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. 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. In addition, Dr. Bahji is a recipient of the 2020 Friends of Matt Newell Endowment from the University of Calgary Cumming School of Medicine. Dr. Bahji also received financial support from a 2020 Research Grant on the Impact of COVID-19 on Psychiatry by the American Psychiatric Association and the American Psychiatric Association Foundation.
Study selection
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. Conversely, medications acting on GABA and NMDA neurotransmitter systems how to store a urine sample 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 and Post-Acute Withdrawal Syndrome (PAWS): Risks, Side Effects & Treatment
Treatment options for alcohol withdrawal syndrome typically involve supportive care to ease the effect of the symptoms. For example, benzodiazepines might be effective for helping people with alcohol withdrawal syndrome, but they won’t be appropriate for someone who has misused benzodiazepines in the past. The PAWS symptoms of alcohol withdrawal can come and go — you might feel well one day and very uncomfortable the next. According to a 2021 study, PAWS is one of the major causes of relapse in people with alcohol use disorder. 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.
- Whether used for medical or recreational reasons, stopping cannabis use might induce withdrawal symptoms, especially if you use it regularly and in high doses.
- This study aims to review the neurobiology and symptomatology of post-acute alcohol withdrawal syndrome (PAWS).
- 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.
- The symptoms lasted from 6 months to more than 23 years, with a median of about 6.5 years.
Because most studies were at high risk of bias, we downgraded the overall ideas for substance abuse groups strength of evidence. For those trying to detox from alcohol, it is vital to do so under the supervision of a doctor, as the withdrawal symptoms may be severe. Alcohol use disorder can lead to various physical and mental health conditions.
One reviewer (A.B.) extracted the following data from included studies while the other two (D.C. and N.E.) confirmed the extracted data for accuracy. We used a standardized tool to extract information about authors, study objectives, sample characteristics, inclusion/exclusion criteria, study design, and outcome variables in Covidence, which we transferred to a Microsoft Excel spreadsheet (Veritas Health Innovation, 2019). 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.
Post-acute withdrawal syndrome symptoms by substance
Whether mildly unpleasant or seriously uncomfortable, withdrawal symptoms come with the territory when you’re in early recovery from alcohol or other drug addiction. In fact, post-acute withdrawal symptoms that persist or pop up during the first months of recovery can become a risk factor 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). In addition, some evidence indicates that protracted withdrawal lasting 3 to 4 weeks appears to induce a long-lasting potentiation of glutamatergic activity in the nucleus accumbens for up to 6 months, which plays a vital role in cue-induced alcohol-seeking behavior (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).
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). Post-acute withdrawal syndrome (PAWS) was a phrase first used more than 20 years ago to describe a quitting cymbalta cold turkey phenomenon of relatively milder, but persistently troublesome withdrawal symptoms that lingered in some individuals who had discontinued benzodiazepine therapy. Anyone who is having severe symptoms of alcohol withdrawal syndrome, such as seizures, hallucinations, or prolonged vomiting needs immediate medical treatment. Less frequently, people can develop severe symptoms of alcohol withdrawal syndrome. PAWS can also be called protracted withdrawal syndrome or prolonged withdrawal syndrome.
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. 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. Nevertheless, PAWS remains an important yet controversial topic, with a lack of consensus about whether it even exists and, if it does, its causes, manifestations, and effect on relapse.