Still, there is a need for a further study exploring the interrelatedness—or lack thereof—between symptoms considered to be part of PAWS. 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. While acute withdrawal refers primarily to the body’s process of healing, a second phase of withdrawal symptoms, known as post-acute withdrawal syndrome, or PAWS, occurs as the brain recalibrates after active addiction.
Consequently, the interprofessional healthcare team must ascertain the most suitable setting based on a patient’s symptoms. The primary limitation is the high heterogeneity between studies owing to the nebulous nature of PAWS, the lack of a shared consensus definition, the variable durations of symptoms presented as components of PAWS and the small sample sizes of the component studies. Furthermore, there is a lack of standardization of PAWS across studies, and the extent of post-withdrawal abstinence was highly variable. In addition, because of a lack of pertinent studies, it remains unclear whether all the symptoms described here are manifested equally in both sexes or in individuals with comorbid substance use disorders.
At the same time, endogenous GABA is downregulated.[3] Thus, when alcohol is withdrawn, a relative deficit of GABA may occur and simultaneous excess in glutamate, resulting in the excitatory symptoms seen in alcohol withdrawal syndrome. Although our review found limited, mixed-quality evidence for different pharmacotherapeutic classes in managing specific PAWS symptoms (such as sleep disruption, mood, or anxiety symptoms), there remains a need to enhance the evidence base for PAWS and its treatment. Consequently, one strategy for improving PAWS research is to recognize it formally. We hope that the present review’s findings—by synthesizing literature across approximately four decades of research—may create a stronger argument for formalizing PAWS as a diagnostic entity. Furthermore, considering that PAWS symptoms are mainly related to the neuro-adaptive changes of GABA and NMDA systems, traditional treatments for AUD—such as naltrexone, nalmefene, and disulfiram—may not be able to suppress PAWS symptoms (Caputo et al., 2020). A small pilot open study confirmed the efficacy of acamprosate in maintaining abstinence and reducing PAWS in 18 recently detoxified alcohol-dependent outpatients (Gualtieri et al., 2011).
- Symptoms often include muscle ache, nausea, headache and increased heart rate.
- 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.
- Similarly, SSRIs can be used to help people who are experiencing depression and anxiety, but not everybody responds well to SSRIs.
- 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.
- Symptoms of alcohol withdrawal tend to peak 24 to 72 hours after your last drink.
Study findings
In addition, much of the literature on PAWS is dated, and there is a shortage of robust, randomized, controlled trials. Furthermore, there is a lack of standardization of PAWS across studies, and the extent of post-acute withdrawal abstinence was highly variable. 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.
Disturbance in serotonin function may mediate acute and protracted alcohol withdrawal; however, there is a lack of consensus (Marcinkiewcz et al., 2016). One study detected a relative increase in the enzymatic degradation of tryptophan, the precursor of serotonin, by indoleamine dioxygenase, suggesting a correlation between PAWS and decreased serotonin availability (Farren & Dinan, 1996). During protracted abstinence, increased tryptophan degradation (measured by kynurenine, a tryptophan metabolite) and reduced serotonin levels appear to induce PAWS symptoms, including fatigue, irritability, and sleep disturbances (Gleissenthall et al., 2014). However, there are no differences in platelet serotonin-stimulated signal transduction in patients with PAWS over controls (Simonsson et al., 1992). To that end, impaired serotonin-stimulated signal transduction is an effect of long-term alcohol exposure; it is not a trait-dependent marker of the serotonergic system of individuals with a constitutional vulnerability to becoming an alcoholic. Treatment can occur in various settings, such as the emergency room, outpatient clinic, intensive care unit, or detoxification facility.
If a loved one is experiencing PAWS, you can show support by reminding them that you’re there for them and encouraging them to reach out to you for help. In some situations, a doctor or psychiatrist might prescribe medication to help with PAWS symptoms. Your medication options depend on symptoms of roofied the substance you used, your symptoms, and your medical history. If certain situations, people, or activities bring you stress and no joy, consider letting them go. If your plate is full, try to avoid adding unnecessary responsibilities to the mix.
Post-acute withdrawal syndrome, or PAWS, can occur after alcohol detox.
