Post Acute Withdrawal Syndrome (PAWS) in Addiction Recovery

Foreign. I'd like to welcome everybody, today's presentation and to the first day of Recovery Month 2020. Today we're going to be discussing post acute withdrawal syndrome, or pause. I am your host, Dr. Donnelly Snipes. We're going to learn what pause is. For those of you who aren't familiar and know it's not just the cute little things on puppies. We'll explore why pause happens and identify steps that we can help people take to reduce and cope with pause. Pause affects people who have engaged in addictive behaviors. In general. Pause is the result of changes in the brain that are either undoing themselves or rehabilitating after something happens. Even prescription medications taken for an extended period, like opioids, can produce pause. So it's important for us to remember that. And PAUSE stands for post acute withdrawal syndrome. Generally, we think of the detox period as the first, you know, three days to maybe two weeks at the, at the outset. But people will experience little bursts of symptoms probably for up to a year, sometimes two years, depending on how intense and how chronic their use was, how old they were when they started. Because we know that people who start abusing drugs, especially who are under the age of 24, when that brain hasn't fully developed yet, are going to likely have more significant brain changes than people who are over the age of 24. Interestingly enough, gender also affects pause as well as the length of time that somebody used and how much they used. Somebody who drinks alcohol, for example, and they have three drinks a night every single night for 15 years, is probably going to have different levels of pause than somebody who drinks, you know, 24 cans of beer a night for six years. You know, it's going to be a little bit different because of the degree of insult from the toxin, which is alcohol. People's physical health will also affect their post acute withdrawal syndrome. Obviously, if they are in poorer for physical health, they are probably going to experience more complications from the post acute withdrawal. And underlying mental health issues can also contribute to pause. We know when people have under mental health issues that their neurotransmitters are likely already out of balance and, and when they are detoxing from substances and their brain is recovering from substance misuse that is also targeting that neurotransmitter system. So there may be some challenges to helping people overcome pause in the if they already have underlying neurochemical imbalances. PAUL Pause begins after acute withdrawal and lasts for up to a year. And like I said, for some people that I've worked With they sometimes report that they have little spurts, even up to two years, but generally a year. We can really tell people to expect that they will have episodes of pause. They will have good days where they're feeling a lot better. And then they may have some bad, bad days when they're feeling fatigued or their cravings are higher. What happens? Memories of substance use alter brain functioning. So even just thinking about substance use can trigger some of those neurochemical reactions, specifically sending that dopamine out and that dopamine says I want that, I need that and triggers those cravings. So memories of substance use alter brain functioning and can promote drug seeking behavior and irritability when blocked from goal achievement. I know when I can't get something I want, I can get really irritable too. And it doesn't have to be, you know, it can be something like ice cream. It doesn't have to be anything huge. We want to recognize that that is just how we're wired. When that dopamine is out there, it's telling us go get it, go get it. You need that, you want that. And when you're getting that message from those neurotransmitters and you're not able to get it, regardless of what it is, you can get a little cranky, you can feel frustrated. Cocaine, amphetamines and alcohol. Let's talk about what happens to brain chemicals when people use cocaine. Amphetamines and alcohol reduce the uptake of dopamine. What that means. It gets a little bit funny the way it's worded. Sometimes the longer the dopamine stays in the synapses, the more of it is available, if you want to think about it that way. So when cocaine, amphetamines and alcohol reduce the uptake of dopamine, that means more dopamine sticking around. So there's more perseveration, more thinking about it, more wanting it, more drive to get it. There's also an increase in glutamate, which is our major excitatory neurotransmitter. So now we want it and we're really revved up to get it. And in high concentrations, interestingly enough, all of these cocaine, amphetamines and alcohol can inhibit monoamine oxidase A or maoa. Now think about the old, old, old fashioned antidepressants. Those were mo, they were monoamine oxidase inhibitors. So we're seeing that cocaine, amphetamines and alcohol can basically alter the brain chemistry to, I don't want to say alleviate depression. It's not a treatment for it, but it's monkeying with those neurotransmitters that are opposite of what would be active with, with depression. So guess what? When people detox, what are they going to experience? The polar opposite. They are going to. Their body has adjusted to having all those things, the glutamate and the dopamine