Reference Guide to Writing Drug Withdrawal

So your character has a substance use disorder (or physical dependence to a substance for another reason). This post will tell you how to write a scene (or story) in which they go through withdrawal.

NOTE: THIS POST DOES NOT INTEND TO COVER ANYTHING EXCEPT WITHDRAWAL, WHICH IS A VERY SMALL PART OF SUBSTANCE USE DISORDER AND PHYSICAL DEPENDENCE.

Substance Use Disorders and Physical Dependence:

Substance use disorders are chronic illnesses in which a person continues to use a substance (commonly nicotine, alcohol, cocaine, opioids like heroin or fentanyl, benzodiazepines, etc...) even when acquiring or using the substance can be dangerous or cause significant problems in their life (such as problems with money, safety, law enforcement, job security, child services involvement, or physical problems like wounds, infections, side effects, hangovers, and withdrawal). Substance use disorders are a common cause of physical dependence.

Physical dependence is also it's own problem and can occur for other reasons too. For example, many people take prescription medications that they would go through withdrawal from if stopped abruptly (say, because the pharmacy couldn't fill it in time and they ran out). Assuming that the medication is being taken as prescribed, physical dependence in itself does not mean someone has a substance use disorder.

So what is withdrawal? Withdrawal (sometimes called "detox") is the process by which a body stops being physically dependent on a substance. Generally speaking, it is unpleasant. This is because when a body is exposed to a substance repeatedly, it changes how it functions to accommodate that substance. When the substance is removed, there is a period of time where the body has to re-adjust to not having the substance.

For example, alcohol is very similar to the neurotransmitter (brain chemical) GABA. If you drink a lot of alcohol (more than about 4 drinks per day) for longer than about a month, the body decreases the amount of GABA it makes naturally to accommodate the "fake" GABA from the alcohol. If the alcohol is suddenly removed, the body doesn't have enough GABA, and the effects of not having enough GABA result in withdrawal symptoms.

The difference being, someone taking a medication they no longer want to take can slowly reduce the dose to minimize withdrawal symptoms. Someone with a substance use disorder usually finds cutting back nearly impossible. Because of this, managing physical dependence in someone with substance use disorder generally means giving them a similar substance which they get from a pharmacy and take continuously (methadone, buprenorphine), or a similar substance they can then taper off of in a controlled way (benzodiazepines, gabapentin).

Specific Withdrawal Syndromes:

Alcohol/Benzodiazepines:

These are the only two substances that result in a potentially life-threatening withdrawal syndrome, and it's essentially the same syndrome. As stated above, when taken for either 2 weeks for benzodiazepines or 4 weeks for alcohol, the body decreases the amount of GABA it produces naturally. GABA is the "brake pedal" in the brain, slowing things down and decreasing the amount of activity. If you don't have enough GABA, you get too much activity, which can result in severe anxiety, insomnia, seizures, hallucinations, high blood pressure, temperature, and pulse rate, heart arrhythmias, and confusion.

If a person makes it through 72 hours, they are usually in the clear as far as life threatening symptoms go, though they may experience mild symptoms like headaches and insomnia for long periods afterwards.

Note that medication for alcohol or benzodiazepine withdrawal like other benzodiazepines, phenobarbital, and gabapentin are given only for the first 5 days of withdrawal, tapering to lower doses each day. This gets the person through the dangerous part hopefully with no life threatening symptoms. It does not mean all symptoms are controlled, but they are hopefully kept on the milder end while the brain learns to make it's own GABA again.

Opioids:

Opioids include a range of drugs including prescription medications like oxycodone, hydromorphone, and morphine, as well as street drugs like heroin. Today, the street drug supply in many places is heavily adulterated. Many samples of heroin (and even "pressed pills" made to look like prescription opioids) contain the much stronger opioid fentanyl (which increases risk of overdose) and the sedative xylazine (which causes wounds) in addition to the expected heroin or oxycodone.

Opioids work by pretending to be endorphins- another neurotransmitter usually used by the body to reduce pain and stress. Similarly to GABA in alcohol use, the body reacts to having sustained high amounts of fake endorphins by decreasing the amount of endorphins it makes itself. This means, when the opioids are no longer present, the body can't make itself feel good or recover from pain.

There are many parts of the body that endorphins work in, including the brain, gut, nerves, and spine. When they are removed, symptoms include:

There is not really a universal timeline for these symptoms like there is with alcohol. For someone who primarily uses short-acting opioids, withdrawal begins 8-24 hours after the last use (though anxiety and cravings can start much sooner). For people who primarily use long-acting opioids, withdrawal can take up to 36 hours to begin following the last use. Generally, symptoms peak within 1-3 days after they start, and acute symptoms last 10-14 days.

Unfortunately, someone who has an opioid use disorder will frequently experience cravings for very long periods of time (potentially the rest of their life) after they stop use. For this reason, people do significantly better at reducing or stopping use over the long haul if they are taking an opioid replacement drug like methadone or buprenorphine.

Methadone and buprenorphine are prescription medications that a person goes somewhere each day to get (methadone) or picks up each day from the pharmacy (buprenorphine). The drugs essentially make it so the person won't go into withdrawal and will have significantly fewer cravings for as long as they take the drug.

The management of opioid withdrawal is usually done by switching the person from a street drug to one of these opioid replacement drugs. However, it is important to note that methadone doesn't work immediately (usually it takes about 2-5 days of titrating it up to get it to a high enough dose to work, longer if the person has a very high tolerance). Buprenorphine requires a certain amount of time in withdrawal (usually a day or two) before it can be given, or it can make withdrawal worse instead of better (something called precipitated withdrawal).

Once someone is on one of these medications, they can choose to stay on them (recommended) or taper off (nice to be off meds in theory, but high rates of return-to-use).

Cocaine/Amphetamines:

Instead of pretending to be a neurotransmitter, stimulants like cocaine and amphetamines prevent the body from re-absorbing the neurotransmitter dopamine, leading to a whole bunch of it hanging out in the brain. This increases concentration and energy and boosts mood. However, taken over long periods of time, the brain kind of burns out and fails to respond to the high levels of dopamine.

You may have heard that amphetamines and cocaine don't have withdrawal states. That would be a myth. People who use stimulants repeatedly for long periods frequently have a withdrawal that is essentially the opposite of the effects of stimulants- they feel very tired, have trouble focusing, and feel depressed because their brains can't use dopamine the same way they did before the drug use. This may last for weeks after cessation of stimulants.

Unfortunately, unlike with alcohol and opioids, there's not a ton that can be done for this withdrawal. There have been several studies, including testing medications like the antidepressant mertazapine, the migraine medicine topiramate, as well as naltrexone and buproprion (also an antidepressant).

In Conclusion:

There is so much more to drug use, substance use disorder, and physical dependence than I am covering in this post. I am just covering a small part of physical dependence, however the cause, by discussing the effects and common treatments for withdrawal.

Thank you all for reading this far! I hope you learned something and will use it in your writing!