Post Acute Withdrawal Syndrome & Treatment Options
What is PAWS?
Post acute withdrawal syndrome (PAWS) is a collection of symptoms that emerge after the typical withdrawal period has ended. Withdrawal syndrome refers to the symptoms that occur when a substance-dependent person abruptly stops taking that substance. Both illicit and prescription drugs can cause withdrawal. It may last anywhere from a few days to a couple of weeks .
Some of the general symptoms of post acute withdrawal include anxiety, sleep problems, memory and attention issues, cravings, and depression. However, the effects and timeline can differ depending on the substance used, the severity of drug dependence, and the presence of co-occurring medical and mental health, or polysubstance abuse problems. PAWS may also be referred to as a post withdrawal syndrome, prolonged withdrawal syndrome, or protracted withdrawal syndrome.
Post acute withdrawal syndrome most commonly manifest after a withdrawal period from alcohol, benzodiazepines, and opioids, but have been known to occur with (cessation of) use of other psychoactive substances. It is estimated that 90 percent of recovering opioid users experience the syndrome to some degree as do 75 percent of recovering alcohol and psychotropic abusers. The precise mechanisms behind PAWS are still being investigated, but scientists believe the physical changes to the brain that occur during substance abuse and are responsible for increased tolerance to the substance are responsible for the recurring symptoms .
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:
- Stress sensitivity
- Anxiety or panic
- Lack of initiative
- Impaired ability to focus
- Mood swings
- Stress sensitivity
- Anxiety or panic
- Lack of initiative
- Impaired ability to focus
- Mood swings
Other symptoms may include:
- Obsessive-compulsive behaviors
- Difficulty maintaining social relationships
- Craving originally abused substances
- Apathy or pessimism
- Disturbances in sleep patterns
These symptoms tend to increase in severity when triggered by stressful situations, but might flare up even without any clear stimulus.
PAWS in Opioids
Reports estimate that as many as 90% of recovering users will encounter some level of opioid post acute withdrawal.
Heroin and prescription pain medications are widely abused substances that are known to trigger post-acute withdrawal symptoms. Reports estimate that as many as 90% of recovering users will encounter some level of opioid post acute withdrawal .
Though the symptoms will vary with each person, PAWS symptoms for opioids include:
- Increased anxiety
- Sleep problems
- Low energy
- Weight gain
- Increase in blood pressure
- Quicker breathing
- Menstrual changes
Former heroin and other opioid users frequently report problems with attention, focus, and concentration levels during post acute opioids withdrawal. Effects such as these can lead to interpersonal relationship issues and affect school and/or job performance.
PAWS in Alcohol
An alcohol-associated post-acute withdrawal syndrome is thought to affect about 75% of people recovering from alcohol dependence or alcoholism. The most frequently cited symptoms of post acute alcohol withdrawal are:
- Anger and aggression
- Frequent or sudden mood changes
- Low energy
- Poor ability to sleep
- Problems with thinking, concentrating and remembering
- Increased levels of pain
- Lack of sexual interest
- Mild tremors
- Coordination problems
Sleep changes are some of the most long-lasting signs of alcohol post acute withdrawal. For years after the last drink, people can be troubled by sleep apnea as well as difficulty falling and staying asleep.
People dependent on this sedative class of medications experience post acute benzodiazepine withdrawal effects similar to post acute alcohol withdrawal. Benzodiazepine post acute withdrawal symptoms include:
- Panic attacks
- Ringing and other noises in the ears
Post acute benzodiazepine withdrawal symptoms are typically more difficult to identify because of several compounding factors:
- Symptom rebound – the reappearance of acute withdrawal signs such as anxiety, insomnia, and restlessness. Rather than peaking and reducing in intensity over time, acute benzodiazepine withdrawal symptoms come and go inconsistently, which can make it difficult to tell when the acute phase is over.
- Symptom reemergence – the return of the original symptoms of anxiety, physical tension, and poor sleep that someone had before they used a benzodiazepine. Symptom reemergence will feel uncomfortable, but it is unrelated to withdrawal or benzo post acute withdrawal.
PAWS in Stimulants
In contrast to benzodiazepines, stimulant post acute withdrawal symptoms are easier to distinguish and separate from acute withdrawal. Acute stimulant withdrawal only lasts for about 5 days, so symptoms beyond this timeframe are more likely to be part of a post acute withdrawal syndrome. Amphetamines and cocaine are the two most researched stimulants when it comes to post acute withdrawal. Post acute amphetamine withdrawal symptoms primarily include problems with executive functioning in the brain, including deficits to:
- Problem-solving skills
Research on post acute cocaine withdrawal reports symptoms such as:
- Problems understanding and controlling feelings
- Difficulty coping with stress and strong emotions
- Poor impulse control, with reckless behaviors
- Low mood
- Cravings for more cocaine
How long do PAWS symptoms usually last?
Withdrawal symptoms, in general, tend to last anywhere from a few days to up to two weeks max. After that, the symptoms fade away and do not return. But, when someone is experiencing post acute withdrawal syndrome, that is not the case.
