You might check out whatmesober.com, Digital Dharma’s sister site, for other addiction-related material.
Post-Acute Withdrawal Syndrome
Note: This material was developed from Relapse Prevention seminars hosted by Terence Gorski, MS. I recommend his excellent “Staying Sober” and its accompanying workbook for anyone interested in following the subject further. Most of these concepts are Mr. Gorski’s, adapted by me for a series of relapse prevention lectures.
Many of the problems associated with early sobriety do not stem directly from drugs and alcohol. Instead, they are associated with physical and psychological changes that occur after the chemicals have left our bodies. When we use, our brains actually undergo physical change to cope with the presence of the drug in our body. When we remove the drugs, our brains then demand more to satisfy the desire caused by the changes. The extreme symptoms that we experience immediately after we stop using are called “acute withdrawal.”
Acute withdrawal, unfortunately, is not the whole story. Our bodies make initial adjustments to the absence of the drug, and the major symptoms ease up. However, the changes that have occurred in our brains need time to revert back to their original state (to the extent that they ever do). During the period of time while this is occurring, they can cause a variety of problems known as Post Acute Withdrawal Syndrome (PAWS).
All we addicts and alcoholics suffer from damage to our bodies and nervous systems from drug/alcohol use, accidents, and malnutrition. We may also suffer from chronic diseases such as diabetes and hepatitis, and we usually bring to early recovery a broad array of other problems. As one alcoholic put it, “When I got sober, things didn’t get any easier, but they got real …ing clear!”
Recovery causes a great deal of stress. Many addicts and alcoholics never learn to manage stress without alcohol or drug use, or do so only after many attempts at sobriety. Our ability to deal with it depends on our willingness to take care of ourselves and maintain a healthy physical, emotional and spiritual lifestyle. Repairing the damage to our nervous systems usually requires from six months to two years with a healthy program of recovery. PAWS is the cause of most relapse in early recovery.
PAWS symptoms reach a peak from three to six months after we get clean. Any use of drugs or alcohol, even in small quantities or for a short time, will effectively eliminate any improvement gained over that time, as it will keep the brain from healing. There are a variety of symptoms. Not everyone will experience all of them. Here are some of the main ones.
Inability to solve problems
Inability to solve problems leads to lowered self-esteem. We feel embarrassed, incompetent, and “not okay.” Diminished self-esteem and fear of failure lead to living and working problems. These all add to our stress, and the stress further exaggerates the other problems. Six things contribute to this: trouble thinking clearly, emotional overreaction, memory problems, sleep disturbances, physical coordination problems and difficulty managing stress.
Inability to think clearly
Our brain seems to work properly only part of the time. Sometimes our head just feels fuzzy because of the changes that occurred in our brains while we were using. The changes take time to improve. It is also due to the simple fact that we are trying to process a lot more information than we did before. While using, we mainly thought about getting more, using, and turning off our brains. Now we are considering the myriad things necessary to truly live our lives. To begin with, it can be a bit much.
Inability to concentrate
Abstract reasoning suffers, and we find our minds, like a confused cowboy, jumping on its horse and riding off in all directions. Also related to the reasons above.
Rigid, repetitive thinking
Thoughts go around and around in our heads, and we are unable to put them into useful order. We have not yet developed the ability to channel our thoughts and concentrate on one thing at a time.
We may hear something, understand it, and 20 minutes later…it’s gone! This sort of thing complicates our lives in many ways. It upsets supervisors, annoys significant others, and makes us wonder if we’re losing our minds.
With memory problems it is hard to learn new skills and absorb new information. We learn by building on what we have already learned, and memory difficulties can make it very difficult (if not impossible) to do that. Again, these difficulties add to stress, especially if we do not understand what’s happening to us. We may think, “This sucks! I might as well be high.”
Emotional overreaction or numbness
People with emotional problems in early sobriety tend to over-react. When this overreaction puts more stress on our nervous systems than we can handle, we react by “shutting down” our emotions. We become emotionally numb, unable to feel anything. We may swing from one mood to another. These mood swings may baffle us, seeming to come without any reason, and may even be misdiagnosed as bipolar disorder. If we have developed insulin resistance or diabetes as a result of our drugs and drinking, this can become extreme. (See H.A.L.T. below)
Disturbed sleep is common in recovery. It may last only a short time, or a lifetime. Often, this depends on what we consider to be a problem. If we are night owls who used alcohol or pills to get to sleep in the daytime, we may discover that the only solution is to make significant changes in our schedule, and perhaps even in our occupations. Sleep deprivation stresses the body, prevents our minds from working well, and generally exaggerates any other difficulties we may be experiencing.
