What Is Post-Acute Withdrawal Syndrome PAWS?
It also provides an overview of the alcohol withdrawal timeline process and when to discuss your drinking with your healthcare provider. Most people with mild to moderate alcohol withdrawal don’t need treatment in a hospital. But severe or complicated alcohol withdrawal can result in lengthy hospital stays and even time in the intensive care unit (ICU).
Risk factors
During this second, or “post-acute” phase of withdrawal, a person may experience symptoms that are more psychological than physical. They may include trouble with sleep and memory, mood swings, and other symptoms of mental health conditions. Post-acute withdrawal, whether mild or serious, is a necessary process in early recovery from alcohol or other drug dependence. Think of the withdrawal syndrome as the brain’s way of correcting the chemical imbalances suffered during active addiction. Further, the authors mentioned that the concept of protracted withdrawal was ambiguous, confounding interpretations of the literature, and precluded derivation of a unified vision of the term, which would be necessary for adding the diagnosis to the DSM (Satel et al., 1993).
- Finally, there is no evidence that melatonin and other agents (homatropine, Proproten-100) show PAWS symptoms.
- Regarding other prescribed medications, researchers behind a 2020 study found that people experiencing withdrawal from antidepressants may experience lasting, severe PAWS symptoms.
- As challenging as it is, post-acute withdrawal is a necessary process that everyone in early recovery must go through, as the brain and body begin to heal and reorient to life without the use of alcohol or other drugs.
- While receiving treatment, healthcare providers will want to monitor you continuously to make sure you don’t develop life-threatening complications.
- There is no exact timeline for alcohol withdrawal, and individual factors, such as the level of dependence on alcohol, will influence it.
Data collection process and data items
Building on Wellman’s findings, Segal and colleagues (1970) were the first to coin the term “protracted withdrawal syndrome” in 1960, describing neurovegetative and emotional instability symptoms persisting long after acute withdrawal had subsided. Following Segal, Kissin (1979) described several protracted alcohol abstinence syndrome cases in 1979, emphasizing their importance to relapse prevention. Following medically supervised detox from alcohol, opiates, marijuana, cocaine, benzodiazepines or other highly addictive substances, most people experience a short phase of physical discomfort, otherwise known as acute withdrawal. Symptoms often include muscle ache, nausea, headache and increased heart rate. Acute withdrawal can produce more dangerous health consequences—even life-threatening complications—if detox isn’t done in a supervised setting. But there’s more to drug and alcohol withdrawal than physical symptoms of discomfort.
What are the most common symptoms of PAWS?
Although PAWS symptoms were first described more than six decades ago and are impairing, the importance of PAWS is its potential association with the risk for relapse. Chronic alcohol consumption appears to induce long-lasting neuroadaptations in the nucleus accumbens and other brain reward system components, regulating intrinsic motivation and cravings for alcohol (Gass et al., 2011). During PAWS, preliminary data suggest that the brain remains in this “allostatic state,” a new equilibrium defined by an ongoing functional reorganization (Le Moal, 2009), which appears to mediate susceptibility to cravings (Marty & Spigelman, 2012). To that end, there is a need for a better understanding of alcohol-induced, long-lasting neuroadaptive changes in the different subregions of the nucleus accumbens (Marty & Spigelman, 2012). Still, if you’re experiencing withdrawal symptoms, it’s essential to get evaluated by a healthcare professional. Depending on the severity of your symptoms, your doctor may recommend monitoring a medical setting or at home.
However, try not to have too many firm expectations, as symptoms can continue for multiple weeks in some people. Severe and complicated alcohol withdrawal requires treatment in a hospital — sometimes in the ICU. While receiving treatment, healthcare providers will want to monitor you online therapy for addiction continuously to make sure you don’t develop life-threatening complications. It affects about 50% of people with alcohol use disorder who stop or significantly decrease their alcohol intake. AUD is the most common substance use disorder in the U.S., affecting 28.8 million adults.
Benzodiazepines
This may include medications, therapy, or both and can be offered in a variety of settings, both inpatient, outpatient, or a hybrid model. Still, try to keep in mind that these symptoms — though uncomfortable — are temporary. The medical professional who evaluated your AWS symptoms may suggest daily follow-ups via telephone or video chat to check on your symptoms and progress. AWS can evolve in a few hours or a few days but often develops between 6 to 24 hours after your last drink.
This article reviews research on post-acute alcohol withdrawal syndrome (PAWS) management. PAWS symptoms include irritability, depression, insomnia, fatigue, restlessness, alcohol cravings, and distractibility. These are most severe in the first 4 to 6 months of abstinence and diminish gradually over several years of sustained abstinence. After the acute phase of withdrawal, a person may still need professional medical care, as PAWS symptoms can be severe and affect the quality of life. Most symptoms last for a few days at a time, although this is dependent on the type of alcohol or drug addiction, and the amount and frequency of substance use (every person’s withdrawal pattern is a little different). Typically, the brain recalibration process takes anywhere from six months to two years before the brain once again naturally produces endorphins and dopamine.
Behavioral treatment programs are helpful for people who want to quit drinking. These programs involve working with a team of mental health professionals in a group and individual setting. Tap into your social network to help support you through alcohol withdrawal. Find a supportive friend or family member to be with you while you withdraw and support your new non-drinking lifestyle.
