your guide to...
Drug withdrawal
Your guide to...
Drug withdrawal
What is drug withdrawal? “Withdrawal� refers to the signs and symptoms that appear when a drug of dependence, which is regularly used over time, is suddenly stopped or the amount taken is greatly reduced. This pamphlet aims to help health professionals and the general public understand the process of drug withdrawal for some common drugs.
WHAT IS DRUG DEPENDENCE? A person is said to be dependent on a drug when: ÎÎ
it is central to their life
ÎÎ
they have trouble cutting down their use
ÎÎ
they experience symptoms of withdrawal when trying to cut down or stop.
Dependence can be physical or psychological, or both. When a person’s body has adapted to a drug and is used to functioning with the drug present, the person is said to be physically dependent upon that drug. Sometimes physical dependence can develop quite quickly. When a person relies on a drug in order to function they are said to be psychologically dependent upon that drug.
WHEN A PERSON’S BODY HAS ADAPTED TO A DRUG AND IS USED TO FUNCTIONING WITH THE DRUG PRESENT, THE PERSON IS SAID TO BE PHYSICALLY DEPENDENT UPON THAT DRUG.
WHAT ARE WITHDRAWAL SYMPTOMS? Withdrawal symptoms differ for different types of drugs and from person to person. Generally, the symptoms of withdrawal are opposite to the effects of the drug. For example, withdrawal symptoms associated with depressant drugs such as alcohol, cannabis and heroin may include restlessness, agitation and tremors. Withdrawal symptoms from stimulant drugs such as ecstasy, cocaine or tobacco might include lethargy and depression. Other common symptoms may include irritability, cramps, nausea, sweating and disturbed sleeping patterns.
3
Common withdrawal symptoms Alcohol Common symptoms: ÎÎ
flushing and sweating
ÎÎ
headaches
ÎÎ
tremors
ÎÎ
anxiety and insomnia
ÎÎ
nausea, vomiting and diarrhoea
More severe, less common symptoms: ÎÎ mental confusion ÎÎ
hallucinations
ÎÎ
dehydration
ÎÎ
seizures and death
Amphetamines ÎÎ exhaustion and increased sleepiness ÎÎ inactivity ÎÎ depression ÎÎ irritability and tension ÎÎ cravings ÎÎ mood swings ÎÎ poor concentration ÎÎ increased appetite ÎÎ paranoia ÎÎ delusions
Benzodiazepines ÎÎ
sleep disturbances
ÎÎ
depression
ÎÎ
aches, pains, numbness
ÎÎ
headaches, dizziness
ÎÎ
panic attacks
ÎÎ
agoraphobia
ÎÎ
sensitivity to noise, light and touch
ÎÎ
reduced concentration and memory
5 Cannabis ÎÎ sleep problems including insomnia and strange dreams ÎÎ mood swings and irritability ÎÎ depression ÎÎ anxiety and nervousness ÎÎ restlessness and physical tension ÎÎ reduced appetite ÎÎ nausea ÎÎ cravings
Cocaine ÎÎ
extreme fatigue and exhaustion
ÎÎ
sleep problems
ÎÎ
agitation
ÎÎ
depression and anxiety
ÎÎ
cravings
ÎÎ
angry outbursts
Ecstasy (methylenedioxymethamphetamineMDMA) ÎÎ cravings ÎÎ general aches and pain ÎÎ anxiety ÎÎ depression ÎÎ loss of concentration ÎÎ sleep problems ÎÎ restlessness ÎÎ agitation
GHB (gammahydroxy-butyrate) ÎÎ
confusion, agitation, anxiety, panic, feelings of doom
ÎÎ
paranoia
ÎÎ
sleep problems
ÎÎ
tremors
ÎÎ
muscle cramps
ÎÎ
perspiration
ÎÎ
hallucinations
ÎÎ
seizures
ÎÎ
tachycardia (rapid heartbeat)
Like alcohol and benzodiazepines, sudden withdrawal from high doses of GHB can be dangerous and may require medical assistance.
