Post Acute Withdrawal Syndrome (PAWS): What You Need to Know

By
Shlomo Hoffman
Medically Reviewed by
Dr. Jefferey A. Berman MD, DFASAM
Last Updated
June 28, 2023

Part of the complete guide to understanding addiction

Table of Contents
  1. What is PAWS?
  2. What Causes PAWS?
  3. Post Acute Withdrawal Symptoms
  4. Post Acute Withdrawal Symptoms by Substance
  5. How Long Does Post-Acute Withdrawal Syndrome Last?
  6. Factors That Affect PAWS
  7. PAWS Rehab Options
  8. Medications for PAWS Symptoms
  9. Diagnosing Post-Acute Withdrawal Syndrome
  10. Treatment for Post Acute Withdrawal Syndrome at Avenues Recovery
  11. Sources

For many people on the road to sobriety, detox is just the start of recovery. Post-acute withdrawal syndrome (PAWS) is a condition that affects many recovering addicts, where symptoms of withdrawal are experienced long after one has stopped using drugs or alcohol. Approximately 90 percent of opioid users and 75 percent of alcohol and psychotropic users experience PAWS symptoms. It is most common among those in recovery from substances such as alcohol, benzodiazepines, and opioids, but is also experienced by those recovering from other substances. Amongst the public, post-acute withdrawal syndrome is not a well-known condition and many substance users entering recovery do not expect to experience it. However, amongst addiction specialists and within the recovery community, post-acute withdrawal syndrome is a well-documented and often reported syndrome.

What is PAWS?

When a patient stops taking a substance it is common for addiction withdrawal to occur while detoxing. These symptoms vary depending on the substance used and other individual factors. Post-acute withdrawal syndrome means that a patient experiences a cluster of symptoms long after the period of acute withdrawal. PAWS symptoms are often mood-related and psychological, generally not physical as acute symptoms are. Post-acute withdrawal syndrome with its psychological effects can still be as distressing to deal with and overcome.

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What Causes PAWS?

There is still much debate amongst scientists about the cause of post-acute withdrawal syndrome, as well as why some patients experience PAWS symptoms and others don’t. However, scientists do have some theories as to the possible causes of post-acute withdrawal symptoms.

The following factors help explain why PAWS after alcohol and drug addiction may occur:

  • Homeostatic adjustment: When a patient becomes physically dependent on drugs or alcohol the brain will adjust itself chemically to maintain balance. It can take a while for these neuropathways to return to normal once a substance is stopped, which can cause symptoms of PAWS meanwhile.
  • Physiological adaptations: The body will become dependent on using the drug to regulate other bodily functions (aside from neurochemical functions) such as digestion and hormones. This will usually manifest in physical symptoms like nausea, vomiting, and stomachaches, which may persist past the acute withdrawal stage and into the post-acute withdrawal period.
  • Stress: When an individual is accustomed to taking drugs it is stressful to stop, especially if they do it cold turkey or alone. This stress can cause post-acute withdrawal symptoms to occur.
  • Hobbies: There are many hobbies that become associated with drug use, such as socializing with specific groups of people. Returning to these habits may cause relapse, however, the absence of them can cause long-term symptoms of PAWS.

Post Acute Withdrawal Symptoms

PAWS symptoms may feel similar to those of an anxiety or mood disorder. Symptoms can range from mild to severe depending on the individual and his/her circumstances. Additionally, symptoms of PAWS can fluctuate, even completely disappearing for a time and then reappearing unexpectedly [1]. One who is experiencing this is encouraged to seek PAWS rehab as soon as possible.

Some of the common PAWS symptoms include:

  • Difficulty performing cognitive tasks
  • Irritability, aggression, or hostility
  • Depression, sadness, and anxiety
  • Mood swings with severe highs and lows
  • Low energy
  • Fatigue or insomnia
  • Thought fog
  • Limited ability to focus
  • Lack of interest in sex
  • Chronic pain

Post Acute Withdrawal Symptoms by Substance

The substance used will often determine whether post-acute withdrawal syndrome will occur. Although PAWS, alcohol, and drugs are all related, the substances below are the ones most often linked with symptoms of PAWS.

