Withdrawal: why it deserves to be taken seriously

“I did try. By the third day my hands shook so badly I couldn’t hold a cup. My wife wanted to call a doctor, and I told her there was no need, that it would pass.”

I hear this sentence in my room more often than I would like. Almost always it comes out in passing, offered as proof that he tried and failed — not as what it actually is: a description of a state that should have had a doctor standing next to it.

We talk about withdrawal wrongly here. We talk about it as a test of character. As something you get through at home, with tea, a blanket and willpower. And that picture is exactly why, every year, someone dies of something that could have been prevented.

This article is not a set of instructions for stopping. Deliberately so. A plan for stopping is not something you read on the internet — it comes out of a conversation with a doctor who knows your history. What I can do is something else: explain why the body reacts the way it does, why it matters which substance we are talking about, and where to go in Slovenia.

Why the body protests when the substance disappears

The nervous system is permanently looking for a balance between excitation and inhibition. Some cells speed things up, some slow them down, and out of the ratio between the two comes what we call calm, or alertness, or anxiety.

A substance that acts as a sedative — alcohol, benzodiazepine tranquillisers, some sleeping tablets — shifts that ratio. Inhibition becomes stronger than it would be on its own. The body does not tolerate that for long, because it does not want balance for aesthetic reasons; it needs it in order to function. So it adapts. It turns its own inhibition down and its excitatory side up, until the sum works out again.

This is what tolerance actually is. Not weakness, and not habit in the sense of a bad routine — a measurable biological adaptation that takes weeks and months to build.

And here is the part people miss. When the substance suddenly disappears, the adaptation does not disappear with it. It stays. A nervous system that was tuned to having something external doing the braking all the time is abruptly left without that counterweight — too little inhibition of its own, too much excitation. Shaking, sweating, a heart that races, sleeplessness, anxiety with no content to it, sometimes a seizure, sometimes the confusion doctors call delirium.

Withdrawal, then, is not a disease. It is the consequence of a body having learnt to live with something that is suddenly gone.

Alcohol and tranquillisers are not the same story as everything else

This is the one part of the article I would want you to keep even if you forget the rest.

With most substances, withdrawal is deeply unpleasant. With alcohol and with benzodiazepine tranquillisers it can be life-threatening. Not often, and not for everyone — but often enough that clinicians everywhere follow the same rule: with these two groups, stopping is not something you do on your own.

Two complications carry the danger. The first is a seizure, which can occur in someone who has never had one before. The second is withdrawal delirium — a state of deep confusion with a strong physical response, which without treatment carries a serious risk of death, and with proper treatment has a low mortality. The difference between those two outcomes often comes down to whether someone was there who recognised what they were looking at.

So: stopping alcohol or tranquillisers abruptly, without a doctor, is not safe. Even if you have been through it before. Even if last time was easier. The risk of repeated withdrawals does not generally go down.

With tranquillisers there is a particular trap: they were prescribed, so people assume that coming off them is their own business. It is not. This is precisely where a doctor-led, gradual reduction matters most, and precisely where the road can be long.

What about opioids, stimulants, nicotine, cannabis

With opioids the withdrawal is severe — pain, nausea, sleeplessness, anxiety, a feeling of the body turning itself inside out — but on its own it is rarely life-threatening in an otherwise healthy person. The danger sits elsewhere and it is real: after a period without the substance, tolerance drops. What was ordinary before is no longer ordinary after a break. That is why the risk of fatal overdose is highest in the first days after a break — after detoxification, after prison, after hospital. It is one of the main reasons the field keeps insisting on substitution treatment and on harm reduction.

With stimulants, withdrawal is primarily psychological: exhaustion, loss of drive, a heavy, empty flatness that can last weeks. It is not physically dangerous, but it is a period in which suicidal thoughts become more likely, and that should not be brushed aside.

With nicotine and cannabis you get irritability, restlessness, disturbed sleep and low mood — real and measurable, even though the people around often do not take them seriously. They are not dangerous. They are frequently the reason someone gives up after three days.

Where to go in Slovenia

The first door is your GP. This is not a bureaucratic step; your doctor knows your health and your other medication, and can judge whether stopping is safe at home or needs supervision. If the situation is acute — heavy shaking, confusion, hallucinations, a seizure — the right address is emergency care or 112, not a waiting list.