excessively high and that monoamine oxidase excessively low. So it has actually altered its structure to try to rebalance itself. So then when it doesn't have the substance coming in anymore, it has, it doesn't have enough receptors for the glutamine or the dopamine because, you know, it was getting too much anyway and it has too many receptors because it was trying to suck up or get a hold of any of the monoamine oxidase that it could. Our brain is geared to maintain a balance. You know, let's just say 30 milliliters and that's not the right amount, but, you know, so if we are giving it more than that, it's, it may not know what to do with it. If we're not getting enough of that, then it's going to try to get more and it's going to do what it's got to do. Alcohol reduces glutamate's excitatory effect on the NMDA receptors and increases dopamine. So alcohol, you know, keeps that glutamate high, keeps that dopamine high. Co administration of nicotine and alcohol. Think about how many people that we work with that abused alcohol also smoked. When you put the two of them together, we know nicotine is one of the most addictive substances on the planet. When we put nicotine and alcohol together, it increases alcohol's rewarding effects. So now nicotine is really hard to quit. And alcohol is even more rewarding because it is upping the rate of that or upping the availability of that dopamine and that glutamate. And people are feeling that drive and they're feeling better and, and, and so it makes it more difficult to stop when they start withdrawing. And this is where post acute withdrawal comes in. During acute withdrawal, detoxification, people usually have the exact opposite symptoms, okay, of whatever their drug of choice was. If they were abusing depressants, they may feel anxious. If they were abusing stimulants, they're probably going to feel depressed. That's overly simplified, but you get where I'm coming from. So during detox, we see that as people move into later phases of recovery, they get past the wall and the honeymoon period and they're maybe even into that readjustment phase. There are going to be a lot of days, hopefully where they feel pretty good. But then there are going to be some days that either because they were thinking about the substance use and it triggers that neurochemical reaction or know they don't exactly know why, but there are some days where people will just wake up and whatever symptoms they had during detox, they may have those same symptoms again for a brief period. And it's important that we let people know ahead of time to expect this to that, you know, some days, hopefully the intensity will be lower and it won't last for very long. But there are going to be some days they're not going to feel as well and they need to have a plan to deal with that, that because in the past those symptoms have often triggered them to use or to relapse. We don't want that. So we want them to have a plan in place. Nicotine. And I know nicotine is not something people go to detox for, but as I said, a lot of people who abuse other drugs also use nicotine products. So we do need to consider it. Nicotine also stimulates dopamine and the reward center and is responsible for mood elevation, an apparent improvement in cognitive functioning. When people are, are detoxing, you know, even from smoking, they may find it more difficult to concentrate because again, even though it's nicotine, even, and I say that because nicotine is supposedly legal and harmless. Well, I know it's legal, but nicotine actually does impact cognition and mood and a whole bunch of other stuff. So. So when people are trying to even quit smoking, they're going to experience withdrawals, they're going to experience post acute withdrawal syndrome, again, potentially for a year. And nicotine is one of those, where I've had people two years down the road say they still have little spurts here and there, where they have more difficulty concentrating, where they have more difficulty with motivation and with energy. Remember, dopamine primarily is our go out and get it neurochemical. It's the one that motivates us. But dopamine is also responsible for energy. When we have too little dopamine, we are fatigued, we're lethargic. Think about people who are on antipsychotic medications that lowers dopamine. What's one of the main symptoms of antipsychotic medications? Extreme fatigue. Well, so when dopamine is low, people are going to be a little bit more tired, they're going to have more difficulty focusing and concentrating and, and it's important to recognize that because, again, people need to have a plan so they know how to deal with it. And they don't get frustrated because they're having difficulty focusing. They don't get frustrated because they don't have the energy that they think they should have at this point. Chronic stimulation by nicotine of the GABAergic neurons. Remember, GABA is our internal, internal volume, if you want to think about it that way. It's our internal calming chemical. Chronic stimulation by nicotine of the GABAergic neurons are desensitized and, and lose their ability to inhibit dopamine, which reinforces the addiction by inducing craving. So as GABA goes up, dopamine goes down. Makes sense. GABA says, relax. Dopamine says, go get it. So, you know, when one goes up, the other goes down. But by constantly stimulating the GABA neurons with