Opiates and The 100-Day Hangover

By Tony O'Neill 04/19/11

If alcohol and drugs stay in your system for just a few days, why do so many people need months to start feeling normal again? Some former heroin users say the secondary, months-long opiate hangover is worse than the initial kick.  The Fix serves up the latest research (and some hard-earned advice) on the savage side effects of sobriety.

Opiate Hangover
Withdrawal symptoms can plague your brain months after you stop using.

When I was an opiate user, I thought I knew all I needed to about how long heroin stayed in my system because as a methadone patient, you tend to learn many tricks that allow you to continue using while giving a clean urine sample. The fact that urine usually betrays no traces of heroin three to five days later enabled many a patient at my old clinic in London to enjoy a bit of fun on the weekend without risking the loss of their methadone prescriptions.

But when I decided to quit smack for good, I learned pretty quickly that even after I had survived that first nightmarish initial withdrawal phase, the heroin still wasn’t out of my system—not really. For six months after detoxing, I felt like death warmed over: horribly depressed, lethargic, sleepless and bad-tempered. My body may have cleared out all traces of the heroin, but it took my brain several rough weeks to recover from the damage inflicted by my addiction. My neurotransmitters and other brain chemicals were way out of whack. In many ways, this long, drawn-out post-withdrawal phase was even harder to deal with than my initial cold turkey break.

How long after you stop using do drugs remain in your system? Most doctors agree that a healthy body metabolizes most substances in a matter of days: coke, meth, and heroin rarely remain in the blood or urine longer than five days. While your body can burn off alcohol within 24 hours, the agonizing agitation, shaking and other symptoms of alcohol withdrawal can last for a week or more. The side-effects of prescription drugs, like benzodiazepines, can last even longer. Ditto for pot if you're a heavy smoker. But while the substances you're withdrawing from may escape your body in a matter of days,  it often takes a lot longer than  that for your mind to return to “normal.” Exactly how much longer depends on which substance you used, along with how much, how long, and how often. (Check out Time magazine’s “Addiction and the Brain” for some cool graphics depicting the science of addiction.)

“With opioids like heroin or methadone, there are two distinct withdrawal phases,” says Dr. Arnold Washton, the author of Willpower’s Not Enough: Recovering From Addictions of Every Kind and the director of Recovery Options, a private practice geared toward high-functioning addicts. “First there's the acute withdrawal—or cold-turkey phase—which is followed by a later, longer-lasting phase known as ‘protracted withdrawal.’” (Protracted withdrawal is also known in some recovery literature as PAWS, or Post–Acute Withdrawal Syndrome.) During protracted withdrawal for opioids, according to Washton, many addicts are still hampered by low energy, sleep problems, depression, hyperirritability, generalized apathy—and, of course, intense cravings for their drug of choice. “For anyone who has been using high-dose opioids, that period can easily go on for six months after the initial withdrawal phase,” Washton says. These symptoms take their own sweet time to leave. Most addicts don’t tell you they feel sick at this stage—instead they complain that “they just don’t feel like themselves,” he says.

That's the conventional wisdom, anyway. In fact, some researchers believe that it can take up to two years for certain chemically-compromised regions of the brain to return to normal. There is also growing evidence that on average, it takes about 90 days for the brain to break free of the immediate effects of the drug and reset itself. Researchers at Yale University call this 90-to-100 day period the “sleeper effect,” a time during which the brain’s proper analytical and decision-making functions gradually recover. That Alcoholics Anonymous recommends newbies to attend a meeting a day for the first 90 days of their recovery might just be a curious coincidence—or a precient prediction of much-later scientific studies.

But an alternative (and controversial) take on withdrawal is offered by Dr. Lance Dodes, the author of The Heart of Addiction and Breaking Addiction and an assistant clinical professor of psychiatry at Harvard Medical School. Dodes disagrees that former opiate addicts are doomed to suffer months of withdrawal. He makes a sharp distinction between those who have merely become physically dependent (like patients recovering from long-term opiate pain control) and people he classifies as “true addicts”—people who are driven to use drugs for deep-rooted psychological reasons. “With highly addictive drugs like heroin, unless you have the psychology to use the drug addictively, once you’re off it, you’re off it,” he says.

