Post Acute Withdrawal Syndrome PAWS Neurochemical Causes & Interventions

i'd like to welcome everybody today's presentation on post acute withdrawal syndrome neurochemical causes and interventions i'm your host dr dawn-elise snipes we're going to briefly review what post-acute withdrawal syndrome or pause is explore why it happens and identify steps to take to reduce and cope with post-acute withdrawal symptom or pause henceforth i will probably just call it pause because that's a whole lot easier to say pause typically affects people who've been engaged in addictive behaviors now that can mean addictive substances alcohol opioids lsd you know those sorts of things it can also mean engaging in

addictive behaviors or even prescription medication if they've taken it for an extended period there is a withdrawal period and what we're talking about is a withdrawal they could may have been taking the prescription medication as directed you know and they didn't have an addiction so to speak but their body built up a tolerance to it and they may have a reaction um during that detoxification period or rebalancing period that is similar to what we see for pause in people who do have addictions the effects of pause are based on a lot of factors your age

people who are younger um you know especially 24 to you know 55 age tend to do a little bit better people who are much younger obviously we've talked before about how pause impacts the the brain of the adolescent and so it is has a stronger impact on the brain of the adolescent so therefore their reaction uh during pause may also be similarly stronger older people it takes them longer to clear things out of their system because as we age our liver becomes less efficient at clearing things our metabolism slows a lot of stuff happens but

we do know that people who are older metabolize substances differently and it takes them longer to clear it from their system gender may also have an impact on the symptoms of pause and the duration of pause partly because of actual gonadal hormones can impact the the way the body handles this um time and this rebalancing period the length and the amount of use is going to affect pause someone who has been using for you know heavily for three months or so has done less damage than somebody who's been using heavily for 30 years so we

do want to give a little a lot a bit of leeway uh when we're telling people how when they ask how long does this last well some the general rule is up to a year but i have talked to some people who have had um substance addiction issues that for an extended period of time you know more than a decade that have said that pause sometimes lasts you know even 18 months to two years for them so we don't want to tell somebody that you know as soon as you pass that year mark you're clear

we do want to take into into account their physiological functioning the duration of use their physical health you know how well is their liver functioning if they've got alcoholic cirrhosis obviously that liver is not going to be doing as well as somebody else if they have autoimmune issues if they have kidney problems those all may make pause a little bit more intense and may make them last a little bit longer and underlying mental health issues can also impact pause for someone who has an underlying anxiety or depressive disorder these symptoms can be exacerbated by the

changes in the neurochemicals and the hormone levels as the body tries to readjust pause begins after the acute withdrawal after somebody is taken off the medications or the substances or they stop engaging in the addictive behavior that caused their body to develop a tolerance to the dopamine rushes so pause begins after acute withdrawal and can last for up to a year during pause people may have memories of substance use or the addictive behavior because these things alter brain functioning uh to promote drug seeking behavior and irritability when blocked from goal achievement so when people are

in this period and you know it's longer than early recovery it's you know like i said for a lot of people at least a year while their brain is rebalancing where their body is becoming less or reducing their tolerance to that substance as well as reducing their tolerance reducing its tolerance to things like norepinephrine and dopamine which also surge when we engage in addictive behaviors so because of the use of something that triggers a um a strong dopamine reaction a strong endorphin reaction as well as just the chemical itself people may have memories it actually

causes our brain to rewire itself cocaine amphetamines and alcohol all three of these you know cocaine and amphetamines are stimulants alcohol when we first ingest it is a depressant but it as it leaves our system our system actually can't replace the calming effects of alcohol quickly enough so we start to feel the glutamate effects of alcohol alcohol does increase glutamate or our one of our stress hormone levels so cocaine amphetamines and alcohol reduce the uptake of dopamine increase glutamate and in high concentrations um inhibit monoamine oxidase a which you know the old old-fashioned uh psychotropic

