Our descent into addiction is so slow that its progress is largely invisible to us. The parts that we notice are; that we are definitely drinking more than we used to and that we are drinking more often than we used to. But there is a parallel decline that we notice but don’t link to our drinking: as the amount we drink steadily creeps up then so do all the changes that come with alcohol-tolerance. We become less care-free and more beset by our concerns, our mood lowers, and our anxiety increases. Anxiety, fear, and depression are inevitable consequences of drinking heavily over a long period; they are opposite sides of the same coin. But we experience these independently of drinking so there is no way for us to directly associate this distress with our alcohol consumption, let alone recognise that the drinking may be the cause of the distress. It seems to us that we are often drinking because of all our worries, but that worry is to a great extent caused by our alcohol-tolerance. We worry when we are sober because of all the changes in our brain that come with alcohol-tolerance, this launches cravings, and then we drink. This has the appearance to us of drinking in response to our problems, but in fact we are drinking in response to being sober: we have “cause” and “effect” back-to-front.
As our addiction progresses then everything escalates: cravings get triggered by more circumstances and the cravings themselves become more compelling. The changes in our brain due to alcohol-tolerance become more severe, further lowering our mood and making us more irritable and even more socially withdrawn. We know we are drinking too much and we try to bring it under control; we try to drink less, we try to drink less often, we try to limit what we drink in a single session, we try moving, we try changing where we drink… but nothing works. We make commitments to others about drinking less and we make commitments to ourselves, but we can’t keep them. We drink in ways that attract shame and the psychological defences we create to deflect that shame become more sophisticated. But nothing we do stops the drinking, so we try to hide it and our cravings and alcohol-tolerance form into a loop and strengthen each other. This progression is incredibly slow, it happens over years and decades, and it becomes seemingly inescapable: controlling our drinking is beyond us. We have tried absolutely everything we can think of and always failed, but life without alcohol is unimaginable: drinking is the only thing in our life that gives us a reprieve from hopelessness and we can’t imagine our life without it. Our position seems inescapable and we are stuck in limbo; we can’t carry on the way we are but we can’t change it either. We keep on trying to bring our drinking under control, and we keep failing; it can’t be done. We are aware of some truth about our position: we have lost control of our drinking and deep down we know this is true. But we can’t admit this because that would make us one of those weak, worthless and useless people… alcoholics. We are perfectly capable in every other aspect of our lives, but not this one. For some inexplicable reason we can’t fix this. We feel the weight of the implied shame of hiding our drinking; perhaps we are weak like people say, perhaps we are bad people, perhaps we really are useless… if we weren’t we wouldn’t drink like this, but we can’t stop. It seems like we drink because we drink because we drink, there’s no reason for it and there’s no stopping it; it will always be like this and the future is impossibly dark. We’ve tried everything we can but there is no way out and this hopelessness pushes us into complete despair.
Something has to change or we will lose absolutely everything, but we are at our wits end. We have tried everything we know but are stuck in a state of confused hopelessness. We can no longer convince ourselves that our drinking is OK but we also know that we can’t bring our drinking under control, so there is an obvious but terrifying conclusion. We start to think the unthinkable idea: we might have to stop drinking altogether, but the mere thought of this fills us with dread. There seems to be no supporting argument linked to this fear, there is only a deep and immediate dread, but the fear is very real. It is built on that deeply learned memory that “drinking is good”, and the thought that we might stop drinking altogether gives us an instant and intense fear of missing out. Our mind responds “but that means no more fun… ever” but the alternative has become equally appalling. We can no longer dismiss or deny the damage that our drinking is doing and even the best of our justifications fails to be plausible. For most of us the day finally comes when denial falters and we start to entertain the possibility that we so don’t want to accept… that we might be an alcoholic! When we start to acknowledge this idea then denial is weakening. While the fight is locked within our own heads it is irresolvable and eventually in desperation we tentatively reach out for other opinions. Most often it is what someone else says that tips the balance but it is not that they say something that is new and convincing, it is the timing of it, because only when denial is exhausted does anyone else’s opinion carry any weight. It is not the words spoken that tip the scales on denial; it is when they are said. Eventually denial collapses and we decide: it has to stop! But this decision to stop drinking does not mean that we start to recover; it only means that recovery ceases to be impossible.
