The Problem with Detox | PAWS or Post Acute Withdrawal Syndrome

Hey there everybody, and welcome to today's presentation on the problem with detox. I'm your host, Dr. Donnelly Snipes. It's important that people understand what detox is and what it isn't. According to Samsa in 2015, detoxification is a set of interventions aimed at managing acute intoxication and withdrawal. The focus here is on acute what the person's going through right then. It denotes a clearing of toxins from the body of the patient who's acutely intoxicated and or dependent on substances of abuse. It's important to recognize that acute detoxification helps get the, for example, alcohol, the alcohol itself out of the system. It does not repair the damage, it does not repair the alterations that the person's body, the person's body has undergone when they were using over a long period of time. Rapid and traditional detox get the person to the point that they are physiologically stable, they're not likely to experience life threatening consequences, and they're past those acute withdrawal syndromes. Acute withdrawal syndromes are the ones that make you feel really, really awful. With some substances, this is the period where the withdrawal symptoms can be life threatening, like with alcohol, when blood pressure can spike and people can have a stroke. With other substances like opioids that tend to not be life threatening in and of themselves. The acute detox period is when those symptoms are the worst. When they feel like they have got the worst flu that they have ever, ever had in their entire life and they are at high risk of relapse. They're at high risk of reaching out and using again in order to stop that discomfort. Unfortunately, using at this point, especially if the person is feeling exceptionally desperate, may lead them to overdose. So supervised detox is definitely extremely helpful, even for substances that again by themselves are typically not going to induce some sort of life threatening crisis because of the detox itself. When people get out of detox, they are not recovered. Their brain has undergone all kinds of changes. Substance abuse causes systemic inflammation and alterations in neurocircuitry, which are almost never resolved during detoxification. What your body has adapted to over the course of three months, three years, 30 years, it's not going to reverse in three days or three weeks. It's important to recognize that the body became used to having this influx of this substance and is adapted to it. So without it, the person may feel flat. For example, with opioids, a lot of people in the post acute withdrawal time frame experience more aches and pains because the body takes time to ramp up its production of internal painkillers again. Their endogenous opioids take a while to get back online, if you will. Dopamine, for example. When people abuse just about any substance, dopamine surges. So the body gets used to having these high levels of dopamine. And when the body is not experiencing that, the person may feel flat and exhausted and apathetic, and that will eventually turn the corner as the body recognizes, hey, there's not going to be a tsunami of dopamine again. So we can be more receptive to any dopamine that comes our way. We don't have to guard against it. We can actually embrace it when it comes. The body must heal from the toxins that have been ingested, the oxidative stress, and that can come not only from the toxins and the inflammation, but from. From disrupted circadian rhythms, from mental stress itself, from a lot of different things. Any kind of stress on the body produces oxidative stress. The microbiome has to rebalance. We know that when we're under stress, physical or psychological, the gut microbiome is altered in order to support, fight, or flee in order to support that HPA axis. And as the body heals, the microbiome needs to rebalance to be able to be more relaxed, if you will, where it's not constantly fighting off threats and fighting off toxins. The brain must heal. There's a part of the brain, and sometimes multiple parts of the brain that actually are killed off with. We see shrinkage in the density of the brain in people who have addictions as they recover. We see something called neurogenesis, where some of these places, like the hippocampus, start to heal and start to regenerate those neurons. But it takes time. The neurotransmitters have to rebalance. The body has gotten used to having, you know, oodles and oodles of dopamine, which also means a lot of serotonin and norepinephrine. And now that that is not being artificially inflated, the body must adjust. The neurotransmitters must rebalance in order to support a more moderate lifestyle. And the nervous system, including the vagus nerve, has to recalibrate a lot of substances that basically hijack the vagus nerve. The vagus nerve is our traffic cop, if you want to think about it that way. It has its grimy little mitts in just about everything, and it controls or helps to control. It relays signals to the brain to let us know when there's time to be stressed and when it's time to relax. Well, substances, if you take stimulants, stimulant substances, that's going to hijack the vagus nerve and say, hey, we need to stay in stress mode. If it, if you're taking depressant type substances, that's going to hijack this vagus nerve and say, hey, just don't worry about it. Don't worry about anything. So the vagus nerve loses its attention to what's going on because it's kind of a lot more responsive to the substances themselves. In terms of acute withdrawal, the time frame for most people is for alcohol, five to seven days. For benzos like Valium and Xanax, between one to four weeks or three to five weeks with tapering. For cannabis, five days. Nicotine, two to four weeks. Opioids, four to 10 days or longer if you're using something like methadone or suboxone, and stimulants, generally one to two weeks. Anybody who's been addicted to these substances knows that after that period of time, they're still not feeling great, which means they're still at high risk of relapse because at a certain point you want to feel better post acute withdrawal. The signs and symptoms of post acute withdrawal from alcohol, for example, may last two years or longer after the last use of alcohol. Alcohol is really hard on the body. Sleep studies using polysomnograph recordings found that sleep abnormalities, including difficulty falling or staying asleep and sleep apnea, can persist for one to three years after stopping alcohol consumption. And