We may experience changes in our sleep patterns, sleeping for long periods at a time, or getting sleepy at different times of the day. Although these may persist, we are usually able to adjust to them. The important thing is to be willing to adjust. We may not be able to keep to our old sleeping habits.
Difficulty managing stress is the most difficult part of post acute withdrawal, and of early recovery in general. Early on, we may not be able to distinguish between low and high stress situations, because for so many years we managed stress by using mood-altering substances.
Worst of all, the other PAWS symptoms become worse when we are under stress, and this causes the stress to increase! There is a direct relationship between elevated stress and the severity of PAWS. Each amplifies the other.
At times of low stress, the symptoms of post acute withdrawal may lessen or even go away completely. When we are well-rested, relaxed, eating properly and getting along well with others, we seem to be fine. It is easy to see how we can get careless at these times, and many a relapse has occurred when things seemed to be going just fine.
Recovery from the damage caused by our addictions requires total abstinence. Abstinence means avoiding drugs and alcohol completely, unless we are under the care of a physician who understands both addictive disease and pharmacology. This specifically includes herbal remedies which, in many cases, are just as powerful and dangerous as prescription drugs.
Understanding and recognizing PAWS symptoms
Because we are addicts and alcoholics, and because repeated relapses will eventually be fatal, we must realize that understanding PAWS is, literally, a matter of life and death. It is absolutely essential that we gain an understanding of post acute withdrawal, be able to recognize its symptoms when they appear, and know what to do about them. We must understand these things well enough that we are able to put them into effect even during periods when our addict instincts are telling us that we don’t want or need to!
We need also to learn about PAWS, and means of controlling it, when our stress levels are low, in order to be able to prevent the symptoms or be able to recognize and manage them if they occur.
Stabilizing our episodes of PAWS
When we begin to experience PAWS, we need to bring it under control as soon as possible. Here are five steps that can help.
We need to talk about what’s happening, to people who will listen and not criticize us. In addition to badly needed support, it helps us to clarify our feelings, look at them more realistically, and helps us recognize our symptoms. When we are in our own heads, our thoughts just go around and around. When we force ourselves to tell someone else, we often find that it puts them into order and they begin to make sense.
We need to express as much as we can about what we are feeling, even if we think it sounds dumb or irrational.
Get a reality check!
We need to ask someone if we are making sense — not just in what we’re saying, but also our behavior. We must be sure our perception of what is happening matches up with reality.
Set a goal
What can we do right now to improve our situation? Taking action and changing things is our choice.
…over what has happened. How did the episode start? What triggered us? What could we have done to reverse it sooner? Were there other options that might have worked better?
We are responsible for protecting ourselves from anything that threatens our sobriety, including anything that triggers post acute withdrawal symptoms. No one else can do it, because no one else can feel the warning signals. Learning about addictive disease, working a program of recovery, finding out more about PAWS—all of these things reduce the guilt, confusion and stress that intensify the symptoms and lead us to relapse. If we learn to do these things, we will begin to accept our own needs, and learn to be firm about letting other people, places and situations push us into reactions that threaten our sobriety.
We must identify our own stress triggers. Then we must learn to change them, avoid them, change our reactions, or interrupt the process before our lives get out of control again. If our Aunt Frizzy is blaming us for all the family problems, and letting us know it every chance she gets, we may need to avoid her for a while (a few years, a life…who knows?) If we find ourselves walking past the beer cooler too often in the store, or past a certain street corner, we need to recognize that, and change our routes through the store and the neighborhood.
Here are some things that will help us avoid PAWS, or control it when it sneaks up (which it will). They may be the most important things we will learn in the first few months of our sobriety. They are so important that we encourage you to print out this article, and to share it with others who may need it too.
With our organ systems damaged by alcohol and drugs, we were not—and may still not be—able to absorb nutrients properly. This, combined with our inattention to diet, has created deficiencies that we must deal with. All active alcoholics (and most other addicts) suffer from malnutrition to one degree or another, and we may continue to feel the effects for months after adopting a healthier lifestyle. Malnutrition contributes to poor health, and poor health contributes to stress. Unless we consciously improve our diets and properly supply our nutritional needs, the poor eating habits that have carried over from our using days guarantee that we will continue to fail at getting the nutrients needed to recover. Our bodies are repairing themselves, and they need the proper materials to do so effectively.
It isn’t necessary to load up on stuff from the health food store. It is much better to spend all that money on good healthy food at the market (although they’ll never tell you that at the health food store). However, we should take a good multivitamin every morning with breakfast. Yes, you will be eating breakfast.