Stopping drinking is incredibly difficult but it is not the fight that we expect; our fight is not with the bottle but with our own minds and it is a fight we are ill-equipped to win. We are fighting ourselves and are therefore at best only the equal of the challenge, but the addicted part of our brain, the reward system, is armed with something that we have no effective counter for: feelings. We can’t apply a superior argument that overcomes these feelings because feelings are impervious to reason. So while we may have made a conscious and considered decision to stop drinking this is the only thing that has changed. Our decision to stop has no impact whatsoever on the reward system which still compels us to drink at every triggering circumstance we meet, and we have hundreds of these. Our memory remains biased towards remembering drinking as a good thing rather than a bad one. Our mood is still depressed, we are still socially withdrawn, and our minds are a roaring, churning torrent of problems. The cravings are going to come, and there’s nothing we can do to prevent that. Our memory will tell us we are missing out, and our mind insists that “a drink will make you feel better”. This is the starting point of our effort to stop drinking. We can only try to overcome the cravings and sabotaging thoughts with willpower and logic, and our experience of trying to do this is very discouraging. In addition to the hugely compelling cravings our mind also moves to sabotage any attempt to stop drinking and the most challenging ideas are; “it isn’t worth it if I am going to be miserable for the rest of our lives”, “stopping drinking is impossible… I’ve already tried and tried but can’t” and “maybe I wasn’t that bad, I just need to try harder”. These are the three themes behind the ideas that our minds present to make us drink again; it’s not worth it, it’s not possible, and it’s not necessary. These have always caught us out in the past and if we are to have any success then we have to change how we address the problem: nothing changes if nothing changes. The most powerful thing we can do to make this attempt different to all the others is to abandon the idea that we can beat this alone. Every time we have tried to do this alone we have failed. If we want to improve our chances of success then we have to do something differently, and by far the single greatest thing we can do to help ourselves is to engage help, any help… all help we can find. The research shows that the likelihood of achieving a lasting recovery entirely alone is virtually nil.
The descent into addiction is slow and seamless, but the path out isn’t; the experience of stopping drinking is a far cry from creeping and imperceptible change. Withdrawal from addiction is an aggressive, raw and volatile experience and the shock to our system when we first stop drinking is enormous. There are incredible cravings to overcome and our brain presents lies to encourage us to drink again, but in the first one or two weeks there are also some externally observable symptoms.
On the first day of stopping drinking we experience symptoms that are not at all unfamiliar; we’ve gone without drink for a day many times in previous efforts to stop so we know exactly what happens. These first symptoms are; shaking, jumpiness, anxiety and sometimes also nausea and abdominal pain. These are all direct consequences of the sudden absence of alcohol. While we drank regularly over an extended period our brain adapted to the slowing effect of regular and large doses of alcohol by increasing release of the chemicals of our flight-or-fight response: cortisol, adrenaline and noradrenaline. But when we suddenly stop drinking completely then our brain still continues to apply these counter-measures until it recognises that they are not needed. When there is no longer any alcohol slowing the brain down then the effects of these are fully exposed. Cortisol makes us wide awake, noradrenaline makes us alert for signs of danger and adrenaline makes the body ready for immediate response: our heart rate accelerates and blood is moved to the large muscles. In the absence of alcohol the noradrenaline over-excites our nervous system, and we tremble. Adrenaline diverts blood from the skin to our large muscles and increases our heart rate. This makes us pale in appearance but overheating internally, so we get cold sweats. The raised cortisol level irritates the stomach causing the cramps and nausea. These first symptoms of withdrawal are the result of the over-excited flight-or-fight response and drinking would normally make all these symptoms disappear, but when we don’t drink we feel their effects directly. The same is the case for the other changes due to alcohol-tolerance. We now no longer spend part of the day lifted from feeling down, alone and anxious. We also don’t slow our brain down with alcohol so the accelerating effects of more glutamate (the accelerator pedal) and less GABA (the brake pedal) hit us fully, and the result is a hyper-active brain. Our brain runs fast and constantly churns over and over our problems; the chatter in our heads is incessant. A side effect of this accelerated brain is that time seems to pass very slowly, and getting through the first few days of not drinking seems to take forever. Not only are the days long, the nights are long too. We were already suffering from significant long-term fatigue caused by elevated cortisol preventing us from achieving deep sleep, but without alcohol slowing our brain down we find it is impossible to sleep at all. We lie awake, restless, hot and sweaty, with our minds racing around and around all our problems. Proper sleep does return, but not for a while.
The first cravings we get during withdrawal are from the triggers related to being sober and those related to our daily routine, so they fire automatically and continuously. During the day our mind races, we are fidgety, we can’t calm ourselves, and the cravings come one after another. The cravings we experience are not only nearly continuous they are also the most powerful we have ever felt, and they are the most powerful because in the past we have always given in to them. We have rarely felt cravings at their peak before and now they all reach their maximum intensity and then we make them linger by thinking about drinking and this keeps re-firing those triggers. The reward system demands that we drink, our minds actively encourage doing exactly that, and the familiar taunts keep coming to us; “just one won’t hurt”, “you’ve done well, you deserve a drink”, “a drink will make you feel better”, and “no-one will know!”
Over the years of drinking our bodies adjusted to be in a perpetual state of readiness for action, this was to offset the impairment of the alcohol that would come. When we drank then the brain slowed the flight-or-flight response which in turn slowed the release of cortisol, noradrenaline and adrenaline and we relaxed. But when we stop drinking we also stop this slowing down, so the reduced production of cortisol, noradrenaline and adrenaline no longer occurs and the release of these stays raised the whole time. This means that for the first few days of not drinking the levels of these three are not just elevated, they continue to rise. As withdrawal progresses the levels of cortisol and adrenaline continue to climb bringing on; higher blood pressure, further increased body temperature, unusual heart rate (palpitations), and sometimes even confusion. The severity of these symptoms is determined by the extent to which our brain adapted to our alcohol intake and these symptoms can make withdrawal hazardous for some people. Supervised medical withdrawal is usually encouraged for those with backgrounds of prolonged and very heavy drinking and those with other medical risk factors.