nicotine, the, they lose their sensitivity, so they lose their ability to actually kind of tampen down that dopamine. So when people start smoking, the dopamine isn't blunted, if you will. Opioids work on the opioid receptors, which are the pain receptors and serotonin and dopamine levels. When people are taking opioids and their body gets used to it, what we take orally, even if you only take, you know, the minimum dose of oral opioids is usually 100 to 10,000, depending on the medication, times more potent and, and more intense than what your body would produce naturally. So you are flooding doesn't even begin to describe what you're doing to those poor neurotransmitters when you take over the counter medications. So when we're taking those, our body starts going, okay, you know, we don't need to make our own opioids anymore. We don't need to make the endogenous opioids because you're taking more than enough in and, and we're getting too much. So I'm going to shut down the production plant of the endogenous opioids. Well, unfortunately, like with anything else, the message doesn't get through right away. And it takes a minute, and by a minute, I mean, could be a couple of weeks for the brain to kick in and go, oh, you're not doing that anymore. So I need to, you know, get that assembly line back online. It's important to recognize that people's pain tolerance will be much lower generally when in the acute phases, especially of opioid detox. But there are also, again, Fits and spurts throughout that first year. And benzodiazepines, your anti anxiety medications, work on GABA and serotonin receptors primarily. It increases GABA and increases certain types of serotonin. Well again, when people stop taking that, then you know, when GABA goes down, dopamine goes up and dopamine is that. I want more of that sort of idea, that perseveration. We need to think about how that's going to impact the person. In chronic substance abuse, the brain comes to rely on the drug to maintain the high degree of pleasure associated with the artificially elevated levels of some neurotransmitters and the reward circuits. It gets used to it, it adapts to it. I'm going to try to give you an analogy in a minute. We'll see how, how well it goes. I've never used this analogy before, but we'll get there. The brain can even adapt to these high neurotransmitter levels by making new receptors which produces depression or anxiety and cravings if consumption ceases. So if you're, think about sponges. If you're flooding an area and you're trying to sop up all that fluid before it falls on the, falls on the floor, you know, you have one sponge and that's usually enough. But when you're taking drugs, it's like pouring an entire gallon jug onto the counter. One sponge ain't gonna do it. So you start, you know, getting out more sponges. Well, when you don't have as much water that you're pouring on the counter anymore, you don't need all of those extra sponges. So you know, it's important to recognize that the brain has adapted to the influx of too much of, of these drugs in order to protect your, protect your brain. Okay, so here's the analogy. In a factory, think of dopamine like one of the raw materials needed to make a product. And we'll call this product happiness. I know, corny, but it's the best I could do. Normally dopamine is on auto shipment. Any of us who've had auto shipments knows, know how this goes. Eventually we get too much. Normally, dopamine's on auto shipment, a steady regular supply. So the factory can produce a steady supply of happiness. The manager sees a deal on dopamine, we all love deals. And wants to increase his department's revenue really quickly so he can get a promotion. So he triples the auto shipment because it's a buy one, get two free sort of thing. So all of a sudden Instead of having the normal amount of dopamine coming in, they've got three times that amount coming into the, into the plant that they're, they need to convert to this end product called happiness. Initially, the workers are able to keep up, but this frenzied pace starts causing them to be exhausted and call out sick. So think about your brain. Your brain at a certain point starts trying to protect itself by shutting down some of those receptors. It says, I can't, can't handle all this stimulation. To deal with this excess, the factory hires new workers and creates a new assembly line. That's like when the brain starts creating those new neural networks. When the manager reduces the auto shipment back down to the normal amount, the sales off. Now there's nothing for the new employees to do, and the factory starts losing money, which is kind of akin to us feeling depressed. You know, there's all of these factory workers, all of these receptors just waiting for this chemical to come in and, and nothing's coming. And it's just, you start feeling depressed, you start getting bored. So what do we do? Well, to balance the budget, the manager either has to increase the shipments again, take another dose of the drug to keep those receptors, keep those workers busy, or fire the new workers. So you don't need to have as much of the raw material, don't need to have as much of the dopamine coming in, which is akin to allowing the brain to heal. Those are kind of your two options. You know, most people have to choose one or the other symptoms of post acute withdrawal. You didn't think we'd