PAWS: Post-Acute Withdrawal Syndrome (Symptoms)

Originally published by Hazelden Betty Ford Foundation, 2019

Whether mildly unpleasant or seriously uncomfortable, withdrawal symptoms come with the territory when you’re in early recovery from alcohol or other drug addiction. In fact, post-acute withdrawal symptoms that persist or pop up during the first months of recovery can become a risk factor for relapse.

We asked clinicians at the Hazelden Betty Ford addiction treatment centers to discuss post-acute withdrawal syndrome (PAWS): the cause, warning signs, duration and coping strategies. Here’s what you need to know about the process of drug and alcohol withdrawal, including acute withdrawal symptoms and post-acute syndrome.

What is Post-Acute Withdrawal Syndrome?

Following medically supervised detoxification (detox) from alcohol, opiates, marijuana, cocaine, benzodiazepines or other highly addictive substances, most people experience a short phase of physical discomfort, otherwise known as acute withdrawal. Symptoms often include muscle ache, nausea, headache and increased heart rate. Acute withdrawal can produce more dangerous health consequences—even life-threatening complications—if detox isn’t done in a supervised setting. But there’s more to drug and alcohol withdrawal than physical symptoms of discomfort.

While acute withdrawal refers primarily to the body’s process of healing, a second phase of withdrawal symptoms, known as post-acute withdrawal syndrome, or PAWS, occurs as the brain recalibrates after active addiction. These symptoms, unlike the first stage of acute withdrawal, typically involve more of the psychological and emotional aspects of withdrawal. Depending on the duration and intensity of alcohol or other drug addiction, this secondary withdrawal syndrome can occur a few weeks into recovery or a few months down the road. More important, even though PAWS is a temporary condition, the symptoms can become a driving factor in relapse. This is true even for people who are fully committed to staying clean and sober.

Most common post-acute withdrawal symptoms

In order to minimize the risk of relapse, it’s important to recognize that many of the unpleasant or uncomfortable sensations and feelings you experience in early recovery could be symptoms of PAWS. It’s also important to understand that PAWS symptoms are temporary. Here are some of the most common symptoms:

• • Foggy thinking/trouble remembering
  • Urges and cravings
  • Irritability or hostility
  • Sleep disturbances—insomnia or vivid dreams
  • Fatigue
  • Issues with fine motor coordination
  • Stress sensitivity
  • Anxiety or panic
  • Depression
  • Lack of initiative
  • Impaired ability to focus
  • Mood swings

Post-acute withdrawal, whether mild or serious, is a necessary process in early recovery from alcohol or other drug dependence. Think of the withdrawal syndrome as the brain’s way of correcting the chemical imbalances suffered during active addiction. PAWS occurs most commonly and intensely among individuals with alcohol and opioid addiction, as well as in people with addiction to benzodiazepines (or “benzos,” which are commonly prescribed for the treatment of anxiety and panic attacks), heroin (an opiate) or medically prescribed pain medication.

Often, symptoms are triggered by stress or brought on by situations involving people, places or things that remind the individual of using. Many people in recovery describe the symptoms of PAWS as ebbing and flowing like a wave or having an “up and down” roller coaster effect. In the early phases of abstinence from substance use, symptoms can change by the minute. As individuals move into long-term recovery from alcohol or drug dependence, the symptoms occur less and less frequently.

While avoidance of post-acute withdrawal syndrome isn’t possible, you can effectively manage your symptoms. By learning to successfully manage post-acute and acute withdrawal symptoms, you will feel better physically and emotionally, improve your self-esteem and reduce the risk of relapse.

Most symptoms last for a few days at a time, although this is dependent on the type of alcohol or drug addiction, and the amount and frequency of substance use (every person’s withdrawal pattern is a little different). Typically, the brain recalibration process takes anywhere from six months to two years before the brain once again naturally produces endorphins and dopamine.

Coping strategies for managing PAWS

Here are 10 practical tips for successfully managing the symptoms of post-acute withdrawal syndrome:

• Make appointments with mental health professionals for both psychiatric and psychological care.
• Be good to yourself. Practice self-care by eating well, exercising, avoiding trigger situations when possible and establishing positive, supportive relationships.
• Talk about what you’re experiencing with your Twelve Step peers, sponsor, counselor, therapist or family—anyone who will not criticize or minimize your experiences.
• Review the events that precede a flare-up of your PAWS symptoms, and think about how you reacted. If you know what to expect, you won’t be caught off-guard the next time the situation arises.
• Consider starting a journal to document your experiences and identify alternative ways of responding.
• If you’re having a hard time concentrating, limit the amount of time you spend on any one task to no more than 15 minutes.
• Interrupt the circular thinking cycle by doing something different (talk to a friend, listen to music, go for a walk).
• If you have problems remembering, write things down or set up reminders on your phone.
• If insomnia is a problem, limit the amount of caffeine used before bedtime and try to establish a sleep routine by going to bed at the same time every night and waking up at the same time each morning (this helps your circadian rhythm).
• Be realistic. You can’t hurry recovery. Yes, you’ll have some bad days. Try to remember “this, too, shall pass.” The symptoms are part of your recovery journey and proof that you’re making progress.

Below is a description of PAWS symptoms related to specific drugs as posted by American Addiction Centers:

• Alcohol: Protracted withdrawal from alcohol is actually well documented. Common symptoms include anxiety, hostility, irritability, depression, mood changes, fatigue, insomnia, problems concentrating and thinking, decreased sex drive, and unexplained physical pain. Anecdotal evidence indicates that symptoms can last 2 years or longer after the last drink. Sleep studies suggest that sleep problems can persist 1-3 years after alcohol consumption stops.

• Benzodiazepines: Benzodiazepine protracted withdrawal is difficult to distinguish from symptom rebound, a common aftereffect of prolonged benzodiazepine use, where intensified withdrawal symptoms, such as anxiety, insomnia, and restlessness return, then subside a few weeks later. Protracted withdrawal symptoms, on the other hand, tend to ebb and flow, be new (not the re-emergence of a symptom) and last for months but subside with continued abstinence.

• Marijuana: Several studies indicate that sleep difficulties and strange dreams persisted for more than a month after stopping the use of marijuana.

• Opioids: There are a number of protracted withdrawal symptoms that have been reported in the weeks and months following opiate detox, including sleep disruption, anxiety, and depression, as well as fatigue, feeling down, irritability, and decreased executive control functions.

• Cocaine: One study found that impulse control continued to be a struggle for study participants after four weeks of abstinence.

While protracted symptoms vary by substance, some of the commonly reported protracted withdrawal symptoms include:

They stress in their post that the evidence for post-acute withdrawal syndrome is a commonly used concept that lacks empirical neuroscientific evidence. Therefore, American Addiction Centers refers to “PAWS” as protracted withdrawal symptoms according to anecdotal data collected over a few decades.