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Post Acute Withdrawal: Detox Part Deux

“What breaks you down is not the amount of pressure you feel at one time, but it’s the way you perceive and handle it.” ~ Ashish Patel No one has ever said that recovery from alcohol and drug addiction is an easy process. While the end result – sobriety – is more than worth all of the effort and discomfort during detoxification, the road to recovery is filled with challenges. Keeping your calm, your optimism, and your determination during recovery requires having realistic expectations of what is to come. While many have a general understanding of the detoxification process, withdrawal symptoms, and trigger events and situations, few recognize that the physical symptoms associated with detoxification can return after weeks, or even months, in recovery. This is known as post-acute withdrawal and can represent a significant struggle for those in recovery, particularly for those who do not expect it. While many people assume that the withdrawal effects of detoxification are experienced only in the first days and weeks of recovery, post-acute withdrawal occurs after the first phase of detoxification – or at least two weeks after alcohol or drug consumption ceases. Many may not expect to experience withdrawal so late, but post-acute withdrawal is experienced by 90% of those addicted to opiates (i.e. prescription pain medication or heroin), and three-quarters of those addicted to alcohol and amphetamine. While the physical symptoms of post-acute withdrawal may be unavoidable, it is possible to mitigate the emotional and psychological impact of this phase by understanding and mentally preparing for it.

Understanding Post Acute Withdrawal is More Than a Mental Exercise

Many people assume that once alcohol or drugs are out of the system, both physical and psychological withdrawals will cease altogether. It’s not a happy truth, but this conception of withdrawal and recovery is just not the case. In fact, there are two main phases to the withdrawal process: detoxification (also known as acute withdrawal), and post-acute withdrawal. As noted above, the vast majority of both drug and alcohol addicts experience post-acute withdrawal symptoms. However, the phenomenon is more likely to occur – and be associated with more severe symptoms – in those who have a long history of alcohol or opioid abuse. Dan Mager, MSW, writes on the likelihood and main symptoms of post-acute withdrawal:

“These symptoms affect many people in the early phases of abstinence from numerous substances, but they occur in an extremely high percentage of those with histories of long-term opioid use. Post-acute withdrawal varies in intensity and duration from one person to another. 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 – most commonly anxiety, irritability, anger, and depression.”

Clearly, post-acute withdrawal is not a pleasant experience. As Mager noted above, the length and intensity of this stage of withdrawal vary from person to person. The one thing that can be counted on, however, is that you are more likely than not to experience post-acute withdrawal. The symptoms of post-acute withdrawal look slightly different than the signs of withdrawal experienced during the initial detoxification:

  • Lack of emotional control (either an overreaction or no reaction)
  • Irritability
  • Depressed mood
  • Anxiety and/or panic
  • Insomnia
  • Increased levels of stress
  • Increased sensitivity to stress
  • Increased social anxiety
  • Low enthusiasm and energy
  • Lack of concentration

The symptoms of post-acute withdrawal are therefore different from the primary physical symptoms of detoxification (or acute withdrawal), which is associated with sweating, nausea, tremors and even seizures. The good news is these extreme symptoms of detoxification are unlikely to return. The bad news is that the symptoms of post-acute can last several months. The other good news is that it is unlikely that an individual will experience all of these symptoms of withdrawal, but it is likely that those in recovery will experience several of these signs several weeks into recovery.

The Secret of Post Acute Withdrawal: It’s Part of the Process

The description of post-acute withdrawal above is not exactly a pretty picture. For those expecting to get over the worst part of detoxification and recovery in the first days and weeks are likely to be surprised. Post-acute withdrawal highlights an important part of addiction and alcoholism: they are ongoing disorders that require ongoing recovery. As Dr. David Sack states, “The brain has a tremendous capacity to heal, but it doesn’t heal quickly. Some people experience a prolonged withdrawal, and it takes a long time to recalibrate.” In Changing for Good, the authors identify the six stages of recovery:

  • Pre-contemplation (awareness of addiction
  • Contemplation (realizing that change is necessary)
  • Preparation (gathering resources and support)
  • Action (taking steps toward recovery and treatment)
  • Maintenance (sustaining patterns of sobriety)
  • Termination (thinking it impossible to return to a former life)

The truth is, most people spend most of their lives in the maintenance stage of recovery. Maintaining sobriety and abstinence in the face of post-acute withdrawal symptoms is crucial to the recovery process as a whole. Understanding post-acute withdrawal as part of the recovery process, rather than a setback or unexpected challenge, should help those facing the withdrawal symptoms deal with them in stride. It may not make the symptoms any easier at the moment, but expecting what is usually unexpected can set up recovering addicts for success. The main stage in addiction recovery is activity and maintenance and dealing with post-acute withdrawal symptoms as part of this stage.

Dealing With Post Acute Withdrawal is Challenging, but Not Impossible

Despite the challenge that post-acute withdrawal poses to your recovery process, it is important to realize that the symptoms are temporary, not permanent. This perspective may help with the reactions and thoughts associated with post-acute withdrawal:

  • “I can’t stand this!”
  • “This is too uncomfortable. I don’t want to deal with it!”
  • “If being clean feels this bad, I might as well use”

These thoughts may be in the back of the mind throughout the recovery process but can become particularly pronounced when facing post-acute withdrawal symptoms. Because these symptoms can serve as a temptation for returning to alcohol or drugs, it is important to take up self-defense during this chapter of the recovery process. Counselors recommend taking measures of self-care, such as meditation, having a regular sleep schedule, keeping a healthy diet, and getting regular exercise. Each of these measures, or even better all of them, can improve attitude and emotional health, ultimately minimizing the effects of post-acute withdrawal. In addition to these simple steps, Dr. Steven M. Melemis recommends the following strategies for surviving post-acute withdrawal symptoms:

  • Go with the flow. Don’t try to do too much on “bad days”, and give yourself leeway for taking care of yourself.
  • Recognize that post-acute withdrawal can be a trigger. Prepare yourself for the symptoms, and remind yourself that they won’t last forever.
  • Be patient. Recovery isn’t achieved in a day, let alone a year. Take the symptoms one day at a time, and seek out help if they get to be too much.