Drug withdrawal: symptoms, timelines, side effects, and treatment

Drug withdrawal is the body’s response to discontinuing or reducing drug use. It involves both physical and emotional symptoms as the body adapts to the absence or withdrawal of prescription or recreational drugs.

Symptoms of drug withdrawal include anxiety, depression, irritability, intense cravings, confusion, nightmares, tremors, sweating, chills, nausea, vomiting, diarrhea, pain in stomach, muscle aches, fatigue, insomnia and changes in appetite. 

The timeline of withdrawal is set within 6-24 hours of last use. The peak varies from drug to drug. The acute symptoms usually subside within 7-10 days. After the initial withdrawal from substances like drugs or alcohol, certain individuals undergo prolonged acute withdrawal syndrome (PAWS), during which symptoms endure over an extended period, affecting both physical and mental well-being. 

The long-term side effects of drug withdrawal include psychological challenges, cravings, cognitive impairment, mental health issues, sleep disturbances, interpersonal and social relationship difficulties, physical health problems, risk of relapse and nutritional deficiencies.

Drug withdrawal treatment involves a multifaceted approach to symptom management and recovery support. From medication-assisted detoxification providing relief during the initial stages to behavioral therapy addressing psychological aspects, the process encompasses a comprehensive approach. Engaging in support groups fosters a sense of community, while outpatient programs allow individuals to receive structured care without disrupting their daily lives. Aftercare involves ongoing support, monitoring, and strategies to prevent relapse, contributing to a more effective and personalized recovery plan.

What is Drug withdrawal?

Drug withdrawal refers to the set of symptoms that occur when a person who is physically dependent on a substance abruptly stops or reduces their intake of that substance. This abrupt change disrupts the body’s delicate chemical balance, leading to the onset of unpleasant symptoms, both physical and emotional. The change occurs after a period of prolonged or regular use of drugs or medications. The withdrawal symptoms vary widely depending on the type of drug, the duration of use, and the individual’s overall health.

Substances frequently misused that trigger withdrawal symptoms include opioids (like heroin or prescription painkillers), benzodiazepines (prescribed for anxiety and sleep disorders), alcohol, nicotine, and a variety of illicit drugs. The range of withdrawal symptoms spans from mild discomfort to severe and potentially life-threatening conditions.

Chapter 2 titled “THE NEUROBIOLOGY OF SUBSTANCE USE, MISUSE, AND ADDICTION” in the book Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health published by the U.S. Department of Health and Human Services (HHS), Office of the Surgeon General in 2016, withdrawal is defined as the negative effect stage at which an individual experiences a negative emotional state in the absence of the substance. Withdrawal from substances leads to decreased dopamine activity which diminishes the responsiveness in the brain. This absence can lead to stress, anxiety, or depression, prompting a person to use the substance again to relieve these symptoms. As the habit deepens, impulsive use turns into compulsive behavior, with the focus shifting from seeking pleasure to seeking relief from negative feelings.

This lower reward sensitivity drives compulsive substance use, as individuals seek to regain the pleasure they once derived from the reward system. The article emphasizes that using substances to alleviate withdrawal symptoms creates a negative cycle, making symptoms worse during subsequent attempts at abstinence.

What are the symptoms and signs of Drug withdrawal?

The symptoms and signs of drug withdrawal are listed below.

• Tremors: Tremors observed in hands or other body parts are a common sign of withdrawal. These are involuntary rhythmic movements and are in response to the body’s struggle to adapt to substance absence.
• Sweating: Profuse sweating is indicative of the body’s effort to regulate temperature. Intense sweating occurs as the nervous system adjusts to the absence of the substance, underscoring the physical challenges of drug withdrawal.
• Chills: Chills alternating with fever frequently accompany drug withdrawal as the body undergoes physiological changes.
• Nausea and vomiting: Nausea and vomiting during withdrawal are prevalent symptoms during drug withdrawal. Its intensity varies from mild to severe. 
• Diarrhea: Diarrhea is caused by the body’s attempt to get rid of the toxins and the disruption of the normal functioning of the gut.  
• Pain in Stomach: In withdrawal, abdominal pain and cramps present as a dull, aching, or stitching sensation that leads to a burning feeling in the stomach.
• Muscle aches: Muscle aches during drug withdrawal bring constant discomfort, and drain energy, making simple tasks feel hard. 
• Insomnia: Difficulty in falling or staying asleep accompanied by restlessness is a feature of drug withdrawal. Every hour stretches into an eternity, filled with frustration and despair. 
• Fatigue: Fatigue sets in during drug withdrawal, marked by a significant loss of energy and exhaustion. This is often accompanied by muscle wasting.
• Changes in appetite: Appetite changes, including loss or increased cravings for unhealthy foods, occur during withdrawal from certain drugs.
• Anxiety: Withdrawal brings anxiety, characterized by feelings of nervousness, worry, and restlessness.
• Irritability: Irritability is a prevalent symptom during drug withdrawal, marked by elevated anger, agitation, frustration, and a short temper. The emotional difficulties influence mood and behavior during the withdrawal process.
• Depression: Depression often accompanies drug withdrawal and is characterized by feelings of sadness, hopelessness, helplessness, and worthlessness. 
• Cravings: Cravings, marked by intense urges to resume drug use, are a distinctive symptom of withdrawal from any addictive substance. These strong urges impact insight to overcome addiction.
• Confusion: Withdrawal from drugs involves challenges in clear thinking, accompanied by difficulties in concentration, and making sound decisions.
• Nightmares: In withdrawal, intense and disturbing dreams provoke fear, contributing to difficulty in sleeping and relaxing at bedtime. These distressing dreams are a factor in disrupted sleep patterns during the withdrawal process.

