Treating alcohol withdrawal with benzodiazepines – Safe if mindful

Alcohol withdrawal can lead to some pretty horrible side effects

Contributing co-author: Andrew Chen

Alcohol withdrawal can be extremely unpleasant (see here for an overview). Symptoms vary from person to person, but most people will experience some negative symptoms of alcohol withdrawal if they try to stop drinking after long term use.

Mild to moderate symptoms include headache, nausea, vomiting, insomnia, rapid heart rate, abnormal movements, anxiety, depression, and fatigue. Severe symptoms of alcohol withdrawal include hallucinations, fever, and convulsions (known as DT’s or delirium tremens). Most people undergoing alcohol detox do not require hospitalization, but in severe cases, hospitalization may be necessary (1). Since their introduction in the 1960s, benzodiazepines have been the drug of choice for treating severe cases of alcohol withdrawal.

Benzodiazepines, or benzos for short, are a class of psychoactive drugs that work to slow down the central nervous system by activating GABA receptors. This provides a variety of useful tranquilizing effects. Aside from relieving symptoms of alcohol withdrawal, benzodiazepines are also commonly prescribed to treat insomnia, muscle spasms, involuntary movement disorders, anxiety disorders, and convulsive disorders.

The most common regimen for treating alcohol withdrawal includes 3 days of long-acting benzodiazepines on a fixed schedule with additional medication available “as needed.” (2)

The two most commonly prescribed benzos are chlordiazepoxide and diazepam. Chlordiazepoxide (Librium) is preferred for its superior anticonvulsant capabilities while diazepam (Valium) is preferred for its safety against overdose with alcohol. Short-acting benzos like oxazepam and lorazepam are less frequently used for treating alcohol withdrawal (1).

Compared to other drugs, benzos are the safest and most effective method for treating difficult alcohol withdrawal. However, benzodiazepines do come with their own potential for dependence and abuse. Ironically, symptoms of benzodiazepine withdrawal are quite similar to those of alcohol withdrawal. Tapering off dosage is the best way to prevent serious withdrawal symptoms. To avoid such complications, benzodiazepines are only recommended for short-term treatment of alcohol withdrawal.

In short

Benzos can be very useful for helping long terms alcoholics deal with the difficult withdrawal symptoms that can accompany the detox period. Just be mindful so as not to find yourself right back where you started.

Citations:

1. Williams, D., McBride, A. (1998) The drug treatment of alcohol withdrawal symptoms: A systematic review. Alcohol & Alcoholism. 33(2), 103-115

2. Saitz, R., Friedmn, L. S., Mayo-Smith, M.F. (1996) Alcohol withdrawal: a nationwide survey of inpatient treatment practices. 10(9), 479-87

Physical addiction or psychological addiction – Is there a real difference?

This is another one of the basic questions I get regarding addiction.

It seems that people think about physical addiction and psychological addiction as somehow separate processes. I think this distinction makes no sense. Even if people really meant what they were saying, the brain is undoubtedly part of the body, and therefore, psychological addictions are also physical.

The “Physical Addiction” Vs. “Psychological Addiction” truth

blackboardWhat people are really referring to when they make this comparison is the distinction between physical withdrawal symptoms and the addictive process in the brain. There’s no doubt that some substances, like alcohol, opiates, and the likes, leave long term users with horrible withdrawal symptoms that are terrible to watch, and even worse to go through. In fact, early addiction theories asserted that it was this horrible withdrawal syndrome that made people go back to drugs. This was called the Tolerance-withdrawal addiction theory.

The Tolerance-withdrawal addiction theory fell apart when addictions to substances that didn’t display such withdrawal effects became obvious (like cocaine addiction), and when getting people through the difficult withdrawal proved insufficient to cure their addiction (naltrexone was thought to be the magic cure once upon a time).

In one of my previous posts about marijuana addiction, a reader suggested that since marijuana does not produce horrible withdrawal symptoms, it can not be physically addictive. While withdrawal from marijuana, cocaine, methamphetamine, nicotine, and numerous other drugs does not result in the stereotypical “opiate-withdrawal-flu-like-syndrome,” there is no doubt that real withdrawal from these substances exists for long term users and it sucks: Fatigue, depression, anxiety, sleep disturbances, and trouble eating are only some of the symptoms that tend to show up.

Withdrawal – The real physical addiction

Withdrawal symptoms occur because the body is attempting to counteract the stoppage of drug ingestion. Just like tolerance builds as the body adjusts to chronic drug use, withdrawal occurs as the body reacts to its cessation.

As crystal meth increases the amount of dopamine present in the brain, the body reacts by producing less dopamine and getting rid of dopamine receptors. When a user stops putting meth in their body, the low production of dopamine must increase and additional receptors must be inserted. Like tolerance, the process of withdrawal, even past the initial, obvious, symptoms, is a long and complicated one. For crystal meth addicts, the initially low levels of dopamine result in what is known as anhedonia, or an almost complete lack of pleasure in anything. There’s no mystery as to why: Dopamine is one of the major “pleasure” neurotransmitters. No dopamine, no pleasure.