One reviewer (A.B.) extracted the following data from included studies, while another (D.C.) confirmed the extracted data for accuracy. We reviewed studies for eligibility using Covidence, a web-based review manager, and Zotero citation manager (Roy Rosenzweig Center for History and New Media, 2018; Veritas Health Innovation, 2019). After removing duplicates, one reviewer (A.B.) independently selected the studies, reviewed the main reports and supplementary materials, extracted the relevant information from the included trials, and assessed the risk of bias; a second author (N.E.) reviewed excluded studies for erroneous selection. Often, symptoms are triggered by stress or brought on by situations involving people, places or things that remind the individual of using. Many people in recovery describe the symptoms of PAWS as ebbing and flowing like a wave or having an “up and down” roller coaster effect.
How can you support a loved one experiencing post-acute withdrawal syndrome?
Because most studies were at high risk of bias, we downgraded the overall strength of evidence. We conducted a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)-guided systematic review of articles from two databases for English-language randomized and nonrandomized studies involving PAWS published between database inception and December 2020. Sian Ferguson is a freelance health and cannabis writer based in Cape Town, South Africa. She’s passionate about empowering readers to take care of their mental and physical health through science-based, empathetically delivered information. After the acute withdrawal stage, some uncomfortable symptoms may linger.
If you’re experiencing intense withdrawal symptoms, individual or group therapy is a fantastic option that we strongly recommend. Having people with first-hand knowledge to talk to will help put things into perspective and motivate you to keep going. While the acute stage of recovery involves intense physical symptoms over a period of one to two weeks, PAWS symptoms can persist, disappear and reappear for months.
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). Another PAWS study (de Timary et al., 2013) found that alcohol cravings decreased alongside ratings of depressed mood, but only in those with higher self-consciousness, a personality trait characterized by a tendency to think and direct attention to the self. These studies indicate the potential for psychotherapeutic and metacognitive approaches to cravings addressing EI and negative affective states (de Timary et al., 2013; Uva et al., 2010).
The Recovery Village aims to improve the quality of life for people struggling with substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare providers.
Alcohol withdrawal is a potentially serious complication of alcohol use disorder. can you drink alcohol while taking levaquin It’s important to get medical help even if you have mild symptoms of withdrawal, as it’s difficult to predict in the beginning how much worse the symptoms could get. 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. But treatment varies based on the severity of alcohol withdrawal and the likelihood that it could progress to severe or complicated withdrawal. Some people experience prolonged withdrawal symptoms, like insomnia and mood changes, that can last for weeks or months.
We also excluded treatment studies, as these were the focus of a parallel review. Post-acute withdrawal syndrome (PAWS) was a phrase first used more than solution focused therapy techniques 20 years ago to describe a phenomenon of relatively milder, but persistently troublesome withdrawal symptoms that lingered in some individuals who had discontinued benzodiazepine therapy. PAWS can also be called protracted withdrawal syndrome or prolonged withdrawal syndrome.
Pharmacological treatments involving antidepressants, sleep-promoting agents, anticonvulsants, gabapentinoids, and two novel therapies have been explored for therapeutic efficacy in PAWS management (Table 1), which we summarize here. Subsequently, 27 observational studies met the inclusion criteria (Figure 1). We did not find any additional articles by reviewing reference lists from the articles we identified. Consequently, the goal of this article was to summarize the extant literature examining the neurobiology and symptomatology of PAWS, paralleling findings from a complimentary review focusing on PAWS treatment. With most substances, PAWS is less common — not everybody experiences it — and the symptoms are usually less intense. Acute withdrawal happens just after you stop using a substance or medication, while PAWS can happen for weeks, months, or even years after you cease use.
Similarly, SSRIs can be used to help people who are experiencing depression and anxiety, but not everybody responds well to SSRIs. The duration of PAWS can depend on a range of factors, including the substance you used and how frequently you used it, as well as your support system. These symptoms are common across substances — in other words, no matter which substance you used, you might experience one or more of the above. This, as well as impulse control disorders, can last up to 4 weeks after discontinuing use. The above-mentioned review states that there’s a lack of research on PAWS from benzodiazepines, but that it can persist for 6 to 12 months — in some cases, even years after stopping benzodiazepine use.
