From the Guidelines
Pervasive arousal withdrawal syndrome, also known as protracted withdrawal, should be preempted and treated with liberal use of adjuvant agents along with adequate clinician time and support, as it can cause dysphoria, irritability, insomnia, anhedonia, or a vague sense of being unwell months after opioid elimination. When managing patients with opioid use disorder, it is essential to consider the potential for protracted withdrawal symptoms, which can be challenging to differentiate from chronic pain symptoms 1. The symptoms of protracted withdrawal can be severe and debilitating, affecting the patient's quality of life and increasing the risk of relapse.
Key Considerations
- Protracted withdrawal symptoms can occur months after opioid elimination and may include dysphoria, irritability, insomnia, anhedonia, or a vague sense of being unwell 1
- These symptoms can be challenging to differentiate from chronic pain symptoms and may reflect an unmasking of the original chronic pain problem
- Preempting and treating protracted withdrawal symptoms with adjuvant agents and adequate clinician time and support is crucial to improving patient outcomes 1
- Clinicians should convey to patients that many individuals receiving long-term opioid therapy (LTOT) actually feel and function better following opioid tapering 1
Management Strategies
- Liberal use of adjuvant agents to manage protracted withdrawal symptoms
- Adequate clinician time and support to address patient concerns and provide guidance
- Gradual opioid tapering to minimize the risk of acute withdrawal symptoms 1
- Consideration of buprenorphine initiation in patients taking opioids for pain, with careful monitoring and dose adjustment as needed 1
From the FDA Drug Label
Pervasive arousal withdrawal syndrome is not explicitly mentioned in the provided drug labels. However, the labels do describe protracted withdrawal syndrome associated with benzodiazepines, which is characterized by:
- Anxiety
- Cognitive impairment
- Depression
- Insomnia
- Formication
- Motor symptoms (e.g., weakness, tremor, muscle twitches)
- Paresthesia
- Tinnitus that persists beyond 4 to 6 weeks after initial benzodiazepine withdrawal. Protracted withdrawal symptoms may last weeks to more than 12 months 2 3.
The key points are:
- Protracted withdrawal syndrome is a potential risk of benzodiazepine use
- Symptoms can persist for an extended period
- Gradual tapering is recommended to reduce the risk of withdrawal reactions. It is essential to note that pervasive arousal withdrawal syndrome is not directly mentioned in the provided labels, and therefore, no conclusion can be drawn about this specific condition.
From the Research
Definition and Characteristics
- Pervasive arousal withdrawal syndrome (PAWS) is a rare mental health disorder that commonly affects children and young people, characterized by dramatic social withdrawal and determined refusal to walk, talk, eat, drink, or care for themselves in any way for several months 4.
- PAWS is often associated with pervasive refusal syndrome (PRS), and in extreme cases, young people may be unable to perform activities of daily living and rely on adults for physical and emotional support 4.
Relationship to Benzodiazepine Withdrawal
- While PAWS is not directly related to benzodiazepine withdrawal, the symptoms of benzodiazepine withdrawal syndrome, such as sleep disturbance, irritability, and increased tension and anxiety, may be similar to those experienced by individuals with PAWS [(5,6)].
- Benzodiazepine withdrawal syndrome is typically characterized by a range of symptoms, including rebound anxiety and insomnia, and can occur after prolonged treatment with therapeutic doses 6.
Conceptualization and Renaming
- PAWS has been conceptualized in various ways, including as a form of post-traumatic stress disorder, learnt helplessness, or depressive devitalisation 7.
- A neurobiological explanatory model based on autonomic system hyper-arousal has been proposed, and a new name for the condition has been suggested to reflect a more sophisticated understanding of the disorder 7.
Clinical Implications
- It is essential for healthcare professionals to be aware of PAWS and have some insight into the most helpful approaches, including validating the experiences of young people and providing emotional support 4.
- Staff should be able to talk and reflect on their feelings to understand and manage their responses to young people with PAWS 4.