When do withdrawal symptoms start?

The withdrawal symptoms typically start 6-24 hours after the last substance use, exhibiting varying peaks among different drugs. Acute symptoms typically resolve within a week to ten days, yet some individuals may undergo prolonged symptoms over an extended period lasting from a few days to several months. 

The onset and timing of withdrawal symptoms during recovery are contingent on factors such as the type of substance, duration of use, and mode of consumption. Higher or more frequent doses may accelerate the manifestation of withdrawal symptoms.

Withdrawal timelines, as detailed by the World Health Organization in 2009, are available in the chapter “Withdrawal Management” in the book “Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings.” For instance, alcohol withdrawal symptoms emerge within 6-24 hours, peak between 36 and 72 hours, and last for 2-10 days. Likewise, symptoms of stimulant withdrawal commence within 24 hours of the last use and endure for a period of 3-5 days.

What are the expected Drug withdrawal timelines?

The expected drug withdrawal timeline can vary significantly depending on the specific drug, dosage, and individual factors. The expected drug withdrawal timelines are listed below.

• Depressants and sedatives withdrawal timeline
• Heroin and opioid withdrawal timeline
• Stimulants withdrawal timeline
• Alcohol Withdrawal Timeline
• Nicotine withdrawal timeline
• Cannabis withdrawal timeline
• Hallucinogen withdrawal timeline
• Inhalant withdrawal timeline

1. Depressants and sedatives withdrawal timeline

Depressants and sedatives, are a category of drugs that slow the central nervous system, inducing relaxation and drowsiness. Drugs in this category include benzodiazepine, barbiturates, and sleep medications.

For short acting benzodiazepines, medium half-life is 10–20 hours, where the acute withdrawal syndrome may last 2–4 weeks. For long half life benzodiazepines, the withdrawal phase may last 2–8 weeks as per the article “Dependence, withdrawal and rebound of CNS drugs: an update and regulatory considerations for new drugs development” by Alicja Lerner and Michael Klein published by Brain Communications in 2019. Withdrawal symptoms manifest more rapidly when discontinuing shorter-acting benzodiazepines such as alprazolam and lorazepam. On the other hand, using a longer-acting benzodiazepine like clorazepate and diazepam, it may take a bit longer for withdrawal symptoms to emerge. 

The benzodiazepine withdrawal triggers symptoms like sleep disturbances, irritability, anxiety, tremors, and sweating. High doses lead to severe complications like seizures and psychosis. Withdrawal from standard treatment results in various patterns, including “rebound” anxiety, a 10-14 day withdrawal syndrome, or a return of persistent anxiety symptoms.

2. Heroin and opioid withdrawal timeline

Heroin and opioid are a broad group of pain relieving drugs that are processed from poppy plants. Heroin is a highly addictive substance as defined in the Department of Justice/Drug Enforcement Administration’s “Heroin-Drug Fact Sheet” in 2020 by the United States Drug Enforcement Administration.

Referred to as opiates, painkillers, or narcotics, opioids share a common mechanism by activating receptors that interrupt pain signals in the brain, providing relief. Examples encompass morphine, heroin, codeine, oxycodone, hydrocodone, and fentanyl. Heroin, a derivative of morphine, takes various forms, such as white or brown powder or a sticky black substance known as black tar heroin.

Short-acting opioids, like heroin, initiate heroin withdrawal symptoms 8-24 hours post-last use, lasting 4-10 days. Long-acting opioids, such as methadone, trigger withdrawal symptoms 12-48 hours after cessation, with a duration spanning 10-20 days, according to the World Health Organization in 2009 in their book “Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings”.

