Where’s That Pink Cloud When You Need It? Understanding and Managing Post-Acute Withdrawal

pink cloud

When I was in training, more years ago than I care to count, my mentors warned me not to float away on the “pink cloud” likely to envelop patients in the early stages of  recovery from substance use disorders.  I was told  that   the initial rockiness of stopping alcohol and/or other psychoactive drugs is often followed by feelings of elation and  great expectations for the future.  In this irrationally exuberant state, recovery can feel essentially effortless and treatment activities may seem like an unnecessary  waste of  precious time.  The danger, of course, is that  abandoning these activities leaves one  defenseless when the pink cloud vaporizes.  At some point,  the hard work of sustaining sobriety in the face of the wreckage wrought by addiction  seems daunting if not overwhelming,  and those who are going it alone and who  fail to  anticipate the transience and fragility of the pink cloud experience often take it hard when their mood darkens,  and  are vulnerable to relapse.

Clinical experience has taught me that some people do pass through a pink cloud after negotiating the acute withdrawal phase of recovery,  but I’ve also learned that the  first year(s) of recovery  are a jarring and complex mix of  emotional highs and lows for most people.  And I’ve found that  some people never catch a  glimpse of the pink cloud in the early going.  They  just feel chronically down,  out, scared and  hopeless for months on end.

Today, the treatment and recovery communities offer  more detailed guidance to practitioners, recovering individuals and family members about the array of difficult and highly individual challenges people face during the first months and years of abstinence from alcohol and drugs. And they caution that it can take a good deal of time  for mood, thinking and behavior to improve and stabilize. Terms likes “Protracted Withdrawal” and  “Post-acute Withdrawal Syndrome (PAWS) are used to describe the psychological and physiological phenomena that can destabilize and derail people in recovery  for an extended period after drug and alcohol use end.

For example,  The Substance Abuse and Mental Health Service Administration (SAMSHA) warns that low feelings are to be expected for most people in early recovery and that protracted withdrawal may persist forweeks, months, and sometimes years”.  In a 2010 Advisory SAMSHA explained that:

“In a pattern unique to each client… signs and symptoms of withdrawal as well as…other conditions such as impaired ability to check impulses, negative emotional states, sleep disturbances, and cravings (may persist). These symptoms may lead clients to seek relief by returning to substance use, feeding into the pattern of repeated relapse and return to treatment.

What Causes PAWS?

Thanks to advances in the field of neuroscience and neuroimaging, we now have some understanding of the anomalies in the brains of people with substance use disorders that are the likely source of post-acute symptoms.   Numerous changes in brain structure and function   occur as a result of these disorders  and many of them are dramatic and long-lasting. Some of the most important changes occur in the cerebral, or prefrontal cortex (PFC), where most of the information processing performed by the brain occurs, and in the mesolimbic dopamine system, which is the most important reward pathway in the brain. It’s a good idea for people in recovery and for  those who love them to understand the nature and the impact of these changes.  It is the kind of information that can help everyone to  manage expectations about what life will be like after drug and alcohol use stop  and to develop strategies and practices that facilitate healing in the brain.

Addiction and the PFC

prefrontal cortex2

While substance use disorders damage the brain in many ways, they  seems to have particularly pernicious effects in the frontal systems of the brain, causing the  PFC to “shrink and degrade . Goldstein and Volkow (2011)  reported that results from structural imaging studies show  reduced PFC grey matter density or thickness across addicted populations of up to 20%.  This type of damage is extremely problematic because the PFC is essentially the brain’s chief executive officer. Many refer to it as the  seat of good judgementThe National Institute on Alcohol Abuse and Alcoholism (NIAAA)  explains that this region of the brain:

“is necessary for planning and regulating behavior, inhibiting the occurrence of unnecessary or unwanted behaviors, and supporting adaptive “executive control” skills such as goal–directed behaviors, good judgment, and problem–solving abilities. Disruptions of the normal inhibitory functions of prefrontal networks often have the interesting effect of releasing previously inhibited behaviors. As a result, a person may behave impulsively and inappropriately, which may contribute to excessive drinking.”

