Management of Post-Acute Alcohol Withdrawal: A Mixed-Studies Scoping Review PMC

Alcohol withdrawal is a potentially serious complication of alcohol use disorder. 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.

Finally, there is a lack of evidence to support the efficacy of melatonin and other agents (homatropine, Proproten-100) for PAWS symptoms. In a review of protracted withdrawal by Satel and colleagues (1993), the authors concluded that symptoms extending beyond the period of acute withdrawal from alcohol—as well as opioids, for that matter—have been relatively consistently described but not conclusively demonstrated. Although it has been nearly 30 years since the publication of the Satel et al. review of protracted withdrawal syndromes, the PAWS field has not advanced remarkably apart from animal studies, which was not the present review’s focus. 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.

The symptoms of PAWS can differ from the symptoms of acute withdrawal, and are often milder and more sporadic. Not everybody experiences PAWS when they stop using or cut back on substances. Patients presenting with alcohol withdrawal syndrome should receive thiamine and folate supplementation as they are often nutritionally deficient. To treat Wernike and the progression of neuropsychiatric manifestations, it is prudent to administer high-dose, intravenous, or intramuscular thiamine, as oral thiamine is unpredictably absorbed.[14] Electrolytes, including magnesium and phosphorus, should also be checked and repleted.

Addiction, Recovery, and PAWS

Taking care of your basic needs is a good way to avoid worsening your mental and physical symptoms. Whether used for medical or recreational reasons, stopping cannabis use might induce withdrawal symptoms, especially if you use long covid alcohol intolerance it regularly and in high doses. Often used to treat anxiety and insomnia, benzodiazepines include drugs like alprazolam (Xanax, Xanax XR), clonazepam (Klonopin), and diazepam (Valium). While effective at treating a number of symptoms, benzodiazepine withdrawal can be uncomfortable. Lastly, researchers have identified a condition called post-SSRI sexual dysfunction (PSSD), where someone experiences sexual side effects after they stop using SSRIs. Although it doesn’t occur in everyone, some people experience PSSD months after stopping long-term SSRI use.

A Note to Your Support System

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. This study aims to review the neurobiology and symptomatology of post-acute alcohol withdrawal syndrome (PAWS). 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).

Alcohol withdrawal syndrome is a clinical diagnosis that relies heavily on the history and physical, which is also used to gauge disease severity. When in doubt, clinicians can refer to the DMS-V criteria for diagnosis. To maintain homeostasis in strengths of xanax the CNS, inhibitory signals from the GABAergic system are balanced by excitatory neurotransmitters such as glutamate. Alcohol, a CNS depressant, stimulates the GABAergic system and, in acute intoxication, causes a range of clinical manifestations such as disinhibition, euphoria, and sedation.

A 2020 study looked at experiences of PAWS after stopping antidepressants based on self-reported symptoms on an internet forum. These experiences were recorded 5 to 13 years after stopping antidepressants. According to American Addiction Centers, anecdotal evidence indicates that PAWS symptoms can last 2 years or longer after someone stopped drinking alcohol.

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.

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.

Alcohol Withdrawal Syndrome

Although there is some evidence for targeted pharmacotherapy for treating specific PAWS symptoms, there are few recent, robust, placebo-controlled trials, and the level of evidence for treatment efficacy is low. 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. 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. Your triggers could include stress, sleeplessness, or even certain foods.

How to Recognize and Manage the Symptoms of Post-Acute Withdrawal Syndrome

If you’re experiencing intense withdrawal symptoms, gallbladder and alcohol 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.

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 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.

1. 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).
2. Alcohol withdrawal can range from very mild symptoms to a severe form, known as delirium tremens.
3. For mild alcohol withdrawal that’s not at risk of worsening, your provider may prescribe carbamazepine or gabapentin to help with symptoms.
4. These experiences were recorded 5 to 13 years after stopping antidepressants.

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).

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. However, PAWS has been a relatively neglected topic (De Soto et al., 1985). Few recent scientific studies support its existence; consequently, the notion of PAWS remains highly controversial (Satel et al., 1993). Although it has not yet gained formal recognition by the DSM (APA, 2013) or the International Classification of Disease (ICD; Hughes, 1994), PAWS has been informally recognized as a high-risk interval for return to alcohol consumption following abstinence (Melemis, 2015). There remains a need for further research regarding the post-acute withdrawal abstinent period (Williams & McBride, 1998). The lack of a shared definition may be why PAWS has not been more widely adopted.

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.