  • Alcohol: PAWS from alcohol can be in the form of cravings, exhaustion, and feeling ill. If someone experiences the more severe acute symptoms of alcohol withdrawal such as delirium tremens, it can increase the likelihood of post-acute withdrawal syndrome occurring.
  • Antidepressants: Although they are not commonly misused recreationally, stopping to take antidepressants suddenly can cause symptoms of intense depression for longer periods after withdrawal.
  • Antipsychotics: If these drugs are discontinued, a person can experience PAWS symptoms such as mood swings for months afterward.
  • Benzodiazepines: These drugs are extremely easy for the brain to become dependent on. Post-acute withdrawal symptoms will mimic panic disorders and can include insomnia, fatigue, and cravings. It can last for months.
  • Marijuana: People can experience feelings of stress, depression, and paranoia after stopping marijuana use. They can also experience persistent symptoms of insomnia. If left untreated, it will cause post-acute withdrawal syndrome.
  • Opioids: Those that experience acute withdrawal symptoms after stopping opioid usage are more likely to experience symptoms of PAWS afterward.
  • Stimulants: PAWS symptoms can be caused by these drugs if withdrawal is mismanaged.

How Long Does Post-Acute Withdrawal Syndrome Last?

Although it varies by individual, post-acute withdrawal syndrome can last anywhere between six months to two years. Receiving medical professional oversight and PAWS rehab will allow one to manage and mitigate the negative symptoms of PAWS. Some individual factors can play a role in how long symptoms of PAWS last, and how severe they are.

Factors That Affect PAWS

These factors can increase the likelihood of experiencing post-acute withdrawal syndrome, and exacerbate symptoms:

  • Type of substance that was misused
  • Duration and frequency of the drug that was taken
  • Co-occurring mental disorders
  • Other physical or emotional illnesses

PAWS Rehab Options

Those suffering from post-acute withdrawal syndrome can feel hopeless and distressed about their situation, which can lead to a relapse. Therefore it’s important to educate those in recovery on the symptoms and meaning of PAWS, as well as the treatment options available. The first step to recovery is being diagnosed by a doctor and receiving medical treatment as needed. There are also strategies that can help one manage post-acute withdrawal symptoms and assist with creating a relapse prevention plan.

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Strategies that can help with PAWS:

  • Have A Support System: Support in recovery can help someone recognize the symptoms of PAWS. The support system should be made up of those that want to see an individual stay sober and will be supportive of them through the process.
  • Avoid High-Risk Situations: When someone is in recovery, they should avoid addiction triggers that are associated with drug and alcohol use.
  • Coping Skills: Learning coping skills to deal with stressors and symptoms can help someone deal with PAWS symptoms. Cognitive behavioral therapy (CBT) for addiction can teach effective coping strategies and how to have positive thought patterns.
  • Treatment: Treatment can help prevent relapse from post-acute withdrawal syndrome. A strong support system, medical assistance, a safe place, and therapy treatment will all be beneficial in preventing relapse.
  • Education: Being aware of what PAWS is can be extremely beneficial. When one understands the meaning of PAWS he or she will know what to expect and will be able to deal better with their post-acute withdrawal symptoms.

Medications for PAWS Symptoms

Since post-acute withdrawal syndrome can be long-lasting, the medications used are usually administered to the patient over time. Acamprosate is commonly used for alcohol withdrawal and was found to be helpful for PAWS symptoms too. Naltrexone can be used to curb cravings. Antidepressants may be prescribed to help with mood stabilizing.

Diagnosing Post-Acute Withdrawal Syndrome

There is still no official diagnosis for PAWS, and it has not been recognized on the DSM-5. This is due to a lack of scientific research and recent studies. It is also challenging to diagnose post-acute withdrawal syndrome since symptoms are psychological and mental, not physical. There is much controversy within the medical community as to whether PAWS is an actual condition. Some believe it is an extension of acute withdrawal and the timeline needs to be adjusted. Regardless, the symptoms of PAWS are experienced by many in recovery, and treatment programs for post-acute withdrawal syndrome are available.

Treatment for Post Acute Withdrawal Syndrome at Avenues Recovery

The human brain and body need time and patience in order to heal. A patient may feel worse before feeling better; however, recovery is possible! With the right support and treatment, a life of sobriety is always possible. At Avenues Recovery, we offer a variety of treatment options to help you manage and alleviate post-acute withdrawal syndrome. If you are experiencing PAWS symptoms yourself, or want to know more information about what p.a.w.s is, reach out to us today. Our experienced professionals are ready to support you through recovery and help you to get back to your best self! 

Sources

[1] sbmi.uth.edu

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