ever get here, did you? Emotional outbursts or lack of emotion. Well, think about it. When you are monkeying with dopamine, glutamate, gaba, serotonin, and norepinephrine, because anytime you mess with one, you mess with all five. It's just the way it is. Anytime you mess with one of those neurotransmitters, you throw the rest of them into kind of a frenzy. So as the brain starts recovering, as the body starts recovering, certain things are going to recover faster than others. And there may be times when, because you're not supplying excess serotonin, because you're not supplying excess gaba, excess dopamine, that life just seems way more overwhelming because you, you don't have enough of those neurochemicals to, you know, help you deal with life on life's terms. You'll get there. It's kind of like running a marathon. You're not going to go out one day and run whatever it is, 23.4 miles or I don't know, you're not going to go and run a long diagonal distance without training for it. You have to build up endurance. Your brain is kind of the same way. It has to slowly rebuild. And your ability to tolerate stress will slowly improve as the brain chemistry normalizes and whatever that means for you. People may have anxiety and irritability or depression and anhedonia, depending on which drug they abused. If it was stimulants, you're going to have more depression and anhedonia. If it was depressants or benzodiazepines, you're going to have more anxiety and irritability. Usually difficulty dealing with stress, fatigue. Well, that's a big one. But it's a no brainer. Like we talked about two slides ago, when our dopamine levels are low, our energy levels are low. It's just the way it is. So yes, glutamate is our main excitatory neurotransmitter, but dopamine is really important too. And the body is doing so much to try to recover during this early recovery period. And I say early recovery. I mean the first year. I really do mean the first year. It takes a while. People may have a hard time sleeping. Strange, strange dreams or changes in sleeping patterns. Well, what do we know? Serotonin is broken down to make melatonin. Melatonin helps us drift off and stay asleep. Well, and our circadian rhythms also tell us when to be awake and when to be asleep. If we are not helping people modulate their circadian rhythms so their brain starts getting on a schedule, that's going to be hard. But all that aside, we know that serotonin levels are going to be going kind of up and down for a little while. It's not going to be calm seas. So because of that, melatonin levels are also going to go up and down, which may make sleep more restless, et cetera. Additionally, you know, if people are anxious, it is harder to sleep. So there's a lot of things that could contribute to difficulty sleeping. It's important for people to be able to be mindful and look at what is making it more difficult for me to sleep right now. Is there anything that I can identify that I'm doing? Sleep hygiene is huge in early recovery. Psychoeducation memory problems make it hard to learn new things. Well, when dopamine is low, our concentration is low. When norepinephrine is low, our, our concentration is low. The brain is worried about recovery. It's not worried about learning advanced calculus right now. Trouble thinking clearly, making decisions, and solving problems. That also goes along with, you know, alterations, imbalances in those neurotransmitters and dizziness and problems with balance and delayed reflexes. All of those. When you understand that addiction has altered the brain chemistry, has altered some of the brain structures, and the body needs to repair. You know, it's kind of like when you get a, you know, a compound fracture, you know, the. The bone sticking out of the skin, and it's. It's just nasty. And the doctor has to bolt everything back together again. And it takes a while for those bones and skin and muscles and everything to knit back together. Some days it's going to hurt more, and some days it's not going to hurt as much. And the same thing is true for our brains. Encourage people to identify two ways to deal with each of these issues, knowing that it is likely that they are going to experience them. Emotional outbursts or. Or lack of emotion. When they're feeling flat, what can they do to bring some color to their day? What can they do? They may not feel elated, but what can they do to feel content? When they're feeling anxious, what can they do to help them get regrounded again? Again, they may not feel 100% great, but we want to help them develop distress tolerance and coping skills to deal with these issues. And in early recovery, part of it may be calling your sponsor. A lot of these skills and tools and things sound great, but when push comes to shove and that dopamine is really high and the cravings are really high, sometimes it's really important to have another actual physical human being saying, I got your back on this. Not just your conscience going, you don't want to do that, but your sponsor or your coach or your best friend saying, come on, let's go out and take a walk or let's go to the park or watch a movie. And until this passes, because sometimes it's really hard to do on your own. Your endogenous opioids, I mentioned those earlier, and endogenous is just one of those fancy ways of saying natural. Your natural opioids reduce the amount of GABA range