Detoxing After Detox: The Perils of Post-Acute Withdrawal

This taxes many of the body’s systems, leading to a wide-awake form of exhaustion, a run-down immune system, greater vulnerability to illness, and yes, more stress. Research shows review and comparison people who have a supportive social network are more likely to remain alcohol-free after withdrawal. Those with a wider circle of support have a better chance of staying sober.

What are some coping strategies for getting through PAWS?

1. However, PAWS has been a relatively neglected topic (De Soto et al., 1985).
2. It’s also important to note that delirium tremens can be life-threatening.
3. The main management for severe symptoms is long-acting benzodiazepines — typically IV diazepam or IV lorazepam.
4. These may still be mild, or the existing symptoms might increase in severity.

Another important aspect of PAWS is the variation in the symptoms occurring in the post-acute withdrawal period, degree of impairment, severity, frequency, duration, and association with the specific substance of use. To that end, it may be less clinically helpful to consider these symptoms as a single construct, particularly in the case of AUD. For instance, craving and negative affect during alcohol withdrawal may stem from underlying psychological and neurobiological changes, whereas sleep disruptions are more physiological and less likely to be relevant to relapse (Cheng et al., 2022).

General PAWS symptoms

If your symptoms are mild (or perhaps even moderate), your doctor may suggest that you reach out to a friend or family member to help you monitor your symptoms at home. You can also regularly send them messages or call them to remind them that you’re thinking of them. In other words, PAWS could occur because your brain’s chemicals are beginning to regulate and return to their earlier state. Antidepressants, including selective serotonin reuptake inhibitors (SSRIs) and serotonin noradrenaline reuptake inhibitors (SNRIs), can be an effective way to manage your mood.

Study findings

As your brain grows accustomed to higher blood alcohol concentration levels, it starts to rely on alcohol to function properly. Some researchers note that these prolonged but lower-intensity symptoms can even persist for 2 or more years — especially symptoms that affect your sleep. Seizures often occur in the early stages of withdrawal, and they may happen in the absence of other AWS. More than 90% of acute seizures occur in the first 48 hours after your last drink.

What is alcohol withdrawal?

Still, people experiencing these withdrawal symptoms are generally fully conscious and can think clearly. You may experience AWS between a few hours to a few days after your last drink or suddenly after reducing heavy alcohol use. Sian Ferguson is a freelance health and cannabis writer based in Cape Town, South Africa.

Still, some symptoms — often more severe — can set in after 2 to 3 days. 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. Post-acute withdrawal is a consequence of the significant changes to brain anatomy and chemistry that take place during active addiction. The brain’s reward system is turned on its head, and its natural ability to cope with stress is undermined. For those who use opiates or opioids—from medically prescribed pain medications to heroin—the brain adjusts by decreasing its natural production of endorphins while increasing the number of opioid receptors.

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. If you’re experiencing alcohol withdrawal, your body might be going through an array of uncomfortable physical and mental changes. Ethanol is the primary alcohol that’s ingested by people with alcohol use disorder. It’s also a central nervous system depressant, and your body may become more reliant on ethanol the longer it’s exposed to it. Still, while it’s essential to have your symptoms evaluated by a medical professional, it may be reassuring to know that people with mild-moderate AWS can often manage symptoms by themselves or with the support of family and friends based on their doctor’s recommendations. Your triggers could include stress, sleeplessness, or even certain foods.

It’s estimated that about 75% of people following acute alcohol withdrawal experience prolonged symptoms. This chronic stress response continues during post-acute withdrawal, receding and effectively resetting only gradually over time. As a result, people come into recovery under the influence of biologically birthed higher levels of stress in combination with dmt n, n-dimethyltryptamine origins, effects and risks enhanced susceptibility to stress. All sorts of stressful situations inevitably arise, and the frustration, confusion, and blistering discomfort of post-acute withdrawal symptoms (stress-inducing in and of themselves) piggyback onto them to produce even more distress. Unstable vital signs increase the risk of complications and can be managed with medications.

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. 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. The symptoms most commonly begin between 6 to 24 hours after your last drink.

This increases sensitivity to pain and makes it much harder to experience pleasure in the absence of using. For most people, alcohol withdrawal symptoms will begin sometime in the first eight hours after their final drink. This article discusses alcohol withdrawal, its symptoms, and potential complications.

In a person with an addiction to benzodiazepines, for example, lasting withdrawal symptoms can stem from functional changes to the neuroreceptors in the central nervous system. Up to 15% of people who have taken benzodiazepines long term physical signs and other symptoms of alcoholism and alcohol abuse experience PAWS. PAWS symptoms can be uncomfortable and distressing, and they can be risk factors for relapse. Having a strong self-care routine, working with medical professionals, and having support from people who understand can help.

Not everybody experiences PAWS when they stop using or cut back on substances. Post-acute withdrawal varies in intensity and duration from one person to another; again, usually in correlation with the intensity and duration of one’s substance use. Its manifestations can fluctuate in severity, coming and going in wave-like recurrences, and include impairments in energy, concentration, attention span, memory, sleep, appetite, and mood—most commonly anxiety, irritability, anger, and depression. 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.

The human nervous system consists of two main parts, the central nervous system (CNS) and the peripheral nervous system (PNS). The PNS consists mainly of nerves that connect the CNS to the rest of the body so that information can be sent back and forth between them. The autonomic nervous system (ANS) is part of the peripheral nervous system.

Gabapentin also improves negative affect and sleep symptoms of PAWS (Mason et al., 2018). However, as gabapentin does not suppress or prevent alcohol withdrawal seizures, it is not recommended as a stand-alone therapy for acute or protracted alcohol withdrawal (Hammond et al., 2015; Leung et al., 2015). In one trial, gabapentin appeared to outperform lorazepam during PAWS for abstinence, cravings, and tolerability (Myrick et al., 2009). 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).

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).

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). We screened 3,024 studies, from which 2,008 were unique citations and 1,016 were duplicate citations. From these, we excluded 1,416 records during the title and abstract screening phase, leaving 592 full-text articles for review. Subsequently, 16 treatment studies met the inclusion criteria (Figure 1).

For people in recovery from a substance misuse disorder, it may not be possible to prevent PAWS. However, adopting self-care strategies and working with healthcare professionals can help. You’ve taken an important first step toward recovery by deciding to stop drinking. Now, try to keep in mind that even though withdrawal symptoms may be unpleasant, they’re temporary, and treatment is available during this time. While you may be able to manage mild symptoms on your own or with the support of family and friends based on your doctor’s recommendations, more severe symptoms usually require medical treatment. Alcohol withdrawal is widespread among people with alcohol use disorders who decide to stop drinking or reduce their intake.