However, the preliminary findings suggest that some methodological issues, such as a lack of control groups, objective measures, and longer term follow-up measures, limit the quality of the available evidence. 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. Thus, research efforts into elucidating PAWS have been stalled for more than two decades, with minimal research explicitly exploring the phenomenon of protracted withdrawal, which may be a consequence of the failure to recognize PAWS as a diagnostic entity formally. Some studies have examined the relationship between protracted alcohol withdrawal and specific gastrointestinal hormones, given the established association between chronic alcohol use and pancreatic function. One such hormone is plasma pancreatic polypeptide (PP), which inhibits pancreatic exocrine function, such as amylase secretion and other digestive enzymes (Fink et al., 1983; Hajnal et al., 1993). PP levels were significantly higher in individuals with AUD than in controls and remained elevated even 2 weeks following acute withdrawal completion (Fink et al., 1983).
Furthermore, persons experiencing PAWS have lower executive functioning measures, including selective attention, visual scanning ability, visual-motor scanning, and cognitive flexibility (Cordovil De Sousa Uva et al., 2010). Although these symptoms typically last a few weeks to months, some subtle residual effects often remain for up to a year of abstinence (Vik et al., 2004). Although the evidence of irreversible effects is less clear for alcohol, subtle lingering cognitive impairment is often undetected and unaddressed (Vik et al., 2004).
Post-Acute Withdrawal Syndrome (PAWS)
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. PAWS occurs most commonly and intensely among individuals with alcohol and opioid addiction, as well as in people with addiction to benzodiazepines (or “benzos,” which are commonly prescribed for the treatment of anxiety and panic attacks), heroin (an opiate) or medically prescribed pain medication. In the 1980s, De Soto and stopping duloxetine cold turkey 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).
One reviewer (A.B.) appraised the study’s risk of bias, which was confirmed by the remaining reviewers (D.C. and N.E.). For coding purposes, studies receiving one high risk of bias rating in any individual domain or two unclear risks of bias ratings had a high overall risk of bias. In collaboration with a health sciences research librarian, we developed a comprehensive search strategy using combinations of terms related to “alcohol,” “post-acute,” “withdrawal,” and “protracted” in PubMed, MEDLINE, EMBASE, and PsycINFO from the date of their inception to December 2020.
In the early phases of abstinence from substance use, symptoms can change by the minute. As individuals move into long-term recovery from alcohol or drug dependence, the symptoms occur less and less frequently. If you have alcohol use disorder and want help, a healthcare provider can guide you to resources and rehabilitation programs to help you quit. Your healthcare provider will recommend and encourage treatment for alcohol use disorder. For mild alcohol withdrawal that’s not at risk of worsening, your provider may prescribe carbamazepine or gabapentin to help with symptoms.
Study findings
Should symptoms worsen, patients and their support person should be instructed to present to the emergency department for evaluation and further treatment. Alcohol withdrawal (alcohol withdrawal syndrome) is a range of symptoms that can happen if you stop or significantly reduce alcohol intake after long-term 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, some of pregabalin’s pharmacokinetic improvements—such as quicker absorption and higher potency—have led to a concomitant increase in its abuse potential (Häkkinen et al., 2014; Schjerning et al., 2016). 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).
Pharmacological treatments
The symptoms of protracted withdrawal can come and go over time depending on triggers. In general, though, PAWS is recorded as lasting a few weeks to a few months after stopping use. Some sources report that PAWS symptoms for morphine users usually start between 6 to 9 weeks after the acute withdrawal phase and persist until 26 to 30 weeks. Several reviews, including a 2018 review and a 2014 review, have noted that sleep disturbances are common during cannabis withdrawal. PAWS can make day-to-day tasks uncomfortable and, if a person is dealing substance abuse counselor definition with addiction, lead to relapses during recovery.
Neurobiology and Symptomatology of Post-Acute Alcohol Withdrawal: A Mixed-Studies Systematic Review
Therapy and support groups can help you cope with the mental and physical stress of PAWS. Post-acute withdrawal symptom (PAWS) is a condition where you experience withdrawal symptoms for an extended period of time — in other words, long after the typical acute stage is over. While acute withdrawal symptoms generally resolve in a few weeks, PAWS symptoms can last for a few months or up to alcohol intolerance covid a year. Post-Acute Withdrawal Syndrome, or PAWS, refers to a number of withdrawal symptoms experienced following the acute withdrawal phase of recovery.
How long do PAWS symptoms usually last?
- Withdrawal symptoms can be daunting, uncomfortable, and in some cases dangerous.
- Thus, research efforts into elucidating PAWS have been stalled for more than two decades, with minimal research explicitly exploring the phenomenon of protracted withdrawal, which may be a consequence of the failure to recognize PAWS as a diagnostic entity formally.
- We screened 3,024 studies, from which 2,008 were unique citations and 1,016 were duplicate citations.
- At some point, the concept of PAWS became overgeneralized to describe any type of protracted course of withdrawal symptoms across the spectrum of substance types.
- Gabapentin also improves negative affect and sleep symptoms of PAWS (Mason et al., 2018).
Fortunately, there appears to be a gradual normalization back to baseline levels for some cognitive symptoms, and mental symptoms are comparatively stable compared with mood and anxiety symptoms (Voltaire-Carlsson et al., 1996). Following alcohol cessation, alcohol withdrawal syndrome typically presents as minor symptoms such as mild anxiety, headache, gastrointestinal discomfort, and insomnia. This syndrome can further progress to severe manifestations, such as alcohol withdrawal delirium, which poses significant diagnostic and management challenges. Mild symptoms may progress to alcohol hallucinosis, characterized by visual or auditory hallucinations that usually subside within 48 hours after alcohol cessation.
These symptoms, unlike the first stage of acute withdrawal, typically involve more of the psychological and emotional aspects of withdrawal. Depending on the duration and intensity of alcohol or other drug addiction, this secondary withdrawal syndrome can occur a few weeks into recovery or a few months down the road. More important, even though PAWS is a temporary condition, the symptoms can become a driving factor in relapse. This is true even for people who are fully committed to staying clean and sober. Alcohol withdrawal syndrome can range in severity from mild to fatal, making it crucial for patients to present to care for evaluation of their symptoms.
Write them down, keep them with you, and always remind yourself that what you’re feeling is nothing more than your brain rewiring itself. The prognosis (outlook) for someone with alcohol withdrawal depends greatly on its severity. When you stop consuming alcohol after prolonged, heavy use, your CNS can’t respond or regulate itself fast enough. In addition, Dr. Bahji is a recipient of the 2020 Friends of Matt Newell Endowment from the University of Calgary Cumming School of Medicine.
The release of cortisol, the endogenous stress hormone, is regulated by corticotrophin-release factor (CRF), whose levels increase during alcohol withdrawal (Heilig & Koob, 2007). Accordingly, individuals experiencing acute and protracted AWS have higher reported basal serum cortisol levels (Heilig & Koob, 2007). However, CRF-like peptides also appear to maintain a negative-affective state, suggesting that they have a specific role in mediating the underlying PAWS stress response (Bruijnzeel & Gold, 2005). 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.