released, so. And reduced GABA increases dopamine. All right? Dopamine is your per toy neurochemical, and it's also involved in energy and attention. I know we already went through this. I'm just kind of summarizing for you. Norepinephrine is responsible for attention and alertness. When you start to get fatigued around lunchtime. They found that generally the main neurochemical that's low at that point is norepinephrine. Glutamate is your main excitatory NeuroTransmitter. When that HPA axis kicks off, cortisol is released and glutamate and norepinephrine are all released to prepare you to fight or flee. Serotonin. And remember earlier I said certain types of serotonin. There are at least 17 different types of serotonin receptors. And depending on which serotonin receptors are activated, there are different reactions. Some serotonin receptors increase anxiety and increase alertness. Other serotonin receptors are more calming. And your cannabinoid receptors are involved in regulating mood, memory, appetite, pain, cognition and emotions. Now, cannabinoid receptors obviously are related to those are the ones that are activated by, guess what? Cannabis. When people stop smoking marijuana or ingesting it, however they're getting it, they will also potentially have pause symptoms because those cannabinoid receptors have been overstimulated for a while and now they're going to have to re regulate to this lower level of stimulation the natural cannabinoids. So mood, memory, appetite, pain, cognition and emotions may also be out of whack for people who are detoxing and recovering from cannabis use disorder and remember nicotine. And in some states, cannabis are legal. In all states, alcohol is legal. It doesn't mean it that those things don't do all kinds of gymnastics with your neurotransmitters. It doesn't mean that stopping them is just going to be a walk in the park, because it's not. Those are actually some of the hardest things to stop adenosine. We've talked about this so many times in different classes. It is one of my, you know, least favorite little neurotransmitters because as it builds up in our brain, it causes us to get sleepy. Adenosine is a central nervous system modulator that has specific receptors. When adenosine binds to its receptors, neural activity slows down and you feel sleepy. That's what they call sleep pressure. As you go through the day, adenosine builds up in your brain, which they call sleep. People call it sleep pressure. When you get that deep sleep at night, it clears out the adenosine well in early with recovery because of pause. Sometimes people don't get good sleep. When they don't get good sleep, they the adenosine doesn't get cleared out, so that contributes to them feeling foggy the next morning. And there's really nothing they can do about it until they get good deep sleep. It's not like you can rinse out your brain and get rid of the adenosine. But it's important to recognize adenosine facilitates sleep and dilates the blood vessels to ensure good oxygenation of the brain during sleep. You know, we do need it in order to keep our brain healthy. Caffeine, you know, we've talked about a lot of other drugs. Caffeine is another one that seems harmless, but it's really not. Caffeine acts as adenosine receptor antagonist, which, which means that it binds to the same receptors. It keeps the adenosine from making us feel sleepy. It doesn't mean it gets rid of it, so to speak, but it keeps, it keeps the adenosine from making us feel sleepy. Which is why when we get sleepy, when we get kind of foggy, a lot of people will drink caffeine and it makes them feel more alert because it's pushed the adenosine out of the way and, and taken over in those synapses. When people detox from caffeine, they are probably going to feel foggy headed. It totally makes sense. Recognizing that it is temporary is so important. Your nicotinic receptors have a modulatory role through and modulate neurotransmitter release. Which is another reason why nicotine is so addictive, because it affects almost all of our neurotransmitters. Interestingly, it's been characterized as an effective anti pain target that functions through a non opioid mechanism. So they have found that high levels of nicotine actually reduce pain. Now that's not saying go out and start using all kinds of nicotine products because nicotine, as I said earlier, is one of the most addictive drugs out there. But it's interesting to recognize. You think, why do people smoke? Why do people relapse on smoking? Why is it so hard for them to quit smoking? Well, let's look at all the things that nicotine does. You know, it is involved in keeping people more alert, helping them focus more and in some cases helping reduce pain. Now not nearly as well as opioids, but it does help when people start to get that stress, headache or, or something. A lot of people will, who smoke or dip or whatever will reach for nicotine. The developing brain is particularly vulnerable to the harmful effects of drugs of abuse, including cocaine, alcohol and nicotine products which activate the nicotinic receptors. So not only nicotine, but all of your drugs of abuse have some level of activation, do some level of activating of those nicotinic receptors and the, the developing brain has difficulty with that. Think of the developing brain, if you've ever made pottery, you know, think of it like pottery that