Neurobiology and Symptomatology of Post-Acute Alcohol Withdrawal: A Mixed-Studies Systematic Review PMC

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. Post-acute withdrawal, whether mild or serious, is a necessary process in early recovery from alcohol or other drug dependence. Think of the withdrawal alcohol addiction and drug rehab centers in california syndrome as the brain’s way of correcting the chemical imbalances suffered during active addiction. Further, the authors mentioned that the concept of protracted withdrawal was ambiguous, confounding interpretations of the literature, and precluded derivation of a unified vision of the term, which would be necessary for adding the diagnosis to the DSM (Satel et al., 1993).

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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. 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. 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.

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

1. Individuals should be prepared to be uncomfortable during this period and have medical help available if needed.
2. In some cases, these sleep disturbances — which may include strange, vivid dreams — persist for weeks or even months.
3. Finally, as a scoping review, the search was limited to only a few databases and published literature.
4. However, adopting self-care strategies and working with healthcare professionals can help.
5. The duration can vary from person to person, and the substance involved may play a role.

We restricted eligibility to human adult populations (ages ≥۱۸), examining any descriptive component of PAWS. In addition, we restricted eligibility to English-language articles or those with an available English-language translation. We considered randomized controlled trials and nonrandomized intervention studies (e.g., pre-post studies).

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We restricted eligibility to human adult populations (ages ≥ ۱۸ years), examining any pharmacological (e.g., medications) or nonpharmacological (e.g., psychotherapy) interventions for the treatment of PAWS. We restricted eligibility to English-language articles or those with an available English-language translation. lsd overdose We considered randomized controlled trials and nonrandomized intervention studies (e.g., pre–post studies). We excluded commentaries, reviews, editorials, and case reports; we did not restrict the study’s data or location. Sleep disturbance is a common finding among individuals with AUD and during PAWS.

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In early abstinence, the brain’s stores of endorphins and dopamine are severely depleted. Dopamine, the neurotransmitter that floods the brain during drug use to produce titanic highs, is also involved in the regulation of mood, and a certain amount is necessary in order to maintain a “normal” mood. The absence of enough dopamine creates a biochemically based depression. It can take between four weeks and six months for the brain to naturally manufacture enough endorphins and dopamine to replenish its inventory of these vital chemicals. These symptoms affect many people in the early phases of abstinence from numerous substances, but they occur in an extremely high percentage of those with histories of long-term opioid use.

The most change occurred within 2 weeks of last substance use (Coffey et al., 2007). In the 1980s, De Soto and 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 alcohol use disorder and ptsd: an introduction pmc following acute withdrawal (De Soto et al., 1985). Fortunately, in a sample of persons who had been abstinent for nearly 10 years, most PAWS symptoms gradually diminished, with near normalization 4 months after detoxification (De Soto et al., 1985). When you stop using a certain substance, you might experience withdrawal symptoms for a few days or weeks. Disturbance in serotonin function may mediate acute and protracted alcohol withdrawal; however, there is a lack of consensus (Marcinkiewcz et al., 2016).

Finally, as a scoping review, the search was limited to only a few databases and published literature. However, it is unclear if this significantly affected the overall conclusions. Unlike a traditional systematic review, only one author (A.B.) reviewed and identified the articles for inclusion, and the second reviewer only reviewed the excluded articles. With future studies, a more extensive systematic review or meta-analysis could be conducted. 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.

Fourteen were pharmacological trials, whereas two were nonpharmacological intervention studies. We did not find any additional articles through reviewing reference lists of identified articles. 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).

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, 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. PAWS can also be called protracted withdrawal syndrome or prolonged withdrawal syndrome. The symptoms of PAWS can differ from the symptoms of acute withdrawal, and are often milder and more sporadic.

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. 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).

The protracted withdrawal period from alcohol appears to induce transient alterations in multiple cognitive domains, including concentration, initiative, pessimism, and even a sense of humor (Voltaire-Carlsson et al., 1996). 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). 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).

However, the content is solely the authors’ responsibility and does not represent the official views of NIDA, the University of Calgary, the CIHR, or the Calgary Health Trust. The authors acknowledge the University of Calgary Health Sciences Librarians for their support in developing our search strategy. We also recognize that our work takes place on historical and contemporary Indigenous lands, including the territories of Treaties 6, 7 & 8 and the homeland of the Métis. We also acknowledge the many Indigenous communities that have been forged in urban centers across Alberta. Keep reading to learn more about PAWS, the causes and risk factors, and how to cope in recovery.

This may include medications, therapy, or both and can be offered in a variety of settings, both inpatient, outpatient, or a hybrid model. Still, try to keep in mind that these symptoms — though uncomfortable — are temporary. The medical professional who evaluated your AWS symptoms may suggest daily follow-ups via telephone or video chat to check on your symptoms and progress. AWS can evolve in a few hours or a few days but often develops between 6 to 24 hours after your last drink.