meds the maoi inhibitors that we wanted to look at so when people are using dopamine now remember reuptake when something's re-uptaken when something sucked up out of the synaptic space is not being used anymore so these substances actually cause dopamine to sit in that synaptic space more so it has a more intense reaction alcohol reduces glutamate's excitatory effect on the nmda receptors and increases dopamine co-administration of nicotine and alcohol increase alcohol's rewarding effects so we've got a couple of things going on here you know we've got somebody ingesting a substance that by all rights triggers

a triggers the stress response we're taking in a toxin of some sort it triggers through stress response since it's a stimulant it triggers glutamate norepinephrine dopamine all of these things also trigger the release of endorphins that's part of the stress reaction remember when we're under acute stress our body wants us to feel no pain and to have no inflammation so we can fight or flee so during this period the body may have higher levels of endorphins as we become tolerant to those substances as our tissues become tolerant to the substances it becomes harder to quote

feel normal when we are operating on the average level that our body produces we start becoming dependent upon those surges from exogenous administration nicotine stimulates the dopamine and reward center and is responsible for mood elevation and impairment improvement in cognitive function now there is some interesting data out there about how nicotine does have some cognitive enhancing effects not that i am promoting the use of nicotine by any means because it is extremely addictive substance but it is interesting think about people you know who um are trying to stop using substances are trying to stop using

certain addictive behaviors who are who smoke when they're having difficulty concentrating and they're trying to calm down and get focused well apparently nicotine actually can help with that a little bit chronic stimula stimulation by nicotine cause the gabaergic neurons are calming neurons to become desensitized and lose their inhibitory effect on dopamine which reinforces the addiction by inducing craving so gaba when we when people use nicotine it stimulates gaba and gaba is our relaxation chemical so they use it they're able to relax help kind of calm that monkey mind focus a little bit better but under

chronic stimulation nicotine loses its ability to do this so when people smoke they don't have or use nicotine however they're getting it they don't have that same calming effect which also by that same action uh causes the body to not be able to suppress dopamine um so they so the person starts craving uh craving nicotine opioids act on the opioid receptors they activate serotonin and dopamine benzodiazepines activate gaba and serotonin in people now benzodiazepines remember are your anti-anxiety medications so all of these substances what is my point here all of these substances get in and

they start monkeying with our body's ability to respond appropriately to endogenous levels of neurochemicals endogenous levels of these substances so we're causing surges that are unnatural in chronic substance use the brain comes to rely on the drug to maintain the high degree of pleasure associated with the artificially elevated levels of some neurotransmitters in its reward circuits the brain can even adapt to these high neurotransmitter levels by making new receptors okay so not only do tissues become tolerant and they start saying you know what i can't allow that much through but they also start forming new

receptors to try to handle the flood basically think about um you know if you've had a lot of rain and normally the channels that you use you know your your gutters on your house move that rain away very efficiently but if it's been raining and raining and raining for days or you have this deluge of rain um maybe the the gutters get overwhelmed so not saying that you're gonna do it but maybe you decide well you know i really need to divert the water so it's not so overwhelming so i'm going to form uh new

downspouts off of all of my gutters and basically the brain is forming these new receptors in order to accommodate the surges of neurotransmitters okay so this is an analogy that we're going to try people have said it kind of makes sense so we're going to try it again think of your body as a factory um in a factory think of dopamine like one of the raw materials to make your product which we're going to call happiness or high or rush we're just going to call it happiness normally dopamine is on on auto shipment a steady

regular supply so the fat so the factory can produce a steady supply of happiness you know every monday the little you know worker bees go and they pick up the the delivery of dopamine and they can make happiness all week that's you know obviously not how it works but just stay with me here the manager sees a deal on dopamine and wants to increase his department's revenue really quickly so he can get a promotion so he triples the auto shipment you know he says okay instead of delivering 100 boxes of dopamine i want 300 boxes