Heroin ÎÎ sleep problems, anxiety, restlessness and fear ÎÎ runny eyes and nose ÎÎ nausea and vomiting ÎÎ diarrhoea ÎÎ muscle, joint, abdominal and back pain ÎÎ flushes and sweating ÎÎ dilated pupils ÎÎ gooseflesh ÎÎ cravings
Ice (crystal methamphetamine) ÎÎ
cravings
ÎÎ
confusion and poor concentration
ÎÎ
decreased energy and apathy
ÎÎ
irritability, depression and anxiety
ÎÎ
headaches and general aches and pains
ÎÎ
increased appetite
ÎÎ
sleep problems
7
Ketamine ÎÎ anxiety ÎÎ sweating ÎÎ shaking ÎÎ irregular and rapid heartbeat ÎÎ cravings
Hallucinogens ÎÎ
cravings
ÎÎ
fatigue
ÎÎ
irritability
ÎÎ
reduced ability to experience pleasure
Withdrawal from ketamine or hallucinogens is unusual, and people having symptoms after using frequent high doses of these drugs should speak to their doctor.
Tobacco ÎÎ cravings ÎÎ irritability, depression and anxiety ÎÎ sleep problems ÎÎ increased appetite and weight gain ÎÎ restlessness and loss of concentration ÎÎ headaches and general aches and pains ÎÎ stomach and bowel problems
CRAVINGS As well as experiencing other withdrawal symptoms, it is common for people trying to give up a drug to experience cravings. Cravings result from positive memories of the drug’s effect on the person using the drug. The brain learns that the easiest and quickest way to feel good is by using the drug, and this becomes a way of dealing with problems and avoiding bad feelings. As someone becomes dependent on a drug they also learn that, to avoid the unpleasant symptoms of withdrawal, they need to keep using it. Cravings are not constant; they come and go, increasing and decreasing in intensity. Some people report craving a drug many years after they have stopped using it. It is important to remember that cravings do not indicate weakness, lack of motivation or poor will power. Managing cravings involves learning distraction and relaxation techniques such as reading, going to the movies, meditating or exercising. WITHDRAWAL FROM ALCOHOL AND BENZODIAZEPINES CARRIES THE RISK OF SEIZURES OR FITS AND CONFUSION.
CAN WITHDRAWAL SYMPTOMS BE STOPPED? Withdrawal symptoms can be stopped or relieved by: ÎÎ
taking more of the drug
ÎÎ
replacing the drug with medication, such as replacing heroin with methadone
ÎÎ
taking medication temporarily to reduce the symptoms
ÎÎ
completing the withdrawal process.
The experience of withdrawal is different for everyone. All individuals react differently during withdrawal. While withdrawal may be uncomfortable and unpleasant for some people, it can be made easier by planning ahead and being in a supportive environment. Various medications are available to help reduce the severity of symptoms.
How long does withdrawal last? The start, duration and severity of withdrawal depends on a number of factors including: ÎÎ the type of drug the person has been using ÎÎ how long the person has been using it ÎÎ whether other drugs have been used ÎÎ the person’s general health ÎÎ the setting where the person is withdrawing. As a general guide, withdrawal usually lasts from a few days to a few weeks. Cravings can occur for months after a drug is ceased.
IS WITHDRAWAL DANGEROUS? Medical assistance may be needed to get through withdrawal safely. Withdrawal is not usually dangerous, but there are exceptions. Withdrawal from alcohol and benzodiazepines (such as Valium® and Xanax®) carries the risk of seizures or fits and confusion. Alcohol withdrawal is also associated with serious risk in some people, including seizures and severe confusion/ hallucinatory states (delirium tremens or DTs). Both DTs and seizures or fits would be considered medical emergencies and should be treated in a hospital.
WHERE IS THE BEST PLACE TO WITHDRAW? This depends on the person and the level of support they will require through withdrawal. Other factors to consider are: ÎÎ
the drug/s being used
ÎÎ
the amount and length of time of use
ÎÎ
if medical assistance will be required.
A doctor, other health practitioner, or drug and alcohol service can provide advice to suit the person’s needs.
