Post-acute-withdrawal syndrome

Post-acute-withdrawal syndrome (PAWS) (also sometimes referred to as post-withdrawal syndrome or protracted withdrawal syndrome) is a set of persistent impairments that occur after withdrawal from alcohol, opiates, benzodiazepines and other substances.[1][2][3][4] Infants born to mothers who used substances of dependence during pregnancy may also experience a post acute withdrawal syndrome.[5][6] Post acute withdrawal syndrome affects many aspects of recovery and everyday life, including the ability to keep a job and interact with family and friends. Symptoms occur in over 90% of people withdrawing from a long-term opioid (such as heroin habit), three-quarters of persons recovering from long-term use of alcohol, methamphetamine, or benzodiazepines and to a lesser degree other psychotropic drugs. Post-acute withdrawal syndrome as a result of GABA-agonist (benzodiazepine, barbiturate, ethanol) dependence and opioid dependence can last from a year to several decades, or indefinitely, with the symptoms entering in to periods of relative remission between periods of instability. Symptoms include mood swings resembling an affective disorder, anhedonia (the inability to feel pleasure from anything beyond use of the drug) insomnia, extreme drug craving and obsession, anxiety and panic attacks, depression, suicidal ideation and suicide and general cognitive impairment.

Contents

Background

Drug abuse, including alcohol and prescription drugs can induce symptomatology which resembles mental illness. This can occur both in the intoxicated state and also during the withdrawal state. In some cases these substance induced psychiatric disorders can persist long after detoxification, such as prolonged psychosis or depression after amphetamine or cocaine abuse. A protracted withdrawal syndrome can also occur with symptoms persisting for months after cessation of use. Benzodiazepines are the most notable drug for inducing prolonged withdrawal effects with symptoms sometimes persisting for years after cessation of use. Severe anxiety and depression are commonly induced by sustained alcohol abuse which in most cases abates with prolonged abstinence. Even moderate alcohol sustained use may increase anxiety and depression levels in some individuals. In most cases these drug induced psychiatric disorders fade away with prolonged abstinence.[7]

Cause

The syndrome may be in part due to persisting physiological adaptions in the central nervous system manifested in the form of continuing but slowly reversible tolerance, disturbances in neurotransmitters and resultant hyperexcitability of neuronal pathways.[8][9][10][11] The symptoms of post acute withdrawal syndrome occur because the brain's ability to react to stress has been weakened by long-term substance use. Stressful situations arise in early recovery, and the symptoms of post acute withdrawal syndrome produce further distress. It is important to avoid or to deal with the triggers that make post acute withdrawal syndrome worse.

Symptoms

Symptoms can sometimes come and go with wave like reoccurrences or fluctuations in severity of symptoms. Common symptoms include impaired cognition, irritability, depressed mood, and anxiety; all of which may reach severe levels which can lead to relapse.[12][13]

The protracted withdrawal syndrome from benzodiazepines can produce symptoms identical to generalised anxiety disorder as well as panic disorder. Due to the sometimes prolonged nature and severity of benzodiazepine withdrawal, abrupt withdrawal is not advised.[14]

Common symptoms of post acute withdrawal syndrome are:[15][16][17][18]

Symptoms occur intermittently, but are not always present. They are made worse by stress or other triggers and may arise at unexpected times and for no apparent reason. They may last for a short while or longer. Any of the following may trigger a temporary return or worsening of the symptoms of post acute withdrawal syndrome:

Post-acute benzodiazepine withdrawal

See also: Benzodiazepine withdrawal syndrome

Disturbances in mental function can persist for several months or years after withdrawal from benzodiazepines. Psychotic depression persisting for more than a year following benzodiazepine withdrawal has been documented in the medical literature. The patient had no prior psychiatric history. The symptoms reported in the patient included, major depressive disorder with psychotic features, including persistent depressed mood, poor concentration, decreased appetite, insomnia, anhedonia, anergia and psychomotor retardation. The patient also experienced paranoid ideation (believing she was being poisoned and persecuted by co-employees), accompanied by sensory hallucinations. Symptoms developed after abrupt withdrawal of chlordiazepoxide and persisted for 14 months. Various psychiatric medications were trialed which were unsuccessful in alleviating the symptomatology. Symptoms were completely relieved by recommencing chlordiazepoxide for irritable bowel syndrome 14 months later.[20] Another case report, reported similar phenomenon in a female patient who abruptly reduced her diazepam dosage from 30 mg to 5 mg per day. She developed electric shock sensations, depersonalisation, anxiety, dizziness, left temporal lobe EEG spiking activity, hallucinations, visual perceptual and sensory distortions which persisted for years.[21]

A clinical trial of patients taking the benzodiazepine alprazolam (Xanax) for as little as 8 weeks triggered protracted symptoms of memory deficits which were still present after up to 8 weeks post cessation of alprazolam.[22]