The main ways to prevent alcohol withdrawal are to avoid alcohol altogether or to get professional help as soon as possible if you think you’re developing alcohol use disorder. Healthcare providers typically prescribe short-term medications to relieve the symptoms of mild to moderate alcohol withdrawal. Although there is some evidence for targeted pharmaco-therapy for treating specific PAWS symptoms, there are few recent, robust, placebo-controlled trials, and the level of evidence is low. In addition, as the presence of PAWS appears to contribute to relapse, there is a need for specific criteria for PAWS to be developed and tested and high-quality treatment studies done involving agents addressing the neurobiological underpinnings of symptoms. Conversely, medications acting on GABA and NMDA neurotransmitter systems to counterbalance the up-regulation of NMDA and the down-regulation of GABA could be used in combination and started as soon as possible (Caputo et al., 2020).
Animal models indicate that atrial natriuretic peptide (ANP) inhibits the effects of CRF, corticotrophin, and cortisol (Ibanez-Santos et al., 1990; Mutschler et al., 2010). However, chronic alcohol consumption and acute withdrawal suppress ANP (Kovács, 2000). Although ANP levels gradually improve over 2 weeks of sustained abstinence, they remain lower relative to healthy controls even after 12 weeks of abstinence. These persistent deficits may sustain the cravings, low mood, and anxiety characteristic of PAWS (Kiefer et al., 2002).
Finally, as a scoping review, the search was limited to only a few databases and published literature. However, it is unclear if this significantly affected the overall conclusions. Unlike a traditional systematic review, only one author (A.B.) reviewed and identified the articles for inclusion, and the second reviewer only reviewed the excluded articles. With future studies, a more extensive systematic review or meta-analysis could be conducted. Although it has been nearly 30 years since the publication of the Satel et al. (1993) review of protracted withdrawal syndromes, the PAWS field has not advanced remarkably apart from animal studies, which was not the present review’s focus.
In early abstinence, the brain’s stores of endorphins and dopamine are severely depleted. Dopamine, the neurotransmitter that floods the brain during drug use to produce titanic highs, is also involved in the regulation of mood, and a certain amount is necessary in order to maintain a “normal” mood. The absence of enough dopamine creates a biochemically based depression. review of answer house sober living It can take between four weeks and six months for the brain to naturally manufacture enough endorphins and dopamine to replenish its inventory of these vital chemicals. These symptoms affect many people in the early phases of abstinence from numerous substances, but they occur in an extremely high percentage of those with histories of long-term opioid use.
We did not identify any psychotherapy studies for the treatment of PAWS. However, there were two nonpharmacological treatments of PAWS from two noncontrolled studies showing short-term subjective benefits. However, the preliminary findings suggest that some methodological issues, such as a lack of control groups, 6 ways to lower high blood pressure without using medication objective measures, and longer term follow-up measures, limit the quality of the available evidence. PAWS can also be called protracted withdrawal syndrome or prolonged withdrawal syndrome. The symptoms of PAWS can differ from the symptoms of acute withdrawal, and are often milder and more sporadic.
Fourteen were pharmacological trials, whereas two were nonpharmacological intervention studies. We did not find any additional articles through reviewing reference lists of identified articles. We applied the Cochrane Risk of Bias Tool for randomized controlled trials (Higgins et al., 2011). In brief, this tool appraises the risk of bias in trials attributable to randomization, allocation concealment, blinding, participant attrition, selective reporting, and other sources of bias (e.g., unclear adherence to treatment, allegiance bias).
Regrettably, PAWS has not received formal recognition as a disorder in any edition of the DSM or the ICD. It remains a relatively underestimated and ambiguously defined clinical condition that follows the acute stage of AWS (Caputo et al., 2020). Protracted withdrawal syndromes, in general, have not received prominent discussion, although they are clinically relevant. Likewise, whereas several trials have explored different PAWS treatments—as evidenced by those uncovered by the present review—few have been extensively studied since the 1990s, even though several of these agents showed promise in small pilot studies. Following acute alcohol withdrawal, PAWS has been clinically identified to involve symptoms of irritability, depressed mood/anhedonia, anxiety, cravings, cognitive impairment, and sleep impairment. In addition, there appears to be some credible evidence to support the concept of PAWS based on neurobiological findings, including differences measured in evoked potentials, orexins, cortisol, CRF, ANP, serotonin, pancreatic polypeptides, and neuronal excitability.
The most change occurred within 2 weeks of last substance use (Coffey et al., 2007). In the 1980s, De Soto and colleagues furthered the concept of PAWS described earlier by Wellman (1954), Segal et al. (1970), and Kissin (1979) in noting that PAWS partially reverses with sustained alcohol abstinence (De Soto et al., 1985). They observed several characteristic mood and anxiety symptoms—such as depressed mood, interpersonal sensitivity, obsessive–compulsive symptoms, and guilt—during the first 3 to 4 months following acute withdrawal (De Soto et al., 1985). Fortunately, in a sample of persons who had been abstinent for nearly 10 years, most PAWS symptoms gradually diminished, with near normalization 4 months after detoxification (De Soto et al., 1985). When you stop using a certain substance, you might experience withdrawal symptoms for a few days or weeks. Disturbance in serotonin function may mediate acute and protracted alcohol withdrawal; however, there is a lack of consensus (Marcinkiewcz et al., 2016).