9
NON-RESIDENTIAL WITHDRAWAL Withdrawal managed as an out-patient is sometimes suitable where such services are available and where the withdrawal is expected to be fairly uncomplicated and mild to moderately severe. It can be undertaken either in a person’s home with a supporting team and a visiting clinician, or where the person is reviewed at a clinical centre through the withdrawal period. Support from a family member or friend at home is often an important part of non-residential withdrawal, as is a plan of ongoing counselling and support.
RESIDENTIAL WITHDRAWAL This usually involves a short stay (5–10 days) in a community residential drug withdrawal unit or hospital, where staff can provide 24-hour support and treatment. Residential withdrawal services provide programs that aim to assist in the management of acute withdrawal and address issues such as relapse prevention. Some programs do not allow clients any external contact for a specified period so that they can focus on their treatment rather than worrying about what might be happening at home. It also restricts contact with other people who use drugs, which can be a strong trigger for cravings.
THINKING ABOUT WITHDRAWAL? If you are considering withdrawal, talk to your doctor or other health practitioner, or contact the drug and alcohol information service in your state or territory (see back cover for details). The companion to this pamphlet, Your guide to... alcohol and other drug treatment, provides a brief introduction to the broad range of treatment options available in Australia. The Australian Drug Information Network (ADIN) provides a list of treatment options in all states and territories. For more information, see www.adin.com.au.
Tips for family and other support people Supporting someone through withdrawal? It is important that you are clear about the role you will be playing in someone’s withdrawal and/or treatment program. Make sure you are well informed. A range of fact sheets and other information about different drugs and what to expect in drug withdrawal are available from DrugInfo (www.druginfo.adf.org.au). It is also important that you have support available and someone to talk to when things become difficult. The state and territory alcohol and drug information services can provide counselling, additional information and referral to services. Specialist family helplines and support groups also exist. See back page for more information. Residential withdrawal If someone is planning a residential withdrawal it is important to be aware of any restrictions regarding contact and what can be brought in. Visiting hours, external contact and other guidelines can vary greatly between residential programs. Deciding to stop When someone decides to stop using a drug, they tend to waver about it. Part of them wants to stop and is able to see that using drugs has many negatives. At the same time, withdrawal can be uncomfortable, cravings can be hard to manage, and changing habits and behaviours is difficult. Making the decision to stop is usually based on their current circumstances and the negatives associated with drug use. They may be anxious about the process and the changes that withdrawal will involve. Having a support person who is positive and encouraging, and who challenges the unrealistic thoughts that occur during withdrawal is important. Dealing with symptoms and cravings Once withdrawal starts, the person is likely to feel anxious about what will happen next. The discomfort they are experiencing and other factors such as fear can trigger strong negative thoughts such as “I’m hanging out. This is too hard. I need to use”.
11
This usually happens at a time when the person experiencing withdrawal is not thinking logically and feels physically unwell. At this time it can be hard for them to remember why they originally wanted to stop. This is why good planning is particularly important. Anyone thinking about withdrawal should write down why they are doing it and what advantages and disadvantages there are to using drugs. Later, when they are “hanging out” they can return to their list and remind themselves of their reasons for giving up. It is also useful to think about negative symptoms in a more positive way, such as signs that the body is getting rid of toxins or doing what it is supposed to do.
Lapse and relapse It is not uncommon for someone to use drugs during withdrawal, so it’s good to talk about the possibility beforehand and have a plan of what to do if it happens. Using drugs (other than prescribed medication) during withdrawal can be viewed as a lapse or mistake. The person may choose to give up treatment and continue to use the drug (relapse), or accept that this was a temporary mistake (lapse) and continue with the withdrawal. If the person decides that it was only a lapse, and continues on with withdrawal, it’s good to talk about what happened and why, and what worked well and what didn’t in helping them get through that stage. It is also good to discuss what could be done differently in the future to prevent further lapses.
Tolerance Tolerance occurs when a drug is used repeatedly. The body gets used to having the drug and needs higher or more frequent doses to get the same effect. While it may take some time to develop tolerance to a drug, this tolerance reduces very quickly so that even 2–3 days of not using it can affect the person’s tolerance to that drug. It is important to note that if a person uses the same amount of a drug that they were using previously, after even a brief period of withdrawal they can be at risk of overdose.