hasn't been put in the kiln yet. And when it's exposed to that, you know, after something's been put in the kiln, you can poke at it and pick it up and turn it over and it's solid. It doesn't. You have to do a lot to it to get it to break or to crack or whatever. The brain is more like the raw, I guess that's what you call it. Clay from, from pottery. When, when the brain is young, when it's still developing, which is prior to age 24, which is, you know, think about it. After people graduate from college, actually, long after people graduate from college, just putting that out there. Disruption of the nicotinic receptor development with early nicotine or drug use may influence the function and pharmacology of the receptors and alter the release of reward related neurotransmitters, including acetylcholine, dopamine, gaba, serotonin and glutamate. So what they're saying is when people start experimenting or using drugs early, even nicotine or alcohol or, you know, marijuana, the list goes on. It can alter the function and structure of these nicotinic receptors, which can persist into adulthood and affect the amount of all of the other neurotransmitters that are available and the balance of those neurotransmitters now in post acute withdrawal syndrome. Remember, the brain's trying to repair itself, so there is hope that things will rebalance themselves. But it is important to recognize that people who start using really young may actually do some level of permanent damage to their brains. So what are the interventions? And I tried hard to get a mnemonic device that would be easy to remember. Best I could come up with was Mr. Escaper. The goal. Remember, we've talked before about our neurotransmitters being like a bath. And when people are abusing stimulants, they're think of it as running like full on hot water. So that bath is really hot. They're really excited. They're going full gangbusters. Think about depressants like running full on cold water. They're really calm, they're, you know, kind of frigid. However you want to think about it, people want to be somewhere in the middle. You want a warm bath where it can get a little warm or it can get A little cool, but you want to be able to alter it. You don't want it to be scalding on, on either end. Because when it's scalding, think about what that's doing to your brain. We want to regulate the temperature of the bath. We want to help people learn tools they can use to try to help their brain and help their body self regulate. So the first one is meditation and breathing. For people who are anxious, who are agitated, their HPA axis is probably hyperactivated, their dopamine levels, norepinephrine, glutamates, probably, you know, higher than they really want it to be. When we practice deep breathing, breathing in for four, hold for four, out for four, and, or meditation, and it can be open meditation, guided meditation, any kind of meditation. But meditation also involves focused breathing and that focused breathing, as people slow down their breathing, their heart rate naturally slows. That's just, they're connected. When heart rate goes up, breathing goes up and vice versa. Meditation and focused breathing can help people modulate that HPA axis response. After you get cut off in traffic, you know, it may have scared the bejesus out of you. So you pull over to the side of the road and you're just a shaken and your legs are going, what do you do? Well, one of the first things you can do, one of the best things you can do is slow your breathing. As you slow your breathing, the heart rate's going to slow. And that fight or flee response, that agitation, anxiety, fear response is going to, the physiological aspect is going to reduce. So that's the first part of it. We want to help the body start to calm down if it's too agitated. Relationships with sober social supports are really important. As I said earlier, sometimes those cravings, the agitation, the depression, whatever it is that is flaring up is going to feel overwhelming. It's going to feel inescapable, escapable. For people in, in early recovery, and it's really important that they don't rely just on themselves. Recovery is a group effort. I can't think of anybody that I've worked with in 20 years or anybody that I've known in 20 years that has been trying to recover from some sort of addiction, who hasn't had to enlist the support of their friends to, to help them get through moments. It's not all the time, it's not 24 hours a day, but sometimes you're having a bad moment or a bad day and it's really helpful. And this is true for anybody. Sometimes it's really helpful to have a friend that says, okay, come on, get out of your pajamas and we're going to go to the movies. At least you won't be sitting around here moping and mulling. And sometimes that can help get people out of that funk and get some of those positive neurochemicals going. One of them, if a friend comes over, one of those neurochemicals would be oxytocin. Exercise is really helpful. And I was reading a really interesting article this morning that they have found that exercise actually changes the brain and helps people tolerate stress more. And I haven't found the journal article. Obviously I want to look at the actual study. But the gist of it is that when we exercise, our levels of cortisol and glutamate increase in our brain because we're, we're getting excited, we're