and you know that's akin to taking uh cocaine or a substance that increases um dopamine levels initially the workers are able to keep up but this frenzied pace starts causing them to be exhausted and call out sick this is when tolerance develops and they start saying you know what i can't handle all i can't handle all 300 boxes coming in this way you know i was good with a hundred but 300 is just too much it's overwhelming and you need to send some of it back to deal with this excess the factory hires new workers

and creates a new assembly line so that's your brain adapting and saying okay you know you can only handle 100 that's fine then we'll create two other departments we'll create additional neurons and receptors in order to handle this flood of stuff well great the manager he's you know they think he's great and he gets this promotion and he says okay you know we can go back down to the normal thing you don't need to bust your hump anymore and go back down to the normal when he reduces the auto shipments back down to normal you

know he created those two other departments there's nothing for them to do and the factory starts losing money so this is akin to us feeling depressed the body gets used to having those 300 boxes coming in and now we're back down to the normal one box and you've got all these other receptors going um i'm not doing anything i'm bored to balance the budget the manager either has to increase the shipments again which would be akin to taking the drug or engaging in the addictive behavior again or fire the new workers and close down their

departments which is akin to allowing the brain to heal you know you're saying okay you know we really just don't need you guys anymore we're going to go back to our normal 100 boxes a day and our original department uh so you can think of use that analogy when you're kind of thinking about tolerance when you're trying to explain uh tolerance to people when we become tolerant of something we need we start needing those 300 boxes to keep going to stay profitable to stay happy and um if you cut back down to the typical amount

then you know then it causes problems so what are the symptoms of post-acute withdrawal as i go through with each one of these symptoms i want you to think what are some of the things that would cause this symptom what are the effects of each of these symptoms on recovery and what might be two ways that we can deal with these symptoms or help clients deal with these symptoms so i'm going to read through them quickly then we'll go back through them one by one post-acute withdrawal symptoms include emotional outbursts or just lack of emotion

being flat apathetic anxiety and irritability depression and anhedonia difficulty dealing with stress fatigue having a hard time sleeping strange dreams and changes in sleep patterns memory problems that make it hard to learn new things trouble thinking clearly making decisions and solving problems dizziness and problems with balance and delayed reflexes okay so let's think really quickly about some of our major neurotransmitters and what they do serotonin is implicated in emotional regulation anxiety depression um stress tolerance energy levels sleep we need serotonin to help us regulate sleep we need serotonin to make melatonin that helps us get

to sleep memory problems serotonin's involved thinking clearly making decisions solving problems well when we have low cell serotonin we have difficulty with these things and actually because serotonin is also involved in managing or helping to manage our heart rate and our blood pressure it's not uncommon when serotonin levels are out of balance for people to have physiological symptoms like dizziness and difficulty with balance the same thing can be said uh so when people are let me go back when people are using substances it generally increases dopamine it generally alters levels of serotonin it generally alters

levels of norepinephrine and endocannabinoids and um glutamate so if they're taking stimulants then it increases the levels of those if they're taking depressants or hypnotics it typically increases the levels of your more calming neurotransmitters but when they quit taking it guess what the their opposite is seems to be intensified so when somebody quits taking for example um an anti-anxiety medication you know they have been exogenously artificially inflating the activity of their gaba receptors when they quit taking that then the activity of their their glutamate which had been raised to accommodate the extra gaba and keep

it in balance well the gaba goes away but the glutamate stays raised that's one of the cool things and one of the frustrating things about our brain and our body no matter what we do it wants to maintain that yin and yang balance so if we increase the the level of gaba in our system our body is going to increase the level of glutamate eventually to kind of match that to keep it in balance because it says no you're not supposed to have 10 times the amount of gaba as you are glutamate so i'm going

to return it to normal balance which is you know protective but then if you quit taking that exogenous substance or quit doing whatever it is that's increasing the gaba it takes a while for the brain to get the message and reduce the glutamate levels another thing that we see we have talked um well in a lot of my other videos i've talked and you're probably aware that dopamine is very intimately involved in the development of addictive behaviors now dopamine is not your pleasure chemical dopamine is your motivation and perseveration chemical but when dopamine goes up