Nutrition Most people who use drugs do not eat well. They may consume large amounts of “junk food” or eat very little when they are using drugs. During withdrawal many people experience strong cravings for junk food, particularly foods with high fat and high carbohydrate content, but it is important to support the person through withdrawal and treatment, by helping them to eat a well-balanced diet. Foods high in fat or sugar can increase mood swings that are often a feature of withdrawal. Maintaining fluid levels is also important and water is a great option. The recommended daily intake is approximately six to eight glasses (at least 150ml each) of a variety of non-alcoholic fluids. If the person is struggling to eat at all, then it is important to be flexible; vitamin supplements may be useful.
Managing time Managing the negative thoughts, cravings and mood swings during withdrawal can be a tough job. It is not useful to sit around and think about how hard it is or to constantly have thoughts of using drugs. Support people can help by providing opportunities to fill the person’s time, however, it’s a good idea to remember that the person’s ability to concentrate may be low and their memory may not be functioning very well. Any activities you arrange need to make allowances for this. Watching television or movies, taking walks, going for short car rides, reading magazines or making short visits and shopping trips are good activities as they are short-term and do not require much concentration or preparation. THE RECOMMENDED DAILY INTAKE IS APPROXIMATELY SIX TO EIGHT GLASSES OF A VARIETY OF NON-ALCOHOLIC FLUIDS.
Stress management Some of the anxieties and stresses associated with drug withdrawal can be improved through basic stress management techniques, such as exercise, massage and talking about what is difficult to manage at that particular time.
13
COMMON TERMS Drug Any substance—solid, liquid or gas—that brings about physical and/or psychological changes in the body.
Dependence Dependence occurs when a drug is central to a person’s life, they have trouble cutting down their use and experience symptoms of withdrawal when trying to cut down or stop using the drug. Dependence can be physical or psychological, or both. When a person’s body has adapted to a drug and is used to functioning with the drug present, the person is said to be physically dependent upon that drug. When a person feels they need to use a drug in order to function effectively or to achieve emotional satisfaction, the person is said to be psychologically dependent upon that drug.
Pharmacotherapy The use of medications in response to drug dependence. Used to ease withdrawal discomfort, as maintenance substitution (for example, methadone) or to reduce craving (for example, nicotine replacement therapy).
Relapse A recurrence of harmful drug use after a period of improvement. Relapse is common among people who are drug-dependent when they are attempting to stop drug use.
Tolerance and dependence People who use drugs regularly can develop dependence on, and tolerance to, them. Tolerance means they need to take larger amounts to get the same effect as when they started using drugs. Dependence on drugs can be psychological, physical or both. People who are dependent find that using drugs becomes far more important than other activities in their lives. They crave the drug and find it very difficult to stop using it. People who are psychologically dependent on a drug may find they feel an urge to use it when they are in specific surroundings or socialising with friends. Physical dependence occurs when a person’s body adapts to the drug and gets used to functioning with the drug present.
Withdrawal Withdrawal describes a set of symptoms that can occur when drug use is cut down or ceased . Withdrawal symptoms can range from mild to severe, and differ depending on what drug the person is withdrawing from.
15
Further assistance For information, counselling or other assistance, contact the alcohol and drug information service in your state or territory. Australia-wide Family Drug Support: 1300 368 186 Counselling Online: www.counsellingonline.org.au ACT (02) 6207 9977 NSW (02) 9361 8000 (Sydney) 1800 422 599 (NSW) NT 1800 131 350 QLD 1800 177 833 SA 1300 131 340 TAS 1800 811 994 VIC 1300 85 85 84 (information) 1800 888 236 (counselling) Family Drug Help: 1300 660 068 WA (08) 9442 5000 (Perth) 1800 198 024 (WA) Produced by the Australian Drug Foundation Š 2012 Celebrating more than 50 years of service to the community, the Australian Drug Foundation is Australia’s leading body committed to preventing alcohol and other drug problems in communities around the nation. www.adf.org.au For more copies of this brochure, contact Australian Drug Foundation: Post:
PO Box 818 North Melbourne VIC 3051
E-mail: druginfo@adf.org.au Web:
www.shop.adf.org.au
Information provided in this brochure is offered for general purposes, and should not be considered a substitute for specific, professional advice.