Hypoglycemia – the secret demon of relapse (H.A.L.T.)
We’re tired and hungry. It’s been a long day, and we won’t be able to have dinner for a couple of hours. A candy bar is just what we need to pick us up and get us through. Forty-five minutes after eating the candy we are angry at our boss, arguing with our co-workers, suffering with tense muscles and a nasty headache, and life sucks again. We’re thinking about using.
Has this ever happened to you? Then you already know something about hypoglycemia.
Our brains use glucose, a kind of sugar, for fuel. If our brains are completely deprived of glucose, we will die just as quickly as we would if our air were shut off. Fortunately, our blood carries glucose to our brain, and as long as our heart is beating we don’t usually have to worry about its fuel supply. Usually.
Glucose is manufactured by our bodies from the carbohydrates that we eat. Carbohydrates (carbs) are a class of nutrients that include several kinds of sugars, pasta, bread, potatoes, and similar starchy foods. Practically all foods contain some carbs, but the most concentrated sources of them are sugars and alcohol.
In addition to fueling our brains, glucose provides energy for every cell in our bodies. Without glucose in the right quantities, our bodies just don’t work right. The carbohydrates most easily converted into glucose are the sugars. This is why we like them so much. Our bodies recognize that they are a ready source of energy.
The problem arises when we are in need of food and our bodies get a big jolt of sugar. The sugar is quickly converted into glucose. The amount of glucose in our blood rises very quickly, and we feel a burst of energy. We may feel some mood alteration as our brains receive a huge jolt of fuel.
We just received a reward for eating some sugar.
The big dose of sugar on an empty stomach causes our blood glucose to rise rapidly. A center in our brain detects the rise, and signals the pancreas to produce more insulin to help our cells absorb the extra sugar, but it produces too much. The insulin causes us to burn the extra glucose rapidly, and our blood sugar comes down, but because there is too much insulin, our glucose levels drop too far. (In diabetics and people who are insulin-resistant the mechanism is different, but the effect is the same—or worse.)
Our bodies—and our brains—are now low on glucose. The brain is running out of fuel. Waste products build up in our muscles. Along with inefficient signals from the brain, this causes tightness and muscle tremors. Partial paralysis of facial muscles may make it difficult or impossible to smile. Our heads begin to ache. Thinking gets fuzzy. Energy levels drop. We push people away, if we don’t scare them away. We may feel sudden bursts of rage, that seem quite reasonable. We begin feeling sorry for ourselves. . We are HUNGRY, ANGRY, LONELY and TIRED.
The big catch? Most of us, in our addictions, knew all too well how to quell those nasty feelings–by using. Poor me…poor me…pour me a drink
Important Point: We taught ourselves to interpret the symptoms of low blood sugar–hunger–as needing to use.
So, how do we avoid the trap? Easy in principle, but it involves some attention, some learning, and some effort. Basically, we don’t let ourselves get hungry.
Diet for Recovery:
- Three nutritious snacks each day,
- between meals and at bedtime
- Avoid Sugar and Caffeine
We are “trapped” in a culture that tells us Three Square Meals A Day is the way to eat. Many of us interpret that as one “round” meal at breakfast time—a doughnut, or bowl of cereal, and a cup of coffee—one “rectangular” meal for lunch—a sandwich and another cup of coffee—and one huge meal in the evening. Since these aren’t really spreading the fuel around too well, we fill in the low spots with candy bars and some more coffee. Our poor pancreas! For, in addition to all that sugar in fits and spurts, caffeine also causes blood sugar swings!
We really need to get this thing under control! Hunger produces stress. Blood sugar swings produce stress. Stress aggravates PAWS and, as we have seen, is extremely dangerous to our sobriety when combined with hypoglycemia—which is caused by poor eating habits, too much sugar, and caffeine. Are we beginning to see a trend here?
Alcoholics and addicts in early recovery literally “take our lives in our hands” each time we plan our daily meals.
A quick word about diet:
Our diets should consist of a balanced mix of vegetables, fruit, carbohydrates, (such as potatoes, whole-grain rice, and dark breads,) protein (not necessarily meat), fat, and dairy products. A nutritionist can be a great help in the beginning, and there are thousands of books on nutrition and meal-planning that may be consulted. If we don’t know how to shop and cook, now is a good time to learn.
The US Department of Agriculture’s Choose My Plate page is a good place to begin.
We should try to plan our schedules so that we do not skip meals—ever—and so that we can have nutritious snacks between meals.
- We must not snack on candy, donuts, soft drinks, (incredibly high in sugar,) potato chips, or other high calorie, low nutrient foods.
