Understanding Post-Acute Withdrawal Syndrome (PAWS) and Why it Makes Sobriety Difficult
Updated: Nov 29
Acute withdrawal is agonizing yet fleeting - a storm to endure before sobriety's dawn. But recovery reveals a more insidious challenge. Emotional turbulence, cravings, fatigue...relapse tempts those struggling with PAWS. Knowledge offers hope. By shining light on this murky phenomenon, we can navigate towards calmer waters.
What is Post-Acute Withdrawal Syndrome (PAWS)?
After the initial crash of detox, many experience lingering withdrawal - the Rolling Stones' "Monkey on My Back." Symptoms like depression, anxiety and brain fog haunt weeks or months after abstinence.
This “post-acute withdrawal syndrome” reflects addiction's deep ruts worn in the brain, needing time to reroute around craving's whirlpools. Post-Acute Withdrawal Syndrome (PAWS) makes maintaining sobriety feel impossible. But within this adversity lies an opportunity for growth.
Why Post-Acute Withdrawal Syndrome Occur?
Years of alcohol or drugs rewire the brain’s signaling, structure, and chemistry - a freight train barreling down distorted tracks. Quitting hits the brakes, but the damage persists.
Symptoms of post-acute withdrawal syndrome are caused by the body recalibrating after depending on substances for so long. An identity crisis of sorts as the mind relearns how to cope and function without its former fuel.
The brain is plastic - it can bounce back. But healing takes time and tenderness. Knowledge empowers. We can ride out PAWS’ turbulence through care, connection and compassion.
Factors that influence the likelihood, severity and duration of PAWS include:
Type of substance abused
Frequency and quantity of use
Length of time using
Method of stopping (abruptly vs tapered)
History of prior withdrawal episodes
Co-occurring medical or mental health issues
In general, the more severe the substance abuse, the more likely PAWS will occur and the longer it will last. Sedative drugs like alcohol, benzodiazepines and opioids have a very high likelihood of causing PAWS.
What are the Signs and Symptoms of PAWS?
Post-acute withdrawal symptoms involve physical, psychological, and emotional symptoms that fluctuate in severity and may come and go. Common symptoms include:
Sleep disturbances like insomnia or hypersomnia
Muscle tension, aches and pains
Stomach upset, diarrhea
Sweating or chills
Irritability and mood swings
Anxiety or panic attacks
Problems with focus and concentration
Feeling emotionally dull or numb
Lack of enjoyment of usual activities
The severity of PAWS depends on many factors like the severity of past use. But in general, symptoms tend to slowly improve over time. Some symptoms may take weeks or months to fully resolve.
Is PAWS a Form of Psychological Dependence?
It’s a common myth that the symptoms associated with PAWS is purely psychological or “all in your head”. Especially when the symptoms of the acute withdrawal phase were so severe compared to the withdrawal symptoms that occur with PAWS. In reality, Post-Acute Withdrawal Syndrome (PAWS) has very real physiological causes from neuroadaptations in the brain’s own neurotransmitters.
However, the psychological and emotional symptoms can still be very distressing. It's important not to minimize or dismiss these symptoms when supporting someone with PAWS. Coping skills and a strong support system are crucial during this extended recovery phase.
What is the Difference Between Acute Withdrawal, PAWS and Protracted Withdrawal?
Acute withdrawal occurs within hours to days of stopping drug or alcohol use. It involves very intense psychological and physical withdrawal symptoms like nausea, vomiting, tremors, sweating, rapid heart rate, agitation, anxiety and drug cravings. These symptoms are common with most alcohol (alcohol withdrawal syndrome) or other drug withdrawals (opioid withdrawal syndrome).
Acute withdrawal symptoms lasts around 3-7 days for shorter acting substances like opioids, or 7-14 days for long-acting substances like alcohol and benzodiazepines.
In contrast, PAWS and protracted withdrawal involves a wider range of psychological and emotional symptoms that tend to fluctuate in severity. Symptoms usually also have a gradual onset and typically persist for weeks to months after acute withdrawal ends.
So in summary:
Acute withdrawal happens rapidly after stopping drug use, PAWS has a gradual onset and symptoms that persist for weeks to months.
Acute withdrawal tends to involve intense physical symptoms, PAWS tends to have more psychological symptoms.
Acute withdrawal usually lasts days to weeks, PAWS can last weeks to months.
However, it’s not uncommon for people to experience some PAWS symptoms during acute withdrawal as well. The transition is more of a continuum than distinct phases.
Factors Affecting How Long Does PAWS Last?
The duration of PAWS can vary considerably between individuals and depends on many factors like:
Type of substance abused
Length of substance abuse history
Frequency of prior withdrawal episodes
Rate of tapering
But some general timelines include:
Opioid PAWS - Usually lasts 2-6 months but symptoms may linger at lower intensity for 1-2 years
Alcohol PAWS - Severity of symptoms peaks at 2-3 months, resolves within 2 years in most cases
Benzodiazepine PAWS - May persist for over a year, averages around 15-27 months
Symptoms can last 2 years or more. However, they generally slowly improve over time, with the most intense symptoms in the first few months. But PAWS involves windows of “good days” and “bad days” with fluctuating intensity.
