Withdrawal symptoms following regular, heavy, and/or long-term use of certain drugs can range from mildly bothersome to intensely painful. This process can have a reputation for being so unpleasant that it acts as a deterrent to attempting to quit and get on the road to recovery, particularly in the case of alcohol, opiates like heroin, and benzodiazepines. Sometimes, severe cases of withdrawal can produce life-threatening symptoms, such as seizures, hyperthermia, and suicidal urges.
Even after getting through the worst of withdrawal, some individuals report lingering symptoms and impairments that have gone on for weeks, months, or even years. This condition has come to be known as post-acute withdrawal syndrome (PAWS), post-withdrawal syndrome, or protracted withdrawal syndrome. Victims may continue to suffer from anxiety or depression, have trouble sleeping, be more sensitive to pain, or even struggle with cognitive problems long after most people have moved on from withdrawal.
Due to a lack of scientific research into the subject, this syndrome is not recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM). However, the fact remains that there are continuous reports of lingering symptoms after withdrawal that individuals hadn’t experienced prior to taking the drug. It’s therefore important to be aware of the possibility of continuing symptoms and understand the options for treatment. Part of understanding post-acute withdrawal syndrome involves an understanding of the nature of withdrawal.
What Is Withdrawal?
Withdrawal happens after extensive drug use or abuse. It can happen with illicit “street” drugs as well as with legal prescription medications given for conditions like chronic pain, insomnia, or anxiety. It can even occur from drugs that produce no noticeable intoxicating effects or everyday substances like caffeine. However, it’s most often associated with addiction disorders – a common problem around the world. In 2009, 23.5 million Americans were considered in need of treatment for a substance abuse problem, according to the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health.
Certain substances affect the brain by stimulating the release of specific neurotransmitters like dopamine and serotonin or by causing them to work longer than they normally would, interacting more with their receptors and producing stronger effects. Other drugs may decrease the sensitivity of or block certain receptors, decreasing activity. To compensate for this abnormal behavior, the brain will reduce or increase the sensitivity of its own neurotransmitter receptors. This produces an effect known as tolerance, and the user will have to take higher doses of the drug to get the same effect.
As time goes on and the individual takes more of the substance, tolerance increases until certain areas of the brain are functioning in a significantly different manner than they were prior to the introduction of the drug. If the dose of the drug is lowered or intake stops altogether, the result is either an inactive or overactive brain, resulting in unpleasant, disruptive, and sometimes unbearable symptoms.
Common withdrawal symptoms include:
- Anxiety or depression
- General discomfort
- Abdominal pain
- Intense cravings
Withdrawal symptoms tend to be on the other end of the spectrum from the effects of taking the drug. For example, people withdrawing from cocaine often experience fatigue and increased appetite, doing little other than eating or sleeping for several days, and they can feel seriously depressed. Those who have been taking depressants may find themselves unable to sleep or even sit still.
Post-acute withdrawal syndrome is so named because it describes the symptoms that occur after the “acute” phase of withdrawal, which typically lasts an average of 7-10 days. It also tends to involve less acute symptoms. Withdrawal symptoms can include intense pain, frequent vomiting and diarrhea, panic attacks, and psychotic symptoms like hallucinating the feeling of bugs crawling on the skin. These more severe symptoms tend to fade after the first few days as lesser emotional symptoms and cravings may linger, though these should be gone by the two-week point.
Post-acute symptoms are most often emotional symptoms but can include cognitive difficulties. The most often reported symptoms are:
- Anhedonia (inability to feel pleasure)
- Impaired concentration
- Increased sensitivity to pain
- Memory problems
- Inability to think clearly
- Social problems
- Stress sensitivity
- Obsessive-compulsive behaviors
- Generalized anxiety disorder
- Panic disorder
Symptoms like anxiety and related disorders are most often reported from those who had been using prescription tranquilizers, or benzodiazepines, while anhedonia and depression are often reported as post-acute withdrawal symptoms from cocaine and other stimulants, though they can be caused by the use of any drug that produces pleasure. One study found that 18.5 percent of a sample of individuals in treatment for substance abuse were experiencing anhedonia.
Without sufficient research, it’s difficult to determine the exact cause of post-acute symptoms. Some point to the physical changes in the brain that result from drug use and the resulting tolerance it produces. Though the brain is supposed to go back to normal after individuals stop taking the substance, it’s possible that some people’s brains will be able to return to the way they were before use began. Particularly in cases of heavy and long-term drug abuse, brain scans have appeared to show long-term changes – potential brain damage. Other people may just heal more slowly, and an extended period of withdrawal is merely due to the extent of the drug abuse.
Other medical professionals and addiction experts suspect that many post-acute withdrawal symptoms occur because they consist of conditions that tend to exacerbate themselves and cause other symptoms if not directly treated. For example, depression and insomnia tend to feed themselves by altering behavior and causing further stress.
Individuals with depression may spend all their time inside, failing to do any physical activities, socialize, or eat properly. All of these things contribute to depression. Insomnia can also lead to anxiety and depression, which leads to more sleep problems in a vicious cycle. At the same time, depression and sleep deprivation can cause any number of cognitive problems, including difficulty concentrating, sensitivity to stress, and memory impairments.
The symptoms of post-acute withdrawal syndrome often have to be treated individually by various medications or therapy. Emotional symptoms from those who experienced withdrawal from a benzodiazepine can be put onto a nonaddictive anti-anxiety drug, including common SSRIs and SSNRIs. Those suffering from insomnia may benefit from short-term sleep aids or alternative treatments, such as meditation, deep breathing exercises, and melatonin supplements.
There are a couple medications that have been indicated specifically for the treatment of PAWS. These include flumazenil, which has been found to reduce hostility and aggression in individuals who have been off benzodiazepines for over four weeks, and acamprosate, a medication used to help stabilize brain chemistry in individuals going through alcohol withdrawal. Trazodone is also often used to counter long-term alcohol withdrawal symptoms, such as depression, anxiety, and insomnia. Carbamazepine, a drug used to control seizures and neuropathic pain, has also been found to be effective.
Cognitive Behavioral Therapy (CBT) is often recommended for those appearing to suffer from PAWS, as it’s been found to be effective in treating depression and generalized anxiety disorder as well as in controlling the impulse control and decision-making problems that can be part of PAWS. CBT has shown to be effective in many studies, producing more positive results in those who receive it.
One study in particular found that the use of CBT in addiction treatment programs resulted in lower dropout rates, with only one-third of clients leaving the program compared to 44.6 percent in programs without CBT. This type of therapy focuses on helping clients identify better thoughts and behaviors to replace ones that are causing problems. Eventually, thinking positively and choosing beneficial behaviors become habits.
Clients may also need to be encouraged to remain active physically, mentally, and socially. Keeping busy, creating and reaching goals, and engaging in healthy social activities are all essential to maintaining good psychological health that naturally reduces depression and anxiety and improves sleep. Seeing a nutritionist is also a good idea, especially after a withdrawal period that followed significant drug abuse. Heavy drug use takes a toll on the body and tends to correspond with unhealthy eating habits or malnutrition. Healthy eating helps to repair the body and the mind.
Post-acute withdrawal syndrome is considered to be fairly uncommon and can often be treated by simple methods. Individuals who have just gone through withdrawal and continue to experience symptoms after the typical detoxification period may think that the symptoms are normal or may fail to seek treatment because they think they deserve extended suffering for their drug use. This is simply not true. Post-acute symptoms should not happen and can often be easily resolved. Talk to a medical professional if symptoms continue troubling you after withdrawal.