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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.
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.
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:
PAWS is a complex syndrome with no one specific cause. 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.
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.
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:
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.