For longer-term treatment there are centres for the prevention and treatment of drug dependence in all the larger towns, as well as specialised units for alcohol dependence; referral goes through a doctor. I have written about how those routes actually work here and how long they take in the piece on referrals and waiting lists, and separately about when a doctor, not a therapist, is the first step.

Therapy — mine and anyone else’s — comes after this, or alongside it. Not instead of it. A psychotherapist is not a doctor and does not manage withdrawal.

Why the next time is not necessarily easier

There is a belief that sounds logical and is wrong: that if you have been through it once, the second time will be easier, because the body knows the way.

Research shows the opposite. In people with several repeated cycles of stopping and returning, withdrawal responses tend to be more pronounced rather than milder, and the risk of a seizure is higher. The field calls this kindling: each time the nervous system swings through this, it becomes more reactive, not less.

The practical meaning is simple. If someone has already stopped unsuccessfully several times, that is a reason for more caution, not less. And it is not a reason for shame — it is a piece of information you give your doctor, because it changes the assessment.

What a doctor actually does

People often avoid the doctor because they picture something enormous: admission, a record, losing their job. Most often it is nothing of the sort.

The doctor first assesses risk — how long the use has gone on, what happened at previous attempts to stop, what other medication you take, what your general health is. From that follows the decision: whether stopping is safe at home with regular monitoring, or needs supervision in a facility. Where it is needed, medication is prescribed that stands in for a few days for what the body can no longer do on its own, and is then withdrawn gradually. All of it is routine work, not a dramatic intervention.

What the doctor mainly does is be the person who notices when something is going wrong — a day or two before you or your family would.

When the physical part is over and it is still not all right

Many people expect the story to end with the last day of shaking. It does not. Physical withdrawal is often followed by a period called protracted withdrawal: sleep that will not come back, emotions that are either too flat or too much, poor concentration, a sense that the world has gone grey and loud at the same time. It can last weeks, sometimes months, and it arrives in waves — a few good days, then a bad week.

That period is often more dangerous for returning to the substance than the first week, because it looks like proof that stopping did not help. It is not proof. It is a sign that a system which took months to adapt also takes months to come back. I have written about how sleep returns during this stretch in the piece on insomnia and the nervous system; and restlessness with no content to it is exactly what I describe in the piece on what happens in the brain during anxiety.

What someone close can do

If you live with someone who intends to stop, the most useful thing you can say is surprisingly unromantic: “Let’s see a doctor first.” Not persuasion, not contracts, not ultimatums — just that.

The second thing is knowing what you are looking at. If in the first days after stopping someone becomes confused, does not know where they are, sees or hears things that are not there, shakes heavily, runs a high temperature or has a seizure — that is not a phase to sleep off. That is a reason to call 112. Do not wait until morning.

And third, less urgent but more important in the long run: policing does not work. Hiding bottles, checking, counting. What works is clarity about what you will and will not do — which is what I write about in the piece on setting boundaries.

Where my own trade does not help

Here is the section I write reluctantly, because it runs against my own craft.

In acute withdrawal, psychotherapy is not useful. It is not merely insufficient — it is the wrong tool. A person who is shaking and has not slept for three nights does not need insight into family patterns; they need a medical assessment and, if necessary, medication that prevents a seizure. Any conversation about why he drinks makes sense only once the body is safe.

It is also not true that everyone needs complete abstinence as a first step. For some people that is the only road and also the goal. For others a realistic first goal is reducing harm — less risky use, a safer pattern, a job kept, health kept. Harm reduction is not a signed surrender but a legitimate professional approach with evidence behind it. A person who is still alive has the chance to stop. A person we lost by insisting on the single permitted goal does not.

And one more thing: withdrawal itself is not treatment for addiction. It is the removal of a substance from a body. Everything the substance was doing for that person — calming, putting to sleep, muffling memory, making the room bearable — remains unresolved. If nothing else follows, the pattern usually returns. This is why detoxification without further treatment very rarely suffices on its own.

What to remember

Withdrawal is the consequence of an adaptation, not a lack of willpower. The body learnt to live with something; when it is gone, that shows until the balance tips back.

With alcohol and tranquillisers it can be life-threatening, and stopping abruptly on your own is not safe — the plan is made by a doctor. With opioids the danger is lowered tolerance after a break. With stimulants the hardest part is psychological.

The first address is your GP; with confusion, a seizure or hallucinations, it is 112. Therapy comes after, or alongside, never instead.

And if you are the person who already tried and failed: what happened to you on the third day was not evidence about you. It was evidence that you were doing it alone.