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eClinical Psychiatry News
April 2002 · Volume 30 · Number 4
by Damian McNamara · Miami Bureau

AMELIA ISLAND, FLA. - Protracted withdrawal from alcohol, hypnotics, psychostimulants, and other agents is a real syndrome with real treatment implications, Dr. David Cohn reported in a presentation at the annual meeting of the American Academy of Addiction Psychiatry.

"It's a very challenging and complex field," said Dr. Cohn, director of substance abuse services at Alta Bates Summit Medical Center in Berkeley, Calif. "I got interested in protracted withdrawal because I had patients who didn't get better."

He likened protracted withdrawal syndrome to the TV show "The X-Files": people know it's out there, but it is not in the books. You won't find protracted withdrawal syndrome in the DSM-IV because "psychiatrists are stuck on [the] nomenclature," he said.

Diagnosis and treatment are challenging because protracted withdrawal can mimic other psychiatric disorders.

The exact incidence of protracted withdrawal syndrome is unknown, but researchers say it affects a sizable minority of addicts and alcoholics. "And it has treatment implications," he said. "If you're not treating a protracted withdrawal that is there, [the patient] will relapse."

Protracted withdrawal syndrome can develop following chronic use of alcohol, sedative hypnotic agents, benzodiazepines, opioids, psychostimulants, and nicotine, said Dr. Cohn, who presented the case of an alcoholic man he described as a "vodka enthusiast." His withdrawal was serious enough to warrant ICU admission. He was restrained, "had tubes in every orifice," and did not leave the hospital for 48 days.

"Looking back, he had a protracted delirium," Dr. Cohn said. Protracted delirium is a physical disorder with disturbed consciousness, attention, cognition, and perception. It develops acutely and then fluctuates in most people. I've seen four cases like his since then. It's scary - no one knows what to do with these patients; they don't get better,

A particularly challenging patient is one who is withdrawing acutely from sedative-hypnotic agents. Such withdrawal is characterized by having at least two of the following symptoms: autonomic hyperactivity, hand tremor, insomnia, nausea or vomiting, transient hallucinations or illusions, psychomotor agitation, anxiety, or grand mal seizures.

"This is a group that will really test your diagnostic acumen," Dr. Cohn said.

Withdrawal from benzodiazepines features symptoms that last from days to weeks, and protracted signs may persist for months. Treatment includes a gradual dosage reduction and pharmacotherapy with antidepressants, beta-blockers, anxiolytics, and anticonvulsants. "Lingering symptoms may be mistaken for another, non–substance-induced disorder," Dr. Cohn said.

Protracted withdrawal from opioids is more easily diagnosed. Long lasting effects include craving or drug hunger; depression and other mood disorders; physiologic effects on respiratory, cardiac, and endocrine systems, among others; and behavioral disturbances. "Opioid-related disorder should be a separate state," Dr. Cohn said. "There is a big association with mood disorders."

A study cosponsored by the National Institute on Drug Abuse and University of California, Los Angeles, is underway to determine if protracted withdrawal syndrome occurs after chronic methamphetamine use. The methamphetamine study will evaluate occurrence of panic and anxiety disorders, as well as long-term neurologic effects, such as movement disorders.

There is some evidence that sensitization and kindling occur with psychostimulants. Someone with cocaine-induced psychosis may experience it repeatedly with subsequent drug use. Most acute withdrawal symptoms from nicotine use disappear in 4 weeks, but weight gain and craving can occur up to 2 years after cessation.

"The old thinking was that protracted withdrawal syndrome was a remnant of something else, but why can't it be a new disorder?" Dr. Cohn asked. There is evidence with psychostimulant medication that de novo symptoms appear that were never there before.

Future studies, including some evaluating basic neuroscience, are needed to effectively identify and treat protracted withdrawal, he said.

Protracted Withdrawal Defined

Protracted withdrawal syndrome has many names, Dr. Cohn said. These names include:

  • Protracted abstinence syndrome.

  • Postacute withdrawal state.

  • Extended withdrawal state.

  • Chronic withdrawal syndrome.

He defined protracted withdrawal syndrome as a set of signs and symptoms that persist, evolve, or appear beyond an expected time frame for acute withdrawal syndrome. In most cases, acute alcohol withdrawal is complete within a week to 10 days, but protracted withdrawal can last from months to years, he said. Some symptoms of acute withdrawal that overlap with the protracted state include anxiety, depression, insomnia, cognitive deficits, and autonomic symptoms, such as a feeling that one has "rubber legs."

Most definitions of protracted withdrawal syndrome include at least the following four features:

  • Structural damage.

  • Lingering drug effects.

  • Psychological components.

  • Reversal of neuro-adapted cellular, molecular, and system functions.

Protracted withdrawal is further characterized by depersonalization, derealization, gastrointestinal disorders, and CNS motor and sensory disturbances, including tinnitus.

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