Post acute withdrawal syndrome can last anywhere from six months to two years on average. The length of time that someone deals with these symptoms can be based on a number of contributing factors, including:
- How long have they actively abused drugs/alcohol?
- What quantities of drugs/alcohol were being abused
- If there are one or more underlying mental illnesses occurring
- What is their past medical and psychological history is
Unfortunately, the longer that someone abuses a mind-altering substance, the more their brains are exposed to several dangers. The abuse of drugs and alcohol can change the way in which the brain functions by interfering with the production and transmission of neurotransmitters and well as causing certain areas of their brains to experience damage to their physical structures. So, for many people who develop post acute withdrawal syndrome, it is likely that they have a past history of long-term and/or heavy abuse.
But, that is not always the case. Anyone can struggle with post acute withdrawal symptoms. During that extended period of time, however, those who do have PAWS can do things to help minimize the intensity of their symptoms so they are more manageable.
When does post acute withdrawal syndrome occur?
It is thought that PAWS is the result of physiologic changes that occur in the brain as a result of substance abuse. During drug abuse, the brain makes adaptations to accommodate for the changes in available neurotransmitters, and these changes can result in excitability when levels of these neurotransmitters change during abstinence. Scientists hypothesize that the brain’s capacity to deal with stress is reduced with prolonged substance abuse and related withdrawal experiences. Infants born to mothers who have repeatedly abused substances are also at risk of developing PAWS.
PAWS can manifest after withdrawal from almost any abusive substance, but those abusing benzodiazepines seem to be the most at risk. There have been reports of benzodiazepine abusers experiencing symptoms of PAWS for years after the final cessation of the abuse.
Can post acute withdrawal syndrome be avoided?
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.
Common Drugs And Their Associated Post Acute Withdrawal Symptoms
Each episode of PAWS can last for a few days, and these can continue cyclically for a year. These symptoms can occur with any intoxicating substance, although post acute withdrawal syndrome most often occurs among people discontinuing the following drugs:
- Alcohol: Though people have struggled to end alcohol addiction for much longer, the symptoms of PAWS were first defined for alcohol use disorder in the 1990s. Suddenly stopping alcohol consumption is dangerous, since it can cause delirium tremens (including seizures and psychosis) and can also increase the likelihood of PAWS (e.g., long-term cravings, exhaustion, and feeling ill).
- Antidepressants: While few people abuse these drugs recreationally since they do not cause a rapid intoxication, stopping them suddenly can dramatically change the levels of serotonin and other neurotransmitters in the brain. Since people who struggle with depression are prescribed antidepressants, the acute withdrawal will feel like intense depression; unfortunately, this experience could continue for months.
- Antipsychotics: These drugs bind to dopamine receptors to decrease hallucinations and delirium. When they are discontinued, especially without a taper, the person could experience withdrawal symptoms like mood swings for months.
- Benzodiazepines: Although these medicines help people with anxiety and panic disorders, they are very easy for the brain to develop a dependence on. Most prescriptions do not cover more than two weeks of regular use because they can be addictive. Withdrawal symptoms mimic panic disorders, making it harder to stop taking them. PAWS symptoms, like insomnia, fatigue, and cravings, can last for months after the physical dependence has ended.
- Marijuana: Many people become reliant on marijuana to relax and feel normal; when they stop taking the drug, they can feel stressed, depressed, and paranoid. One of the most common withdrawal symptoms is insomnia, and without medical help, this could persist and become PAWS.
- Opioids: Whether prescription opioids or illicit versions like heroin, these drugs can lead to post acute withdrawal syndrome if they are not tapered off properly. People who experience the full intensity of acute withdrawal are more likely to develop PAWS, which includes cravings, exhaustion, and cognitive impairment that does not go away for a long time.
- Stimulants: Drugs from Ritalin to cocaine can cause post acute withdrawal syndrome if withdrawal is not managed appropriately. Although a person taking stimulants may experience negative side effects like paranoia, twitching, and tremors, and aggression, the opposite symptoms – extreme fatigue, deep depression, and physical weakness – can be harder to manage psychologically.
How is PAWS Treated?
Treatment is generally administered over an extended period of time because the symptoms of PAWS can continue for months or years. Acamprosate, a drug commonly used to help recovering alcoholics, has been found to be somewhat effective in managing some PAWS symptoms. Other drugs may also be used. Most patients undergo psychotherapy as well, in the form of cognitive-behavioral therapy, group therapy, or both to learn to cope with the symptoms.
Post acute withdrawal syndrome can be challenging to deal with, especially after going through detox and then working to resist relapse. The unpredictable fluctuations of symptoms can be stressful, but a combination of drugs and therapy can help make those symptoms more manageable.
If someone is struggling with drug or alcohol addiction and its intense and often dangerous alcohol withdrawal symptoms, they should consider inpatient rehab. We Level Up NJ addiction specialists are standing by to help.
 NIAAA – https://pubs.niaaa.nih.gov/publications/arh314/348-361.htm
 NCBI – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7872486/
 NCBI – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4767205/#:~:text=Seizures%20are%20a%20common%20toxic%20complication%20of%20numerous,cases%20are%20due%20to%20drug%20toxicity%201%2C%202.
 NCBI – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6286444/