Post-acute withdrawal syndrome (PAWS) is marked by persistent impairments that result after one abstains from certain substances.1 What is unique about this condition is that withdrawal symptoms last significantly longer than the traditional half-life of a given substance. PAWS is met with controversy, as there is limited research supporting its existence.2
What Is Post-Acute Withdrawal Syndrome?
PAWS is an acronym commonly used to refer to post-acute withdrawal syndrome, prolonged withdrawal syndrome, or protracted withdrawal symptoms.1 The key feature of this condition is that symptoms experienced occur over an extended duration that is atypical for the typical timeline of any given substance.
Often, withdrawal symptoms can resolve in a matter of days or weeks. With PAWS, withdrawal persists for much longer.1 Accordingly, PAWS is not typically diagnosed until prolonged symptoms are experienced for a duration of months or even longer.3 Additionally, it can be difficult to differentiate this condition from many mood and anxiety disorders, as they may share similar characteristics.4 Therefore, PAWS may not be readily apparent in the presence of co-occurring disorders.
Controversies Around PAWS
Though PAWS may occur after detoxifying from a variety of psychoactive substances, it most commonly occurs upon withdrawing from alcohol, benzodiazepines, and opioids.5 According to the University of California Los Angeles (UCLA), roughly 90% of individuals recovering from an opioid addiction and 75% of recovering alcoholics will experience PAWS at some level.1
What is interesting about this statistic–which conflicts with others claiming the condition does not exist–is that even with these numbers, the precise mechanism leading to PAWS is still unknown, though changes in neurotransmitter activity due to prolonged drug use could potentially be a predisposing factor.1 If people are experiencing PAWS or anything similar, it is imperative that we call attention to and treat it accordingly.
Symptoms of Post-Acute Withdrawal Syndrome
Symptoms of PAWS may appear intermittently, but are primarily emotional and psychological in nature, unlike the physical symptoms of acute withdrawal. Given that everyone’s physiology is different, individual experiences with PAWS vary. Further, every PAWS substance detox will be unique, but people can expect similar symptoms across them all.
Common symptoms of PAWS 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
Substance-Specific PAWS Symptoms
Beyond symptoms generally common to PAWS, each substance comes with its own unique effects. Again, people can experience PAWS from alcohol and other substances. Variability in symptoms stems from the addiction potential of the substance, among other factors.
Substances that may cause severe PAWS symptoms include:
Marijuana
Individuals who abuse marijuana or suffer from marijuana addiction can experience PAWS. Although withdrawal symptoms and severity are oftentimes less intense than with other substances of abuse, post-acute withdrawal is real.
While traditional acute withdrawal typically lasts up to five days, with PAWS, it may last 45 or longer.6,7 There is a strong link between marijuana and anxiety symptoms, along with other corresponding impairments including poor sleep and appetite.5,8
Methamphetamine
Methamphetamine is among the most addictive of all substances of abuse, which is why many people find themselves battling a meth addiction. Given the intensity of methamphetamine, many users who discontinue experience withdrawal—some of which is severe in symptomatology.
Generally, symptoms begin within one or two days of termination and last up to a month.9 With PAWS, symptoms resurface four to eight weeks after detox and may last months or an entire year.9 Within this time, symptoms may eb and flow. However, the experience is unpleasant.
Common symptoms include:
- Anhedonia
- Anxiety
- Cognitive problems
- Depression
- Fatigue
- Hostility
- Ineffective executive functions
- Intense cravings
- Mood swings
- Sleep problems
- Stress
Opioids
Perhaps the greatest link between PAWS and a substance is that of opioid use, especially opioid addiction. It is believed that some 90% of those in recovery will experience some PAWS symptomatology.1
With opioid use, one’s executive control can be affected. Executive control is housed in the prefrontal cortex, which is among the primary areas impacted by substance use and withdrawal symptoms. Accordingly, concentration and judgment may be significantly impacted.
Common symptoms include:6
- Anxiety
- Depression
- Fatigue
- Increased blood pressure
- Irritability
- Menstrual disruptions
- Quicker breathing
- Sleep problems
- Weight gain
Cocaine
Like other substances, cocaine withdrawal typically is met with the most severe symptoms during the acute phase of detox.10 PAWS symptoms tend to rise and fall, sometimes abruptly, over the course of up to a year.
Common symptoms include:10
- Anxiety
- Chronic pain
- Decreased libido
- Difficulty focusing
- Difficulty thinking
- Depression
- Fatigue
- Hostility
- Insomnia
- Low energy
- Mood swings
Benzodiazepines
When discontinuing benzodiazepines that were taken as drugs of abuse or for medical treatment, those detoxing from these medications experience PAWS at a rate similar to that of alcohol.6
It is important to understand the phenomenon of symptom rebound, which occurs when previously subdued symptoms return. These include undesirable symptoms stemming from another condition which led to benzodiazepines use in the first place. Thus, individuals not only struggle with PAWS symptomatology, but also a return of previous symptoms. The combination is unpleasant and even painful.
Common symptoms here include:6
- Anxiety
- Depression
- Dizziness
- Headaches
- Panic attacks
- Tinnitus
Alcohol
PAWS resulting from alcohol withdrawal can result in a myriad of complications, many of which resemble typical alcohol and anxiety symptoms. Sleep disruption is also common. 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.