Does PAWS Increase Risk of Relapse?
PAWS can definitely make staying abstinent more challenging because of the uncomfortable symptoms. The combination of psychological symptoms like depression, cravings and anxiety paired with physical fatigue makes for a potent relapse risk factor.
Being aware of PAWS and prepared for the likelihood of symptoms can help increase resilience. People also often relapse when they mistake PAWS symptoms as lasting brain damage, causing despair.
Seeking professional treatment, attending support groups, treatment programs, and adopting healthy lifestyle habits can all help reduce the risk of relapse during PAWS. The symptoms do eventually resolve with sustained abstinence.
What Factors Influence the Severity of PAWS Symptoms?
Some key factors that impact the likelihood, severity and duration of PAWS include:
Type of Substance – Sedatives like alcohol, opioids and benzodiazepines tend to cause more intense PAWS given their impact on neurotransmitters like GABA. Stimulants generally cause milder PAWS.
Length of Use – The longer the duration of substance abuse, the more ingrained the neural changes become. Someone with decades of alcoholism typically has worse PAWS.
Frequency of Use – More constant, heavy use causes greater neuroadaptations compared to occasional use. Using alcohol or opioids daily predicts worse PAWS.
Prior Withdrawals – Repeated withdrawals may sensitize neurotransmitter systems and worsen future PAWS episodes.
Genetics – Genetic differences affect neurotransmitter systems and neural recovery rates, influencing PAWS variability between individuals.
Mental Health – Pre-existing or co-occurring mood disorders like anxiety and depression can worsen PAWS symptoms.
Overall, heavy, chronic substance abuse predicts more severe, persistent PAWS symptoms. But even mild use can still generate PAWS lasting weeks to months.
What Conditions are Associated with PAWS?
Since PAWS arises from neural changes from substance abuse, it’s most commonly seen with addiction involving:
Alcohol – One of the most well-studied causes of PAWS, usually lasting 2 months to 1 year. Symptoms often occur more intensely among individuals with alcohol withdrawal syndrome.
Benzodiazepines – Long-acting benzodiazepines like diazepam and clonazepam often cause protracted PAWS
Opioids – Both illegal opioids like heroin and prescription painkillers frequently cause PAWS
Stimulants – Drugs like cocaine and methamphetamine can induce milder PAWS symptoms
PAWS is less common with cannabis dependence and very rare with psychedelics like LSD or psilocybin.
Sedative substances that powerfully impact GABA and glutamate neurotransmitter systems have the highest risk of inducing PAWS. Even prescribed use of sedative medications can result in PAWS.
Is PAWS a Recognized Diagnosis?
Despite over 50 years of research on PAWS, it still does not appear as a formal diagnosis in medical resources like the DSM-5 or ICD-10.
However, Post-Acute Withdrawal Syndrome (PAWS) is informally recognized in clinical settings and addiction medicine textbooks. The DSM-5 does recognize longer-term physiological effects from sedative withdrawal.
Since PAWS is not a formal diagnosis, there are no billing codes specific to PAWS treatment. But therapists and doctors treating PAWS symptoms can still bill for individual encounters.
The lack of formal recognition of PAWS can make it harder to educate clients and gain insurance pre-approval for extended treatment. But PAWS is becoming more well-known over time.
When Should You Seek Medical Care for PAWS?
In most instances of PAWS, symptoms can be managed through lifestyle remedies and psychological support. But there are some cases where medical help at a treatment center may be needed for recovery from alcohol or drug addiction:
Suicidal thoughts or self-harm urges
Severe depression with inability to function
Anorexia or malnutrition from appetite loss
Severe, persistent fatigue impacting daily activities
Delirium or pronounced cognitive impairment
Persistent insomnia preventing daily function
Severe, constant anxiety or panic attacks
Hypertension or irregular heart rate
Re-emergence of acute withdrawal symptoms
Seeking the help of therapists and psychiatrists can help manage more severe emotional and psychological symptoms through counseling and medication when appropriate.
What Medications Are Used in Addiction Treatment for Managing Paws?
While medications are not a cure for PAWS, some prescriptions can help manage specific symptoms:
Antidepressants like SNRIs and TCAs may help with mood, anxiety, cravings and insomnia
Beta blockers like propranolol can treat autonomic arousal and panic
Anticonvulsants like gabapentin help anxiety, insomnia, mood and cravings
Antipsychotics treat agitation, mood swings and sleep issues
Benzodiazepines should be avoided but may help severe anxiety short-term
The risks, benefits and side effects of medications should always be carefully considered. While using medications may ease your symptoms, building non-pharmaceutical coping skills is also crucial to manage these symptoms. But short-term medications can provide PAWS symptom relief.
