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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).

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Building on Wellman’s findings, Segal and colleagues (1970) were the first to coin the term “protracted withdrawal syndrome” in 1960, describing neurovegetative and emotional instability symptoms persisting long after acute withdrawal had subsided. Following Segal, Kissin (1979) described several protracted alcohol abstinence syndrome cases in 1979, emphasizing their importance to relapse prevention. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), alcohol is the most commonly used substance in the United States, with over 75% of individuals aged 12 and older reporting lifetime consumption. Alcohol consumption spans a spectrum from low-risk to severe alcohol use disorder (AUD).

The main management for severe symptoms is long-acting benzodiazepines — typically IV diazepam or IV lorazepam. It’s important to be honest about your alcohol use — and any other substance use — so your provider can give you the best care. Each of these symptoms can increase in intensity depending on the severity of the withdrawal. All authors contributed to this study’s design, the interpretation of the data, subsequent manuscript drafts (and revisions), and final approval for submission. Dr. Bahji wrote the initial draft of the work and managed revision feedback from the other authors. The authors acknowledge the University of Calgary Health Sciences Librarians for their support in developing our search strategy.

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).

1. Whether you’ve experienced addiction or are withdrawing after using prescription medication, it can be helpful to find a support group.
2. In addition, there is some evidence that acamprosate initiation following alcohol detoxification can mitigate relapse and PAWS (Gual & Lehert, 2001).
3. After all, if you’re currently experiencing fatigue and nausea, skipping meals and sleeping too little will only make you feel worse.
4. The symptoms can range from mild to severe, with the most severe being life-threatening.
5. 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.

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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.

How long do PAWS symptoms usually last?

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 fetal alcohol syndrome celebrities outpatient support in the hospital setting.

Data collection process and data items

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.

How can you support a loved one experiencing post-acute withdrawal syndrome?

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.

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).

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 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) what is a substance abuse counselor management.

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. narcissistic alcoholic mother 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).

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

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).