By Jeanene Swanson
No one said recovery would be easy. And for the majority of addicts and alcoholics, detox is just the beginning.
While addiction specialists may know about post-acute withdrawal syndrome (protracted withdrawal syndrome), or PAWS, many addicts and much of the public do not. Understanding the lingering effects of substance abuse can go a long way toward educating addicts about relapse prevention and maybe most importantly, giving them hope that this, too, shall pass.
“I’m certain I suffer(ed) symptoms of PAWS,” recovering alcoholic Amy Parrish says. “My sleep cycles were off, my emotions were all over the place; I would alternate between feeling good, really good, and certain, and then like I couldn’t take all the soul searching one more minute.”
By definition, PAWS is a series of post-acute symptoms of recovery from dependence on benzodiazepines, barbiturates, and ethanol; opiates; and sometimes, antidepressants. Some commonly abused benzodiazepines are Valium, Xanax, and Ativan, and some opiate drugs of addiction are heroin, Vicodin, and OxyContin. Symptoms of PAWS 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.
“The brain has tremendous capacity to heal, but it doesn’t heal quickly,” says Dr. David Sack, CEO of Promises Treatment Centers and Elements Behavioral Health. Sack says that in general, PAWS symptoms peak around four to eight weeks after quitting. As the body moves toward homeostasis, says Dr. Joseph Lee, Medical Director of the Hazelden Youth Continuum, it has to reach a “new kind of normal” in the process. Some people experience a more prolonged withdrawal, he says, “and it takes a long time to recalibrate.” In fact, instead of feeling better, many addicts in recovery feel worse.
Sack says that most addicts know about PAWS from their experience of quitting and then relapsing because they felt terrible, they just don’t have a name for it. “I felt mostly good for the first five months, then I really felt sort of down and fatalistic,” Parrish says. “I knew I would never drink again, and that was OK, but I felt like I would never heal.” She says it took about four months of feeling “sad and lost” for her to begin to feel like herself again. “In those four months I had episodes of contentment, but felt mostly just down.”
While making new friends, acquiring new coping skills, and getting used to life without drugs is indeed part of recovery, untreated symptoms of PAWS don’t have to be.
Over the past several decades, much has come to be known about the long-term effects of drugs of addiction, especially on the neurobiology of the brain. GABA-agonists like alcohol and benzodiazepines, opiates, and stimulants all lead to lasting changes in learning, motivation, and pleasure. Primarily, these drugs hijack the brain’s reward circuits, a prime moving part of which is dopamine. In the case of drug abuse and dopamine, the brain not only becomes tolerant, but it also gets primed for an excess of dopamine, meaning the user eventually experiences a simultaneous lack of dopamine with increased signaling for that circuit. In other words, not only does an addict feel bad without the drug, his focus turns solely to it to make him feel good again.
However, dopamine’s not the only culprit. Building upon decades of research, key brain structures have been implicated in addiction—the nucleus accumbens and the amygdala—as well as several key neurotransmitters, including dopamine, but also opioid peptides, serotonin, GABA, and glutamate. Scientists at the Medical University of South Carolina and others are beginning to look beyond neuronal misfiring in reward and pleasure regions—these explain how drugs take hold of the brain, but they don’t explain why addiction is so hard to beat. New research on glutamate finds that drug addiction can be viewed as impaired reversal learning, and this can be attributed to disrupted glutamate signaling.
In essence, withdrawal from drugs of abuse results in a full range of emotional, behavioral, and cognitive impairments. Damages to pathways involved in reward, pain relief, stress maintenance, sleep and arousal, learning, and memory can have effects that last long beyond quitting.