serotonin goes up and endogenous opioids goes up so that's where your pleasure comes from dopamine just says whatever it was i want to do it again because i want more of those opioids and serotonin when people are in detox when they're experiencing post acute withdrawal they may go through periods as their brain rebalances as those some of those excess receptors get pruned back um as their body becomes less tolerant to the substance um and this can come in fits and spurts so there may be times when there are emotional outbursts or just lack of emotion

because the body's trying to rebalance everything there also may be explanations for the emotional outburst or lack of emotion because addictive behaviors whether it is gambling sex drugs um addictive behaviors put a huge strain on your stress response system or your hpa axis and when that system gets out of balance then you may be more likely to experience emotional dysregulation where you the person maybe may feel flat you know most of the time you know they're just not getting enough dopamine and stuff to really feel happy but then when they're triggered they have an exaggerated

reaction they have a stronger than expected reaction and that is a normal symptom of hpa axis dysregulation which again occurs because of stress because of trauma but also because of the stress induced from addictive substances and behaviors anxiety and depression are generally more associated with serotonin but norepinephrine and dopamine are also implicated in mood regulation so with any addictive behavior since dopamine is one of those things that we know has been monkeyed with it is going to the levels of dopamine are going to directly impact the levels of serotonin and norepinephrine fatigue if you've worked

with clients who are on atypical antipsychotics or antipsychotics these are drugs that directly affect the levels of dopamine when you reduce dopamine levels people get sleepy dopamine is hugely intertwined with our energy system sleep is partially um impacted by dopamine but serotonin is really our our big bugaboo for sleep here but the changes in sleep patterns may also happen because you know there's a lot of stuff that goes on in the brain while we sleep and if that brain is trying to repair itself it can cause interesting you know connections and synapses to fire off

memory problems dopamine norepinephrine are two of your main chemicals involved in learning memory and attention well we know in addiction those are highly activated during the addiction and during the withdrawal process they are insufficient that the person feels like they have insufficient levels to think clearly make decisions and solve problems and you know dizziness again can be attributed to alterations in in neurotransmitters so what do we do about these things we can't just wish them away for people you know i wish wish we could but we can't so is it's important for us to help

them ident learn about all of the symptoms of post-acute withdrawal to understand why it's happening and that there is an end to it in most cases now in some cases when there's been significant brain damage when there's you know alcoholic-related dementia other things there may be some enduring effects but most of the time the brain is able to largely recover it just takes some time we need to provide them tools to figure out how to handle all of this stuff and this is true as well for somebody for example who's been on opioids because of

a car accident or surgeries or something and they may have ended up on opioids for a long period of time and then for some reason they're coming off of them right now i know when i worked in florida one of our units was specifically soldiers and every single one of them was on long-term opioid prescriptions i don't know if that is the same way now but it was that way back then so if for some reason they needed to come off even though they weren't addicted they weren't experiencing addiction in the behavioral sense their body

had developed a tolerance to it so they may experience a lot of these symptoms and it's important that we put um we we inform them about this and help them figure out tools to deal with it how can they handle stress you know in addiction recovery we encourage people to not make any major decisions for the first 12 months well part of that is because of pause their brain is still recovering um and they've got a lot of other stuff going on in their life but helping them recognize that this time may be exceptionally stressful

and it they may get triggered easily so what can they do to reduce their stress as much as possible we want to talk about environments you know what can you do to make your environment as calming and relaxing and safe feeling as possible what can you do for time management what can you do for personal care so you don't get run down and burned out what strategies can you use to handle emotional dysregulation and that changes for each person um help them complete a sleep hygiene inventory and talk with them about their sleep patterns you

know check in with them each week or each session about how they're sleeping if they're having strange dreams how they feel when they wake up if they're having a hard time sleeping they can talk to their doctor about interventions if they have enough insurance coverage they can go get a sleep study which can be helpful but it's also important for them to recognize that the sleep distress or the sleep problems um will partially resolve if not completely resolve when their brain has healed when their body has healed now some people would have had hard time

