Post-Acute-Withdrawal Syndrome (PAWS): An In-Depth Guide
In the first days and weeks following cessation of drug and alcohol use, individuals may experience acute withdrawal symptoms, which can be more severe for some than others and will vary depending upon the drug of choice among other factors.Withdrawal syndrome refers to the symptoms that occur when a substance-dependent person abruptly stops taking that substance. Both illicit and prescription drugs can cause withdrawal. It may last anywhere from a few days to a couple weeks. Doctors will usually work with their patients to manage withdrawal symptoms. However, people who struggle with addiction and substance abuse are likely to experience withdrawal symptoms if they attempt to stop taking the drug on their own or if they are unable to acquire the drug.
Although withdrawal symptoms are uncomfortable, they typically end after two weeks at most, especially when a medical professional oversees the detox process. However, some drugs can lead to prolonged or protracted withdrawal, lasting for months and sometimes up to a year. People who consume a large amount of an intoxicating substance for a long time are more likely to develop this condition, which is called post-acute withdrawal syndrome (PAWS).
The term was created to describe the cluster of ongoing withdrawal symptoms, which are largely psychological and mood-related, that can continue after acute withdrawal symptoms have gone away. Although post-acute withdrawal rarely involves aches and pains, nausea, cramping, headaches, or other physical symptoms, it can be just as intense as acute withdrawal and still puts a person at risk of relapse, as they may return to drug use in an attempt to stop the discomfort.
What Is PAWS?
PAWS refers to any symptoms that persist after acute withdrawal has resolved. It 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 a year. These symptoms can occur with any intoxicating substance, although post-acute withdrawal syndrome most often occurs among people discontinuing the following drugs:
- Alcohol: Though people have struggled to end alcohol addiction for much longer, the symptoms of PAWS were first defined for alcohol use disorder in the 1990s. Suddenly stopping alcohol consumption is dangerous, since it can cause delirium tremens (including seizures and psychosis) and can also increase the likelihood of PAWS (e.g., long-term cravings, exhaustion, and feeling ill).
- Antidepressants: While few people abuse these drugs recreationally since they do not cause a rapid intoxication, stopping them suddenly can dramatically change the levels of serotonin and other neurotransmitters in the brain. Since people who struggle with depression are prescribed antidepressants, acute withdrawal will feel like intense depression; unfortunately, this experience could continue for months.
- Antipsychotics: These drugs bind to dopamine receptors to decrease hallucinations and delirium. When they are discontinued, especially without a taper, the person could experience withdrawal symptoms like mood swings for months.
- Benzodiazepines: Although these medicines help people with anxiety and panic disorders, they are very easy for the brain to develop a dependence on. Most prescriptions do not cover more than two weeks of regular use because they can be addictive. Withdrawal symptoms mimic panic disorders, making it harder to stop taking them. PAWS symptoms, like insomnia, fatigue, and cravings, can last for months after the physical dependence has ended.
- Marijuana: Many people become reliant on marijuana to relax and feel normal; when they stop taking the drug, they can feel stressed, depressed, and paranoid. One of the most common withdrawal symptoms is insomnia, and without medical help, this could persist and become PAWS.
- Opioids: Whether prescription opioids or illicit versions like heroin, these drugs can lead to post-acute withdrawal syndrome if they are not tapered off properly. People who experience the full intensity of acute withdrawal are more likely to develop PAWS, which includes cravings, exhaustion, and cognitive impairment that does not go away for a long time.
- Stimulants: Drugs from Ritalin to cocaine can cause post-acute withdrawal syndrome if withdrawal is not managed appropriately. Although a person taking stimulants may experience negative side effects like paranoia, twitching and tremors, and aggression, the opposite symptoms – extreme fatigue, deep depression, and physical weakness – can be harder to manage psychologically.
As acute withdrawal symptoms fade, PAWS may be an issue for people in recovery. These symptoms, too, will vary in characteristic and degree based upon a number of factors. In general, however, many clients in recovery report experiencing some or many of the following post-acute withdrawal symptoms:
- Irritability and hostility
- Mood swings
- Low energy and fatigue
- Sleep disruption, including insomnia
- Limited ability to focus or think clearly
- Lack of libido
- Inexplicable chronic pain
Physical and Psychological Issues That Exacerbate PAWS
The following is a list of conditions that tend to inform and/or worsen the experience of post-acute withdrawal symptoms:
- The drug or drugs of choice
- How long, how frequently, and how much of these substances the person uses regularly
- Acute emotional issues that arise during the first year or years of recovery
- Co-occurring physical and/or mental health conditions
- The support provided by substance abuse treatment professionals
In addition to the post-acute withdrawal symptoms listed above, those in recovery from specific drugs may also, or instead, experience various issues, as outlined below:
- Marijuana: A number of studies support the existence of acute as well as post-acute withdrawal symptoms during marijuana detox. One study suggests that sleep disruption including intense dreams may persist up to 45 days or longer.
- Cocaine: Impulse control continued to be a struggle for study participants after four weeks of sobriety, according to a study published in the journal Drug and Alcohol Dependence.