simulating fight or flee when we're exercising. And that over stimulation actually causes the brain to change because the brain says, okay, overstimulated, I need more workers on the line. The brain actually changes, so it is more able to handle influxes of high levels of stress chemicals like cortisol and glutamate. So when we experience psychological stress, those same areas in the brain are activated. But since you've trained them, since they've got more workers that are ready to handle the influx of the, of the cortisol and glutamate, evidently it doesn't trigger that HPA axis as strongly. You know, they're already ready for the marathon. I know I keep mixing my metaphors today, but. So I thought that was a really interesting study. And people don't have to exercise, you know, super hard every single day. They found that it was the equivalent of power walking or jogging three miles four times a week. And I know for a lot of people that's like, oh my gosh, I can't even think about that. But anything is going to be better than nothing. Sleep is so important. We got to help the brain clear out that adenosine. But when people sleep, you know, think about what I talked about earlier. When people sleep, the blood vessels in the brain dilate to increase oxygenation. We increase oxygenation. That creates a much better environment for the brain to heal. You know, our tissues, you know, do much better in an oxygenated environment. When we're sleeping, our body's not worried about digesting. It's not worried about driving. It's not worried about anything else. It can focus all of its energy on rebalance and repair. So sleep is really important. But. And this Takes us down to circadian rhythm restabilization. It's important that we make sure that people aren't sleeping all the time. In early recovery, a lot of people are exhausted, they're fatigued because their dopamine levels are in the sub basement. I get it. However, sleeping all the time is going to mess up the circadian rhythm. So your brain doesn't know when it is supposed to sleep. So the sleep the person does get is probably not going to be quality sleep. Now, does that mean we need to force our clients to stay up all day, every day? No. However, we need to encourage them to learn about sleep hygiene. Limit their naps during the day to maybe 20 minutes, 45 minutes at the max, so they don't go into that deep sleep state. When I worked in residential, we used to have a quiet time right after lunch from 12:30 until 2:00', clock, where the clients were allowed to mull around and work on their assignments. They were allowed to meditate, go out and walk, do whatever they wanted, but it was a quiet time. They weren't supposed to be, you know, out there playing volleyball. And this was a time where a lot of people took the time to sort of rejuvenate. And there's lots of things that can trigger our dopamine. Anything we do that makes us happy is going to increase dopamine. So I would encourage people during those downtimes not to always go to sleep. Let's think about, you're fatigued right now. Maybe it's because your dopamine's low. What can we do to help you raise that? What do you enjoy doing? Make a list of 10 things that you enjoy doing that you can do here and in residential. That was kind of limited, but there were things that people could do. And a lot of times they found when they started engaging in something enjoyable, they started to wake up a little bit. Now they didn't feel great, but, you know, they were two weeks out of detox. I wouldn't expect them to feel great. Back going back to that circadian rhythm stabilization, helping people start going to sleep at a regular time, practicing good sleep hygiene. And if they're, if they have to nap during the day because they're just so fatigued, keeping it under 45 minutes is going to be really helpful. So their brain learns that melatonin, okay, we start secreting it at this, this time, whatever it is for that person. 10 o', clock, 11 o', clock, for me, 8 o', clock, you know, awareness and mindfulness, super important. People need to be checking in with themselves when they get up in the morning, at lunchtime, at dinner time, before bed. How am I feeling emotionally and physically? Is there anything that I need to do? What is my body telling me that I need right now? This mindfulness goes a long way to preventing relapse because if people are aware of what's going on, then they will notice these subtle changes or sometimes not so subtle changes, and they can do something about it. You know, if they wake up and they're feeling kind of flat one morning, they can just recognize that, okay, this is part of the recovery process. This is going to be one of those not so great days. What is my plan to handle it? Pleasurable activities. Kind of mentioned those earlier. Pleasurable activities help increase dopamine, and depending on the activity, it can also increase norepinephrine, glutamate and serotonin. Because pleasure, pleasurable activities are associated with happiness. They're associated with sometimes excitement. Now, some of those pleasurable activities, doing a puzzle, you know, that's not super excitable. So if somebody doesn't have a lot of energy, maybe that's something they enjoy doing or doing a crossword or looking at stuff on, on Pinterest or Instagram or whatever it is. My daughter spends a whole lot of time on Pinterest and Instagram, but