A clinician’s perspective on stimulant withdrawal

Stimulants – such as cocaine, amphetamines, and certain prescription drugs – are widely misused substances in the UK1 with significant physiological and psychological effects. While these substances can provide a temporary boost in energy, focus, or euphoria, they also come with a high risk of addiction and dependence2. 

Withdrawal from stimulants presents a unique set of challenges for clinicians and patients alike, as it can encompass a range of symptoms that affect the body, brain, and emotional wellbeing.

One report found that up to 15% of individuals not currently on medication will become addicted following prescription3; another concluded that the age-standardised prevalence of amphetamine dependence is 96 per 100,000 population4. It’s estimated that the “majority of people who use psychostimulants, particularly methamphetamine (MA) and cocaine, experience withdrawal upon abstinence from sustained use.”5

Many individuals undergoing stimulant withdrawal experience severe depression during the initial detox phase, increasing the risk of self-harm6. This blog will explore the clinical nuances of stimulant withdrawal, its symptoms, and evidence-based strategies for long-term recovery. 

What are stimulants? How do they affect the body?

Stimulants are a class of psychoactive substances that increase activity in the central nervous system (CNS). They work by enhancing the release and inhibiting the reuptake of neurotransmitters like dopamine, norepinephrine, and serotonin7. 

Examples of stimulants include illicit drugs like cocaine and methamphetamine, as well as prescription medications such as methylphenidate (Ritalin) and amphetamine salts (Adderall).

Physiologically, stimulants increase heart rate, blood pressure, and respiratory rate. Chronic misuse can lead to cardiovascular strain, hypertension, and increased risk of arrhythmias or stroke8. 

Beyond the physical effects, stimulants disrupt normal appetite regulation, contributing to malnutrition and weight fluctuations. Their euphoric effects often give way to tolerance, necessitating higher doses to achieve the same ‘high,’ which compounds the health risks.

How about the brain? 

Stimulants exert their primary effects on the brain’s reward system, particularly the mesolimbic dopamine pathway9. Prolonged use can lead to dopamine depletion, impairing the brain’s ability to regulate mood, motivation, and decision-making. This neurochemical imbalance contributes to cravings, depression, and cognitive dysfunction during withdrawal.

 Effects on an individual’s wellbeing

Stimulant misuse profoundly impacts an individual’s overall wellbeing. While the initial effects may enhance energy and confidence, prolonged use often disrupts personal, professional, and social domains10. 

→ Consider a hypothetical case:

• A high-net-worth executive begins using stimulants to meet demanding deadlines. 

• Over time, their dependency leads to erratic behaviour, strained relationships, and declining job performance. 
• Despite outward success, their addiction deepens, causing emotional distress, physical health problems, and isolation.

This scenario underscores the insidious nature of stimulant addiction, and the pressing need for effective intervention and recovery strategies.

The symptoms of stimulant withdrawal 

Stimulant withdrawal presents a spectrum of symptoms that vary in severity and duration based on factors like the type of stimulant, duration of use, and individual health status. 

Timeline of stimulant withdrawal

• First 24-48 hours

→ intense cravings, fatigue, and irritability dominate. Patients often report overwhelming tiredness and a lack of motivation as their body begins adjusting to the absence of stimulants.

• 3-7 days

→ acute withdrawal symptoms peak, including mood disturbances, sleep disruptions, and heightened appetite. This phase is marked by physical discomfort and psychological distress, requiring careful monitoring.

• 2-4 weeks

→ gradual reduction in physical symptoms occurs. However, psychological symptoms such as depression and anxiety often persist. This phase is crucial for initiating therapeutic interventions to address underlying mental health issues.

• 1-3 months

→ emotional and cognitive recovery begins, but cravings may intermittently arise, especially in response to environmental triggers or stress. Building resilience and coping mechanisms is essential during this phase.

Physical symptoms

Physical symptoms during stimulant withdrawal reflect the body’s attempt to restore homeostasis:

• Fatigue and hypersomnia: the body compensates for prolonged periods of overstimulation by demanding more rest.
• Increased appetite and weight gain: a rebound effect occurs, as suppressed appetite mechanisms normalise11.
• Muscle aches and tremors: these are common due to neurotransmitter imbalances and physical stress12 during substance abuse.
• Headaches and general malaise: these symptoms may reflect dehydration, nutrient deficiencies, or vascular changes.

Psychological symptoms

For many, the psychological symptoms of stimulant withdrawal are often the most challenging aspect:

• Intense cravings for the substance: these cravings are driven by the brain’s adaptation to high dopamine levels and can lead to relapse without appropriate interventions. Intriguingly, cannabis has shown recent promise as a potential method of harm reduction in managing stimulant withdrawal cravings13.
• Depression and anxiety: neurochemical depletion exacerbates mood disorders.
• Cognitive impairment: difficulty concentrating and memory lapses are common and may impact daily functioning14.
• Irritability and mood swings: emotional regulation becomes challenging as the brain adjusts to normal neurotransmitter levels.