- Methamphetamine: Long-term issues with executive control function were shown to be a persistent issue for people in recovery from methamphetamine abuse, according to a study published in the journal Addiction.
- Opiates: There are a number of post-acute withdrawal symptoms that have been reported in the weeks and months following opiate detox, including sleep disruption, anxiety, and depression, as well as decreased executive control functions.
- Benzodiazepines: People in recovery from benzodiazepine abuse and addiction often struggle with reemergence of the symptoms that originally created the need for the prescription in addition to post-acute withdrawal symptoms. Any new symptoms that occur during the post-acute detox period are generally identified as post-acute withdrawal, even if they occur after a long period of being asymptomatic. For example, extreme anxiety, panic, and symptoms that often look like other mental health disorders may wax and wane during the months following detox but gradually dissipate as long as abstinence is maintained.
Theories of Post-Acute Withdrawal Syndrome’s Causes
PAWS is a complex syndrome with no one specific cause. There are no clearly defined timelines for post-acute withdrawal symptoms. Some clients will not experience any significant issues following acute detox while others will experience ongoing post-acute withdrawal symptoms for years, and still others will have periods of being symptomatic followed by periods of being symptom-free. With personalized care and long-term support in recovery, clients can learn to manage post-acute withdrawal symptoms as they arise and remain active and successful in sobriety.
Psychologists and doctors do not agree completely on reasons for the condition, but many suggest that stress response and changes to that area of the brain during the course of addiction may contribute to the development of PAWS. However, the stress response can be triggered for any number of reasons. Theories about the causes of PAWS include:
Homeostatic adjustment: A person’s physical dependence on drugs or alcohol leads to brain chemistry changes over time; when the body does not have the chemical flowing in, triggering neurotransmitters and endorphins to release, it cannot reach equilibrium on its own. The brain can take a long time to completely reach homeostasis without chemical help, and this can manifest in mood swings, exhaustion, cravings, and other psychological signs during PAWS.
Physiological adaptations: Other parts of the body may be used to an influx of drugs to regulate functions like digestion or hormones. Withdrawal symptoms reflect this – for example, nausea, stomach cramps, and diarrhea are common opioid withdrawal symptoms – but sometimes, these can take longer than two weeks to return to normal. For example, heart rate may be more rapid after overcoming an addiction to CNS depressants.
Stress: It is psychologically stressful to stop taking a drug, especially for people who try to do it cold turkey or alone. This stress may lead to relapse, or it could lead to a prolonged experience of withdrawal symptoms, as the individual tries to make sense of life without drugs or alcohol.
Habit: Part of rehabilitation is to retrain behaviors and responses to drugs or alcohol. Recovering heroin addicts mention the ritual of cooking and injecting the drug, while people who overcame alcohol use disorder note the loss of social situations. Returning to habit leads to relapse, but the loss of the habit or tradition can enhance psychological symptoms like depression, cravings, anxiety, or exhaustion, leading to PAWS.
Controversy around the Syndrome
While many people may experience PAWS, it is not an official medical diagnosis. There is published research regarding PAWS, but the symptoms are largely self-reported by the people experiencing them. They are hard to measure, more like a mental health condition than an illness like the flu. Because PAWS does not have a medical definition – acute withdrawal is recognized by the medical community – the syndrome is considered controversial.
Some people believe that PAWS is an excuse when a person in recovery relapses. Others believe the medical community invented the concept in order to make more money through long-term treatment. A few rare practitioners believe that PAWS is just withdrawal, arguing that the condition should be measured in months instead of weeks. The lack of consensus on what the syndrome is and how to best treat it makes it difficult to engage with.
There is growing concern about prolonged experiences of withdrawal, leading to more understanding and investigation of this condition.
How Is PAWS Treated?
Because PAWS symptoms are largely psychological and emotional, ongoing support from therapists and counselors is important in reducing the intensity of this experience. Here are steps medical professionals may take to help their clients:
- Educate clients about withdrawal and what to expect for recovery.
- Celebrate every accomplished step in the process.
- Encourage patience.
- Find natural ways to help with sleep problems.
- Prescribe exercise and healthy diet.
- Assess potential co-occurring disorders, which may emerge or re-emerge.
- Encourage joining mutual support groups.
- Help to manage impulse control.
- Take self-reported symptoms seriously.
Some medicines may help with specific drugs. For example, naltrexone is available to reduce cravings in people who are overcoming alcohol or opioid addiction. Antidepressants may help to stabilize mood for many people overcoming struggles with stimulants or psychoactive drugs. The risk of experiencing PAWS can be reduced by receiving professional detox, enrolling in a rehab, and receiving ongoing support and treatment well after initial substance abuse treatment has ended.
The professional detox services at AAC can help to mitigate the experience of acute and post-acute withdrawal symptoms in clients and reduce the risk of relapse during this critical period of recovery. Through medical detox and long-term therapeutic intervention and support in recovery, clients will have access to the resources they need to effectively manage PAWS.