2.3.4 Rapid withdrawal symptoms, hypo/hyper-metabolism
The metabolic consequences of Small Intestinal Bacterial Overgrowth (SIBO) and Gut Fermentation Syndrome are often not immediately clear. These conditions can create complex biochemical disruptions in the body, similar to the effects seen in chronic alcohol users.
https://www.ncbi.nlm.nih.gov/books/NBK513346/
Much like in alcohol dependence, individuals with SIBO may experience metabolic impairments due to the fermentation of sugars into alcohol and acetaldehyde within the gut. This process can disrupt homeostasis, precisely mimicking the metabolic challenges faced by chronic alcohol users.
When treating alcoholism, the typical approach involves gradually reducing alcohol intake, supported by high doses of thiamine (Vitamin B1) and adequate amounts of Vitamin C. In addition, psychological counseling is often recommended as part of the recovery process
https://pmc.ncbi.nlm.nih.gov/articles/PMC8302359/
In some cases, doctors may prescribe Naltrexone, a medication that can help regulate dopamine and GABA metabolism, offering relief from alcohol cravings. Naltrexone has additional benefits beyond this primary use, such as improving mood and reducing anxiety - however there is are some additional benefits.
https://pmc.ncbi.nlm.nih.gov/articles/PMC2565602/
What has not been fully understood or appreciated is that alcohol -> acetaldehyde elevation further elevates endogenous synthesis of morphine, codeine and gamma-hydroxybutyrate (GHB).
For endogenous morphine and codeine synthesis, the mechanism is related to dopamine metabolism. When ALDH1A1 and/or ALDH2 are inhibited, elevated dopamine and DOPAL cause an elevation of Tetrahydropapaveroline (THP) (also known as (S)-norlaudanosoline), which is the first step in the morphine biosynthesis pathway. This altered metabolism leads to behavioural changes that overlap ADHD, coupled with homeostasis alterations and dependence .
https://onlinelibrary.wiley.com/doi/10.1111/j.1755-5949.2009.00114.x
https://www.pnas.org/doi/10.1073/pnas.050324410
https://www.science.org/doi/10.1126/science.557839
THP has also been observed in Alzheimer's and Parkinson's disease patients, however the model suggests it will be found in numerous others. Morphine and DHMA has been observed in collected data by younger members of the Born Free community, without any exogenous use.
https://www.mdpi.com/1420-3049/28/5/2166
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3560700/
https://pubmed.ncbi.nlm.nih.gov/1545408/

Naltrexone, particularly in its low-dose form (LDN), is a well-known therapeutic intervention for managing opioid use disorder. It is also increasingly used to treat conditions such as Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), Long COVID, and Post-Vaccine Syndrome. The disease model suggests additional mechanisms for its observed therapeutic benefits.
https://pubmed.ncbi.nlm.nih.gov/38267326/
The body’s production of gamma-hydroxybutyrate (GHB) is linked to changes in GABA metabolism through a process connected to the GABA shunt. In this pathway, GABA is normally converted into succinic acid via an intermediate called succinic semialdehyde (SSAL). However, when the enzyme ALDH5A1 is inhibited, often due to low NAD+ levels, while NADPH levels are elevated, SSAL is instead metabolized into GHB.
https://www.ncbi.nlm.nih.gov/books/NBK1195/

GHB is marker #75 on the OAT results and is often quite elevated in more severe patients:

As we gain a better understanding of how the gut microbiome interacts with these metabolic processes, it becomes crucial to anticipate potential withdrawal symptoms during microbiome remodelling. A rapid improvement in gut health, especially after a significant dietary shift or use of antimicrobials and/or biofilm breakers, can lead to sudden withdrawal from multiple endogenous narcotics.
The more rapidly any successful gut fermentation syndrome remediation is performed, the more likely that someone will go into rapid withdrawal symptoms for multiple simultaneous narcotics.
For instance, transitioning to a ketogenic diet or using antimicrobials can trigger an initial wave of endotoxemia (toxins released from dying bacteria), which may temporarily suppress withdrawal symptoms. However, as microbial production of alcohol and its byproduct acetaldehyde decreases, there is a corresponding reduction in the synthesis of morphine and GHB. This may result in metabolism and symptoms expected during chronic alcohol, opioid, and GHB withdrawal, which can peak about a week after significant microbiome changes.
Depending on the significance of the alcohol / endogenous narcotic reduction, symptoms may include:
Insomnia, Nausea and Vomiting, Sweating, (Severe) Fatigue, Hypothermia (Low Body Temperature), Diarrhea, Abdominal Cramping, Hypometabolism, Tremors, Tachycardia (Rapid heartbeat), Muscle Aches/Cramps, Seizures, Hypertension (High blood pressure), Anxiety, Agitation, Reduced Motivation, Difficulty Concentrating, Hallucinations, Delirium/Confusion, Depressed Mood, Psychosis, Yawning, Goosebumps (Piloerection), Runny Nose (Rhinorrhea), Lacrimation (Tearing), Dilated Pupils, Internal Vibrations, "Band Around Head" Pressure (warning, this is an indication for severe withdrawal, ahead of seizures).
These can be potentially life-threatening / self-harm inducing. Ironically, the logical solution is fairly simple, although it may understandably raise some initial concerns.
It has often been said that "alcohol is the cause of and solution to all of life's problems" and never more literally than in this instance.
This observation has been shared by various well-known people with ME/CFS and related online groups such as https://www.reddit.com/r/hangovereffect/.
Although this author's opinion is bound to attract some criticism, I'd also advocate that using exogenous alcohol, as an over-the-counter tapering schedule against withdrawal from the microbial-sourced alcohol (and the 2 downstream endogenous psychoactive substances) is a far simpler and less problematic therapeutic intervention than administering exogenous opioids and/or benzodiazepines, in an attempt to create an effective tapering schedule.
These 2 classes of drugs are both well-known to be "drugs of dependence" and will likely require high doses to be effective symptomatically. High doses of these interventions can create a long tapering schedule of their own that may last 6 months to a year and is known to be highly unpleasant.
Following a strict alcohol tapering schedule and avoiding dosing at levels which induce alcoholic intoxication is required. The goal is to remain in a tolerable level of withdrawal symptoms during the taper, rather than attempting to make the process "feel pleasurable". This will be highly personalised and likely involve multiple doses over the day / night, which decrease over time. Having appropriate monitoring and management would be highly advisable.
Caveats and Risks
1) It would be optimal to avoid alcohol reaching the gut microbiome.
Neat alcohol such as gin, vodka or whiskey, when taken in small sips
and absorbed largely via the mucous membranes found in the mouth, throat
and oesophagus would be a preferred route of administration.
2) While alcohol add-back therapy is known to be problematic in chronic alcohol use withdrawal due to the risk of behavioral disorders, such issues are less likely to arise in conditions like ME/CFS or Long COVID where alcohol consumption was not voluntary or habitual. However, professional oversight and adequate peer support is still recommended to manage the process effectively and provide a safety-net.
In addition to alcohol tapering, certain supplements may also help manage withdrawal symptoms relating to hypometabolism.
These include:
Coffee or caffeine.
Forskolin (will need tapering).
Hesperidin.