Treatment

The condition gradually improves over a period of months or in severe cases years after.[23][24] Acamprosate has been found to be effective in alleviating some of the post acute withdrawal symptoms of alcohol withdrawal.[25][26] Carbamazepine or trazodone may also be effective in the treatment of post acute withdrawal syndrome.[27][28][29] Cognitive behavioural therapy can also help the post acute withdrawal syndrome especially when cravings are a prominent feature.[30]

See also

References

  1. ^ Collier, Judith; Longmore, Murray (2003). "4". In Scally, Peter. Oxford Handbook of Clinical Specialties (6 ed.). Oxford University Press. p. 366. ISBN 978-0198525189. 
  2. ^ Miller FT (Mar-Apr 1994). "Protracted alcohol withdrawal delirium". J Subst Abuse Treat 11 (2): 127–30. doi:10.1016/0740-5472(94)90029-9. PMID 8040915. 
  3. ^ Ashton H (1991). "Protracted withdrawal syndromes from benzodiazepines". J Subst Abuse Treat (benzo.org.uk) 8 (1-2): 19–28. doi:10.1016/0740-5472(91)90023-4. PMID 1675688. http://www.benzo.org.uk/ashpws.htm. 
  4. ^ Wu JM; Wei DY, Luo YF, Xiang XY (November 2003). "[Clinic research on heroin de-addiction effects of acupuncture and its potentiality of preventing relapse]". Zhong Xi Yi Jie He Xue Bao 1 (4): 268–72. doi:10.3736/jcim20030412. PMID 15339529. 
  5. ^ Lejeune C; Floch-Tudal C, Montamat S, Crenn-Hebert C, Simonpoli AM (March 1997). "[Management of drug addict pregnant women and their children]". Arch Pediatr 4 (3): 263–70. doi:10.1016/S0929-693X(97)87247-8. PMID 9181022. 
  6. ^ Gaillard MC; Borruat FX (April 2002). "[New finding: transitory horizontal pendular nystagmus secondary to neonatal abstinence syndrome]". Klin Monatsbl Augenheilkd 219 (4): 317–9. doi:10.1055/s-2002-30650. PMID 12022028. 
  7. ^ Evans, Katie; Sullivan, Michael J. (1 March 2001). Dual Diagnosis: Counseling the Mentally Ill Substance Abuser (2nd ed.). Guilford Press. pp. 75–76. ISBN 978-1572304468. http://books.google.co.uk/books?id=lvUzR0obihEC. 
  8. ^ Rimondini R; Sommer WH, Dall'Olio R, Heilig M (March 2008). "Long-lasting tolerance to alcohol following a history of dependence". Addict Biol 13 (1): 26–30. doi:10.1111/j.1369-1600.2007.00079.x. PMID 17850416. 
  9. ^ Ahveninen J; Jääskeläinen IP, Pekkonen E, Hallberg A, Hietanen M, Näätänen R, Sillanaukee P (June 8, 1999). "Post-withdrawal changes in middle-latency auditory evoked potentials in abstinent human alcoholics". Neurosci Lett 268 (2): 57–60. doi:10.1016/S0304-3940(99)00378-X. PMID 10400077. 
  10. ^ Kiefer F; Andersohn F, Jahn H, Wolf K, Raedler TJ, Wiedemann K (January 2002). "Involvement of plasma atrial natriuretic peptide in protracted alcohol withdrawal". Acta Psychiatr Scand 105 (1): 65–70. doi:10.1034/j.1600-0447.2002.0_011.x. PMID 12086228. 
  11. ^ Bruijnzeel AW; Gold MS (November 2005). "The role of corticotropin-releasing factor-like peptides in cannabis, nicotine, and alcohol dependence". Brain Res Brain Res Rev 49 (3): 505–28. doi:10.1016/j.brainresrev.2005.01.007. PMID 16269317. 
  12. ^ Stojek A; Madejski J, Dedelis E, Janicki K (May-Jun 1990). "[Correction of the symptoms of late substance withdrawal syndrome by intra-conjunctival administration of 5% homatropine solution (preliminary report)]". Psychiatr Pol 24 (3): 195–201. PMID 2084727. 
  13. ^ Bokhan NA; Abolonin AF, Krylov EN, Vetlugina TP, Ivanova SA (2003). "Comparative Efficiency of Proproten-100 during the Therapy of Patients with Alcoholism in the Stage of Therapeutic Remission". Bull Exp Biol Med 135 (Suppl 1): 171–5. doi:10.1023/A:1024709014483. PMID 12949690. 
  14. ^ a b c Riba, Michelle B.; Ravindranath, Divy (12 April 2010). Clinical manual of emergency psychiatr. Washington, DC: American Psychiatric Publishing Inc. p. 197. ISBN 978-1-58562-295-5. http://books.google.co.uk/books?id=l8veL1bDoF8C&pg=PA197. 
