From ecstacy to agony: What is withdrawal?
FAQs | Withdrawal management: Practices & limitations
FAQs uses experiential knowledge to address common drug-related topics. If you have a topic or question in mind, please contact us.
Withdrawal is hard to describe.
Withdrawal is when you take something away and don’t replace it with something else.
Withdrawal is a pharmacological reaction.
And it’s not like the flu. At all.
It gets worse before it gets better.
You can’t relieve withdrawal symptoms with over-the-counter cold meds and cough syrup.
Withdrawal feels like torture.
I felt like my skin was on fire.
No one warned me about withdrawal, so when it finally happened to me, I thought I was dying.
Don’t go to the hospital when you’re in withdrawal. They won’t help you.
They’ll think you’re drug seeking and turn you away.
Of course you’re drug seeking — withdrawal is a direct result of stopping — or being forced to stop — the drugs you’re on.
Withdrawal is a natural result of slowing or stopping a psychoactive substance or drug you’ve become dependent on. Symptoms range in severity, depending on the drug or drugs consumed, and the amount(s) and frequency consumed over time.
The body and brain work to maintain a state of balance known as homeostasis. Taking a substance changes that balance, so your body has to take steps to adjust including changing the levels of certain neurotransmitters. These substances act on your brain's reward system, triggering the release of chemicals. — What Is Withdrawal?
Withdrawal tends to manifests as some acute combination of (distressing/intolerable) physical and mental/emotional symptoms. Withdrawal is generally not considered serious enough to warrant hospitalization.
Treatment depends on the type of dependency. For example, folks hooked on nicotine are sometimes prescribed Champix, or told to chew Nicorette. And when anti-depressant medications are discontinued (usually because side-effects are unbearable), prescribers may recommend a cross-taper protocol (completed “in community,” aka from home).
Stimulant withdrawal can include depression, anxiety, insomnia, psychomotor agitation, and cognitive impairment. But treatment for stimulant withdrawal is vague (at best):
There are currently no medications approved for treating stimulant withdrawal. Treatment primarily consists of supportive care, which may include providing adequate nutrition, supporting sleep hygiene, mental health assessment, and working with the patient to identify their goals and the supports that would help them achieve them. — Stimulant Use Disorder: Practice Update, BCCSU
Western approaches to withdrawal management
In BC, withdrawal management programs are part of a suite of bed-based recovery supports that advocate total abstinence as the only cure for drug and alcohol addiction. To date, WTH is not aware of any treatment program that tolerates drug use of any kind.
BC’s addiction recovery industry enjoys a lot of freedom. Unlike our healthcare system, recovery programs are not accountable to regulatory bodies, or bound by public health policies, accreditation and safety standards, or local, provincial and federal guidelines.
Health authorities — like Vancouver Coastal Health (VCH) — oversee certain aspects of bed-based recovery programs, but the exact nature of their oversight is not easily understood.
Licensed treatment and recovery services are required to meet residential care regulations established by the Community Care and Assisted Living Act. But these regulations tend to focus on operational, staffing, space, and emergency preparedness requirements.
Withdrawal management is often considered the first step on the road to recovery from substance use. In Vancouver, detox programs tend to cater to folks experiencing opiate, alcohol and benzodiazepine withdrawal — considered by many to be the most serious of all drug-related dependencies.
“It’s not possible for a non-user to understand the harrowing, horrifying sensation of opiate withdrawal,” says one of our team members. “Withdrawal is beyond words. The only way to know it is to experience it.”
Cold turkey detox is (mostly) a thing of the past. At it’s most severe, alcohol withdrawal causes delirium tremens, a condition that can induce heart attacks and/or strokes. Folks suffering from benzodiazepine withdrawal risk seizures. In both cases, withdrawal can be fatal.
Death is not commonly associated with opiate withdrawal, though fatalities can and do occur — in prison, for example, when opiate-dependent folks are (cruelly/barbarically) denied opioid agonist treatment.
But it’s a mistake to underestimate the impact of non-fatal withdrawal. Prolonged, untreated withdrawal traumatizes the body. When relief isn’t possible — due to financial constraints or disruptions to the drug supply — folks can grow desperate, hopeless — even suicidal.
Unfortunately, many healthcare workers — including so-called addiction medicine experts still regard withdrawal as “subjectively severe but objectively mild.” In fact, you’ve probably heard experts use the flu as a way to describe opiate withdrawal. This comparison is frustrating for many opiate consumers, who feel that any attempt by non-opiate users to describe opiate withdrawal is futile.
“It’s not possible for a non-user to understand the harrowing, horrifying sensation of opiate withdrawal,” says one of our team members. “Withdrawal is beyond words. The only way to know it is to experience it.”
Medication-assisted treatment
Maintenance medications are the bread and butter of withdrawal management programs. Without them, detox wouldn’t be much more than a place to sweat it out.
Opioid agonist treatment (OAT) is a type of medication assisted treatment for opiate-dependent folks. OAT involves substituting illegal street opioid use with sustained retention on regulated prescription opioid medications. Methadone, buprenorphine (aka Suboxone) and slow-release oral morphine (aka ˆ) are OAT meds that are commonly used to treat opiate withdrawal symptoms.1
[O]pioid agonist treatments have been shown to be superior to withdrawal management alone in terms of retention in treatment, sustained abstinence from opioid use, and reduced risk of morbidity and mortality. — A Guideline for the Clinical Management of Opioid Use Disorder
These days, a person referred to detox is assumed to have an addiction or “substance use disorder.”2 Medication is therefore a reasonable treatment method. But withdrawal is nonetheless hard to treat, and outcomes are uncertain (at best).
OAT opponents have been known to say that medication-assisted treatment is akin to substituting one drug for another. Drugs like methadone (for example) are often stigmatized in recovery-oriented/abstinence-only peer groups (like Narcotics Anonymous).
But regardless of the ability — or failure — of agonist treatment to reduce/eliminate street drug use, the research shows that OAT definitely reduces drug-related harms, like infection, toxicity and overdose. And in the midst of a (seven-year-long) drug toxicity crisis, that is good news for drug users.
… At least, it’s better than nothing, no?3
Some prescribers believe that OAT medications also reduce cravings, and some research shows that OAT is correlated with continued adherence to other treatments.
WTH doesn’t necessarily agree with the pathologizing of substance use as a “disorder,” despite its inclusion in the DSM-5. We understand how inclusion of substance use as a disorder, or illness, can garner sympathy — as opposed to moral outrage, and individual shame and blame — but we believe that substance use is often a response to a feeling/sensation/memory/past trauma/etc. In other words, substance use is more likely a reaction or symptom — not to mention a recreational pastime.
Innovations in withdrawal management interventions (like maintenance drugs) are long overdue. Given the toxic/poisonous state of our current street supply, the window for successful agonist drugs is closing. On the other hand, this depends on how we define success.