3. Stimulants withdrawal timeline

Stimulants are a drug category that accelerates the central nervous system, enhancing alertness, energy, and focus. They act as potent counterparts to caffeine, exerting stronger effects. Stimulants flood the brain with dopamine and norepinephrine, elevating focus, energy, and euphoria. They disrupt natural fatigue signals, prolonging wakefulness. Examples include prescription stimulants like Adderall, and Ritalin; illegal stimulants such as cocaine, and methamphetamine; and over-the-counter stimulants like caffeine in coffee, tea, and energy drinks.

As detailed in the 2019 article “Dependence, withdrawal, and rebound of CNS drugs: an update and regulatory considerations for new drugs development” by Alicja Lerner and Michael Klein in the Brain Communications Journal, the cocaine withdrawal process comprises three phases: crash, withdrawal, and extinction.

The crash phase initiates as stimulant effects diminish, lasting several days, marked by fatigue, a flat emotional state, increased sleep, and reduced cravings, with the potential for severe depressive symptoms.

The withdrawal phase typically commences 2–4 days after the last amphetamine use and 1–2 days after the last cocaine use, featuring strong cravings, psychomotor changes, vivid dreams, insomnia or hypersomnia, aches and pains, hallucinations and bradycardia. Withdrawal symptoms gradually decrease over 1–2 weeks for cocaine, though some persist during the extinction phase/protracted withdrawal.

While withdrawal from stimulant drugs is generally not medically dangerous, depressive symptoms with suicidal ideation or behavior may occur, representing the most serious issues during stimulant withdrawal.

The extinction phase can extend up to 28 weeks, characterized by episodic cravings and dysphoria (feelings of sadness).

4. Alcohol withdrawal timeline

Alcohol , chemically known as ethanol, is a psychoactive substance found in beverages such as beer, wine, and spirits. It is produced through the fermentation of sugars by yeast. Upon ingestion, alcohol functions as a depressant for the central nervous system, resulting in outcomes such as relaxation, diminished inhibitions, and impaired coordination.

As outlined in the article “Alcohol Withdrawal”  by Richard K. Newman et al. published in StatPearls, symptoms of alcohol withdrawal manifest when individuals cease or significantly reduce long-term alcohol consumption.

The range of symptoms varies, starting from mild indicators like tremors, palpitations and increased blood pressure. Moderate symptoms, such as hallucinations and alcohol withdrawal seizures, typically appear 12 to 24 hours after discontinuing alcohol. 

Delirium tremens, the most severe form of alcohol withdrawal, is characterized by altered consciousness, significant autonomic dysfunction, and vital sign abnormalities. The effects of delirium tremens persist for up to seven days following the cessation of alcohol use and may endure for an extended period. 

5. Nicotine withdrawal timeline

Nicotine is a substance found in tobacco plants, making up 0.6-3.0% of the dry weight of tobacco. Nicotine in tobacco acts as a stimulant. Nicotine is present in various tobacco products like cigarettes, cigars, pipe tobacco, chewing tobacco, and snuff. Even in e-cigarettes/electronic vape, nicotine is present.

Nicotine withdrawal syndrome emerges within 4-24 hours after discontinuing the chronic use of nicotine-containing products, according to the chapter “Nicotine Withdrawal” by Ian McLaughlin, John A. Dani and Mariella De Biasi in the 2015 book “The Neuropharmacology of Nicotine Dependence”. Symptoms reach their peak around the third day and gradually diminish over the subsequent 3–4 weeks.

6. Cannabis withdrawal timeline

Cannabis, commonly known as marijuana, is derived from the Cannabis sativa or Cannabis indica plant, having dried leaves, flowers, stems, and seeds, containing the psychoactive compound Tetrahydrocannabinol (THC). The 2021 National Survey on Drug Use and Health  (NSDUH) Annual National Report titled “Key Substance Use and Mental Health Indicators in the United States” published by SAMHSA, reveals that cannabis is extensively used in the United States, especially among the youth.

Symptoms of cannabis withdrawal emerge 24–48 hours post-cessation. The majority peak between days 2 and 6, and in heavy cannabis users, certain symptoms persist for three weeks or longer, as Jason P. Connor et al outlined in article “Clinical Management of Cannabis Withdrawal” published by the journal Addiction in 2021.

7. Hallucinogen withdrawal timeline

A hallucinogen is a class of psychoactive substances that induce altered perceptions, sensations, and profound changes in thought processes, mood, and consciousness. Hallucinogens cause hallucinations, sensory distortions, and an altered sense of reality. Examples of hallucinogens include LSD (lysergic acid diethylamide), psilocybin (found in certain mushrooms), mescaline (found in peyote cactus), DMT (dimethyltryptamine), and MDMA (3,4-methylenedioxymethamphetamine or ecstasy). The effects of hallucinogens vary widely, and their use leads to intense and unpredictable psychological experiences.

