Withdrawal - Withdrawal From Drugs of Abuse

Withdrawal From Drugs of Abuse

Central to the role of nearly all drugs that are commonly abused is the reward circuitry or the "pleasure center" of the brain. The science behind the production of a sense of euphoria is very complex and still questioned within the scientific community. While neurologists have discovered that addiction encompasses several areas of the brain, the amygdala, Prefrontal Cortex, and the nucleus accumbens are specifically responsible for the pleasurable feelings one may experience when using a mind or mood-altering substance. Within the nucleus accumbens is the neurotransmitter dopamine, so while specific mechanisms vary, nearly every drug either stimulates dopamine release or enhances its activity, directly or indirectly. Sustained use of the drug results in less and less stimulation of the nucleus accumbens until eventually it produces no euphoria at all. Discontinuation of the drug then produces a withdrawal syndrome characterized by dysphoria — the opposite of euphoria — as nucleus accumbens activity declines below normal levels.

Withdrawal symptoms can vary significantly among individuals, but there are some commonalities. Subnormal activity in the nucleus accumbens is often characterized by depression, anxiety and craving, and if extreme can drive the individual to continue the drug despite significant harm — the definition of addiction — or even to suicide. In general, the longer the half-life of the drug, the longer the acute abstinence syndrome is likely to last. However, with drugs with a longer half-life, the acute abstinence syndrome will be much milder than that of those with shorter half-lives.

However, addiction is to be carefully distinguished from physical dependence. Addiction is a psychological compulsion to use a drug despite harm that often persists long after all physical withdrawal symptoms have abated. On the other hand, the mere presence of even profound physical dependence does not necessarily denote addiction, e.g., in a patient using large doses of opioids to control chronic pain under medical supervision.

As the symptoms vary, some people are, for example, able to quit smoking "cold turkey" (i.e., immediately, without any tapering off) while others may never find success despite repeated efforts. However, the length and the degree of an addiction can be indicative of the severity of withdrawal.

Withdrawal is a more serious medical issue for some substances than for others. While nicotine withdrawal, for instance, is usually managed without medical intervention, attempting to give up a benzodiazepine or alcohol dependency can result in seizures, psychosis, and death if not carried out properly. An instantaneous full stop to a long, constant alcohol use can lead to delirium tremens, which may be fatal.

Additionally, benzodiazepines have clearly been shown to induce a withdrawal syndrome in some people that is often severe and protracted in course. Doctors Ashton and Lader are two separate internationally recognized contributors who researched and described this condition that is now referred to as protracted benzodiazepine withdrawal syndrome (PBWS). Noteworthy, some patients become physically dependent on a small duration and dose (therapeutically prescribed dosages) of benzodiazepines. Patients may develop physical and psychological adaptations that may manifest while taking the medications and/or up on cessation that may lead to a severe withdrawal and discontinuation syndrome (PBWS). There is no known cure for PBWS, except time (in some cases 4, 5, or perhaps 6 years or more is needed for the withdrawal symptoms to slowly fade from 'misery' to 'comfort'). Paxil (an antidepressant) and benzodiazepines share this unique phenomenon known as 'discontinuation syndrome'.

Although a distinguishing characteristic of a benzodiazepine is that the withdrawal effects clearly may protract in course for an inordinate amount of time, iatrogenic dependence (doctor induced) can be an overlooked phenomenon with benzodiazepines. When patients begin to complain and/or shown signs of tolerance, dependence, interdose withdrawal, withdrawal, or protracted withdrawal to tranquilizers such as benzodiazepines, the patient may be misdiagnosed with yet another physical or psychological classification or diagnoses. This is because a great majority of health care providers have minimal training in addictionology/chemical dependency, especially with recognizing the signs and symptoms related to benzodiazepine dependency en route to tranquilizer withdrawal. Doctors may become perplexed or frustrated with such patients and assign the patient with a diagnoses such as anxiety, psychosis, somatization disorder, or other diagnoses pertaining to the wide range of symptoms that tranquilizer dependent patients may complain about while on the medications or up on cessation of these medications.

Unfortunately, a sizeable minority of tranquilizer victims endure the withdrawal syndrome with minimal help from the medical community, while finding support from various organizations or internet support groups with individuals who have made their lives and stories available to help support others who are trying to recover. For those susceptible individuals who manifest with PBWS, recovering from benzodiazepine dependency is serious business requiring an understanding of the 'slow and waxing-waning nature of the withdrawal' as well as extreme patience.

An interesting side-note is that while physical dependence (and withdrawal on discontinuation) is virtually inevitable with the sustained use of certain classes of drugs, notably the opioids, psychological addiction is much less common. (Hence the "cold turkey method.) Most chronic pain patients, as mentioned earlier, are one example. There are also documented cases of soldiers who used heroin recreationally in Vietnam during the war, but who gave it up when they returned home (see Rat Park for experiments on rats showing the same results).

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