Another critical function associated with the PFC is working memory.  Working memory is important because  it enables  us to hold in mind information we have gleaned in the past that is necessary to plan, problem-solve and anticipate consequences in a situation that is occurring presently.   Tracy Packiam Alloway, PhD.,  assistant professor of psychology at the University of North Florida in Jacksonville, Florida, calls  working memory the brain’s Post-it note and observes that it “makes all the difference to successful learning.”  Abernathy et al (2010) add that working memory underlies the capacity to construct strategies to obtain reward as well as the ability to inhibit “behaviors that pose undue risk or harm to the individual”. The image below shows the dramatic cortical changes that occur in the brain of an alcoholic.

cortical damage from alcohol cropped

Fortunately,  the PFC rebounds after a period of abstinence.  In 2008, Fulton Crews and Kim Nixon  reviewed  several studies about alcohol-induced brain neuronal death and about the loss of neurogenesis in alcoholism as well as brain regeneration in abstinence. They concluded that abstinence permits regrowth of brain cells as well as partial reversal of alcohol-induced  cognitive deficits  across regions of the brain.  The caveat here is the authors’ observation that these improvements occur  “after months of abstinence.” Goldstein and Volkow (2011) were more precise  in a later paper,  noting that  grey matter PFC decrements, particularly  in the dorsolateral PFC (which plays a key role in executive functions) “can  persist from 6–9 months up to 6 years or more of abstinence“.

In the same article, Goldstein and Volkow explained that other   research has verified that addicted individuals are not fully aware of the severity of their illness, including the extent of their pursuit and use of substances and the consequences associated with these activities. They made the interesting point that since higher-order functions, including the capacity for self-awareness, are so dependent on the PFC, drug- and alcohol-related impairments in this region may be key to understanding why  denial  is almost universally present among addicted individuals.

With a singular focus on   damage to the pre-frontal cortex that occurs as a result of substance use disorders, we can say that addiction undermines  many, if not all of the capacities needed to maintain abstinence and true emotional sobriety. It compromises the  ability to anticipate and weigh consequences, undermines sound judgment, blunts awareness of the impact (on self and others)  of past and future substance use and weakens the capacity  to formulate and  execute effective strategies for change and to regulate  powerful emotions .  Moreover,  depending on individual differences (such as the severity and duration of  use and  specific psychological and physiological vulnerabilities) these functions can remain at subpar levels for 6 years or more.

Addiction and the Mesolimbic Dopamine System

But the PFC is not the only aspect of neuroanatomy  affected by substance use disorders. Neuroimaging and clinical research show us that the mesolimbic dopamine system, which is the most important reward pathway in the brain, is also profoundly affected in addiction.  This system is   composed of the VTA  (ventral tegmental area) and the  NAc (nucleus accumbens).  The brain’s reward systems are key to our ability to learn new things, so  structural and functional changes in these areas are believed to be crucial to the development of compulsive drug and alcohol use. An article produced by one  NIDA team  explains how the dopamine system facilitates learning  by orienting us to sources of reward:

“… activation of the pathway tells the individual to repeat what it just did to get that reward. It also tells the memory centers in the brain to pay particular attention to all features of that rewarding experience, so it can be repeated in the future.”

Dr. Martha Burns of Northwestern University refers to   dopamine  as the “save button” in the brain.  She explained  that, “When dopamine is present during an event or experience, we remember it; when it is absent, nothing seems to stick.”

Addictive drugs are like important biological stimuli, including food and sex,  in that they increase dopamine release from cells in the VTA into the PFC, and into the striatal  complex of the brain (which includes the NA) and the amygdalae,  structures which are important to memory, decision-making and emotional reactions  (Kalivas and O’Brien,  2007,  Neuropsychopharmocology) .  Follow the blue lines in the graphic below to visualize the dopamine pathways in the brain.

dopamine pathways best

Kalivas and O’Brien  explain that there are important differences  between dopamine that is released by addictive drugs and dopamine triggered by  environmental stimuli.  For one thing, “release of dopamine by addictive drugs is of greater amplitude and duration”  than the release that occurs as a result of physiological mechanisms. Kalivas and O’Brien say that, “Simply put, drug pharmacology drives dopamine release beyond physiological limits”  by overcoming the  means and mechanisms the brain normally employs to control dopamine release.