sleeping even before that because they had crappy sleep hygiene or they've got trauma issues they haven't dealt with but those are all things that we can probe about those are things that we can help with with memory problems encouraging them to be patient and kind to themselves recognizing they're they're recovering and even though they're not using anymore even though it's been some a lot maybe six months since they used they still may have some cognitive difficulties because their brain has not completely restored that dopaminergic system therefore if they need to remember something or they need

to learn something what can they do to facilitate that i'm huge on encouraging people to make lists and notes at least during this period you know i i make lists and notes all the time not everybody loves doing that but during this point in time it can help people stay organized and remember things so they don't get frustrated encourage them to also be mindful of how their memory and attentional abilities are improving over time you know encouraging them to reflect each week you know compared to the week before last how was last week as far

as remembering things having fogginess in their head etc they can keep a daily journal it's ideal even if it's a fill in the blank worksheet if they're willing but if they're not just retrospectively thinking about how things are improving how their symptoms are improving each week to notice and embrace those baby steps forward in terms of dizziness and problems with balance and delayed reflexes this needs to be evaluated by a physician to make sure that there's not some other underlying physiological problem but with all that being ruled out encouraging them to identify what they can

do to keep themselves safe so holding on to railings when they're going up and down stairs a lot of times people have postural hyper hypotension so when they get up really fast they get really dizzy so they may need to pay more attention to getting up more slowly so they don't get dizzy and fall down but these are practical things a lot of these things are very practical life skills um strategies that they can use in order to manage the post-acute withdrawal period and have their highest quality of life when i do the pause group

we go through i have these symptoms up on the board and we go through when i have people everybody has a worksheet in front of them and i have them identify while they're in group two strategies they can use to handle each one of these symptoms should it occur um and that's a way that they can engage you know instead of just sitting through a lecture you know we're talking you know i'm asking them what works for you so they're using kinesthetic learning strategies they're using auditory learning strategies by hearing it and talking about it

and they're using visual learning strategies by writing it down and they've got it written down so if they are having memory challenges they can go back and review it later in terms of your neurotransmitters and receptors that are altered your endogenous opioids the opioids that your body makes itself reduces the amount of gaba released reduced gaba increases dopamine so when we're not um when we're not as chill you know when we're more hyped up when there's more glutamate there's more dopamine which makes sense because dopamine says let's get motivated and let's go get it which

is counterproductive to gaba which says let's just chill for a while dopamine is the pers perseverance neurochemical and is also involved in energy and attention norepinephrine is responsible for attention and alertness and glutamate is the main excitatory neurotransmitter serotonin interestingly enough can have both stimulatory and calming influences when it's too high it can actually cause anxiety when it's too low it can contribute to depression when it's just right that goldilocks hypothesis again um then it helps balance our moods it actually acts in different ways in different parts of our body now all of these neurotransmitters

are intertwined when as i as i mentioned earlier for example when dopamine and norep norepinephrine go up serotonin also often goes up your cannabinoid receptors are also involved in regulating mood memory appetite pain cognition and emotions your cannabinoid receptors these are the ones that are we have in endogenous uh cannabinoids but your cannabinoid receptors are the ones that are activated by cannabis based products or cbd based products and those also alter the levels of all of your other you know big five neurotransmitters gaba dopamine norepinephrine glutamate and serotonin adenosine is a central nervous system neuromodulator

that has specific receptors we've talked a lot about adenosine before because when we go through our day as our brain goes through its daily processes as adenosine builds up in the brain cortisol drops as adenosine goes up as adenosine goes up we start to feel what they euphemistically call sleep pressure um so adenosine is a cis central nervous system modulator when it binds to its receptors neural activity slows down and you feel sleepy it facilitates sleep dilates the blood vessels and helps ensure oxygenation of the blood of the brain during sleep caffeine and other stimulants