  15. ^ De Soto CB; O'Donnell WE, Allred LJ, Lopes CE (December 1985). "Symptomatology in alcoholics at various stages of abstinence". Alcohol Clin Exp Res 9 (6): 505–12. doi:10.1111/j.1530-0277.1985.tb05592.x. PMID 3911810. 
  16. ^ Voltaire-Carlsson A; Hiltunen AJ, Koechling UM, Borg S (Sep-Oct 1996). "Effects of long-term abstinence on psychological functioning: a prospective longitudinal analysis comparing alcohol-dependent patients and healthy volunteers". Alcohol 13 (5): 415–21. doi:10.1016/0741-8329(96)81678-8. PMID 8888936. 
  17. ^ Watanabe KI; Ogihara-Hashizume A, Kobayashi Y, Mitsushio H, Komiyama T (April 2001). "Impaired sleep during the post-alcohol withdrawal period in alcoholic patients". Addict Biol 6 (2): 163–169. doi:10.1080/13556210020040244. PMID 11341856. 
  18. ^ Vik PW; Cellucci T, Jarchow A, Hedt J (March 2004). "Cognitive impairment in substance abuse". Psychiatr Clin North Am 27 (1): 97–109. doi:10.1016/S0193-953X(03)00110-2. PMID 15062633. 
  19. ^ Janiri L; Martinotti G, Dario T, Reina D, Paparello F, Pozzi G, Addolorato G, Di Giannantonio M, De Risio S (June 3, 2005). "Anhedonia and substance-related symptoms in detoxified substance-dependent subjects: a correlation study". Neuropsychobiology 2 (1): 37–44. doi:10.1159/000086176. PMID 15942262. 
  20. ^ Modell JG (Mar-Apr 1997). "Protracted benzodiazepine withdrawal syndrome mimicking psychotic depression" (PDF). Psychosomatics (Psychiatry Online) 38 (2): 160–1. PMID 9063050. http://psy.psychiatryonline.org/cgi/reprint/38/2/160.pdf. 
  21. ^ Shader RI; Greenblatt DJ (1981). "The use of benzodiazepines in clinical practice". Br J Clin Pharmacol 11 (Suppl 1): 5S–9S. PMC 1401641. PMID 6133535. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1401641. 
  22. ^ Curran, Hv; Bond, A; O'Sullivan, G; Bruce, M; Marks, I; Lelliot, P; Shine, P; Lader, M (November 1994). "Memory functions, alprazolam and exposure therapy: a controlled longitudinal study of agoraphobia with panic disorder.". Psychological medicine 24 (4): 969–76. doi:10.1017/S0033291700029056. ISSN 0033-2917. PMID 7892364. 
  23. ^ Roberts AJ; Heyser CJ, Cole M, Griffin P, Koob GF (June 2000). "Excessive ethanol drinking following a history of dependence: animal model of allostasis" (PDF). Neuropsychopharmacology 22 (6): 581–94. doi:10.1016/S0893-133X(99)00167-0. PMID 10788758. http://www.nature.com/npp/journal/v22/n6/pdf/1395491a.pdf. 
  24. ^ De Soto CB; O'Donnell WE, De Soto JL (October 1989). "Long-term recovery in alcoholics". Alcohol Clin Exp Res 13 (5): 693–7. doi:10.1111/j.1530-0277.1989.tb00406.x. PMID 2688470. 
  25. ^ Beleslin D (1991). "[Modern drug therapy in alcoholism]". Med Pregl 44 (7-8): 279–84. PMID 1806768. 
  26. ^ Wilde MI; Wagstaff AJ (June 1997). "Acamprosate. A review of its pharmacology and clinical potential in the management of alcohol dependence after detoxification". Drugs 53 (6): 1038–53. PMID 9179530. 
  27. ^ Malcolm R; Myrick H, Brady KT, Ballenger JC (2001). "Update on anticonvulsants for the treatment of alcohol withdrawal". Am J Addict 10 Suppl: 16–23. PMID 11268817. 
  28. ^ Le Bon O; Murphy JR, Staner L, Hoffmann G, Kormoss N, Kentos M, Dupont P, Lion K, Pelc I, Verbanck P (August 2003). "Double-blind, placebo-controlled study of the efficacy of trazodone in alcohol post-withdrawal syndrome: polysomnographic and clinical evaluations". J Clin Psychopharmacol 23 (4): 377–83. doi:10.1097/01.jcp.0000085411.08426.d3. PMID 12920414. 
  29. ^ Mueller TI; Stout RL, Rudden S, Brown RA, Gordon A, Solomon DA, Recupero PR (February 1997). "A double-blind, placebo-controlled pilot study of carbamazepine for the treatment of alcohol dependence". Alcohol Clin Exp Res 21 (1): 86–92. PMID 9046378. 
  30. ^ Hori T; Komiyama T, Harada S, Matsumoto T (2005). "[Treatment of substance dependence by a bio-cognitive model based on behavioral pharmacology]". Seishin Shinkeigaku Zasshi 107 (11): 1147–58. PMID 16408423.