Senior Substance Abuse

Post-Acute Withdrawal Syndrome - A Real Problem for Senior Drug Abusers?

by Don Drake, Connelly Law Offices, Ltd.

Attorney RJ Connelly III

"In the past, the use of illicit drugs usually declined after the user reached young adulthood," said certified elder law Attorney RJ Connelly III. "But today, with some aging baby boomers bringing their patterns of substance abuse behaviors into old age, this is now not always true. We have documented the increase in substance addiction among this group in previous blogs, with both illicit and prescription drugs, but in this one, we want to explore a little-discussed subject - which is not without controversy - Post-Acute Withdrawal Syndrome (PAWS)."

When Attorney Connelly says it is not without controversy, it's because there continues to be a dearth of scientific evidence that PAWS actually exists. In fact, some professionals in the addiction treatment field feel that PAWS is a convenient excuse for just another relapse episode while providing the addict cover for their choice to use once again. Others have questioned whether PAWS is just an invention of the Addiction Treatment community in an effort to try and justify the need for long-term treatment and, of course, increased billing incomes. There are also some who say older individuals seem to be more prone to PAWS-type symptoms as the result of an aging brain.

"But for those who experience these symptoms, something is occurring, and it is indeed very real and extremely difficult to manage."

But for those who really experience these symptoms, something is occurring, and it is indeed very real and extremely difficult to manage. To that end, let's look at Lillian's story, an older client to whom I provided treatment services a few years back in Boston who presented with a classic PAWS-type history.

Lillian's Story

Lillian M. lived in Dorchester, a neighborhood in Boston. She had been drinking for decades, living in a subsidized apartment alone, isolating herself from the world by choice. "The only time I go out is when I need to buy beer or vodka, maybe once a week," she told me. "Then I found a store that would deliver to me and that ended my excursions into the outside world."

Neighborhood liquors in Boston

Lillian wasn't what most would think of when discussing an inner-city alcoholic woman living in low-cost housing. She was a retired schoolteacher who kept her alcoholism hidden for decades from her employer, her students, and even her daughter. "Drinking was everything to me," she said. "It cured my anxiety, animated me, and it turned out to be the liquid cement that held me together, just like super glue." Her drinking began in college and didn't stop until she got married, but that was just temporary.

"I was raised in northern Rhode Island in a relatively rural community and going to college in the Boston area exposed me to a whole new world. But it was scary, a big place with even bigger expectations, and my anxiety went through the roof," Lillian explained. "It was the late 1960s, a time when drugs and alcohol were a way of life on the campus. I tried everything and anything. But alcohol became my best friend."

"When I had my first drink, it started a love affair for me," Lillian said. "From that very first time, I remember it like it was just hours ago, a warm confidence went through my body, and I thought, this is how normal people must feel and I like it. I liked feeling normal for once."

"From that very first time...a warm confidence went through my body, and I thought, this is how normal people must feel and I like it. I like feeling normal for once."

Lilliam graduated, got her first job as an elementary school teacher, and managed to stop her drinking after meeting a man who later became her husband. The couple had one child, a girl named Talia, who also became a teacher and moved to St. Louis.

"When I quit drinking, it was difficult, and I felt really sick for almost the entire summer. Other kids I went to school with didn't seem to have this problem, they could drink more than me and seemed fine the next day. But in the end, I toughed it out," Lillian said. "Going back to regular life was tough, I had to learn how to socialize without that liquid courage, but day by day, the real Lillian emerged, and I felt good. But occasionally, I would slip, conceal some vodka in my purse, and drink it in the bathroom before bed, but it wasn't a regular thing. I kept it well hidden from my family." Then came a major loss.

"I used alcohol as my crutch..."

"It was a little after the World Trade Center event when my husband got the news that he had a serious heart issue that needed immediate surgery. Before he could be admitted, he had a massive heart attack and died. I was alone, went back to using alcohol regularly as my crutch, and when my daughter came back for the funeral, I could tell I was an embarrassment to her," she said.

