Many addicts are well aware of what it takes to get off drugs. Acute withdrawal can include every uncomfortable symptom imaginable, including anxiety, sweating, shaking, insomnia, irritability, vomiting and diarrhea. This acute withdrawal phase can last up to two weeks. But it ends. What happens next, in the weeks and months to come, might be physically less severe, but it isn’t easy.
Many addicts don’t know about this phase of depression in recovery — which UW Health calls post-acute withdrawal syndrome (PAWS) — and are unprepared to deal with it. PAWS can last from a month to several years after quitting, and is a leading cause of relapse.
Chicken or egg?
Long-term drug and alcohol addiction doesn’t just damage one brain pathway, it wreaks havoc on many, including those involved in reward, stress, pain, sleep, learning and memory. Drugs of abuse have long-term physical consequences on the nervous system, said Dr. David Sack, CEO of Promises Treatment Centers and Elements Behavioral Health, “and these are different from the kinds of things we treat in acute [withdrawal].” In fact, the post-acute withdrawal phase presents a host of its own problems, many so intertwined with an addict’s drug-using lifestyle that it can be difficult to determine which came first.
While symptoms of PAWS can range from lasting irritability to recurring difficulty sleeping and intermittent anxiety, some addicts also experience prolonged depression. Sometimes, it’s just “the blues.” Often, there is an accompanying lack of motivation that can make doing regular things — going to work, eating dinner or watching a movie, for example — nearly unbearable.
About half the time, these symptoms disappear as the addict’s physiology and brain chemistry balance out over the course of recovery, Dr. Sack said. For the other half, when the depression doesn’t go away, antidepressants and cognitive-behavioral strategies can be helpful.
Where does PAWS end and depression begin? “The bottom line is, it’s a very complex situation,” says Dr. Ashish Bhatt, an addictionologist who serves as medical director at The Recovery Place in Ft. Lauderdale, as well as chief medical officer for Elements Behavioral Health’s Florida region. “Unfortunately, clients often have a very difficult time expressing their feelings, [so] it can be challenging to tease out.”
PAWS or dual diagnosis?
Compared with the general population, people addicted to drugs are roughly twice as likely to suffer from mood and anxiety disorders, and vice versa. Drug and alcohol abuse can lead to temporary symptoms of these disorders, or the substance use can exacerbate an underlying mental illness.
Distinguishing PAWS from an underlying mood disorder, especially depression, is the key to effectively treating patients during the post-acute withdrawal period of recovery. “The best way to tease these out is to do a thorough, chronological history, going back in time from birth to the present moment,” Dr. Bhatt said. “If you’ve done an accurate history and you know how [a specific addictive drug] acts on the brain, from that history you come up with a logical conclusion” if the symptoms are part of coming off the drug or a primary illness.
The complexity of treatment
“It can be a tricky thing to assess,” said Dr. Joshua Smith, outpatient director of the Center for Drug and Alcohol Programs at the Medical University of South Carolina, considering the fact that often patients remember things differently at different points in their recovery process, which is why he likens assessment to going down a rabbit hole. However, he says, “PAWS doesn’t seem to have the same intensity and the same constancy as [mood] disorders do.” Treatment sometimes consists of “getting past the why part” and soothing the symptoms of PAWS.
However, PAWS can be confused with true depression, and not treating an underlying condition puts addicts at higher risk of relapse. Changes in energy, appetite, motivation, concentration — these are the hallmarks of depression, but these are also disrupted in the PAWS phase, Dr. Sack said. “If someone has physical symptoms, and it’s not getting better after the first month, it’s probably better to treat it as depression than to ignore it and hope that it just goes away.”
Most interviewed said that they would intervene at four weeks if the symptoms of depression are severe, typically prescribing an SSRI like Lexapro or Paxil. However, that’s by no means a hard and fast rule.
If the symptoms include suicidal depression, “that’s not a typical picture, [and] now you’re seeing something much more worrisome,” says Dr. Roger Weiss, chief of the Alcohol and Drug Abuse Treatment Program at Harvard’s McLean Hospital. It depends on the individual’s history as to when Weiss will begin treatment for depression. “Picking a time point — ‘we’re going to wait four weeks no matter what’ — isn’t ideal. It’s a reasonable guideline, but all things are not always equal.”
In fact, while the DSM is used for official diagnoses, it’s important for the addictionologist to understand not only the short- and long-term physical symptoms of drug abuse, but also how any medication might interact with those symptoms. While SSRIs are a first-line treatment for depression, it might be inappropriate — even detrimental — to prescribe them too early during the PAWS phase of recovery.
Drugs that work on the serotonergic system can worsen the initial symptoms of PAWS, Dr. Bhatt says. “Often the first effects of serotonergic antidepressants are restlessness, nausea, sexual side effects, GI upset. Assessing the profile and effects of illicit drugs of abuse compared with the effects of prescription medication is often overlooked, and is essential to ensure prescription treatment is not inadvertently making the symptoms a client is suffering from worse.”
Often, Dr. Bhatt will prescribe medications that balance out the PAWS symptoms before immediately going to an SSRI, waiting for the proper time to initiate antidepressants. If the person does have a primary depressive disorder, Dr. Bhatt will start medications sooner but at a lower dose — “slow and low” — to reduce the side effects. “Often people coming off drugs are more susceptible to feel side effect profiles,” which he says is “something very important to consider.”
The significance of treatment that lasts longer than 30 days is underscored in these tricky dual diagnosis cases. It can take weeks for antidepressants to kick in; if patients are leaving facilities at 30 days, they’re not only just beginning to feel the height of PAWS — Dr. Sack said symptoms peak four to eight weeks after getting sober — but they’re also beginning to feel the effects of the medication, which may or may not improve their symptoms. More comprehensive, individualized treatment plans for recovering addicts with mood disorders would go a long way toward improving relapse rates.
By Jeanene Swanson