Post-Acute Withdrawal Syndrome (PAWS): Symptoms, Causes, & Treatment

What Is Post-Acute Withdrawal Syndrome?

Post-acute withdrawal syndrome (PAWS), prolonged withdrawal syndrome, or protracted withdrawal occurs after abstinence from a substance. PAWS symptoms persist for months or even longer, resembling those of many mood and anxiety disorders.^3,4

Dependence and tolerance to a substance develop with prolonged use, meaning the desired effect gradually decreases. The brain and nervous system adjust to accommodate prolonged use, and people ultimately continue using a substance to “feel normal.” Cessation causes immediate physiology compromise, affecting blood pressure, heart function, and emotion. With higher dosages, PAWS symptoms can be more intense after abstinence.

Though post-acute withdrawal syndrome may occur after detoxifying from a psychoactive substance, it most commonly develops after cessation of alcohol, benzodiazepines, and opioids.⁵ Research states that roughly 90% of individuals recovering from opioid addiction and 75% of recovering alcoholics will experience PAWS at some level.¹

Symptoms of Post-Acute Withdrawal Syndrome

Post-acute withdrawal syndrome symptoms are primarily emotional and psychological, unlike the physical symptoms of acute withdrawal. Physiology differs across populations, so individual experiences with PAWS vary. However, common PAWS symptoms include increased anxiety, irritability, and stress.

Common symptoms of PAWS may include:

• Anxiety
• Panic attacks
• Depression
• Insomnia
• Lack of motivation
• Mental fatigue
• Impulsivity
• Apathy
• Chronic pain
• Difficulty concentrating
• Irritability
• Obsessive-compulsive behaviors
• Interpersonal challenges
• Increased sensitivity to stress
• Dry drunk behaviors

Substance-Specific PAWS Symptoms

Protracted withdrawal symptoms vary based on various substance-specific factors. People can experience PAWS from alcohol and other drugs, so symptom differences stem from the addiction potential, unique chemical structure, and effects of the substance.

Substances that may cause severe PAWS symptoms include:

Opioids

The link between PAWS and opioid use is most significant, especially if individuals struggle with opioid addiction. Research shows that about 90% of those in recovery from opioid abuse will experience PAWS symptomatology.¹ Opioid use affects executive control in the prefrontal cortex, which leads to impaired concentration and judgment.

PAWS symptoms of opioid cessation may include:⁶

• Anxiety
• Depression
• Fatigue
• Increased blood pressure
• Irritability
• Menstrual disruptions
• Quicker breathing
• Sleep problems
• Weight gain

Alcohol

Post-acute withdrawal from alcohol abstinence can result in numerous complications, many resembling typical alcohol and anxiety symptoms. With PAWS, individuals may struggle to fall and stay asleep. This factor will contribute to compromised executive function and mood. In combination, recovery becomes more challenging.

PAWS symptoms of alcohol cessation may include:⁶

• Anxiety
• Anger and aggression
• Cognitive struggles
• Compromised coordination
• Depression
• Dizziness
• Increased pain
• Irritability
• Low energy
• Lowered libido
• Mild tremors
• Mood swings
• Sleep problems

Methamphetamine

Methamphetamine is among the most addictive substances, and many people battle meth addiction. Given the intensity of methamphetamine, many users who discontinue experience post-acute withdrawal symptoms, some of which are severe.

Generally, symptoms begin within one or two days of termination and last up to a month, possibly resurfacing four to eight weeks after detox.⁷ Within this time, symptoms may ebb and flow. However, the experience is unpleasant.

PAWS symptoms of methamphetamine cessation may include:

• Anhedonia
• Anxiety
• Cognitive problems
• Depression
• Fatigue
• Hostility
• Ineffective executive functions
• Intense cravings
• Mood swings
• Sleep problems
• Stress

Marijuana

Individuals who misuse marijuana or suffer from marijuana addiction can experience post-acute withdrawal syndrome. Although marijuana PAWS symptoms are often less intense than other substances, post-acute withdrawal is possible. Traditional acute withdrawal typically lasts up to five days, but PAWS may last longer than a month.^6,8 There is a strong link between marijuana and anxiety symptoms, poor sleep, and appetite.^5,9

Cocaine

Like other substances, protracted withdrawal symptoms from cocaine are typically most severe during the acute detox phase.¹⁰ PAWS symptoms tend to rise and fall, sometimes abruptly.

PAWS symptoms of cocaine cessation may include:¹⁰

• Anxiety
• Chronic pain
• Decreased libido
• Difficulty focusing
• Difficulty thinking
• Depression
• Fatigue
• Hostility
• Insomnia
• Low energy
• Mood swings

Benzodiazepines

Individuals discontinuing benzodiazepines experience PAWS at a rate similar to that of alcohol.⁶ Symptom rebound may occur, with previously subdued symptoms returning. Symptoms of a mental health condition previously treated by benzodiazepines may also re-emerge.

PAWS symptoms of benzodiazepine cessation may include:⁶

• Anxiety
• Depression
• Dizziness
• Headaches
• Panic attacks
• Tinnitus

What Causes Post-Acute Withdrawal Syndrome?