To back up his contentions, Dodes cites The Robins Study, a landmark 1971 look at the experiences of Vietnam veterans who had returned home addicted to the cheap, plentiful heroin available on the front line. The numbers were staggering: almost half (45%) of all US troops had experimented with heroin or opium while overseas; 20% claimed to have become addicted at some point during combat; and 11% tested positive for opiates on the way home. Yet despite such high rates of drug use, the Robins study showed that only 5% of all soldiers who came home from the war addicted to heroin had relapsed within the first 10 months of their return and only 12% within the first three years. “Obviously it isn’t just the drugs themselves that make the addict, because physically these soldiers were just as addicted as the stateside civilians,” Dodes says. For many veterans, once they had escaped from the daily horrors of war—and the easy availability of heroin—they no longer needed to get high. ”They simply didn’t feel the compulsion to use the drug once they were out of Vietnam," he says.

While Dodes has “heard stories” from patients suffering from protracted withdrawals, he says that the majority of former addicts do not experience such long-term cravings and other woes. “So you have to wonder if it’s the drug or the person that is the cause of all these symptoms,” he says. “I don’t deny that people suffer from withdrawal experiences, but I believe they're as much psychological as physical.”

Dodes, who has seen some patients switch “from compulsively drinking to compulsively cleaning their house,” says that the heart of addiction is a primal feeling of being helpless or overwhelmed. “When you’re overwhelmed you have to do something. That is a perfectly normal reaction. Imagine you were trapped in a cave—you’d have to fight back in some way. It would be abnormal just to sit down, get quietly depressed and die,” he says. “Addiction is when you do something because you feel helpless—but it’s a displaced, or substitute, action.” Which action you choose to soothe the chaos within—drinking, say, or gambling—is a secondary issue. Says Dodes: “Addiction is a mechanism of the mind—and the same as any other number of compulsive behaviors that we don’t normally think of as addictions."


According to Dodes's take on addiction, I suppose I would be classified as a “true addict." My depression and lethargy were in some way related to the fact that I had formed an emotional attachment to the drug. The kicking junkie undergoes a strange kind of grieving process: you are letting go of your favorite sensation, your greatest comfort, and the ultimate emotional crutch.

Yet it’s true that there is that other type of user. I’m thinking of one particular guy I used to score with back in LA who fooled around with heroin for years but never developed an overwhelming psychological need for the drug. Sure, he’d fall into something of a habit now and then. But when he felt himself getting too out of control, he'd just stop cold-turkey, with the nonchalant manner of a man who knew he’d be back on his feet in a week or so. For him, heroin withdrawal was merely an inconvenience—something akin to a trip to the DMV…with additional stomach cramps and violent diarrhea.

Even though Dodes does not agree that PAWS is an inevitable part of kicking the habit, he acknowledges that physical symptoms typically come with withdrawal. “It’s common for people to feel aches and pains when they are under stress—the mind and the body are connected that way. But the cause is psychological,” he says.

The length of withdrawals varies from drug to drug, according to Washton. When it comes to stimulants like cocaine or amphetamines, the half-life is “much shorter than opiates,” he says. Once you quit cocaine, says Washton, it might take you a number of weeks to get back into a normal sleep cycle. If your coke or meth use had gotten to the point where you were already experiencing cognitive impairments, severe depression, or psychiatric symptoms, “most of those symptoms will pretty much disappear within six weeks or so,” Washton says. “You don’t see many lingering symptoms with stimulant addicts, especially when compared to alcoholics, opiate addicts or users of other sedatives.”

