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. One author (A.B.) wrote the initial draft of the work and managed revision feedback from the other authors. 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. During PAWS, the brain is proposed to enter a relative state of hyperexcitability by activating central stress systems (Ahveninen et al., 1999). Several studies have attempted to describe the components of this process (summarized in Table 2).

Data collection process and data items

There currently is a lack of controlled trials for nonpharmacological therapies for PAWS, so these cannot be recommended. 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.

Post-acute withdrawal, whether mild or serious, is a necessary process in early recovery from alcohol or other drug dependence. Think of the withdrawal syndrome as the brain’s way of correcting the chemical imbalances suffered during active addiction. PAWS occurs most commonly and intensely among individuals with alcohol and opioid addiction, as well as in people with addiction to benzodiazepines (or “benzos,” which are famous fetal alcohol syndrome commonly prescribed for the treatment of anxiety and panic attacks), heroin (an opiate) or medically prescribed pain medication. 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 following acute withdrawal (De Soto et al., 1985).

Alcohol withdrawal can range from very mild symptoms to a severe form, known as delirium tremens. 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.

Study findings

Patients who have had prior complicated withdrawals should not attempt to decrease their alcohol intake without consultation with their healthcare team. If a patient begins experiencing signs and symptoms of severe withdrawal, including but not limited to seizure, altered mental status, or agitation, they should seek emergency care immediately. When alcohol withdrawal syndrome has resolved, patients ought to be evaluated for AUD and offered treatment, if appropriate, including pharmacotherapy and behavioral treatment. To our knowledge, this is the first scoping review to explore the treatment of PAWS, which ASAM defines as a syndrome with persistent, subacute symptoms of irritability, anxiety, and sleep disturbance (ASAM, 2020).

What is alcohol withdrawal?

Antidepressants, including selective serotonin reuptake inhibitors (SSRIs) and serotonin noradrenaline reuptake inhibitors (SNRIs), can be an effective way to manage your mood. According to UCLA’s Semel Institute for Neuroscience and Human Behavior, PAWS symptoms are experienced by roughly 9 in 10 recovering opiate users and 3 in 4 recovering alcohol users. Many involve a combination of group psychotherapy (talk therapy) and medications. Consequently, the goal of this article was to summarize the extant literature examining the treatment (pharmacological and nonpharmacological) of PAWS.

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). Animal models indicate that atrial natriuretic peptide (ANP) inhibits the effects of CRF, corticotrophin, and cortisol (Ibanez-Santos et al., 1990; Mutschler et al., 2010). However, chronic alcohol consumption and acute withdrawal suppress ANP (Kovács, 2000). Although ANP levels gradually improve over 2 weeks of sustained abstinence, they remain lower relative to healthy controls even after 12 weeks of abstinence.

Write them down, keep them with you, and always remind yourself that what you’re feeling is nothing more than your brain rewiring itself. The prognosis (outlook) for someone with alcohol withdrawal depends greatly on its severity. When you stop consuming alcohol after prolonged, heavy use, your CNS can’t respond or regulate itself fast enough. In addition, Dr. Bahji is a recipient of the 2020 Friends of Matt Newell Endowment from the University of Calgary what is a drinker’s nose Cumming School of Medicine.

1. 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.
2. While physical symptoms tend to resolve in two or three weeks, the chemicals in the brain take much longer to rebalance themselves.
3. Alcohol withdrawal syndrome can range in severity from mild to fatal, making it crucial for patients to present to care for evaluation of their symptoms.
4. These are most severe in the first 4 to 6 months of abstinence and diminish gradually over several years of sustained abstinence.
5. Finally, as a scoping review, the search was limited to only a few databases and published literature.
6. To our knowledge, this is the first scoping review to explore the treatment of PAWS, which ASAM defines as a syndrome with persistent, subacute symptoms of irritability, anxiety, and sleep disturbance (ASAM, 2020).

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. 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). 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).

These persistent deficits may sustain the cravings, low mood, and anxiety characteristic of PAWS (Kiefer et al., 2002). Alcohol withdrawal syndrome is a clinical condition that may arise following the cessation or reduction of regular, heavy alcohol consumption. Given its spectrum of manifestations from mild to severe and potentially fatal, all healthcare team members must recognize the signs and symptoms of this condition. Timely assessment and accurate treatment are vital to preventing disease progression. Comprehensive patient care entails acute management and outpatient support in the hospital setting.

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. If you have alcohol use disorder and want help, a healthcare provider can guide you to resources and rehabilitation programs to help you quit. Your healthcare provider will recommend and encourage treatment for alcohol use disorder. For mild alcohol withdrawal that’s not at risk of worsening, your provider may prescribe carbamazepine or gabapentin to help with symptoms.

A Note to Your Support System

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 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).

Participants received either 1,332 mg/day or 1,998 mg/day, depending on their weight, for 30 days; however, there was no placebo control group (Gualtieri et al., 2011). Acamprosate was well tolerated, improving whats in whippits alcohol craving and relapses while reducing protracted withdrawal symptom severity measured using the Clinical Institute Withdrawal Assessment for Alcohol (Gualtieri et al., 2011). This article reviews research on post-acute alcohol withdrawal syndrome (PAWS) management.

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. Most people with mild to moderate alcohol withdrawal don’t need treatment in a hospital. But severe or complicated alcohol withdrawal can result in lengthy hospital stays and even time in the intensive care unit (ICU).

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).