Post-Acute Withdrawal Syndrome (PAWS): What Is PAWS?

2 min read · 4 sections
Withdrawal is the body's physical and mental response following the sudden discontinuation or drastic decrease in alcohol or drug consumption.1

In the first days and weeks following cessation of drug and alcohol use, individuals may experience acute withdrawal symptoms, usually referred to as withdrawal symptoms, which range from mild to severe, depending on the substance, the frequency, duration, and quantity used.1,2

Alcohol and illicit and prescription drugs can cause withdrawal symptoms, which, depending on the substance can last few days or several weeks.3

Some drugs, however, can lead to a protracted withdrawal phase, defined as substance-specific and non-substance-specific signs and symptoms common to acute withdrawal, but persisting, evolving, or appearing well past the general acute withdrawal timeframes, lasting for several months and sometimes a few years.2,3

Healthcare providers can help individuals manage withdrawal symptoms and should be consulted before stopping a substance on your own, which can lead to dangerous, potentially life-threatening complications, depending on the substance.1

Withdrawal symptoms can be daunting, uncomfortable, and in some cases dangerous. If you or a loved one is experiencing withdrawal symptoms it is important that you seek medical treatment. At American Addiction Centers (AAC), we are here to help. Our healthcare team of medical professionals will support you through your withdrawal process safely with a treatment plan that is unique to you. If you would like to learn more about our treatment programs and how we can help with your withdrawal, give us a call today at .

What Is PAWS?

Post-acute withdrawal syndrome (PAWS) was a phrase first used more than 20 years ago to describe a phenomenon of relatively milder, but persistently troublesome withdrawal symptoms that lingered in some individuals who had discontinued benzodiazepine therapy.

At some point, the concept of PAWS became overgeneralized to describe any type of protracted course of withdrawal symptoms across the spectrum of substance types. It has since become largely uncommon in medical literature, though the term remains online, despite not having much authoritative information behind it.

Chronic substance use can change the molecular, cellular, and neurocircuitry in the brain that affect emotions and behaviors and can persist after the acute withdrawal symptoms end.2

The research on protracted withdrawal (especially for substances other than alcohol) signs and symptoms is scant. While there have been some clinical observations, the evidence is mostly anecdotal but indicates the following.2

  • Alcohol: Protracted withdrawal from alcohol is actually well documented. Common symptoms include anxiety, hostility, irritability, depression, mood changes, fatigue, insomnia, problems concentrating and thinking, decreased sex drive, and unexplained physical pain. Anecdotal evidence indicates that symptoms can last 2 years or longer after the last drink. Sleep studies suggest that sleep problems can persist 1-3 years after alcohol consumption stops.
  • Benzodiazepines: Benzodiazepine protracted withdrawal is difficult to distinguish from symptom rebound, a common aftereffect of prolonged benzodiazepine use, where intensified withdrawal symptoms, such as anxiety, insomnia, and restlessness return, then subside a few weeks later. Protracted withdrawal symptoms, on the other hand, tend to ebb and flow, be new (not the re-emergence of a symptom) and last for months but subside with continued abstinence.
  • Marijuana: Several studies indicate that sleep difficulties and strange dreams persisted for more than a month after stopping the use of marijuana.
  • Opioids: There are a number of protracted withdrawal symptoms that have been reported in the weeks and months following opiate detox, including sleep disruption, anxiety, and depression, as well as fatigue, feeling down, irritability, and decreased executive control functions.
  • Cocaine: One study found that impulse control continued to be a struggle for study participants after four weeks of abstinence.

While protracted symptoms vary by substance, some of the commonly reported protracted withdrawal symptoms include:2

  • Irritability and hostility.
  • Depression.
  • Anxiety.
  • Low energy and fatigue.
  • Sleep disruption, including insomnia.
  • Memory problems.
  • Limited ability to focus or think clearly.
  • Cravings.
  • Impaired executive control.
  • An inability to feel pleasure.
  • Difficulty focusing on tasks.
  • Lack of libido.
  • Inexplicable chronic pain.

What Causes Protracted Withdrawal?

Due to a lack of scientific evidence, protracted withdrawal and its causes are not well-documented.

A person’s physical dependence on drugs or alcohol can lead to brain chemistry changes. When someone suddenly stops using the substance, the brain no longer has the chemical to trigger neurotransmitters and endorphins to release. The brain must re-adjust to being without the substance, and the brain can take time to adjust. Adaptive changes in the central nervous system can lead to affective changes that persist beyond withdrawal.2

Diagnosis of PAWS

Despite clinical observations and anecdotal reports of the symptoms experienced by some beyond the acute withdrawal stage, protracted withdrawal, as a diagnosis, has been excluded from the “Diagnostic and Statistical Manual of Mental Disorders.”2 The lack of consensus on what the syndrome is and how to best treat it makes it difficult to screen, diagnose, and discuss.

How Is Protracted Withdrawal Treated?

Relapse continues to be a concern for individuals who may experience protracted withdrawal symptoms since they may want to alleviate those symptoms by returning to substance misuse.2 Therefore, after completing a formal treatment program, long-term recovery is sustainable with participation in an aftercare or continuing care program, which may include:2

  • Education. Understanding that even after periods of symptom-free abstinence, some individuals may experience protracted withdrawal symptoms can help individuals in the early stages of recovery prepare and cope.
  • Celebration. Every accomplishment during recovery deserves recognition.
  • Visits with healthcare providers. It’s important to keep appointments with medical professionals who can consistently assess your needs through recovery.
  • Sleep. Good sleep habits help prevent sleep problems.
  • Activities. Mental and physical exercises can improve sleep, your emotional state, reduce stress, avoid triggers, and distract you from symptoms.
  • Patience. Recovery is a process and takes time. Don’t try to do too much too quickly, which can increase stress and exacerbate symptoms.
  • Medications. Some medications may be prescribed to help minimize cravings and prevent relapse.
  • Mutual-help groups. Participation in groups such as Alcoholics Anonymous or Narcotics Anonymous help support long-term recovery.
  • Therapies. Continued interventions like cognitive-behavioral therapy (CBT) can help manage impulse control and problem solving.

The professional detox, treatment using evidence-based interventions, and aftercare services offered at AAC can help to mitigate an individual’s experience with acute and protracted withdrawal symptoms and reduce the risk of relapse during recovery.

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