Still, the cessation of cocaine or meth use commonly triggers a depression in most former users. “Because people reliably show these depressive symptoms, it naturally raises the question ‘Is depression the reason why people use cocaine in the first place?’” Washton asks. In his view, the abrupt withdrawal of self-medication may simply allow pre-existing emotional problems like depression to resurface. Another theory posits that chronic drug abuse depletes the brain of certain neurotransmitters that govern your mood, such as serotonin, dopamine and norepinephrine, which is manifested as depression. As the brain recovers its capacity to produce adequate levels of these chemicals, the bad mood will lift. Treatment with antidepressants, such as Lexapro, Effexor, or Wellbutrin, may alleviate drug-related depression, but they're not a sure bet. "There are plenty of people who feel depressed after stopping cocaine who simply don’t respond to antidepressants,” Washton says.

People addicted toalcohol also tend to suffer long-term effects of withdrawal, but the crucial difference is that alcohol use is often associated with cognitive impairment. “I’ll see an alcoholic and when he or she stops drinking, pretty reliably after four weeks or so they’ll tell me, ‘You know, I didn’t realize that I wasn’t really on my game before. Everything seems clearer now, I can concentrate better,’” he says. This muddled thinking syndrome commonly lasts for three months, although with a severe dependence that has endured for decades, it will take even longer.

The road to recovery can be even more arduous with other depressants, such as the benzodiazepines. “The half lives of those drugs are much longer than alcohol,” Washton says. “The longest acting are Ativan and Valium, which can take up to five days to get out of a person’s system. So whatever cognitive impairment alcohol would cause, benzodiazepines would likely cause similar impairment but for longer. Certainly if someone was combining alcohol with benzodiazepines—which is not uncommon—you get a double whammy.” Because benzos and alcohol are synergistic with each other, the effect is additive, says Washton. If you're drinking five Martinis a day, plus taking 50 mg of Valium, your level of dependence is the alcohol plus the Valium. Cut the Martinis, and you'd probably need another 15 to 25 mg of the benzo to feed the addiction beast. “That’s why when an alcoholic goes into detox, we typically switch them over to long-acting benzodiazepines like Klonopin or Valium—drugs  will substitute for alcohol.” 

Whatever substance you’re detoxing from, “there’s always an attachment,” says Washton. “We’re talking about people who are cutting off something that has started to feel as vital to them as the air they breathe. So you inebitably go through this painful period of wrenching yourself away from it, and now you’re feeling lousy. It’s pretty common for many recovering addicts to ask, “Is this the reward I get for getting clean?’ Most people are led to believe that once they stop using, their life will start to get better, when in reality this next period can really suck. But it gets better.”

How can a person experiencing withdrawal start to feel better? To start with, try to get some sleep. “Lack of sleep really drives people crazy,” Washton says, “but there are non-addictive medications like Trazadone [a non-addictive anti-depressant often used as a sleep aid] that are prescribed to people in recovery that wouldn’t put them in danger of relapsing or developing a substitute addiction,” Washton says. Opiate addicts, in particular, suffer the greatest sleep disruption during withdrawal. But the most crucial aid to beating withdrawal blues doesn’t come in a pill bottle. “Having support and not dealing with this alone is key,” says. “And you have to plan activities to fill up the void left by the drugs or alcohol.” Staying busy with exercise, meditation, sports, and spending time with people who do not use are all highly recommended activities—but the hardest part can be just getting off your ass and out the door.

In many ways, I was lucky. As I was going through my own secondary withdrawal phase, my daughter was born. As anybody who has cared for a newborn child knows, while lack of sleep is definitely par for the course, long periods of time where you dwell on your condition are very hard to come by. According to Washton, this may have been a blessing in disguise. “The worst thing a former addict can do is to sit around feeling mad at yourself or sorry for yourself—and physically uncomfortable at the same time,” he says. “That’s what most often leads to relapse.” Instead I was lucky enough to get woken by loud shreiking every three hours and change diapers eight times a day. Now that’s a real high.

Please read our comment policy. - The Fix
Tony O'Neill_0.jpg

Tony O'Neill, a regular contributor to The Fix, is the author of several novels, including Digging the VeinDown and Out on Murder Mile and Sick City. He also co-authored the New York Times bestseller Hero of the Underground (with Jason Peter) and the Los Angeles Times bestseller Neon Angel (with Cherie Currie). He lives in New York with his wife and daughter. You can follow Tony on Twitter.