How Medications Ease Withdrawal Symptoms and Fortify Recovery: An Interview With Dr. Steven L. Batki

To understand how pharmacological withdrawal treatment works, you must first understand how withdrawal itself works. “The phenomena that occur during withdrawal are all due to neuroadaptation, or adaptation of the central nervous system to taking drugs over long periods of time,” Dr. Batki says.

Chronic use of drugs leads to brain changes or adaptations that can be thought of as resulting in the opposite kind of symptoms or effects than what the drugs of abuse produce. This is because when we take drugs that affect certain neurotransmitters in the brain, and during the process of taking those drugs we end up reducing or “down-regulating” the amount of those neurotransmitters that our own brain makes, or we reduce the number of the receptors on brain cells that are affected by those drugs.

For example, alcohol increases GABA-related neurotransmission in the brain (GABA is a relaxing, sedating chemical that alleviates anxiety and acts as an anticonvulsant). Chronic alcohol consumption reduces our brain’s natural GABA production, so that if alcohol use is suddenly discontinued, we are left with a “GABA deficit”.

When we stop drinking and we’re no longer getting this artificially high GABA effect from the alcohol, we are left with a brain that has inadequate amounts of its own GABA. That will lead to all the opposite effects — rather than relaxation, there’s going to be anxiety. Rather than sedation, there’s going to be excitability. Rather than anticonvulsant effects, there might be seizures.

For individuals addicted to alcohol, opioids, and benzodiazepines, the natural withdrawal process can be deeply distressing both emotionally and physically, leading many to return to drug use in order to stave off the physical and psychological pain of these withdrawal symptoms.

In some cases, withdrawal can be life-threatening, if the brain is unable to stabilize rapidly enough to prevent the emergence of dangerous symptoms such as seizures. As a result, it is imperative to seek medical attention if you are withdrawing from long-term, chronic alcohol or benzodiazepine addiction. Withdrawal from opioid addiction, while not life-threatening, is often intensely uncomfortable.

The judicious use of certain medications can dramatically minimize or eliminate withdrawal symptoms in early recovery from certain types of drugs of abuse, providing both mental and physical comfort while reducing the urge to use. In the case of alcohol and benzodiazepine addiction, they can even be essential to the withdrawal process by preventing physical harm from seizures.

Medications are used to alleviate withdrawal symptoms by essentially making up for — or correcting — the neuroadaptation that drug use has caused. If chronic alcohol consumption reduces your levels of GABA, then we can give a medication that provides some of that GABA effect, and then withdraw or taper that medication in a gradual fashion to prevent the emergence of the withdrawal syndrome.

The pro-GABA effects of a medication such as phenobarbital can help in treating withdrawal from benzodiazepines such as Xanax, allowing you to safely and gradually detox from drugs of addiction with minimal withdrawal symptoms.

In the case of opioid withdrawal, opioids themselves are typically employed to alleviate withdrawal symptoms and allow the brain time to recover by gradually removing the effects of opioids from the body. Because they are longer-lasting and have lower risk profiles, medications such as buprenorphine (Suboxone) offer significant therapeutic benefits and provide safe and comfortable withdrawal from drugs of abuse. Adjunctive use of the non-opioid blood pressure medication Clonidine may also allow for reduced reliance on opioid medications.

Unfortunately, withdrawal medications are not available for all types of drugs. “We do not have detox medications proven to be effective for cannabis or for stimulants such as methamphetamine or cocaine, or for certain other drugs classified as hallucinogens or dissociative anesthetics like ketamine,” Dr. Batki tells me. But for the addictions for which treatments are available, medications can make a big impact, and might mean the difference between recovery and relapse.

While withdrawal medications can be a critical part of early recovery, the nature of your treatment must be tailored to your specific needs. This is especially true if you are experiencing a co-occurring mental health disorder, which may complicate withdrawal by augmenting withdrawal symptoms.

The best example of this is a patient with severe anxiety disorders or severe mood disorders, particularly depression. Individuals who are very anxious and have benzodiazepine addiction or alcohol use disorder are going to have both a benzodiazepine or alcohol withdrawal syndrome when they stop using, and they’ll also have their pre-existing anxiety disorder adding to it. They might be much more anxious and agitated when they go through withdrawal than a person who does not have an underlying anxiety disorder.

Similarly, people with depression often have more severe depressive symptoms during withdrawal than someone without underlying depression. As a result, those with co-occurring mental health disorders may require withdrawal symptom-reducing medication longer or at higher doses.