act as an adenosine receptor antagonist so your stimulants actually prevent adenosine from locking into those receptors to help you get sleepy and have good sleep people who are abusing stimulants are keeping adenosine at bay when they're in their active addiction people who are abusing um depressants and and opioids when they stop using guess what all of those um excitatory neurotransmitters are just you know chomping at the bit to get in there um so that their normal neurotransmitters actually displace the adenosine and keep them from getting quali the quality sleep that they need so we do

want to recognize that it's not just serotonin or melatonin that contributes to sleep there's a lot of other stuff and adenosine is one of those which is directly um counteracted by stimulants exogenous stimulants by stress the hpa axis when it releases cortisol or glutamate and by our excitatory neurotransmitters when they are too high in our system they will actually act to displace the adenosine so people who were using a substance that typically slowed them down often have more problems with sleep later on than people who were abusing a substance or that or using for an

extended period a substance that was stimulating like adhd medications even when taken as prescribed if they're taken and the person is you know taking them over years those are stimulant type medications so when they quit taking that stimulant type medication they may experience significant sleepiness for a period of time your nicotinic receptors more commonly have a modulatory role through modulation of release of all of those neurotransmitters it's been characterized as an effective anti-pain target that functions through a non-opioid mechanism your cannabinoid receptors are the same so when people are addicted to nicotine they are stimulating

these receptors when they stop using nicotine guess what whatever they were you know counteracting with the nicotinic receptors it's going to be much more intense potentially in that post use it during that withdrawal period so if they were using it to count nicotine to counteract pain or anxiety then when they quit using instead of having you know just regular old run-of-the-mill pain or anxiety it's probably going to be intensified for a period of time the developing brain is particularly vulnerable to the harmful effects of abuse including cocaine alcohol and nicotine which activate nicotinic acetylcholine receptors

disruption of the nicotine receptor development with early nicotine use may influence the function and pharmacology of the receptors and alter the release of reward related neurotransmitters including acetylcholine dopamine gaba serotonin and glutamate so people who start using nicotine products early in life before that brain is fully you know fully developed may actually alter the ability this the nicotinic receptor's ability to modulate the release of all of those different neurotransmitters so let that sink in for a second you know it's amazing how powerful nicotine is as a drug and it's legal just thinking so what do

we want to do and y'all know i love my mnemonic devices and this one is mr escaper we want to help people regulate the temperature of the bath remember i said earlier that when we start taking a substance which is way more than what our body would naturally produce our body ramps up its antagonist to meet that so if we normally took in you know three boxes and we upped it to nine boxes our body is going to amp up the counter balancing neurotransmitter the same amount when we decide hey we're not going to use

that anymore all of a sudden poof it's gone but our brain takes a while to get the message so it's kind of what we want to do is help the body balance the neurotransmitters like creating a warm bath we don't want too much cold we don't want too much hot too much slowing or too much um excitable neurotransmitters so we want to help them figure out how to regulate their bath based on their neurotransmitter bath based on their current state so if they were for example um using depressant type substances things that slowed them down

then in this post-acute withdrawal period they may have anxiety and irritability and agitation and sometimes spurts of really intense anxiety so we want to help them figure out what can you do to help yourself calm down to trigger your body to convince your body to release more of those calming chemicals to help balance out what's going on um if they are were uh using um stimulants then they may feel sleepy and depressed and lethargic again we want to help them figure out how can you prompt the release of some of those excitatory neurochemicals so you

can see color so you can get excited about life so you can get motivated all of these can be tweaked by the person in order to um affect their current condition meditation and breathing getting focused meditation and slow breathing can help slow down the heart rate and trigger the rest and digest it can increase oxygenation which can also increase energy levels you know it can help people feel more clear-headed so to speak they can meditate on a calming scene or they can meditate and think about something that is truly exciting something they think about and