While different drugs of abuse lead to different sub-sets of PAWS symptoms, PAWS that occur from alcohol and benzodiazepines are more similar because they’re pharmacologically more similar in mode of action, says Dr. Roger Weiss, Chief of the Alcohol and Drug Abuse Treatment Program at Harvard’s McLean Hospital. “Some of the key things are irritability, anxiety, and sleep difficulties,” he says, adding that how long addicts experience these symptoms is typically a reflection of how long they were using drugs as opposed to how much. One of the most important parts of the recovery strategy is educating addicts about these symptoms and letting them know that they’re going to experience them. “In general these improve over time, but they can improve very gradually,” Weiss says. “So it’s a process of learning how to tolerate some of these feelings, and then symptomatically, dealing with the issues that people are struggling with.”
Even though acute withdrawal is over after the first or second week, “drugs of abuse have long-term physical consequences because of how they change the way in which the nervous system responds,” Promises’ Sack says. “It turns out that there [is] a whole host of wiring that actually gets worse in the next four to eight weeks.” One of these is cue-induced stress response—people in early recovery are more responsive than non-addicts to stress surrounding people, places, and things that remind them of using. This measurable increase in symptoms of stress is the “physical evidence of craving,” Sack says. Cue-induced stress responses get worse over time and seem to peak between 4 and 8 weeks; the intensity of how much stress addicts feel correlates to relapse, he says. Unfortunately, this peak in stress or craving is typically the time when people leave treatment facilities—“we’re sending people out when this is getting worse.”
The second thing that gets worse is that addicts experience increased impulsivity. Studies have shown that first, addicts continue to make more mistakes than non-addicts when trying to learn how to do things differently, and second, they tend to continue to put less value in future, or distant, rewards, Sack says.
Finally, addicts continue to experience a loss of working memory—they have trouble remembering the things that they’re supposed to do. This is more the case for alcohol and benzodiazepine withdrawal than for opiates, he says.
The biggest thing Sack’s seen in his patients is increased anxiety. People are “more nervous, more anxious, less resilient; and that anxiety is experienced as fear, as uncertainty, a greater sensitivity to rejection.” Some of this excessive reactivity is linked to the glutamate neurotransmitter system, as many drugs of abuse block glutamate. In response, the body ups its production of this chemical, even after the drug is taken away.
This emotional reactivity can be seen with people who abuse opiates, too, and it can be referred to as hyperalgesia. “When people are on pain meds for a long time, their tolerance for pain and discomfort goes down,” Hazelden’s Lee says. This applies to psychological and emotional pain as well, he says.
Lee thinks every addict looking to quit should start by seeing a medical professional—mainly because both the acute and post-acute withdrawal processes “could be fairly serious,” he says. “Like many things in life, I would advise against anyone trying to tough it out on their own.”
While there are specific treatments for acute detox, most PAWS treatments are still in the experimental phase. For instance, a long-standing question in the opiate treatment field is whether buprenorphine (Suboxone) is a better opiate replacement therapy than methadone, and for how long to give these drugs to addicts post-acute withdrawal. Naltrexone, typically used for managing alcohol cravings, has shown promise in reducing cravings in opiate addicts.
Acamprosate and naltrexone have both been used to treat PAWS in alcohol addicts, and a recent study found flumazenil might be effective in decreasing feelings of hostility and aggression in patients with protracted benzodiazepine withdrawal symptoms.
PAWS can often mimic depression, but not treating co-morbid depression and anxiety—mood disorders that existed outside the substance abuse—would subject addicts to increased risk of relapse. All the medical specialists interviewed said that they would not hesitate to prescribe an antidepressant—typically an SSRI—to recovering addicts if they have symptoms of depression that persist beyond four weeks. SSRIs are non-addictive and non-habit forming; however, they can have withdrawal symptoms of their own. Meditation, yoga, and aerobic exercise as well as cognitive behavioral therapies help with depression and anxiety, too.
“The advice I would give is to be patient with the time it takes to heal and feel better,” Parrish says. “These tough issues weren’t created overnight, and they won’t disappear overnight. I have learned that when I feel particularly “PAWS-y,” that means I’m subconsciously working something out—this makes dealing with the symptoms of feeling a little crazy and not sleeping less exhausting. It won’t last forever.”