Kalivas  and O’Brien go on to explain that another major difference between drug-induced dopamine release and release that occurs when people encounter biological stimuli is that tolerance develops to the release of dopamine by biological stimuli. In other words,   once an individual has figured out the most efficient way to obtain biological rewards such as food or sex, no more dopamine is needed to strengthen that person’s understanding that certain situations and behaviors result in pleasure,  so the release no longer occurs.  However, addictive drugs cause the release of dopamine every time they are taken (though higher doses may be needed to obtain the same effect).  This  promotes “increasing associations between the drug and life events” surrounding ingestion of the drug.  As  Kalivas  and O’Brien explain, this relentless flow of dopamine can eventually “cause drug-seeking behaviors to encroach upon all facets of daily life”, In 12-step parlance, all the people, places and things that are present when someone uses drugs and alcohol can  become “slippery” (cues for relapse) due to dopamine flooding that causes them to become associated with drug/alcohol-related highs. Future contact with them will prime the brain with an initial rush of dopamine that leads to craving and ultimately,   drug-seeking. As we will see below, the capacity for drugs of abuse and slippery entities to induce dopamine in the brain and stimulate craving can persist for a long time.

The brain eventually remodels itself to defend against a substance-induced flooding with dopamine by producing less dopamine and becoming less sensitive to it over time.  This tolerance leads addicts to pursue and use drugs even more frantically and it also reduces the pleasure they feel from doing things that used to please them.  Consequently, drug rewards eventually become more important to addicts than anything else. 

It is not entirely clear how long changes to the mesolimbic  dopamine system in the brain endure after abstinence is established. However, this image,  from a 2001 study by Volkow et al in the  Journal of Neuroscience (21:9414–18) illustrates how neurological healing proceeds in the case of methamphetamine abuse. It shows profoundly reduced levels of dopamine transports in a meth abuser (center image yellow and green) as compared with a control subject (left) , and then a return to  nearly normal  levels after 14 months of abstinence (right). 

dompamine receptors in addiction

Addiction and the Persistence of Memory

The  fact that executive functions and the capacity to find pleasure in day-to-day life take months and perhaps years to normalize in abstinence creates real stress for individuals and families who long for a return to some semblance of normalcy. However, even more problematic for recovering addicts and their families is the fact that  memories of  drug rewards and of  the people, places and things that are associated with these rewards are exceedingly long-lasting.  When people use psychoactive substances,  a protein called delta FosB begins to accumulate in the nucleus accumbens.  This protein leads to the establishment of  new neural connections and it also  strengthens old ones.  It is an extremely stable protein and can remain active in nerve cells for weeks to months after someone ingests a drug.  (Read more about Delta FosB and its role in memory and relapse in my post, Relapse and the Persistence of Memory.)

Managing PAWS

While post-acute withdrawal is  distressing to contemplate and difficult to endure, there are strategies and practices that can make life manageable during this period, even in the event of severe flare-ups.  Most people will have to employ several of these measures to give themselves the best shot at achieving long-term sobriety, which is a very different matter than abstinence.  Sobriety refers, in part, to the  ability to regulate mood and behavior, establish rewarding intimate relationships and establish a perspective in life that allows peace of mind.  Recovering individuals and their families frequently feel resentful of the amount of time and effort it takes to establish and maintain sobriety once abstinence is in place.  It can be useful to remember that one of the important criteria for diagnosing a substance use disorder is that  a great deal of time is spent in activities necessary to obtain the substance, to use it, and to recover from its effects.  Individuals will differ in what they require in order to to create a manageable and rewarding life after abstinence, but many will find that, for a time, they have to be as involved in recovery activities as they were involved in using activities.