they're like oh my gosh that is so amazing so they can trigger the release of potentially dopamine and some of those positive neurochemicals through meditation relationships with social supports can help regulate that temperature i think most of us have some friends that are just they are gangbusters go gangbusters all the time they're always wanting to go to the park go out to eat go do this go do that they're the ones that are going to drag you out of your house and go let's have some fun and they can be really helpful to get people

moving and sometimes that's all it takes is for them to get moving in order to get that dopamine flowing a little bit other friends are the ones that are just really chill and calm and you know let's just sit here and stare at the bonfire for a while knowing who those social supports are having a plan that includes relationships includes people that are helpful to you um regardless of whether you feel like you're running too hot or too cold one day can be helpful exercise increases dopamine levels increases serotonin levels increases endorphin levels so all

of these things are things that tend to be low especially in people who are recovering from addictive behaviors addictive substances or long-time use of prescription medications that have psychotropic effects so exercise is good sleep everybody needs sleep the brain does a lot of repair during sleep and as we talked about earlier people who were using stimulants probably aren't going to have a whole lot of problem with sleep um or feeling sleepy they may have more difficulty waking up but they may they still may not be getting quality sleep so we want to encourage them to

keep a sleep diary we want to encourage them to communicate with the other people on the multi-disciplinary team if they need assistance getting adequate quality restorative sleep on that note remember that sleep apnea keeps people from getting that adequate quality restorative sleep so if they have apnea that's something we do need to make a referral for circadian rhythm stabilization is also important and that's different from sleep sleep is one of the things that our circadian rhythms trigger but circadian rhythms also trigger your hunger your satiation when you want to sleep it's involved in your libido

it's involved in your immune system circadian rhythms are actually stabilized not only by the level of light you know when it's bright out our brain receives through through the pineal gland that we're supposed to be awake when it is dim our brain gets the message that hey it's time to start you know slowing down and winding down but light is only part of it it's also activities temperature and socialization level so our brain takes information from all of those things and says either it's time to be awake or it's time to be be asleep and

and that is important for people to recognize that they need to be cool they need to be calm they need to be collected sorry in order to help regulate those circadian rhythms so there's a lot more to circadian rhythm stabilization and sleep than than just light levels awareness and mindfulness is huge as we mentioned earlier in the symptoms there are days when people may feel depressed there's days when they may feel irritable there's days when they may feel anxious there's days when they may not feel at all um and somehow i feel like a dr

seuss book would fit with that but in any event it is important it is crucial i can't underscore enough the importance of mindfulness of the moment so people can recognize how they're feeling their feelings thoughts wants and needs in the moment both physical and emotional cognitive you know there's lots of stuff so that it's important for people to start checking in with themselves if they're recovering from addictive behaviors again sex addiction gambling or substances doesn't matter a lot of times during their addiction they were probably just oblivious kind of numb and during this time is

going to be a huge change and they're going to have to have some targets some cues to remind them to regularly check in with themselves and for some some of our clients even when they check in with themselves they may not get any reading because they're alexthymic because they've never learned to label their emotions because they may just you know kind of be numb all over so we want to help them develop strategies to become more mindful and aware of what they need in the moment and recognize that it's going to fluctuate not necessarily even

on a day-to-day basis sometimes it's an hour-to-hour basis pleasurable activities are essential pleasurable activities promote dopamine serotonin and endorphins doing something every day even if it's just listening to a really funny comedian watching an adorable video on youtube something that makes them happy or could make them happy has made them happy in the past is important engaging in those things in order to prime those dopamine uh systems eating healthfully is important they don't have to go you know crazy on it but trying to eat colorfully and reducing the amount of caffeine and processed highly processed

foods you know refined sugars and things and increasing the amount of water they drink to help flush those toxins out of their body can be super helpful and finally relaxation everybody well most everybody probably needs to set aside time each day to relax in early recovery or in that first year or two of recovery a lot of times people have a lot of guilt about stuff that they did or stuff that they should have done or this or that and they may actually schedule themselves too much so there's no time for relaxation they actually just