The length of hallucinogen withdrawal is highly individualized and dependent on the particular type of hallucinogenic drug used. The severity of withdrawal symptoms varies significantly, complicating the determination of a specific timeline. As detailed in the article “Clinical Applications of Hallucinogens: A Review” by Albert Garcia-Romeu et al., published by the United States Department of Health and Human Services in 2017, the subjective effects of LSD in humans can last up to 12 hours, showing rapid tolerance with repeated use and no distinct withdrawal evidence has been observed.

8. Inhalant withdrawal timeline

Inhalants are volatile substances that emit chemical vapors, inducing psychoactive effects when inhaled. The term encompasses a diverse range of chemicals, making precise categorization challenging. Four main categories are volatile solvents, aerosols, gases, and nitrites. 

Volatile solvents, found in common household and industrial products, include paint thinners, degreasers, and glues. Aerosols, like spray paints and deodorants, contain propellants. Gases encompass medical anesthetics and household products like butane lighters. Nitrites, commonly referred to as “poppers” are commonly sold in bottles of air fresheners, leather cleaners and nail polish removers.Withdrawal symptoms begin within 24 hours of abstinence and last for several days as highlighted in The Primary Care Companion To The Journal of Clinical Psychiatry’s article titled “Baclofen in the Management of Inhalant Withdrawal: A Case Series” authored by Kesavan M et al. in 2008 by the Department of Psychiatry at the National Institute of Mental Health and Neurosciences in Bangalore, India. These symptoms encompass irritability, dysphoria, sleep disruption, headache, dry mouth, and lacrimation.

What are the causes of Drug withdrawal?

The causes of drug withdrawal are listed below.

• Drug dependence: Drug dependence presents a substantial challenge to health and productivity, influenced by various factors. This condition is characterized by compulsive drug use, loss of control over intake, and withdrawal symptoms upon discontinuation. Cellular and molecular insights, as discussed in the research article “Cellular and molecular mechanisms of drug dependence: An overview and update” authored by Swapnil Gupta and Parmananda Kulhara in the Indian Journal of Psychiatry in 2007, delve into the intricate biology of addiction. The mesolimbic dopamine system, activated by substances, notably influences drug dependence, with receptors acting as crucial regulatory components. 
• Neurochemical mechanism: The neurochemical equilibrium in the brain is disrupted from prolonged use of substances impacting neurotransmitters like dopamine, serotonin and GABA. These molecules play an important role in regulating mood, stress and sleep. Over time the brain adapts to the presence of the drug by reducing its own production of the neurotransmitters or decreasing the sensitivity of their receptors. This develops a state of dependence resulting in a struggle for the brain to maintain its normal functioning. Hence, causing the onset of withdrawal symptoms to make up for the lack of the drug.
• Genetics: Genetics significantly shapes drug withdrawal by influencing neurotransmitters and reward pathways in the brain. In 2018, Alcohol & Clinical Experimental Research Journal published a study led by Andrew H. Smith et al., titled “Risk locus identification ties alcohol withdrawal symptoms to SORCS2” and identified the SorCS2 gene’s significant involvement in alcohol withdrawal among humans.
• Environmental factors: Environmental factors, like the places and people linked to substance use, can impact withdrawal. When individuals face these cues, cravings and stress may increase, triggering withdrawal symptoms as the body expects the substance. Outside stressors, like work or relationship issues, worsen withdrawal by adding to overall stress when someone stops using drugs.

What are the types of Drug withdrawal?

The types of drug withdrawal are listed below.

• Acute withdrawal
• Protracted withdrawal

1. Acute withdrawal

Acute withdrawal is the onset of predictable signs and symptoms resulting from the sudden cessation or rapid reduction of a psychoactive substance, as described in a 2010 report “Substance Abuse Treatment Advisory” by the Substance Abuse and Mental Health Services Administration (SAMHSA).  

Acute withdrawal symptoms typically arise within hours or days after the substance’s last use and gradually subside, with the duration varying based on the specific substance. 

The intensity of acute withdrawal symptoms varies, based on the drug involved. Certain substances, such as benzodiazepines, induce severe and life-threatening withdrawal effects. Acute withdrawal makes activities of daily living (ADLs) difficult and brings about feelings of illness, lethargy, and difficulty in getting out of bed, feeding oneself, bathing, dressing, grooming, working, and managing personal hygiene. This makes relapse even more probable. 

2. Protracted withdrawal

Protracted withdrawal refers to the persistence of signs and symptoms even after the expected timeframe for acute withdrawal. The symptoms of PAWS persist for months to years after the cessation of the substance. 

