Author: John Carter

Coping with post acute withdrawal syndrome

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). 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).

We considered randomized controlled trials and nonrandomized intervention studies (e.g., pre–post studies). A rare but very serious syndrome called delirium tremens can occur during alcohol withdrawal. Also known as DTs, an estimated 2% of people with alcohol use disorder and less than 1% of the general population experience them. There is credible evidence to support the concept of PAWS based on this review’s findings. High-quality treatment studies involving agents addressing its neurobiological underpinnings are also recommended. 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).

Pregabalin has shown efficacy for treating uncomplicated AWS and related negative affective symptoms in a 2-week open-label study (Di Nicola et al., 2010) and a 2-week multicenter trial versus tiapride and lorazepam (Martinotti et al., 2010b). These findings were replicated in a 16-week multicenter trial against naltrexone, which found that pregabalin was well tolerated, improving withdrawal symptoms as well as naltrexone (Martinotti et al., 2010a). 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). Although the two groups had similar baseline symptoms, the mirtazapine group consumed more alcohol per day, suggesting greater AUD severity (Liappas et al., 2004). One reviewer (A.B.) extracted the following data from included studies, while another (D.C.) confirmed the extracted data for accuracy.

Graduate School of Addiction Studies

They may include nausea and an increased heart rate, for example.Withdrawal symptoms may linger or develop later on, possibly a few months into recovery from substance misuse disorder. 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. PAWS has been a relatively neglected topic (De Soto et al., 1985), and few recent scientific studies support its existence. Consequently, the notion of PAWS remains highly controversial (Satel et al., 1993).

We did not find any additional articles by reviewing reference lists from the articles we identified. We reviewed studies for eligibility using Covidence, a web-based systematic review manager, and Zotero citation manager (Roy Rosenzweig Center for History and New Media, 2018; Veritas Health Innovation, 2019). After removing duplicates, one investigator (A.B.) independently selected the studies, reviewed the main reports and supplementary materials, and extracted the relevant information from the included studies; a second author (N.E.) reviewed excluded studies for erroneous selection. Using the Cochrane Risk of Bias tool ratings (Table 2), only 6 of the 16 studies received a low overall risk of bias rating. The most common reasons for the higher risk of bias ratings in the component studies were unclear randomization and blinding methods.

1. Several neurobiological and endocrinological features appear unique to PAWS, including enhanced glutamatergic activity in the nucleus accumbens, increased hypothalamic–pituitary–adrenal axis activity, decreased serotonin, and orexin availability, and contribute to the report of subjective symptoms.
2. It also provides an overview of the alcohol withdrawal timeline process and when to discuss your drinking with your healthcare provider.
3. For people in recovery from a substance misuse disorder, it may not be possible to prevent PAWS.
4. Furthermore, from a theoretical perspective, cravings for alcohol may be driven by the incentive value of the drug rather than be a feature necessarily related to withdrawal (Berridge & Robinson, 2016; Tiffany & Wray, 2012).
5. The strength of evidence overall for pharmacologic treatments is low, with often only short-term results being reported, small treatment samples used, or inconsistent results found.

From these, we excluded 1,416 records during the title and abstract screening phase, leaving 592 full-text articles for review. Fourteen were pharmacological trials, whereas two were nonpharmacological intervention studies. We did not find any additional articles through reviewing reference lists of identified articles. 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.

We also acknowledge the many Indigenous communities that have been forged in urban centers across Alberta. The duration can vary from person to person, and the substance involved may play a role. A urine test can help doctors rule out withdrawal from specific drugs or combinations.

Support Groups

If you experience PAWS, contact medical professionals or addiction specialists to help manage your symptoms. PAWS symptoms are extremely uncomfortable and typically affect a person’s mental health and physical health. The condition is described as ongoing withdrawal symptoms, typically mood-related. If you are thinking about quitting drinking, talk to your healthcare provider. Medical supervision, behavioral health treatment, and mutual-aid groups can help you through alcohol withdrawal and stay stopped. For people who experience hallucinations as part of alcohol withdrawal, these may begin in the 12- to 24-hour time frame.

In addition, we supplemented the electronic database searches with manual searches of all eligible articles’ reference lists and previous reviews for additional studies. Unstable vital signs increase the risk of complications and can be managed with medications. People who experience severe withdrawal symptoms or DTs may require hospitalization or intensive care unit (ICU) treatment during alcohol. For most people, alcohol withdrawal symptoms will begin sometime in the first eight hours after their final drink. 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). In addition, there is some evidence that acamprosate initiation following alcohol detoxification can mitigate relapse and PAWS (Gual & Lehert, 2001).

It is the second withdrawal stage, often called post-acute withdrawal symptoms (PAWS). 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. 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.

What are some coping strategies for getting through PAWS?

However, Trevisan and colleagues (2008) did not replicate these findings when they compared 1,200 mg/day of gabapentin to valproic acid (1,500 mg/day or less) and placebo for PAWS. Pregabalin is a newer gabapentinoid with more rapid absorption and time to peak serum concentration (1 vs. 3 hours to reach peak levels) and a longer half-life elimination time, allowing twice-daily rather than thrice-daily dosing (Mason et al., 2018). If a person with substance misuse disorder abruptly stops using the substance, they may experience withdrawal symptoms. The initial symptoms may be relatively short-lived, but they can be very dangerous.

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. For those with alcohol use disorder, withdrawal is just the first (but very important) step on a long journey to recovery. These first few weeks are critical because they are when the risk of relapse is highest. When that person cuts out alcohol, there is a period when their brain hasn’t yet received the message and still overproduces the stimulating chemicals.

Neurobiological and endocrinological features

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. For example, if a person tapers off benzodiazepine use, their withdrawal symptoms usually resolve within 6–18 months of the last dose. However, anecdotal reports suggest that some symptoms persist for up to a decade following cessation. The Food and Drug Administration (FDA) confirms that benzodiazepine withdrawal symptoms can last weeks to years. If you or a loved one is in need of help managing PAWS in addiction recovery, or seeking treatment for co-occurring mental health or substance use disorders, there is help and there is hope for you at the Hazelden Betty Ford Foundation.

The strength of evidence overall for pharmacologic treatments is low, with often only short-term results being reported, small treatment samples used, or inconsistent results found. However, for PAWS negative affect and sleep symptoms, more evidence supports using the gabapentinoids (gabapentin and pregabalin) and the anticonvulsants (carbamazepine and oxcarbazepine). Although acamprosate has some preliminary data, there were no controlled trials. Despite an older treatment trial showing some positive data for amitriptyline for mood, clinical measures used were problematic, and its side effects and safety profile limit its utility. Finally, there is a lack of evidence to support the efficacy of melatonin and other agents (homatropine, Proproten-100) for PAWS symptoms.

However, these studies have not formally emphasized the notion of PAWS (Potgieter et al., 1999). Furthermore, as most extant AWS studies are limited to acute withdrawal treatment, further research remains needed regarding the post-acute withdrawal abstinent period (Williams & Mc-Bride, 1998). 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).