she always manages to find these hilarious or at least adorable videos and she spends about 15 minutes each night showing them to me. So there's just this barrage of different things that she found on, on Pinterest. So there are good things out there on social media. It's not all doom and gloom and stress. When we do pleasurable activities, it increases our pleasure. Neurochemicals. That is important. Eat healthfully. We need to provide the body those raw, raw materials so it can. They can. The body can make dopamine, the body can make norepinephrine and serotonin and estrogen and testosterone and thyroid hormones and. And all that stuff. Eating healthfully also keeps the gut healthy. And if the gut is healthy, then it is better able because most of your neurotransmitters are actually made in your gut. It's better able to support health and happiness and relaxation. Some people don't need to be revved up. They need help calming down. Either way, people need to learn how to regulate that HPA axis a little bit. Relaxation is about helping your body secrete the calming forms of serotonin and gaba. Helping your body chill out. And it's mental as well as physical. Encourage People to think about what is it that they do that helps them relax? Is it yoga? Is it meditation? Is it reading? Is it stretching? Is it all of the above? What is it that helps them? And relaxation, like I said, is partly physical, can also help reduce muscle pain. If somebody is, has, has chronic pain, relaxation can go a long way to helping release gaba. Interestingly enough, benzodiazepines are one of the drugs that physicians sometimes prescribe to people who have muscle strains. Because the benzodiazepines cause the person to relax not only mentally, but also physically. There's also your muscle relaxants that are out there. But it is important to recognize that GABA is, and relaxation go hand in hand. Eating healthfully supports all the neurotransmitters. Pleasurable activities goes along more with your, with your dopamine and some of your serotonin and then sometimes norepinephrine. People will start exploring these things and they will figure out what things work best to help them. I know for me, and I've shared this with you guys before, when I'm in a funk and sometimes he needs to use a crowbar to do it. But my husband will pry me out of my, out of my little divot in the sofa and he'll say, you know, let's go out into the garden. And if I'm out there five minutes, once I get out there, I usually enjoy being out there. I'm getting some sunlight, increasing my vitamin D, which is another, you know, good thing to do. But it's important to know which things work for you. You know, there are some things like, I don't know, riding a motorcycle that wouldn't be up there on my pleasurable list of things to do. It is for some people, some people swear by it. So encouraging people to figure out what is it that's pleasurable for them so they can learn how to naturally increase their feel good chemicals, but also helping them learn how to naturally reduce or modulate their HPA axis through meditation, breathing and relaxation. Pause is an expected issue for at least the first year as the brain and body recover. Pause symptoms are caused by imbalances in the brain's neurotransmitters either because there's too much neurotransmitter, not enough neurotransmitter, too many receptors, not enough receptors, and it's irrelevant what the, the take home message is that there's an imbalance in those neurotransmitters in early recovery. It's not helpful or realistic to ignore or Minimize pause symptoms. The body is often telling the person what is needed. So by cueing into that, they can become more aware of themselves and their needs and their, you know, ebbs and flows. The goal should be to minimize stress, just like when recovering from any other issue. Illness. Help people minimize stress during this first year so their body can devote more energy to the recovery process. It's important to integrate what the body is saying with the recovery process, though. For example, sleep is important, but sleeping all day, as we talked about, has its own problems. So we need to make sure that what they're doing is just like everything else, in moderation and at the right time. And, and, you know, if they're sleepy all day long, if they're having difficulty focusing in group, you know, I'm, again, I'm coming from a residential perspective where people were, you know, brand spanking new out of detox. And a lot of times I was just happy if they were able to get up and show up. And that's all I really expected for like the first two weeks was, you know, all right, you may not be getting a whole lot out of this, but we need to help train your body and reset those circadian rhythms and start providing it the nutrients it needs to recover. As they got further into recovery, obviously, you know, the hope would be that the circadian rhythms were more stabilized and they would start developing tools to deal with those occasional spurts of post acute withdrawal symptoms. Are there any questions? If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allceus.com or getting your agency to sponsor an episode. A direct link to the on demand ceus for this podcast is@allce.com podcastce that's allce.com podcastce to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week. Go to allce.com sponsor. Thank you.