Post Acute Withdrawal Syndrome

Shlomo Hoffman
Medically Reviewed by
Dr. Jefferey A. Berman MD, DFASAM
Last Updated
July 29, 2022

Part of the complete guide to understanding addiction

Table of Contents
  1. Post Acute Withdrawal Syndrome
  2. What does PAWS mean?
  3. Diagnosing PAWS
  4. What causes PAWS?
  5. Post Acute Withdrawal Symptoms
  6. How long does PAWS last?
  7. Post Acute Withdrawal by Substance
  8. PAWS Treatment Options
  9. Paws Medications
  10. Conclusion
  11. Sources

Post Acute Withdrawal Syndrome

The road to sobriety is difficult, and for many people detox is just the start of recovery. Post-acute withdrawal syndrome is a condition that affects many recovering addicts. Approximately 90 percent of opioid users and 75 percent of alcohol and psychotropic users experience prolonged withdrawal. It is most common amongst those in recovery from substances such as alcohol, benzodiazepines, and opioids, but is also experienced by those recovering from other substances. Amongst the public, PAWS is not a well-known condition and many substance users do not expect to experience it before beginning recovery. However, amongst addiction specialists and the recovery community, it is a well documented and often reported syndrome.

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What does PAWS mean?

When a patient stops taking a substance it is common for acute withdrawal symptoms to occur while detoxing. These symptoms vary depending on the substance used and individual factors. The term post-acute withdrawal syndrome was created to describe when a patient experiences a cluster of symptoms after the period of acute withdrawal. These symptoms are often mood-related and psychological and are generally not physical as acute symptoms are. However, they can be as distressing to deal with and overcome. [1]

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Diagnosing PAWS

There is still no official diagnosis for PAWS, and it has not been recognized on the DSM-5. This is because of a lack of scientific research and recent studies. It is also challenging to diagnose PAWS 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.

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What causes PAWS?

There is still much debate amongst scientists about the cause of PAWS, as well as why some patients experience it and not others. However, scientists do have some theories as to what the possible cause may be.

Some of the probable causes are.

  • Homeostatic adjustment: When a patient becomes physically dependent on a drug 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 in the meantime.
  • Physiological adaptations: The body will get used to 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.
  • Stress: When an individual gets accustomed to taking drugs it is stressful to stop, especially if they do it cold turkey or alone. This stress can cause prolonged symptoms of withdrawal.
  • Habit: There is a lot of habits reported around drug use, such as cooking or socializing. Returning to these habits may cause relapse, however, the absence of them can cause long-term psychological symptoms.

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Post Acute Withdrawal Symptoms

The symptoms of PAWS may feel like those of an anxiety or mood disorder. Symptoms can range from mild to severe depending on the individual.

Some of the common 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

Symptoms can fluctuate, even completely disappearing for a time and then reappearing unexpectedly. [2]

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How long does PAWS last?

Although it varies by individual, symptoms tend to last anywhere between six months to two years. Receiving the proper treatment and medical oversight for PAWS will allow one to manage and mitigate negative symptoms. Some individual factors can play a role in how long and severe symptoms of PAWS last.

Factors That Effect PAWS

These factors can increase the likelihood of experiencing PAWS and exacerbate symptoms.

  • Substance that was misused
  • Duration and frequency that the substance was taken
  • Emotional issues
  • Physical or mental illnesses

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Post Acute Withdrawal by Substance

The substance used will often determine whether PAWS will occur. Although, it can occur with any substance the substances below are most linked with symptoms of PAWS.

  • Alcohol: Long-term symptoms from alcohol can be 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 PAWS occurring.
  • Antidepressants: Although they are not commonly misused recreationally, stopping to take antidepressants suddenly can cause symptoms of intense depression for longer periods.
  • Antipsychotics: If these drugs are discontinued, a person can experience mood swings for months.
  • Benzodiazepines: These drugs are extremely easy for the brain to become dependent on. Prolonged 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. It can also cause 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 PAWS.
  • Stimulants: PAWS can be caused by these drugs if withdrawal is mismanaged.

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PAWS Treatment Options

A person can feel hopeless and distressed from PAWS symptoms, which can cause relapse. Therefore, it is important that those in recovery are educated in the symptoms of PAWS.  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 symptoms of PAWS and avoid relapse.

Some strategies are.

  • Support System: Having a support system in place 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 help them through the process.
  • Avoid High-Risk Situations: When someone is in recovery, they should avoid triggers that are associated with drug use.
  • Coping Skills: Learning coping skills to deal with stressors and symptoms can help someone deal with the effects of PAWS. Cognitive therapy can help teach someone effective coping strategies and how to have positive thought patterns.
  • Treatment: Treatment can help prevent relapse because of PAWS symptoms. A strong support system, medical assistance, a safe place, and therapy treatment can prevent relapse.
  • Education: Knowing what to expect can help individuals deal with the symptoms that arise.

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PAWS Medications

Since symptoms can last a while, medications that used are usually administered over time. Acamprosate is usually used for alcohol withdrawal and was found to possibly be helpful for PAWS symptoms. Naltrexone can be used to curb cravings. Antidepressants may be prescribed to help with mood-stabilizing.

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It takes time and patience, for the brain and body 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 possible.

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