What is Post-Acute Withdrawal Syndrome (PAWS)?

Most people know about acute drug or alcohol withdrawal symptoms, which occur very soon after substance use has been stopped and the body detoxifies. Acute withdrawal is often very uncomfortable and can be hard to overcome on one’s own. In the case of alcohol withdrawal, it can sometimes be dangerous or fatal because of the risk of seizures. However, once acute withdrawal is complete, the journey to full recovery is often not completely over. After this initial stage of withdrawal, post-acute withdrawal syndrome (PAWS) can occur, and can sometimes cause a person to return to substance use if they are not properly prepared.

PAWS is sometimes also referred to by different terms, including:

• Protracted withdrawal
• Long-term withdrawal
• Subacute withdrawal
• Chronic withdrawal
• Extended withdrawal

What Is Post-Acute Withdrawal Syndrome?

Post-acute withdrawal syndrome is a set of symptoms that can occur after the initial detox phase of recovery from alcohol use disorder or other substance use disorders. Not every person who is in recovery from a drug or alcohol use disorder will experience PAWS. Symptoms of PAWS can be quite uncomfortable, so those who experience it may have a difficult time staying sober, especially if they are not prepared for the possibility of its occurrence.

Acute withdrawal usually lasts a week or two, depending on the individual. However, symptoms of PAWS may start and stop periodically, and might return after several months, and can last any amount of time. PAWS can cause a lot of emotional and mental distress, which can sometimes be very difficult to overcome. If a person in recovery is aware of the possibility of post-acute withdrawal symptoms and knows some of the common causes, they can better prepare themselves to deal with these symptoms if they do occur.

PAWS can last for weeks or months after substance use is stopped, and may not even occur in some people. Those who have used substances heavily and for longer periods are more likely to experience PAWS. The symptoms of PAWS occur as the brain and body heal, and the person adjusts to substance-free living.

PAWS Signs and Symptoms

Although symptoms of PAWS varies from person to person and depends on the substance that was previously being used, it has some common manifestations. Some people don’t experience post-acute withdrawal syndrome at all, and some experience very severe forms of it. PAWS symptoms tend to occur in waves and last for short or long periods with each wave.

Some common symptoms of PAWS are:

• Decreased energy
• Concentration problems
• Attention difficulties
• Memory problems
• Sleep problems
• Changes in appetite
• Anxiety
• Irritability
• Depression
• Anger
• Impulse control problems
• Mood swings

Causes of PAWS

In general, PAWS occurs after a substance that the brain and body has become dependent on is taken away. This syndrome is complex and not fully understood, and the actual mechanisms that cause PAWS depend on what substance or substances were being used. Since different substances have different effects on the brain, removing those substances will have different withdrawal symptoms, including PAWS symptoms.

For many people with substance use disorder, the initial reason for the development of addiction is the influence of dopamine in the brain. Dopamine is a feel-good neurotransmitter involved in many neurological processes associated with addiction, especially the reward system in the brain. Dopamine is a contributor to overall mood, and if the brain is getting a dopamine rush from substance use, it will stop producing its own dopamine. Once substance use is discontinued, the lack of dopamine reserves can cause a person to feel moody, depressed or sad.

Drug Classes Associated With PAWS

• Alcohol: Due to changes in the brain that occurred during alcohol use disorder, long-term sobriety can be difficult. As the brain recovers and adjusts to an alcohol-free lifestyle, PAWS symptoms can be uncomfortable and stressful.
• Benzodiazepines: PAWS symptoms during recovery from benzodiazepine use often include anxiety, agitation or panic. Since benzodiazepines work to depress the nervous system, once they are not present in the body, nervous system activation can occur.
• Opioids: PAWS symptoms related to opioid use recovery can include fatigue, moodiness, irritability and sleep disturbances. In some cases, issues with cognitive function and decision-making abilities may also be experienced. Many people also feel increased sensitivity to pain and difficulty experiencing pleasure during opioid-related PAWS.
• Stimulants: During recovery from stimulant use disorder, PAWS symptoms can include sleep difficulty and problems with cognitive function like mental fog.
• Cocaine: Impulse control problems are a common component of PAWS during recovery from cocaine use disorder.
• Antidepressants: PAWS symptoms related to antidepressant recovery can include agitation and mood problems. This is likely due to changes in brain chemistry that occurs after stopping antidepressant use.

How Long Does PAWS Last?

PAWS symptoms can occur in some people for up to two years after substance use has stopped. Most of the time, PAWS symptoms are not persistent, and they come and go for brief periods. For most people, these symptoms eventually resolve completely.

Challenges of Post-Acute Withdrawal Syndrome

It can be difficult to deal with PAWS, especially if someone is under the impression that the initial detox process and acute withdrawal is the only hard part of substance use recovery. It is important to be aware of the possibility of PAWS and to have solutions in place to keep it from being debilitating. The most important thing to know about PAWS is that sometimes it can be a trigger for substance use relapse since it can increase the desire to start using the substance again. It may be difficult to deal with the symptoms of PAWS, but if one is prepared and patient, they will eventually subside and go away completely.

Treatment for PAWS

Working with a certified addiction treatment professional and having a long-term recovery plan can often help people be prepared for the possibility of post-acute withdrawal syndrome symptoms. Developing a daily routine without substance use and knowing that recovery is difficult, but not impossible, can help when PAWS symptoms occur. Knowing that symptoms will not last forever, and will eventually become more bearable can help, even though these symptoms may be intense and uncomfortable.

If someone is receiving professional treatment for their substance use disorder, a major part of most recovery plans includes solutions to help if and when PAWS occurs. Focusing on small improvements and realizing that full recovery is within reach can help a person cope with PAWS symptoms. Maintaining a good diet, healthy sleep habits and attending individual or group therapy can help cope with PAWS as well.

The Recovery Village Ridgefield can help in the road to recovery. It’s never too late to seek help. Contact us today and speak with an addiction specialist to learn more about treatment options for your recovery.