The peak of withdrawal is usually experienced at around Day 4 or Day 5 and the period with observable effects lasts roughly a week although this can be two or even three weeks depending on the individual; but it does not last forever… there is an end to it. The changes to our brain and body were in response to regular and heavy drinking and these changes start to reverse themselves out when alcohol is consistently absent. The first things to come right are the changes related to the flight-or-fight response. Over the course of one to three weeks the levels of cortisol, noradrenaline and adrenaline steadily move back to our pre-drinking levels and this brings some very welcome benefits. The cold sweats stop, our hearts stops pounding and most notably our sleep returns, but not only does it return it is different. Elevated cortisol levels have for years prevented us from achieving a proper deep-sleep state, and when sleep does come back it is deep, restoring and refreshing. But while sleep is the thing we notice the most it is something else that people around us see; our skin colour returns. As the levels of noradrenaline fall then the trembling stops. Then as the adrenaline levels drop our heart slows down and blood is released back to the skin from our large muscles; we lose the pale appearance and begin to look healthier again. But while our flight-or-flight response steps down quite quickly it takes longer for our proper GABA and glutamate levels to restore themselves and even longer for serotonin and dopamine to return to normal. We are physically in much better shape than we were but we still have a racing mind and our mood is still low. We still have huge cravings that come nearly non-stop, and our mind is still churning and churning over our problems. All these symptoms would disappear if we only had a drink, and we know this! While we are fighting against the cravings our mind is actively working against us and the challenges return again and again; “Just one won’t hurt”, “you’ve done well, you deserve a drink”, “no-one will know”, “a drink will make you feel better”. Of all the justifications our minds present it is that last one that is the most challenging, and it is the most challenging because it is completely true; a drink will make us feel better. Our minds also make us doubt ourselves; “you know you won’t keep this up, you may as well have that drink now”, “it’s not worth being like this forever”, “a drink will make you feel better”… “a drink will make you feel better”… “a drink will make you feel better”. It is unrelenting.
We have previously only endured cravings for limited periods, but now they run the whole time and they all climb to their full strength. It is difficult to describe what the non-stop insistence of these cravings is like, but a crying baby is a fair comparison:- Imagine you are in a room. There is no-one else there except a baby, and the baby is crying. The crying is horribly piercing and incredibly irritating. You know you only have to pick the baby up to stop it crying but you are not allowed to. The screaming is excruciating, like the screech of nails on a chalk-board and it continues without pause. The longer you leave the baby alone the more insistent the crying becomes but even though it would be incredibly easy to pick it up and make the screaming stop, you must not. There’s nowhere to hide and no way to get away from the screaming; it just goes on and on and on. You close your eyes, cover your ears, scream and shout to make it go away but it just keeps going. There’s no escape from it, and no way to not hear it. Time passes incredibly slowly as the wailing and screaming just won’t stop. The only way to make it stop is the thing you mustn’t do, you must not pick up the baby, but who would know? Would it really hurt to pick it up to make the screaming stop for one minute? You could just pick it up for a short spell, nobody would know, you’d feel better for a few minutes. But you must not. It goes on all day, continues all through the night, carries on the next day, and the day after, and the day after that; there seems no end to it. It is agonising and never stops for more than a few minutes; then it starts again. It seems unbearable and almost impossible to resist the very simple thing that will make it stop… to pick up the baby… it would be really easy… that’s all you have to do… nobody would know… nobody would know… nobody would know.
This is what cravings are like when we first stop drinking and this is how they should be. When we experience this then it confirms the unnaturally extreme extent to which our reward system has bound itself to alcohol and only when we stop drinking is this fully revealed. What we are experiencing in withdrawal is the extent to which our brain and body have adapted to offset the regular impairment of alcohol. But just as our brain changed to counter the effect of large and regular amounts of alcohol it changes again when that alcohol is no longer routinely present, and these changes happen faster than the decades it took to become alcohol-tolerant.
The initial withdrawal is marked by some physical discomforts but there has been an ongoing and larger internal struggle against cravings which continues throughout. As we resist the cravings then our mind steps in to try to convince us to drink and this is by far the greatest challenge in stopping drinking. The test is not so much the physical aspects of cravings and withdrawal but what happens inside our own heads.
The internal fight through withdrawal is relentless and at the same time as we are enduring the most severe cravings we have ever encountered our minds are trying to convince us that drinking is a good idea. We feel depressed, isolated, irritable, obsessed with all our problems, and sleep deprived. It is a perfect storm. It is no wonder that so many relapse in the first week of withdrawal, in fact it is remarkable that any manage to get through it at all; yet so many do, and eventually most will.