Behavioural symptoms

Changes in behaviour often accompany stimulant withdrawal15:

• Social withdrawal and isolation: feelings of shame or fear of judgment may prevent individuals from seeking help.
• Restlessness or agitation: the absence of stimulants can lead to physical and emotional discomfort, manifesting as fidgetiness or unease.
• Reduced productivity: a lack of focus and motivation can hinder workplace or academic responsibilities.
• Impulsivity: some individuals may engage in risky behaviours as a coping mechanism.

Emotional symptoms

Additionally, the related emotional symptoms highlight the deep psychological toll of stimulant withdrawal:

• Feelings of hopelessness or guilt: individuals may struggle with self-blame, complicating recovery efforts16.
• Emotional numbness: a lack of emotional response can result from neurochemical imbalances and exhaustion.
• Heightened sensitivity to stress: even minor challenges may feel overwhelming17.

How likely is a relapse? 

Relapse rates for stimulant addiction are notably high. Studies suggest that over half of people with stimulant use disorders relapse within one year of leaving treatment18, and 75% of people who undergo treatment for stimulant abuse relapse within five years19.

Factors contributing to relapse generally include unresolved psychological issues, lack of a robust support system, and environmental triggers. However, one systematic review highlights that integrating behavioural therapies with pharmacological support20 can dramatically reduce relapse rates.

The foundations of enduring recovery

Enduring recovery from stimulant withdrawal requires a whole-person, curated, multidisciplinary approach. Key components of this include:

Therapy

Evidence-based interventions like Cognitive Behavioural Therapy (CBT) and contingency management address maladaptive thought patterns and reinforce positive behaviours.

Medication

While further research is needed into potential medications for stimulant withdrawal, the use of drugs like bupropion or modafinil have shown some encouraging signs21,22 in alleviating certain symptoms.

Diet and nutrition

Replenishing essential nutrients can help restore physical health and energy levels.

Confidentiality

Ensuring privacy fosters trust, away from unwanted attention, and encourages individuals to seek help without fear of stigmatisation.

A serene healing environment

Similarly, having access to peaceful, supportive settings that are designed to facilitate healing enables recovery and reduces stress.

Lifestyle adaptations

Incorporating exercise, mindfulness, and structured routines supports long-term sobriety.

Rebuilding fulfillment. Rediscovering wellness

Stimulant withdrawal is a challenging, but transformative, process. 

By addressing both the physiological and psychological dimensions of addiction, clinicians can guide patients toward sustained recovery from stimulant addiction. The road to wellness involves rebuilding a life that aligns with the patient’s values, aspirations, and sense of purpose.

Ultimately, a compassionate and evidence-based approach is essential in helping individuals reclaim their health and wellbeing. For healthcare professionals encountering patients struggling with stimulant use, early intervention and tailored treatment plans are vital. Harbor London is here to provide the expertise and support needed to navigate this journey – reach out now to learn more.

References

1. https://www.gmmh.nhs.uk/focus-on-stimulant-misuse/#:~:text=If%20a%20person%20is%20misusing,prescribed%20dexamphetamine%20following%20the%20assessment.
2. https://www.dea.gov/sites/default/files/2020-06/Stimulants-2020.pdf
3. https://pmc.ncbi.nlm.nih.gov/articles/PMC3056348/
4. https://pmc.ncbi.nlm.nih.gov/articles/PMC6924572/#:~:text=Prevalence%20of%20cocaine%20and%20amphetamine%20dependence&text=Globally%2C%20the%20age%2Dstandardised%20prevalence,%E2%80%935%C2%B76%20million%5D).
5. https://pmc.ncbi.nlm.nih.gov/articles/PMC10069411/
6. https://www.ncbi.nlm.nih.gov/books/NBK576550/
7. https://adf.org.au/drug-facts/stimulants/
8. https://www.ncbi.nlm.nih.gov/books/NBK576548/
9. https://pubmed.ncbi.nlm.nih.gov/16099045/
10. https://www.apa.org/monitor/2011/10/stimulants
11. https://medlineplus.gov/ency/article/002149.htm#:~:text=During%20recovery%20from%20substance%20use,if%20they%20were%20taking%20stimulants.
12. https://www.addictioncenter.com/stimulants/withdrawal-and-detox/#:~:text=During%20the%20first%2024%20to,hallucinations%2C%20paranoia%2C%20and%20panic. 
13. https://www.sciencedirect.com/science/article/abs/pii/S0306460323002629
14. https://pmc.ncbi.nlm.nih.gov/articles/PMC4837011/#:~:text=While%20acute%20drug%20and%20withdrawal,ameliorated%20by%20abstinence%20from%20stimulants.
15. https://academic.oup.com/braincomms/article/1/1/fcz025/5588408
16. https://www.sciencedirect.com/science/article/pii/S0149763405000412
17. https://www.ncbi.nlm.nih.gov/books/NBK576548/
18. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2719577#:~:text=Harmful%20drug%20use%20accounts%20for,6%2C7
19. https://pa.highfocuscenters.com/relapse-statistics-you-need-to-know/#:~:text=A%20study%20in%20the%20journal,right%20mindset%2C%20treatment%20and%20support.
20. https://pmc.ncbi.nlm.nih.gov/articles/PMC6389220/
21. https://pmc.ncbi.nlm.nih.gov/articles/PMC10191240/#:~:text=While%20there%20is%20no%20clear,use%2C%20and%20reducing%20relapse%20use.