Protracted withdrawal is a real threat to sobriety.

Mary’s first year of sobriety was marred with anxiety, sleeplessness, and what she describes as chronic PMS. Now three years sober, Mary is a 43-year old brunette who works in the healthcare field, but though she knew about the typical symptoms of withdrawal, she had no idea how long the subtler ones could last.

“I didn’t understand,” she explains. “I mean at first I had to go through detox, but then it just seemed like [even] though I wasn’t physically sick, I was emotionally sick. People kept telling me to stick around, ‘Don’t quit before the miracle happens,’ but it didn’t seem to get any better.”

Unfortunately, Mary is not alone. For many alcoholics and addicts, the first year (and even more) can be riddled with anxiety, depression, issues with sleep, and other psychological as well as medical conditions. As Dr. James C. Garbutt, Professor of Psychiatry and an addiction specialist at the University of North Carolina, explains, “From my perspective, when we think about withdrawal, we think about it mainly as the acute form, which typically lasts three to ten days and occurs with either alcohol or opiates. With alcohol, it can be life threatening, and with opiates, it can be very, very painful. We’ve known about this type of withdrawal for hundreds of years.”

He continues, “But then there’s this phenomenon that can persist after acute withdrawal, which is called PAWS, Protracted Alcohol Withdrawal Syndrome. You’re still having withdrawal symptoms but they’re not as acute – you may not be feeling well, but even more than that, the feelings can contribute to relapse risk. This phenomenon cuts across different classes of drugs – alcohol, cocaine, heroin, and we’re still learning more about marijuana. We still don’t have good clinical definitions for it, but most people who work with addicts are aware it’s there.”

Doug didn’t know what protracted withdrawal was but he was painfully aware of the experience. An attorney with a wife and three children, Doug thought that once he quit drinking and once the cravings were gone, he would be fine. “But I wasn’t,” he explains. “Instead, I just got depressed, and the depression made me feel like if I drank maybe I would feel better. I knew rationally that wasn’t the case, but even after the physical cravings were gone, I just felt too raw to deal with life.”

According to recent research by Roy A. Wise, Ph.D. and George F. Koob, Ph.D., inNeuropsychopharmacology, “Collapsing the cycles of impulsivity and compulsivity yields a composite addiction cycle composed of three stages – binge/intoxication, withdrawal/negative affect, preoccupation/anticipation – in which impulsivity often dominates at the early stages and impulsivity combined with compulsivity dominates at the later stages.”

Dr. Garbutt describes this phenomenon in further detail, offering, “The compulsive side is to repeat the behavior again and again. The impulsivity is taking the action without taking the steps to stop it. Withdrawal is a negative effect and is a key factor in going back to using. Clinically, something might trigger a return to the behavior and then the behavior takes on a life of its own. That’s when we see people doing something and not even being fully aware that they’re doing it.”

In addition, Drs. Wise and Koob have used imaging studies to display what many alcoholics have described as the lack of mental defense, realizing “that drug abusers tested during protracted detoxification show[ed] evidence of disrupted activity of frontal regions… which is hypothesized to underlie their impaired inhibitory control and impulsivity and contribute to relapse.”

Doug experienced that mental slip at nine months sober, after beginning to obsess over the drink he knew he could not have. After another year of drinking, Doug tried again to get sober and began to recognize how protracted withdrawal was actually one of the primary obstacles to his recovery. “Of course I didn’t understand the science behind it. It wasn’t until I found a new therapist who had some understanding of what I was going through and why I felt closer than ever to a drink.”

As Wise and Koob explain, the neurological systems are damaged by the use of alcohol and drugs, making newly recovering individuals more susceptible to effects like anxiety and depression, “Another common between-system response to acute withdrawal and protracted abstinence from all major drugs of abuse is the manifestation of anxiety-like responses.”

Dr. Garbutt explains further, “Dopamine systems become disregulated and dysfunctional in this protracted withdrawal period and don’t really respond. They may not be able to experience natural pleasures, motivations, and interests. One of the effects of protracted withdrawal is the inability to enjoy the world that a lot of other people are able to enjoy.”

This inability to enjoy the good things in life gets coupled with the mutual inability to cope with the negative things. As Garbutt describes, “The whole stress system is activated, which can bring anxiety and frustration. It may lead to more hormonal consequences where cortisones are altered and sleep patterns are disrupted. Your brain is linked up to the idea that if it takes a drug it can feel better. These symptoms act as triggers.”

Mary didn’t have to relapse to understand what was happening to her, but the experience was no less pleasant. “You know how they say your worst day sober is better than your best day drinking? Well, they haven’t had my worst day sober. There were days on end when I couldn’t sleep, I gained so much weight. I didn’t really like myself and I really didn’t like life.”

Not everyone has such an experience but according to Drs. Wise and Koob’s work, “All drugs of abuse are associated with a motivational withdrawal syndrome characterized by dysphoria, irritability, emotional sleep, and sleep disturbances that persist even after protracted withdrawal. The neurobiology of acute withdrawal is distinct from protracted or motivational withdrawal, and both contribute to relapse.”

These symptoms of irritability are sadly par for the course. As Dr. Garbutt explains, “The thing about protracted withdrawal is the drugs make you feel euphoric, and so when you feel bad, you take the drug to stop feeling bad. Though after a while, those feelings of irritability and anxiousness are no longer relieved by the drugs or alcohol, there is still the memory that they will solve the problem. It’s an interesting way to conceptualize what drives people to do the things they do when it destroys their life in so many ways.”

Fortunately, for alcoholics and addicts like Doug and Mary, science is beginning to prove what addicts have known for a long time – that abstinence and risk of relapse negotiate an incredibly tricky relationship, one which doctors like Garbutt hope to begin addressing more clearly in their work with patients.

“It opens the door for how we might discover new treatments, such as non-addictive drugs that can help people get through the protracted withdrawal,” Dr. Garbutt offers. “But staying sober is still the number one obvious recommendation. In general, good nutrition, rest, and exercise are really helpful. Maintain sleep and eating cycles – these things help the body recover. If you stay sober, you can repair these processes.”

Doug has found that knowing what he is going through has been one of the biggest changes in his new sobriety. “I think I have a different expectation of myself now,” he concludes. “If I’m feeling tired or out of it, I cut myself some slack, and just remember that after a while, if I stay sober, it will go away. I just have to stay sober to get there.” Article Link…