The process of addiction in the brain

So, if we’re going to try to dissect which drugs cause what effects on the body, it’s important that we understand the underlying causes for those effects and that we use the proper language. Withdrawal, tolerance, and addiction are different, though obviously related topics. Their interplay is key for understanding the addiction process, but their more subtle points can often be lost on those observing addicts unless they are well trained.

As I’d mentioned in earlier posts, our current best notions about addiction are that the process involves some obvious physical and psychological processes and some much more subtle effects on learning that are still being studied. A study I’m currently conducting is meant to test whether drugs interfere with some of the most basic learning processes that are meant to limit the amount of control that rewards have over behavior. Such fine distinctions are no doubt the result of the ways in which drugs alter the neurochemical reactions that take place in our brain. Such basic changes can not possibly be seen as any less important than physical withdrawal symptoms.

All in all, the only way to look at Addiction is as both a psychological addiction AND a physical addiction that are inextricably liked through our psyche’s presence in the brain, a physical part of the body. It may seem like a small thing, but this distinction makes many users feel as if their problem is less, or more, sever than that of other addicts. As far as I’m concerned, if you have a behavior that is making your life miserable and which you can’t seem to stop, it doesn’t matter if you’re throwing up during withdrawal or not. It’s an issue and you need help.

Crystal meth withdrawal – It’s not like heroin, but don’t expect it to be easy

Heroin, or opiate, withdrawal symptoms is the gold standard of addiction withdrawal. Imagine the worst flu of your life, multiply it by 1000, and then imagine knowing that taking a hit of this stuff will make it all better. Think sweats, fever, shaking, diarrhea, and vomiting. Think excruciating pain throughout as your pain sensors get turned back on after being blocked for way too long. Now you have an abstract idea of the hell and it’s no wonder why heroin withdrawal has become the one every other withdrawal is judged against.

Crystal meth withdrawal

Withdrawing from crystal meth use is nothing like opiate withdrawal and there’s no reason that the withdrawal symptoms should be. Opiates play a significant role in pain modulation and opioid receptors are present in peripheral systems in the body, which is the reason for the stomach aches, nausea, and diarrhea. Dopamine receptors just don’t play those roles in the body and brain, so withdrawal shouldn’t be expected to have the same effect.

But dopamine is still a very important neurotransmitter and quitting a drug  that has driven up dopamine release for a long time should be expected to leave behind some pain, and it does.

One of the important functions of dopamine is in signaling reward activity. When a dopamine spike happens in a specific area of the brain (called the NAc), it signifies that whatever is happening at that moment is “surprisingly” good. The parentheses are there to remind you that the brain doesn’t really get surprised, but the dopamine spike is like a reward signal detector, when it goes up, good things are happening.

Well guess what? During crystal meth withdrawal, when a crystal-meth user stops using meth, the levels of dopamine in the brain go down. To make matters worse, the long-term meth use has caused a decrease in the number of dopamine receptors available which means there’s not only less dopamine, but fewer receptors to activate. It’s not a surprise than that people who quit meth find themselves in a state of anhedonia, or an inability to feel pleasure. Once again, unlike the heroin withdrawal symptoms, anhedonia doesn’t make you throw up and sweat, but it’s a pretty horrible state to be in. Things that bring a smile to a normal person’s face just don’t work on most crystal-meth addicts who are new to recovery. As if that wasn’t bad enough, it can take as long as two years of staying clean for the dopamine function of an ex meth-addict to look anything like a normal person’s.

This anhedonia state can often lead to relapse in newly recovered addicts who are simply too depressed to go on living without a drug that they know can bring back a sense of normalcy to their life. The use of crystal-meth causes the sought-after spike in dopamine levels that helps relieve that anhedonic state.

When it comes to more physiological sort of withdrawal symptoms, the meth addict doesn’t have it that bad, I guess. After an extended period of sleep deprivation and appetite suppression that are some of the most predictable effect of meth, the average addict will do little more than sleep and eat for the first week, or even two, after quitting the drug. Many addicts experience substantial weight gain during this period as their metabolism slows and their caloric intake increases greatly. Like everything else, this too shall pass. With time, most addicts’ metabolism return to pre-use levels and their appetite catches up and returns to normal as well. Still, there’s no doubt that a little exercise can help many addicts in early recovery steer their bodies back on track.

There’s some research being talked about around the UCLA circles to see if detoxification from meth may help people do better in treatment for meth addiction by reducing the impact of their withdrawal. Detox before addiction treatment is an accepted fact in opiate and benzodiazepine addiction, but because of the supposedly “light” nature of crystal meth withdrawal, it’s been ignored. Hopefully by now, you realize that was a mistake.