Protracted withdrawal is referred to through different synonyms like, post-acute withdrawal syndrome (PAWS), subacute withdrawal, and late or long-term withdrawal. This condition arises from the toxic changes and chemical imbalances induced by drugs and alcohol in the brain. Prolonged substance use creates a dependency on these substances for normal brain function. Individuals during treatment have persistent symptoms such as brain fog, insomnia, depression, anxiety, and intense drug cravings, even months after discontinuing drug use. While the body heals relatively quickly, the brain requires more time to readjust and relearn normal functioning without drugs. A 2010 report “Substance Abuse Treatment Advisory” by the Substance Abuse and Mental Health Services Administration (SAMHSA), shows that sleep difficulties last for 1 to 3 years after stopping alcohol consumption.

What are the most dangerous Drugs to withdraw from?

The most dangerous drugs to withdraw from are listed below.

• Alcohol: Alcohol withdrawal symptoms appear as early as 6 hours after the initial decline from peak intoxication. Severe alcohol withdrawal symptoms are characterized by hallucinations, confusion, and disorientation. Another significant withdrawal manifestation is delirium tremens, with a mortality rate ranging from 5 to 25 percent, as disclosed in the article “Complications of Alcohol Withdrawal” authored by Louis A. Trevisan et al. and published by the Alcohol Health and Research World Journal in 1998. The article also discloses that more than 90 percent of alcohol withdrawal seizures occur within 48 hours after the patient stops drinking.
• Benzodiazepines: A research article titled “Benzodiazepines: Uses, Dangers, and Clinical Considerations” authored by Amber N. Edinoff et al. and published by the Neurology International Journal in 2021 reveals that regular benzodiazepine (BZD) use induces significant psychological and physical dependence. The withdrawal process of benzodiazepines presents a range of psychological symptoms like increased excitability, nightmares, delirium, panic attacks, hallucinations, paranoid thoughts, seizures, numbness, altered sensation of limbs and tremors. Due to the life-threatening nature of their withdrawal symptoms, benzodiazepine withdrawal is considered to be the most dangerous drug to withdraw from.
• Opioids: The article “Opioid Withdrawal” by Mansi Shah and Martin R. Huecker published by StatsPearls states that opioid withdrawal is a serious and potentially life-threatening condition. resulting from opioid dependence. Another study published in the article “Yes, people can die from opiate withdrawal”, authored by Shane Darke et al. published in the journal Addiction in 2017, outlines that people can die during opiate withdrawal due to severe vomiting and diarrhea, leading to dehydration and elevated blood sodium levels, potentially resulting in heart failure. 
• Barbiturates: Barbiturate withdrawal presents significant complications such as seizures and delirium tremens. In the article titled “[Barbiturate withdrawal syndrome: a case associated with the abuse of a headache medication]” by C Sarrecchia et al. in 1998, published in the journal Annali italiani di medicina interna, it emphasizes that barbiturates can lead to psychological and physical dependence, resulting in withdrawal symptoms within days of discontinuation. These symptoms encompass anxiety, restlessness, insomnia, rhythmic intention tremors, dizziness, seizures, and psychosis. Failure to recognize and treat the syndrome appropriately may lead to hyperthermia, circulatory failure, and death.

Is it bad to quit cold turkey?

Yes, it is bad to quit cold turkey as abruptly quitting high-risk drugs leads to severe withdrawal symptoms, including life-threatening complications such as seizures, delirium tremens, and even death. Medical supervision is crucial for a safer and more manageable withdrawal process. While quitting lower-risk drugs like nicotine or caffeine is not life-threatening, it is still uncomfortable, and the risk of relapse is higher without proper support and management of withdrawal symptoms.

Can Drug withdrawal be fatal?

Yes, drug withdrawal can be fatal, especially in the case of certain substances like alcohol, barbiturates, and benzodiazepines. Abrupt cessation of these substances leads to severe withdrawal symptoms, including life-threatening complications such as seizures, delirium tremens, and even acute respiratory failure. The risk of fatality is particularly high if withdrawal is not managed under medical supervision. It is essential to recognize the potential dangers of drug withdrawal, seek professional guidance, and undergo withdrawal in a controlled and monitored environment to minimize the risk of fatal complications. The severity of withdrawal symptoms varies depending on the substance and individual factors, emphasizing the importance of personalized care and supervision during the withdrawal process.

What are the long-term side effects of Drug withdrawal?

The long-term side effects of drug withdrawal are listed below.