The precise mechanism leading to post-acute withdrawal syndrome is still unknown, though changes in neurotransmitter activity due to prolonged drug use could potentially be a predisposing factor.¹ People experiencing PAWS or similar must call attention to and treat long-term withdrawal symptoms accordingly.

Risk factors that can increase the chances of post-acute withdrawal syndrome include:^6,7,11,12

• Co-occurring psychiatric issues
• Environmental conditions and stressors
• Family history of addiction and dependence
• Increase in alcohol consumption before cessation
• Pre-existing medical conditions
• Previous experiences with substance withdrawal
• Lack of social support
• The number of previous withdrawal episodes
• Type of substance used

Does PAWS Result in Relapse?

Given that post-acute withdrawal syndrome warrants further research, some consider the condition “an excuse for relapse” to curb withdrawal.² However, this is not the case. Other factors, such as heightened stress, may leave one vulnerable to relapse. Symptoms experienced with PAWS can cause a person to relapse.

Can Post-Acute Withdrawal Syndrome Be Prevented?

Abstinence is the best way to prevent protracted withdrawal symptoms. More realistically, individuals may engage in an addiction-free lifestyle by avoiding highly addictive substances. Use alcohol and marijuana responsibly, preferably under the advice of a medical professional. Take prescribed medication as directed by a physician to limit the risk of addiction.

How to Cope With Post-Acute Withdrawal Syndrome

Post-acute withdrawal syndrome is highly unpredictable as durations, types, and severity of symptoms vary by person and substance. The biggest challenge is getting past the discomfort and not relapsing if PAWS occurs.

When the onset of PAWS symptoms becomes noticeable, it is time to take immediate action. Enact coping skills, utilize support systems, or speak with a professional. Withdrawal symptoms will pass. Relapse only extends the process, making it more challenging to maintain a recovery effort.

The following are tips to help you better manage PAWS symptoms: 

• Practice self-care: An intentional and consistent self-care routine helps individuals remain balanced during stressful times. Rather than the bottom falling out when times get rough, this balance yields resilience and keeps you on track.
• Exercise regularly: Physical activity naturally floods the body with relaxing neurotransmitters and hormones, helping to enhance physical health and self-esteem.
• Start a journal: Writing your thoughts down is cathartic, as it adds a layer of processing in reflection. Delving deeper helps you become more self-aware of your struggles with substance use.
• Use relaxation techniques: Relaxation strategies, such as progressive muscle relaxation (PMR), activate the parasympathetic nervous systems and calm the body.
• Maintain proper sleep: Proper sleep is ideal and provides sufficient time to engage in REM sleep and reset your system. Cell rejuvenation is most significant when recovering from PAWS.
• Find a support group: Finding the right support group can make a significant difference. Here, individuals exchange stories, hold one another accountable, affirm each other, and share helpful resources.
• Avoid caffeine: Caffeine agitates physiology, potentially leading to a heightened stress response and difficulties relaxing. Minimizing or eliminating intake will further support other relaxation strategies.
• Focus on purpose: People who lack a sense of purpose flounder. Finding meaning in something—regardless of how small—may serve as a motivating force in recovery.
• Avoid triggering stimuli: Avoiding stressful situations, abusive people, and negativity is beneficial.

Treatment for PAWS

The sooner you seek professional help and treatment for post-acute withdrawal syndrome, the better. Addictions are pervasive and intensify over time without intervention. Though PAWS results from prolonged post-detox withdrawal, symptoms may lead to relapse and further feed the addiction cycle.

Focus on a concerted, ongoing holistic recovery effort. Given that this process can be extensive, especially at first, help from medical professionals and social support can keep you on track. In this case, many individuals opt for outpatient therapy, which may encompass therapy and medications to help manage adverse PAWS symptoms.

Therapy

The best therapeutic interventions are as holistic as possible, addressing impairments along the mind-body-spirit pathway and considering strengths and areas of improvement. Cognitive behavioral therapy (CBT) is often a frontline therapeutic approach, as the therapist and patients work together to find maladaptive beliefs and values impairing perception and responses. Patients can find relief through exploration, processing, and behavioral experiments.

Additional treatment options for PAWS include:

• Dialectical behavioral therapy (DBT)
• Person-centered therapy (PCT)
• Psychoanalysis
• Reality therapy
• Multimodal therapy

Medication

There are no medications designed to treat post-acute withdrawal syndrome. However, some individuals benefit from prescriptions that treat specific symptoms, co-occurring mental health disorders, or pre-existing medical conditions. Prescribing physicians specializing in mental health and addiction disorders should monitor medications.

Medications that may help treat symptoms of post-acute withdrawal syndrome include:

• Anti-anxiety medications
• Antidepressants
• Acamprosate
• Methadone
• Buprenorphine

Final Thoughts

Post-acute withdrawal syndrome (PAWS) is a severe condition. Taking measures and reducing your drinking or drug use is crucial in preventing the need for emergency medical services. Seek help from a medical professional if you need assistance cutting back. If you believe you or a loved one has PAWS, support is available to curb symptoms and reduce the risk of relapse. It all begins by educating yourself and reaching out for help.