"After his death, I sold our modest home in Framingham and moved into an apartment in Needham, where I drank up the money from the house sale," she recalled. "I then cashed in other money I had saved, including retirement accounts. It's amazing how fast money can go. It got to the point that I couldn't pay my bills and ended up applying for subsidized housing. But the drinking continued."

Lillian went to rehab to stop her drinking but was unsuccessful. "Just like in college, when I stopped, I felt like garbage for months, no matter what I did, nothing helped," she told me. "The only thing that worked was to keep drinking. I was told I was just a drunk looking for excuses, but I was really trying and trying hard. I went to AA meetings where people who had just quit did not have the same problems I had. They would say to me, 'when you're ready, come back', dismissing what I was feeling. This led to more relapses. It was depressing, I had no answers."

"Then, one peer in recovery discussed post-acute withdrawal syndrome with me, and it made a lot of sense as to why I was feeling like I felt, and why I didn't have the same recovery timeline as others with addictions had. I didn't see it as an excuse, but as the reason I felt the way I did. She told me if I just hung in there with support from therapy, I would make it. It's still a struggle but putting a name on what I am experiencing gives me hope that it's something I can beat."

There are thousands like Lillian who experience a prolonged period of withdrawal symptoms after the acute withdrawal episode has ended. Let's learn more about this process.

Drugs and Post-Acute Withdrawal Syndrome

First, we'll define the term acute withdrawal. Acute withdrawal occurs within hours when an addicted person stops using a substance. During this initial period, a person may begin to feel physical and psychological symptoms. Physically, they may feel the onset of flu-like symptoms which could include vomiting, nausea, tremors, and fatigue.

Relapsing is a part of PAWS

Psychologically, there could be irritability, anxiety, and other mood changes. For most, this could last for up to two weeks and is usually considered the first stage of the detox process. According to the literature that exists, post-acute withdrawal (PAWS) refers to any prolonged symptoms that occur after acute withdrawal has resolved.

PAWS can feel like a “rollercoaster” of symptoms, which come and go unexpectedly. Each episode of PAWS can last for a few days, and these can continue cyclically for up to a year, or even more in some individuals. These symptoms can occur with any intoxicating substance and even some prescribed medications. Post-acute withdrawal syndrome appears to occur among people discontinuing the following drugs/medications most often:

  • Alcohol - The symptoms of PAWS for alcohol use were first defined in the 1990s. Those who stopped alcohol use suddenly and experienced delirium tremens (DTs), also appeared to suffer from a more prolonged withdrawal.

  • Antidepressants - Few abuse these medications because they do not create a rapid intoxication, but rapidly halting their use can cause a sudden change of the serotonin levels and other neurotransmitters in the brain. Acute withdrawal can cause a deep depression while a prolonged withdrawal can continue with this feeling for months.

  • Antipsychotics - These medications bind to the dopamine receptors of the brain to decrease hallucinations and delirium. When stopped without a taper, mood swings could occur for months.

  • Benzodiazepines - This class of medication is beneficial for those with anxiety and panic disorders but is also widely abused. Benzodiazepine dependence can occur rapidly. When attempting to stop using them, it creates a feeling of panic making it more difficult to stop their use. PAWS symptoms can last for months after the physical dependence has ended.

  • Marijuana (Cannabis) - Yes, marketers of the new miracle drug will tell you about the safety of cannabis, but those who have worked in the treatment field know of the long-term issues associated with its use. Users who stop using the drug begin to feel stressed, depressed, and paranoid. Insomnia can exist for months after stopping use.

  • Opioids - This class of drug has been all over the news with the "opioid epidemic" headlines of recent years. If used either illicitly or with a prescription, PAWS can occur if not tapered properly. These symptoms may include cravings, severe exhaustion, and cognitive impairment.

  • Stimulants - Whe