When a someone with a substance use disorder discontinues regular use, it takes weeks or months of abstinence after complete detoxification before the brain's pleasure mechanisms are able to achieve equilibrium.  This occurs through an increase in the production and utilization of neurotransmitters to levels that can maintain a stable and optimistic mood. During this period, identified as the protracted abstinence syndrome, first by Martin and Sloan in 1968 and then by Dr. Ockert and others in the early 1980s, this person experiences distinct stages of physical and psychological symptoms that can last from six months to eighteen months. This period is the time of greatest relapse; most people with a substance use disorder in the U.S. relapse within three months of detoxification (estimates range as high as 98%).

The symptoms of protracted abstinence change as the patient proceeds through its various stages (as identified in Rawson's neurobehavioral model*). Stages include:

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• Temporary rebound ("pink cloud") which occurs 10 to 45 days after detoxification and is characterized by overconfidence, an inability to initiate change and episodic cravings

• The "wall phase" which occurs 45 to 120 days into abstinence and is characterized by intense and often sudden onsets of anhedonia (lack of pleasure), mood swings and depression as well as justification for relapse

• The "adjustment" phase, which lasts 120 to 180 days into abstinence and is characterized by job dissatisfaction, relationship problems and lack of goals.

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The body also changes during the protracted abstinence period.

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• Opioids: body temperature, blood pressure and pulse rate shift from above to below pre-addiction levels

• Alcohol, cocaine and benzodiazepines: similar changes in physiological activity are associated with sleep disturbance, lack of energy, transient attention deficit, impulsive and erratic behavior, and low frustration tolerance.

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Psychological and emotional signs and symptoms may include:

• Depression

• Anxiety

• Self-doubt and boredom, coupled with confusion, hostility, inappropriate coping responses and fear.

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Stabilization during acute and post-acute symptoms and protracted abstinence:

In addition to psychosocial supports, pharmaceutical interventions can make a critical difference in recovery success. There is an ongoing evaluation of the patient’s needs as they progress through the stages of the protracted abstinence syndrome.

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Dr. Ockert's Podcast, "Why is relapse so common is early recovery?":

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* To read more, click here.