• Psychological challenges: Persistent mental health issues such as anxiety, depression, mood swings, and irritability endure beyond the initial withdrawal period.
• Cravings: Intense and persistent cravings for the substance persist, posing challenges to maintaining abstinence.
• Cognitive impairment: Prolonged drug use has lasting effects on cognitive function, leading to difficulties in memory, learning, concentration, and impaired decision-making.
• Mental health issues: The long-term side effects of withdrawal on mental health include persistent challenges such as anxiety, depression, cognitive impairments, mood swings, and difficulties in concentration and memory. These mental health issues may endure beyond the withdrawal phase and vary depending on the substance involved.
• Sleep disturbances: Insomnia or other sleep disorders causing difficulty in falling and staying asleep emerge. 
• Interpersonal and social relationship difficulties: Rebuilding relationships becomes difficult and leads to social isolation. The impact of addiction strains personal and professional ties both.
• Physical health problems: Long-term drug use contributes to various physical health problems including organ damage, neurological impact, cardiovascular, renal, gastrointestinal issues and suppression of the immune system. For example, heavy alcohol use leads to liver cirrhosis, which has lasting effects even after withdrawal.
• Risk of relapse: The risk of relapse remains a long-term concern, especially in the absence of adequate support and treatment.
• Nutritional deficiencies: Drug use depletes the body of essential nutrients, and withdrawal is not immediately restore these deficiencies. This leads to long-term health problems like anemia and osteoporosis.

What is post-acute withdrawal syndrome (PAWS)?

Post-acute withdrawal syndrome (PAWS) refers to a prolonged set of symptoms that can persist after the acute phase of withdrawal from substance use. Prolonged use of substances triggers the neurocircuitry changes in the brain, altering the mental and physical well being post acute withdrawal.  The symptoms arise later than anticipated in the initial withdrawal phase, lasting for an extended period, and in certain cases, proving irreversible.

PAWS has been documented in substances like benzodiazepines, amphetamines, cocaine, alcohol, opioids, antipsychotics, and antidepressants. The symptoms in post-acute withdrawal syndrome vary across different drug withdrawals due to the distinct impact each psychoactive drug has on the brain. This is articulated in a 2010 report, “Substance Abuse Treatment Advisory,” published by the Substance Abuse and Mental Health Services Administration (SAMHSA). 

The defining characteristic of post acute withdrawal symptoms is its prolonged duration, often extending for weeks and months after the cessation of the drug. Additionally, new disorders may arise during this extended period. PAWS is a less recognized facet of dependence and withdrawal; nevertheless, its duration and intensity impact an individual’s capacity to discontinue therapeutic drugs.

What are the symptoms of post-acute withdrawal syndrome (PAWS)?

The symptoms of post-acute withdrawal syndrome are present in three primary domains—emotional, cognitive, and physical. Emotional manifestations encompass a spectrum, including anxiety that spans from mild to severe panic attacks, depression characterized by feelings of hopelessness, helplessness, and worthlessness, irritability accompanied by outbursts of anger and heightened emotional sensitivity, unpredictable mood swings, anhedonia leading to a lack of interest, and emotional dysregulation manifesting as difficulty in effectively managing and expressing emotions.

Cognitive symptoms encompass enduring fatigue that affects daily functioning, brain fog characterized by difficulties in concentration, clear thinking, and memory recall, impaired judgment leading to indecisiveness, and sleep disturbances such as insomnia, nightmares, and restless sleep. Physical symptoms persist, including aches, pains, digestive issues, and sleep disturbances.

In the article titled “Neurobiology and Symptomatology of Post-Acute Alcohol Withdrawal: A Mixed-Studies Systematic Review” authored by Anees Bahji et al. and published in the Journal of Studies on Alcohol and Drugs in 2022, highlights the PAWS associated with alcohol withdrawal include mood and anxiety symptoms persisting from the first 3 to 4 months following acute withdrawal up to 10 years. Cognitive impairment spans a few weeks to months, with residual effects lingering for up to a year after abstinence.

In an article titled “Dependence, withdrawal and rebound of CNS drugs: an update and regulatory considerations for new drugs development” published by Brain Communications journal in 2019, a study on abrupt morphine withdrawal is mentioned. It revealed a protracted withdrawal phase manifesting between the sixth and ninth weeks following morphine withdrawal. This phase continued through weeks 26-30 and was characterized by constricted pupils, low blood pressure, heart rate, and body temperature.

What are the available treatments for Drug withdrawal?

The strategies for addressing drug withdrawal encompass both the physical dependence and psychological facets to manage withdrawal symptoms and the underlying psychological factors.

The available treatments for drug withdrawal are listed below.

