Withdrawal III: Stimulants

10 June 2023

The regular readers of this blog will know that what follows is the second (of at least three) promised blogs on withdrawal from the four major groups of psychoactive drugs: depressants (here) hallucinogens (here) opioids (upcoming), and stimulants, below.

Stimulants heighten your mood, give you energy, and postpone tiredness.  This group includes cocaine, methamphetamine, amphetamines, methylphenidate (Ritalin, Concerta), anorexiants, decongestants, khat, bath salts, betel, nicotine, and caffeine. Excepting the last two, the neurotransmitters involved are primarily dopamine and secondarily norepinephrine and/or serotonin (Csiernik, 2019, p. 7). 

Probably the most severe symptoms, of withdrawal from stimulants, occur where the drug of choice (DoC) is methamphetamine, cocaine, or large quantities of other stimulants.  During the first week of withdrawal, psychotic symptoms including violence to self and others can occur.  This happens in a minority of patients but justifies the involvement of an MD or detox centre to manage withdrawal safely—for all concerned.  When less invasive withdrawal management fails, drugs such as diazepam are administered until the patient is sedated.  During sedation observation by medical personnel is required.

More typical symptoms of withdrawal from stimulants include aching muscles, increased appetite and sleep, depression, as well as agitation and irritability, all of which can begin within 24 hours of ceasing use (National Library of Medicine, 2023, Section 4.5).  Psychological hazards of withdrawal include heavier depression and anxiety, in addition to the psychosis, mentioned above.

More regular treatment of stimulant withdrawal symptoms includes the patient consuming 2-3 litres of water each day and upping multivitamin supplements “…containing B group vitamins and vitamin C.”  Unfortunately, withdrawal from stimulants goes on for a while.  The National Library of Medicine calls that period “...a protracted withdrawal phase of 1-2 months duration, characterized by lethargy, anxiety, unstable emotions, erratic sleep patterns, and strong cravings for stimulants.” 

Well into stimulant withdrawal, therapeutic interventions switch from psycho-physiological to psychosocial.  The headings alone—provided by America’s National Library of Medicine—are fascinating grouped as they are beneath Essentials for Conducting Psychosocial Interventions:

• Staff training
  • Interventions should be delivered by staff qualified in relevant healthcare
  • Security staff should be clearly separated from healthcare staff
• Accept that different people have different treatment needs
  • Only some users will experience negative consequences resulting from dependence and, as such, the intensity of interventions varies widely.
• Don’t tell the patient what to do
  • Only patients can decide which interventions they wish to work on, if any.  The healthcare provider’s role is to help patients improve thoughts, emotions, and behaviours the patient has identified.  Interestingly the site being referenced suggests that if a patient asks, “What would you do?” the best response is, “It doesn’t matter what I’d do, because I’m not you.”  There’s an alternate answer that might be more helpful: “Do what your best self would do.” 
• Maintain a respectful, non-judgmental attitude
  • Healthcare providers may be trapped by their own judgments of human activities such as sex work, drug use, and/or criminal acts but using words like “prostitute”, “addict”, or “gangster” only bring shame, embarrassment, and often anger to a person at their most vulnerable.  As a healthcare provider, I have found that not a single story shared by a client has made me more judgmental—but just the contrary—as I wonder how they had the strength and guts to end up working with me.
• Encourage the patient to talk
  • Open ended questions work best (ones that can’t be answered with a “yes” or “no” answer).  Listen more than talk, and express quiet empathy.  A good thing to remember is that that patient’s alliance with you is building a bridge away from addiction and toward connection.
• Acknowledge & praise positive change
  • My experience in this realm is different than the Medical Library input.  They advise giving a patient confidence through praise.  While I don’t disagree, many people recovering from addictive behaviours simply cannot or will not believe in themselves or practice positive self-talk for accomplishments that seem obvious to healthcare personnel.  That’s why I’ve become such a big fan (and proponent) of “maybe” and Emily Dickinson’s “dwelling in possibility.”  “Maybe” you have the strength to go another 24 hours.  What would it be like for you to believe success is possible?
• Maintain confidentiality
  • Basic and vital (Most of this list from National Library of Medicine, 2023, Section 5.1, with thanks). 

A Canadian source, (Csiernik, 2019, p. 15) wrote of the crash that comes with withdrawal from stimulants.  He also cited the financial cost of using stimulants and listed a few more physical symptoms of withdrawal like anxiety, sweating, shaking, and an irregular heartbeat.  More broadly, from my own experience in this community, drug use often costs marriages, families, careers, properties, and mental health. 

If you are using stimulants, and have read this far, you’re probably thinking of quitting.  Do it.  Reach out to a friend, professional (RAAM Clinic) or group (SMART Recovery, Narcotics Anonymous…).  No matter where you’re at, as the 12-steppers put it, my worst day in recovery was better than my best day using.  Things can get a lot better.  I see the proof every day.

Dan Chalykoff is (finally!) a Registered Psychotherapist (Qualifying).  He works at CMHA-Hamilton and Healing Pathways Counselling, Oakville, where his focus is clients with addiction, trauma, burnout, and major life changes.  He writes these blogs to increase (and share) his own evolving understanding of ideas.  Since 2017, he has facilitated two voluntary weekly group meetings of SMART Recovery.  Please email him (danchalykoff@hotmail.com) to be added to or removed from the Bcc’d emailing list.