- We should carry raw vegetables, wheat crackers, a half sandwich (peanut butter and jelly on whole wheat is excellent; easy on the jelly), nuts, or even a package of cheese and crackers.
- These, along with a glass of water or milk, will keep our blood sugar steady and our moods elevated until time for the next meal. Having a nutritious snack before we begin to feel hungry will prevent our craving for sweets, as well.
It’s a good idea to actually schedule our snacks, halfway between meals and about ½ hour before bedtime. We must not miss breakfast!
Losing Weight While Eating Six Times A Day
These eating habits are not inconsistent with meal planning for weight loss. Competent dietitians and honest diet doctors know that several smaller meals are more conducive to weight loss than three larger meals, since the body more easily uses the smaller quantities of food, and is less likely to store it as fat. Properly planned meals will contribute to our health, energy and feelings of well-being, and make it easier for us to engage in exercise, (the real secret to weight control.) Our hunter-gatherer ancestors ate fruits and berries during the day, and gorged on game when they could kill something. Metabolically, we aren’t very far from those folks. The big difference between us and them?
Exercise helps our bodies to rebuild themselves and maintain proper functioning. It also helps control our metabolism and prevent unnecessary weight gain. (Weight gain due to increased muscle mass may precede any loss due to burning fat.) Exercise produces chemicals in our brains that act as natural tranquilizers and relieve pain, anxiety and tension. It greatly improves our chances of getting a good night’s sleep.
Our ancestors lived together in small tribes of no more than twenty or so adults and a few children. They walked from place to place, following the food supply, eating whatever they could find. They carried everything they owned with them.
This lifestyle, during the eons preceding the beginnings of agriculture, is the lifestyle for which our bodies are best suited. Humans—like the herds we have followed since the beginning of our history—walk.
So, how much should we walk? Simple. We should walk fast enough and far enough to work up a sweat, and continue walking for at least 20 minutes thereafter, followed by a slower cool-down of 5 to 10 minutes. We should do that at least three times a week—preferably every other day.
We can walk at the mall; walk to the store; walk to the park. We can walk with a friend. When we’re walking we can chat, unlike most other forms of exercise. All we need is decent shoes and, if we’re over 50 or under a doctor’s care, our physician’s permission. And while we do it, we’re continuing a tradition that goes back thousands of years. How about that, sports fans?
Relaxation = stress reduction
Playing and relaxation are absolutely essential to a successful recovery.
Playing is not so much what we do as how we do it. Playing is having fun, laughing, and being childlike and free. Playing is not working at preparing for a marathon, participating in competitive sports at which we “must” win, or taking chess lessons. Of the 37 definitions I quickly scanned, perhaps the one that best describes it is “participating in an activity for amusement.” If it isn’t fun—if we have to work at it—it isn’t play.
Other ways of relaxing include bubble baths, our walk (by ourselves or with a friend), a massage, a swim, and watching children and animals at play. Whatever we do, if we don’t feel better after doing it, it was the wrong choice.
Meditation is part of the 11th Step: “Sought, through prayer and meditation, to improve our conscious contact with god, as we understood him, praying only for knowledge of his will for us and the power to carry that out.”
Regardless of how we feel about god, we need to meditate. We need to learn to calm our minds, and to allow our subconscious to help us solve problems by serving up whatever it may have processed during the rest of the day. The only way to do that is to meditate in one form or another.
Think that’s too hard to learn? You already do it. Daydreaming is meditation. All we need to do is apply the skills we already know, whenever we want to.
One of the best relaxation exercises is also one the simplest. We find a comfortable sitting position. We move our bodies until our weight is centered, so that we can nearly go limp without changing position. We begin counting our breaths in our mind. We count up to ten, and then start over. We think only about breathing. In comes the fresh air and we…relax…and breathe the tension out. If other thoughts come in, we don’t fight them, we just recognize that they are there, and go back to counting breaths, always silently.
This is one of the oldest and most-used relaxation techniques in the world. It goes back at least 3500 years. We can do it for five minutes, then ten, working up to thirty minutes or more. It might be a good idea to set an alarm, in case we fall asleep sitting up. It happens.
Spirituality is an active relationship with a power greater than us, which gives our lives meaning and purpose. When we work a spiritual program, we consciously try to become a part of something bigger, greater and more powerful than we are, whether that be a 12-step group, our family, other humans generally, or that “god as we understood him.”
Trust in a higher power gives us a peace of mind and serenity that comes from awareness that there is something that is not restricted by our own weaknesses and limitations. Through spiritual development, we develop new confidence in our own abilities and develop a sense of hope. Through a spiritual program we can reach toward the future with hope and a positive attitude.