NIDA has a useful advisory about protracted withdrawal that points  practitioners and people and families in recovery toward activities and behaviors that are likely to reduce post-acute symptomatology and promote physical, psychological and emotional healing from substance use disorders. Here are some highlights from the advisory and a few additional ideas that may be helpful.

Stay Active.

Consider Medication

  • There are medications such as acamprosate, which help to relieve some of the symptoms of post-acute withdrawal.  Methadone or buprenorphine replacement treatment can be helpful for people who are recovering from opiod addiction. NIDA reports that it sponsored a large multisite clinical trial which demonstrated that suboxone (a combination of burprenorphine and naloxone) has a “robust effect in reducing opiate use and drug cravings in heroin abusers and (which) confirmed its safety and acceptability”.

Get Assessed for a Co-Occurring Disorder

  • PAWS symptoms are similar to those of psychological disorders such as depression and anxiety.  Sometimes severe mood disorders make people more vulnerable to addiction in the first place.  In any case, appropriate treatment for symptoms of anxiety and depression can help to stabilize people in early recovery.

Join a Support Group

  • In a previous post I explained that people with substance use disorders typically become progressively more isolated and alienated from family and friends, partly because neurological changes associated with addiction make them more oriented to drug rewards and less interested in and responsive to social relationships. One of the important tasks of recovery is to learn, or re-learn  that people and relationships can be significant sources of reward–that they can offer meaningful companionship and provide comfort and soothing in times of emotional and physical distress.  Twelve-step groups are important during recovery for many reasons, but even people who are skeptical and mistrustful at first often find  the acceptance and care they receive from their peers in these groups to be restorative and, not infrequently, life-saving.  The usual guidance is to try out a few different meetings in order to determine if there is at least one place you feel sufficiently comfortable to “keep coming back”.  You don’t have to believe the group will help or that it will change your life and you probably won’t.  Remember, the brains of most people in early recovery are fixated on substances  as the source of  relief. But new  experiences are required in order to develop new reward pathways in the brain. Confidence in the power of the group and other people to promote healing will develop over time with enough exposure to and experience with supportive others.

Try Meditation

  • Stress is a well-known trigger for relapse, as are cravings. There is evidence that meditation can help to alleviate many of the psychological stressors that plague so many people for a lengthy period after they stop using drugs and alcohol, including anxiety, depression and sleep problems. A study performed by researchers at Stanford University indicated that in addition to reducing anxiety, mindfulness  meditation, may help people to improve their self-image, by stimulating a a brain network in the posterior cortical region that helps us pay attention. The ability to consciously control attention can allow people to shift the mind away from troubling, distorted self-perceptions. Shame and a poor self-image are significant problems for many people in recovery.  In many cases, lack of self-esteem was a significant driver of compulsive behavior in the first place, and heightened  ability to focus attention away from negative thoughts about the self could be very helpful to these people.
  • There is a relatively new behavioral treatment called mindfulness-based relapse prevention (MBRP) that teaches people in recovery how to use  meditation to reduce  craving and unpleasant emotions that can lead to relapse. MBRP training teaches cognitive-behavioral relapse strategies along with  mindfulness meditation. The mindfulness practices aim to help people accept  uncomfortable feelings and thoughts and to face  challenging situations instead of reflexively reacting to these as they would have in the past. Research indicates that people trained in MBRP have lower rates of substance use and greater decreases in craving following treatment than control subjects. Those with MBRP training also indicated that they did not experience  increased craving or substance abuse when they had negative feelings. Investigators believe that “MBRP may affect numerous brain systems and may reverse, repair, or compensate” for changes in brain structure and function that are associated with addiction.

Post-acute withdrawal presents a significant challenge to many people for at least a year after they stop using alcohol and or other psychoactive substances. Knowing what to expect, and how to reduce the symptoms of PAWS  can help individuals and families work together to make life far more manageable in early recovery.

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