• Medication-assisted detoxification (MAD): Medically assisted detox is a supervised process that helps individuals safely withdraw from substances, using medications to manage withdrawal symptoms. Healthcare professionals monitor vital signs and adjust medications to ensure safety. This method is crucial for substances with severe withdrawal effects like opioids, alcohol, and benzodiazepines. While it provides a supportive environment for successful detox, it’s only the initial phase of addiction treatment. 
• Behavioral therapy: Behavioral therapies constitute psychological interventions aimed at modifying behavior patterns associated with substance abuse, playing a vital role in addiction treatment by addressing the psychological facets of withdrawal and promoting enduring behavioral changes. The effectiveness of cognitive-behavioral therapy (CBT) is substantiated by a study titled “Cognitive-Behavioral Therapy for Substance Use Disorders,” conducted by R. Kathryn McHugh et al. and published in the journal Psychiatric Clinics of North America in 2010.

The research indicates that CBT for substance use disorders has proven effective as both a standalone therapy and as part of combination treatment approaches. Despite the diverse elements within CBT protocols, such as operant learning strategies, cognitive and motivational elements, and skills-building interventions, several core elements consistently emerge. 

These elements focus on overcoming the potent reinforcing effects of psychoactive substances. The study provides substantial support for the efficacy of CBT in the treatment of substance use disorders, emphasizing its versatility and effectiveness across various therapeutic strategies.

• Support groups: Support groups play a crucial role in the journey of recovery from substance abuse, offering individuals a supportive and empathetic community where they share experiences, struggles, and victories. These groups provide a safe space for individuals with similar challenges to connect, reducing feelings of isolation often associated with addiction. 

Led by trained facilitators or peers who have successfully navigated recovery, support groups offer encouragement, understanding, and practical advice. The sense of belonging and shared understanding within these groups fosters motivation, accountability, and a strong sense of community. 

Popular examples include Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and SMART Recovery. The collective strength of support groups lies in their ability to provide emotional support, encouragement, and a platform for individuals to learn from one another’s experiences on the path to sustained recovery.

• Outpatient programs: Outpatient programs provide a flexible and accessible route to recovery, offering a supportive community and structured therapy sessions without disrupting daily life. These programs, a versatile alternative to residential care, allow participants to attend regular counseling sessions, support groups, and educational meetings while fulfilling work or family responsibilities. 

The adaptable nature of outpatient programs enables individuals to reintegrate into their daily routines, navigate triggers, and develop healthy coping mechanisms in real-world settings.

• Aftercare planning: Aftercare planning involves strategies to support sustained well-being post-treatment. Tailored to an individual’s needs, it includes ongoing counseling, support groups, and relapse prevention techniques. 

Aftercare ensures a smooth transition from formal treatment to independent living, promoting long-term recovery success by addressing potential challenges and providing ongoing assistance.

• Holistic and complementary therapies: Holistic approaches and complementary therapies embrace a comprehensive strategy to promote overall well-being in addiction recovery. Beyond traditional treatments, these methods consider the mind, body, and spirit. Holistic approaches include yoga, meditation, and nutritional counseling. 

Complementary therapies complement conventional treatments and involve art therapy, music therapy, or mindfulness practices. By addressing various aspects of an individual’s life, holistic and complementary approaches aim to enhance the effectiveness of addiction treatment, offering a more well-rounded and individualized recovery experience.

How do you cope with Drug withdrawal?

Coping with drug withdrawal involves adopting a multifaceted approach to address physical and psychological symptoms. First, seek professional guidance from healthcare providers experienced in addiction treatment. 

Establish a support network, including friends, family, or support groups, to provide emotional assistance. Develop a structured daily routine to minimize idle time and distractions, engaging in activities that promote physical and mental well-being. 

Stay hydrated, maintain a balanced diet, and prioritize sufficient sleep. Employ relaxation techniques such as deep breathing, meditation, or mindfulness to manage stress and anxiety. Communicate openly with your healthcare team about your experiences, adjusting your treatment plan as needed. 

Is it safe to go through withdrawal at home?

No, it is not safe to go through withdrawal at home, particularly for certain drugs like alcohol, benzodiazepines, and barbiturates. Abruptly stopping these substances leads to life-threatening complications such as seizures and delirium tremens. 

Even with lower-risk drugs, unforeseen complications like severe dehydration arise, necessitating immediate medical attention. Home withdrawal lacks the symptom management and psychological support provided by medical supervision, which is essential for a comfortable and successful process. While there are cases of manageable home withdrawal with careful planning, especially for mild withdrawal symptoms or under a medically supervised taper plan, the decision should be made in consultation with a healthcare professional considering individual circumstances and safety.

How can you help someone through withdrawal?

Helping someone through withdrawal requires a compassionate and informed approach. Begin by educating yourself about their specific substance withdrawal symptoms. Offer emotional support and encouragement while remaining non-judgmental. 