if you've watched any of my other videos on the YouTube channel, you're aware of how integral the good quality sleep is in mental health, as well as regulated circadian rhythms. If either one or both of these is out of whack, it is going to make it a lot harder to, to feel happy, to feel healthy, to feel energetic. Opioid withdrawal symptoms can last for months after acute detoxification. And this is one of my pet peeves, if you will, of rapid detox. Because a lot of rapid detox places tell people when you wake up the, the opioids will be out of your system and you'll feel great. You just need to go to counseling to learn some tools to cope with stress. That ain't it, that ain't it. When people finish acute detox, yes, they need to learn tools to deal with stress, but they need to recognize they are not going to be back to their old selves for a long time. They need to know this. They need to be prepared to deal with post acute withdrawal symptoms. During this post acute phase, people who are withdrawing from opioids may experience anxiety, depression, anhedonia, that is a loss of pleasure and just not having feelings about much of anything. Low energy, lack of motivation and sleep disturbances. Now again, lots of videos on the YouTube channel that can trace this back to certain neurotransmitters and the effects of addiction. But what's important, important in the takeaway here is for people who've abused opioids for a significant period of time, the these symptoms may occur sporadically for the next up to two, maybe even three years. And that is really hard to wrap your head around now with post acute withdrawal. One of the things that I think is important in order to maintain hope and motivation is the fact that it gets easier with time. Just like grief, initially after you experience a loss, that grief is palpable, that grief is hard to deal with. But as you get further away from that loss, you may have occasional grief bursts where something hits you and you suddenly become melancholy. But the intensity, the duration and the frequency of those symptoms goes down significantly. And the same thing is true for post acute withdrawal. And it's important that we let people know that it will get better. And it's important to for a lot of people to keep a log so they can see those incremental improvements in their energy levels, in their mood, and their motivation with benzodiazepines. These are your Valium, your Xanax, your anti anxiety medications. Clients may have no symptoms for a time after initial detox and then suddenly become extremely anxious. These fluctuating symptoms may last for months, but gradually subside with prolonged abstinence. One of the things that is interesting is that there are a lot of substances, including cannabis. And opioids are lipophilic. They are stored in fat tissue. So think about that. If you lose weight and that fat gets metabolized, it's possible that it may release trace amounts. Now sometimes this is not enough to really even notice. Just like when you use a substance like caffeine, for example, and when you first use it, you can feel the effects, but then after it's gotten been in your system for a while, you don't hardly notice it anymore. And a lot of times we talk about half life. So when the substance is fully in your system, you may feel the effects, but once you get past that half life, a lot of times these symptoms and the effects of it are not super noticeable. And so it's important to recognize that people can still have cannabis Benzos, alcohol, well not so much alcohol in their sim, in their system, but not have the intense acute effects. It's not like they suddenly wake up and they're like ooh, I feel like I just had a dose in general and, and this depends on the person's feed, physiological makeup, their co occurring mental health issues as well as the substance they were using. But possible symptoms of protracted withdrawal or post acute withdrawal syndrome include anxiety, sleep difficulties, problems with short term memory, persistent fatigue, difficulty concentrating and making decisions, alcohol or drug cravings, impaired executive control. Executive control is attention, concentration, problem solving. So people who are experiencing pause or post acute withdrawal may have more difficulty, they may seem a little bit more addled than they used to until their brain heals. Anhedonia, that lack of feeling about much of anything, definitely difficulty experiencing pleasure, difficulty focusing, dysphoria or depression, irritability, unexplained physical complaints, and reduced interest in sex. Well, where does that sex one come from? When the body is going through post acute withdrawal, it is under stress. When the body's under stress, a lot of times the, well, when the body's under stress, anytime the gonadal hormones, that HPG axis, that hypothalamic pituitary gonadal axis is involved. But to kind of shortcut this explanation, when the body's under stress, a lot of times the brain says, you know what, we don't have the energy reserves to focus on sex, on procreation right now. And you know what, if there's a threat out there, it may not be the right time to bring another life into the world. For more information, you can watch my long video on post acute withdrawal syndrome@allce.com pause, withdraw all symptoms is important, but it's also insufficient. Discharging clients without further biopsychosocial treatment sets them up for failure and hopelessness. Disease detox is not it. Some people when they get out of detox, they think they're feeling better and they may not be motivated for treatment. So that's one of the things that we need to do in detox, is make sure to increase motivation using those motivational enhancement tools. Treatment must involve helping the person improve their sleep, hygiene, circadian rhythms, maintain a diet supportive of recovery, address underlying medical issues, reduce stress, address grief and guilt and trauma issues that preceded or relate to the addiction. There are no shortcuts in the recovery process. Even once the person gets past post acute withdrawal and their body has theoretically healed as much as it can from the addictive substance. If they have not addressed the the anger, grief, guilt, trauma that either precipitated the addiction or occurred as a result of the addiction, then their HPA axis is still going to be disregulated. They're probably still going to have difficulty maintaining sobriety because they're still feeling so much pain in recovery. There are no shortcuts, sorry to say.