Common symptoms 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
Risk Factors & Causes of PAWS
Regardless of the substance, it is important to recognize the concepts of dependence and tolerance developed with prolonged use. Even for those who adhere to the script for an opioid painkiller, tolerance forms. This means that the desired effect of the substance gradually decreases over time. With higher dosages, withdrawal symptoms can be more intense when the drug is eventually discontinued.
When one becomes dependent on a substance, the brain and nervous system adjust to accommodate the chemicals in the substance. People ultimately continue using just to “feel normal.” Removing the substance puts a strain on the body. Physiology becomes immediately compromised, and physiologic changes can occur, affecting blood pressure, heart function, emotions, and more.
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
Danger of Relapse With PAWS
Given that PAWS is still a condition warranting further research, some consider it “an excuse for relapse.”2 There is a belief that for some people struggling with recovery, they will begin using again in an attempt to curb withdrawal. Other factors, such as heightened stress, may leave one vulnerable for relapse. Assuming that PAWS is a true phenomenon, which I believe it is, symptoms experienced here can cause a person to relapse.
How to Avoid & Prevent PAWS
The best means of preventing PAWS is to not abuse substances. However, more realistically, one may engage in an addiction-free lifestyle–that is, do not engage with highly addictive substances. Use alcohol and marijuana responsibly, preferably under the advice of a medical professional. If taking a prescribed medication that may lead to dependence, use only as directed by a prescribing physician.
Abstaining from substances of abuse may be done on one’s own, but likely requires social support if they are struggling to do so. If loved ones are using substances themselves, it is important to distance from them while leaning closer on other supports. If this is not something readily available, seeking professional support is highly recommended.
How to Cope With Post-Acute Withdrawal Syndrome
PAWS is highly unpredictable. The duration, type, and severity of symptoms varies by person and substance. The biggest challenge is getting past the discomfort and not relapsing when symptoms arise.
Self-awareness is important here. When the onset of symptoms becomes noticeable, even if minimally, it is time to take immediate action. This may include enacting coping skills, utilizing support systems, or speaking with a professional. Withdrawal symptoms will pass. Relapse only serves to extend the process, further making it more difficult 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 difficult times. Rather than the bottom falling out when times get rough, this balance yields resilience, which keeps one on track.
- Exercise regularly: Exercise is a great means of naturally flooding oneself with relaxing neurotransmitters and hormones. This can also enhance one’s physical health and self-esteem.
- Start a journal: Writing one’s thoughts down is cathartic, as it adds an additional layer of processing in reflection. By delving deeper, one becomes more self-aware, which leads to wisdom.
- Use relaxation techniques: Relaxation strategies, such as progressive muscle relaxation (PMR), activate the parasympathetic nervous systems, which calms the body. This lowers the stress response and allows people to retain their baseline.
- Maintain proper sleep: Proper sleep is ideal as this provides sufficient time to engage in REM sleep (the important kind) and reset the system. Cell rejuvenation is most significant during this time.
- 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: As a stimulant, caffeine agitates one’s physiology—potentially leading to a heightened stress response and difficulties relaxing. Minimizing or eliminating intake will further support all other relaxation strategies mentioned here and otherwise.
- Focus on purpose: Without having purpose, people flounder as they have nothing to work toward. Finding meaning in something—regardless how small it may seem—may serve as a motivating force.
- Avoid triggering stimuli: It is helpful to avoid stressful situations, abusive people, and negativity.
- Seek professional help: Mental health professionals, particularly those specialized in substance use disorders, are specifically trained to assist with dependence, addiction, and withdrawal. They are there to ensure one has everything needed for a successful recovery.
When to Seek Professional Help
The sooner one seeks professional help and treatment for PAWS, the better. Addiction disorders are pervasive and intensify over time without intervention. Though PAWS results from prolonged post-detox withdrawal, symptoms may lead to relapse, further feeding the addiction cycle.
Treating PAWS alone can increase the risk of relapse. One must focus on a concerted, ongoing holistic recovery effort. Given that this process can be extensive, especially at first, help from a medical professional and social support can keep a person 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 those that are as holistic as possible. They address impairments along the mind-body-spirit pathway, considering strengths and areas of improvement among the Eight Dimensions of Wellness (i.e., emotional, environmental, financial, intellectual, occupational, physical, social, and spiritual).
Cognitive behavioral therapy (CBT) is oftentimes considered a frontline therapeutic approach, as the therapist and patient work together to find the meaning behind maladaptive beliefs and values that impair one’s perception and response to the world. Through a combination of exploration, processing, and behavioral experiments, patients can find relief.
Other common therapy options for PAWS include:
- Dialectical behavioral therapy (DBT)
- Person-centered therapy (PCT)
- Psychoanalysis
- Reality therapy
- Multimodal therapy
Medication
Although there is no medication designed to treat PAWS itself, some individuals benefit from prescriptions that treat specific symptoms, co-occurring mental health disorders, or pre-existing medical conditions. Medications should be monitored by a prescribing physician specialized in mental health and addiction disorders.
Some medications that are used may include
- Anti-anxiety medications
- Antidepressants
- Acamprosate
- Methadone
- Buprenorphine
Final Thoughts
Post-acute withdrawal syndrome (PAWS) is a severe condition that people should not take lightly. Taking precautionary 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 feel assistance is needed in cutting back on your use. If you already believe you or a loved one has PAWS, there is much that may be done to curb symptoms and reduce risk of relapse. It all begins with educating oneself and reaching out for help.
Post-Acute Withdrawal Syndrome (PAWS) Infographics