Assist in creating a comfortable environment, ensuring proper hydration, nutrition, and rest. Encourage regular communication with healthcare professionals and accompany them to medical appointments, providing a sense of companionship. Be patient and understanding, as mood swings and irritability are common during withdrawal. 

Help engage in positive distractions or activities to keep their mind occupied. Respect their boundaries and decisions, avoiding pressure or criticism. Keep a watchful eye for any physical or emotional signs, and seek professional help if needed. Your support and empathy can significantly contribute to their successful recovery through withdrawal.

What is the difference between withdrawal and detox?

The terms “withdrawal” and “detox” are frequently used interchangeably, but they hold distinct meanings. Withdrawal involves the physical and mental symptoms arising when an individual dependent on a drug abruptly stops or significantly reduces usage. It focuses on the physiological and psychological reactions, such as tremors, anxiety, and cravings. 

On the other hand, detoxification, or detox, is the systematic and supervised process aimed at eliminating the substance from the body. While withdrawal symptoms are a natural response to abrupt substance cessation, detox involves actively managing these symptoms to ensure safety and comfort. Essentially, withdrawal is the body’s reaction, and detox is the methodical intervention to assist the body in clearing the substance. 

Detox encompasses medically monitored detoxification, often involving therapy and interventions. While withdrawal is the body’s discomfort when deprived of a drug, detox serves as the controlled intervention to manage that reaction and prepare individuals for further treatment.

When do you need medical supervision for drug withdrawal?

Medical supervision for drug withdrawal is needed, particularly when discontinuing substances like alcohol, benzodiazepines, or opioids, which can lead to severe withdrawal symptoms. Certain medications, such as methadone, help alleviate withdrawal symptoms and reduce cravings, as discussed in the article “Withdrawal Management” in the book Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings by the World Health Organization in 2009. Methadone doses should be regularly reviewed and adjusted based on symptom control and side effects. 

Patients experiencing protracted withdrawal benefit from psychosocial interventions to prevent relapse. Individuals with a history of complicated withdrawals, underlying medical or psychiatric conditions, those on multiple medications, or pregnant individuals require medical oversight to manage potential complications and ensure a safer withdrawal process. The heightened risk of overdose after opioid withdrawal underscores the importance of caution and reduced opioid use.

What are the medications used to reduce withdrawal symptoms?

The medications used to reduce withdrawal symptoms are listed below.

• Medications for alcohol withdrawal: Medications for alcohol withdrawal include benzodiazepines, barbiturates (usually phenobarbital) and propofol. As evidenced in the study led by S. C. Kaim et al. in the article “Treatment of the Acute Alcohol Withdrawal State: A Comparison of Four Drugs” published online by The American Journal of Psychiatry in 2006, chlordiazepoxide, a benzodiazepine, proved notably superior in preventing seizures and delirium tremens (DT) among patients experiencing alcohol withdrawal. Other benzodiazepine medications that are used include diazepam, lorazepam and oxazepam.
• Medications for opioid withdrawal: Medications for opioid withdrawal include methadone codeine phosphate, clonidine and buprenorphine as highlighted in the 2009 World Health Organization publication “Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings.” Methadone and codeine phosphate relieve symptoms and cravings, buprenorphine excels in easing symptoms and curbing cravings of moderate to severe withdrawal, and clonidine relieves various physical symptoms of  withdrawal.
• Medications for stimulant withdrawal: Antipsychotic medications are employed to address withdrawal symptoms associated with stimulants. In cases where patients experience heightened agitation during stimulant withdrawal, diazepam is utilized to induce sedation. The 2009 publication titled “Withdrawal Management” within the World Health Organization’s book, it is noted that methamphetamine, amphetamine, and cocaine, despite their diverse effects, share similar withdrawal symptoms that are addressed using the same medications.
• Medications for benzodiazepine withdrawal: The medications for benzodiazepine withdrawal usually involves giving decreasing doses of benzodiazepines. This helps in easing withdrawal symptoms and reducing the likelihood of seizures. The neurology international journal in 2021, in its article “Benzodiazepines: Uses, Dangers, and Clinical Considerations” authored by Amber N. Edinoff et al. outlines alprazolam as a commonly employed medication in benzodiazepine withdrawal due to its quick impact resulting from a short half-life and rapid absorption. It works quickly to relieve symptoms, making it one of the fastest-acting benzodiazepines.
• Medications for cannabis withdrawal: There are no FDA approved medications for managing cannabis withdrawal syndrome as mentioned in the article “Clinical management of cannabis withdrawal” authored by Jason P. Connor published in the journal Addiction in 2022. However, symptomatic treatment options, such as prescribing ibuprofen for pain, metoclopramide for nausea and stomach pains, temazepam for sleep disturbances, and diazepam for anxiety and tremors, are utilized.