermined. As long as an individual uses drugs, their brain adjusts by decreasing its natural production of endorphins while increasing the number of receptors, making it much harder for the individual to experience pleasure in the absence of using. These symptoms affect many people in the early phases of abstinence from numerous substances, but occur in an extremely high percentage of those with histories of long-term opiate abuse. Post-acute withdrawal varies in intensity and duration from one person to another, again, usually in correlation with the intensity and duration of one’s active addiction. Its manifestations can fluctuate in severity, coming and going in wave- like recurrences, and include impairments in energy, concentration, attention span, memory, sleep, appetite, and mood, such as irritability, anxiety, and depression. Even though it’s a driving factor in many relapses, post-acute withdrawal is often under-recognized and its impacts under-appreciated. Both addicts and their significant others are commonly encouraged to believe that as soon as the high cost of low living is relinquished, life will begin to improve rapidly. When reality fails to fulfill this unrealistic expectation, disappointment sets in. It is not unusual for addicts in very early recovery to return to using, believing that “if this is what being in recovery feels like, screw it; I might as well use!” This blog post is an excerpt from Some Assembly Required – A Balanced Approach to Recovery from Addiction and Chronic Pain by By Dan Mager, MSW; Published by Central Recovery Press (CRP).