Spiritual discipline is uncomfortable for many recovering people.
We have lived lives of immediate gratification, and discipline is the reverse of that. Many of us have trouble with the concept of a higher power, as well. We may have been brought up as atheists or agnostics. Perhaps the god of our childhood was a vengeful god whom we cannot even begin to contemplate in the light of some of our past behavior.
This is why we say that our higher power can be god, as we understand god, or our recovery group, or the great outdoors — whatever. Recognizing a higher power is simply admitting that we aren’t perfect and don’t know everything. We let all those grandiose feelings go, substituting a bit of humility instead, and becoming willing to listen to the ideas and advice of others. In a sense, it is not so much recognizing the presence of a god as it is the realization that we aren’t one.
Spiritual discipline should always include meditation, fellowship, and regular inventory of spiritual growth. It is about our relationship with the human spirit. It is not about someone else’s idea of a relationship we should have with a god. That is religion. While religion may be an important part of our recovery, it cannot take the place of spirituality.
In working on our spirituality, it is important that we use the principles of our 12-step programs. They provide guidelines for “increasing our conscious contact with god” (as we understand god). We do not have to have any particular image of, or belief in, a god to increase our conscious contact. We have only to be willing to recognize the possibility of a “higher” power, — be willing to experiment at listening, and opening ourselves up to others and their ideas.
Many people joke about having a tree as your higher power. The writer had that sort of relationship with a majestic Casurina tree for some time. He used it to remind himself that he was not nearly as good at taking care of himself—yet—as that beautiful tree. Did it work? Who knows? At the time of this writing, he is 20 years clean and sober. Something did.
Peace and Contemplation
It is important that we structure our lives in such a way as to spend time alone each day. We need to examine our values, and look within ourselves to determine whether our lives are in harmony with those values. Perhaps we can combine this with our meditation, contemplating life issues and then meditating to let our subconscious come up with some answers.
We strongly recommend keeping a journal, and writing in it every day without fail—even if we only write the date. Forcing ourselves to organize our thoughts and put them on paper clears our minds. Reading what we wrote some years later can be highly instructive, and lets us see how we have grown in our recovery.
Balanced Living–the aim of recovery
Balanced living means that we are healthy physically and psychologically, and that we have healthy relationships with others and, more importantly, with ourselves. It means that we are spiritually whole. It means that we are no longer focused on just one aspect of our lives. That is no longer necessary. It means we are living responsibly, giving ourselves time for our jobs, our families, our friends, and time for our own growth and recovery. It means allowing a higher power to work in our lives, even if that is only the influence of people around us. With balanced living, we addicts and alcoholics give up immediate gratification as a lifestyle, in order to attain fulfilling and meaningful lives.
It means a balance between work and play, between fulfilling our responsibilities to other people and our own need for self-fulfillment. It means functioning at our optimum stress level: maintaining enough stress to keep us functioning in a healthy way, but not overloading ourselves so that it becomes a problem.
Stress, in and of itself, is not necessarily bad. It can be the tension that keeps life interesting. But stress is unsafe for us until our new found ways of dealing with it are second nature. Until then, when it arises we run the risk of returning to our old ways of stress management.
Balanced living requires loving ourselves and taking care of ourselves. Nutrition, rest and exercise all receive the proper focus in our lives to provide energy, manage stress, allow freedom from illness and pain, fight fatigue, and rebuild our damaged bodies.
If we are under a physician’s care, and have been told to take certain medications, we do so. We do not stop taking them without consulting the physician. We communicate with our physicians regarding the effects that we perceive, the ways that we feel, and function as partners with her/him in our own treatment. We do not take the advice of amateurs, in the rooms of recovery or out of them, in place of the counsel of doctors with twenty-plus years of education. That’s just plain dumb. However…
We always tell our health providers that we are in recovery, and always double-check their suggestions regarding medications with a person knowledgeable about their effects on recovering people. Doctors are not pharmacists. They do not have time to study drugs and the details of their action. A good relationship with a pharmacist has saved the butt of many an addict/alcoholic.
Freedom from physical distress allows psychological growth. When we feel good, it is easier to do the work we need to do, eliminate denial, guilt and anger, and move on to self-confidence, self-esteem and learning to feel good about ourselves.
Balanced living requires a strong social network that nurtures us and encourages a healthy, recovery-oriented lifestyle. This network provides a sense of belonging. It includes relationships in which we are a valuable part of a whole: immediate family members, friends, relatives, co-workers, counselors, therapists, employers, 12-step group members, and sponsors.
Recovery is not about quitting alcohol and drugs. It is about learning to live a life that does not require mood-altering chemicals to be worth living.