kind of create a whole other way of staying numb and mindless so it's important to encourage people to find time to schedule in relaxation so mr escaper stands for meditation relationships exercise sleep circadian rhythms awareness of the present moment pleasurable activities eating healthfully and relaxation over ten thousand people come to betterhelp every day looking for a counselor betterhelp makes it easy for you to move your practice online and focus on what you love most helping others betterhelp's easy to use platform takes care of referrals and billing and provides a secured platform to communicate with your

clients join more than eighteen thousand therapists at better help helping to improve people's mental health and lives post-acute withdrawal syndrome or is an expected issue for at least the first year as the brain and the body recover pause symptoms are caused by imbalances in the brain's neurotransmitters it's really important that people understand not only the client themselves but their loved ones and even other counselors and staff and in treatment centers understand that some of the emotional ability some of the exhaustion some of the symptoms of that may seem like either resistance or relapse may be

actual actually symptoms the person's experiencing caused by rapid fluctuations in their neurotransmitters now this isn't always the case you know i worked in residential addictions treatment for uh 14 years and sometimes people try to you know work the system but there's also you know the occasion for the person who's been um abusing cocaine for 15 years you know in that first 60 days after detox yeah they may actually need to sleep more it's not that they're trying to be resistant they just need sleep and that adenosine is just pouring in um for people who have

been abusing benzodiazepines or opioids their anxiety levels may go through the roof and they may be more irritable and have difficulty focusing in uh in group or in session and and it's not necessarily it's not necessarily something that is a um underlying pathology so to speak that you know like adhd or something it very well may be a physiological and relatively temporary physiological adjustment that is happening as a result of substance use and now withdrawal in early recovery it's not helpful or realistic to ignore or minimize pause symptoms the body is often telling the person

what is needed which is why um mindfulness is so important so the person can articulate what is needed and understand and try to respond to the best of their ability i mean you know if they're back at work 40 hours a week and at 2 o'clock in the afternoon you know they're like oh my gosh i could lay down and go to sleep for four hours you know that ain't gonna happen but thinking about what are some reasonable accommodations the person can make in their schedule if they are feeling sleepy frequently can be a big

help you know helping them figure out how to work with the symptoms they're experiencing to maximize their quality of life the goal during this period should be to minimize stress just like when recovering from any other illnesses let's try to not add extra stress on the body emotional or excessive physical stress it's important to integrate what the body is saying with the recovery process for example sleep is important but sleeping all day is going to throw those circadian rhythms out of whack and cause poor sleep all the time uh so we need to find that

happy medium that goldilocks principle for all of our basic activities of daily living are there any questions i want to re-emphasize the fact that you know a lot of people in who go through addiction treatment um are going to us often almost always experience pause to a certain extent and it can come in fits and spurts they may have like a month or even three months where they're feeling great and then all of a sudden one morning they wake up and they're having cravings and they're irritable and that's okay you know helping them recognize that

what we're aiming for is for those spurts to be less intense fewer and further between yes this can apply to behavioral addictions as well because when people engage in something like gambling or pornography use or or sex it increases dopamine and norepinephrine levels way higher than they would quote normally be be raised when it happens you know once in a while somebody decides to go to las vegas for the weekend or even for a week on vacation that's not a big deal but when it is ongoing for months or years and the brain is constantly

being bombarded by those extra high levels those surges of dopamine and and glutamate norepinephrine then the body starts actually making physiological alterations to the brain um in terms of psychotropics um psychotropics are an interesting thing yes we do a lot of times see people develop tolerance to psychotropics however a lot of times they're taking those psychotropics because there was an imbalance to begin with now i like to really dig deeper and say okay well if your serotonin was low or your norepinephrine was low what's causing that instead of just you know turning up the water

pressure turning up the power i want to find out what's actually causing it to be low physiologically or cognitively or both but you know some people may have dysfunctional neurotransmitter systems that will need to forever have the supplementation um so psychotropics you know are really a sticky wicket for a lot of people everybody have an absolutely positively fabulous weekend and i will see you on tuesday