What Behavioral Addictions May Emerge During PAWS?
Recovering from substance addiction involves learning to cope without the influence of drugs or alcohol. This adjustment can unmask underlying behavioral and process addictions as alternate unhealthy coping mechanisms.
Common behavioral addictions that may emerge during PAWS include:
Compulsive sexual behavior
Digital addictions like video games, social media, pornography
Eating disorders like food addiction or binge eating
Being aware of these potential new issues emerging is important to avoid substituting one unhealthy behavior for another. Developing balanced, healthy coping skills is key.
Do PAWS Symptoms Ever Plateau or Recur?
PAWS symptoms usually slowly improve over time after peaking in the first few months. But some people do experience points where symptoms seem to plateau and get “stuck.”
Recurrence of more intense symptoms is also possible during the first 1-2 years in recovery when going through major life stresses. Holidays, job loss or divorce may re-awaken PAWS symptoms.
Awareness helps prevent discouragement from plateaus or recurrences, which are a normal part of extended recovery. Support groups and self-care help weather these phases.
Why Do Some People Experiencing Acute Withdrawal Not Develop PAWS?
The development and severity of PAWS depends on many factors like genetics, mental health and the degree of past substance abuse.
Someone who only used prescription opioids briefly at low doses may get through acute withdrawal with no PAWS. Conversely, people with heavy alcohol use for decades almost always experience PAWS.
Mild, intermittent substance use can induce acute withdrawal, but may not cause the deeper neuroadaptations that drive PAWS. There is a correlation between addiction severity and PAWS likelihood.
Is PAWS More Common in Middle Age and Older Adults?
Studies show that older adults tend to experience more severe, prolonged PAWS compared to younger people withdrawing from the same substance.
Potential reasons for worse PAWS in older populations include:
Longer duration of lifetime substance abuse
Age-related changes in liver metabolism
Reduced cognitive reserves in older individuals
Higher rates of co-occurring health conditions
Smaller social support networks in older adults
This makes close medical monitoring and psychosocial support even more crucial for older people undergoing detoxification and PAWS.
Why Do Some People Experience PAWS from Prescribed Benzodiazepines?
Benzodiazepines include drugs like diazepam and alprazolam elicit profound physical dependence when taken continuously. This means withdrawal symptoms frequently emerge even after appropriate prescribed use.
Factors that increase the risk of PAWS with prescribed benzodiazepines include:
High daily dose prescriptions
Taking benzodiazepines for more than 2-4 weeks
Addiction to benzodiazepines
Abrupt discontinuation rather than gradual tapering
Prior history of substance abuse
Following prescriber instructions for tapering can help mitigate PAWS from medically prescribed benzodiazepines. But Post-Acute Withdrawal Syndrome (PAWS) may still occur and require management.
Can PAWS Be More Severe Than Acute Withdrawal?
For most people, acute opioid or alcohol withdrawal are the most intense phase of withdrawal due to severe physical and psychological symptoms.
However, some individuals do report their PAWS symptoms ended up being equal or even more distressing than their acute withdrawal experience. This can be due to:
High levels of anxiety, depression or fatigue during PAWS
Significant work/life disruption from impaired cognition
Social isolation from anhedonia and emotional numbness
Financial stress amplified by inability to work
Lack of rapid symptom relief compared to detox
Counseling and social support are crucial during PAWS to help cope with persistent symptoms.
What Are Some Healthy Coping Skills and Self-Care for PAWS?
Managing PAWS requires implementing healthy new habits and coping mechanisms. Some positive ways to help reduce symptoms include:
Eating a nutritious diet and staying hydrated
Getting regular exercise to reduce anxiety and improve sleep
Practicing relaxation techniques like meditation, yoga and deep breathing
Prioritizing high-quality sleep through sleep hygiene habits
Avoiding excessive caffeine, sugar and junk food
Taking hot baths or massages for muscle tension
Pursuing hobbies, especially involving creativity or nature
Staying busy and having a structured routine
Journaling feelings rather than internalizing them
Attending recovery meetings and counseling
Practicing positive self-talk and being patient with the process
What Tactics Help Manage PAWS Symptoms During the Workday?
PAWS can significantly impact workplace performance and focus due to fatigue, mental fog, anxiety and low motivation. Some accommodations and tactics that can help include:
Requesting a flexible or reduced schedule to allow for rest
Avoiding high-stress positions during early recovery
Discussing workload adjustments with supervisors
Maximizing natural light exposure
Taking regular small breaks to walk, stretch or meditate
Snacking on protein and complex carbs to stabilize energy
Using productivity apps to stay organized
Having inspirational reminders to “push through” tough moments
Applying mindfulness techniques when feeling overwhelmed
Staying hydrated and limiting caffeinated beverages
Planning meetings and focused work during peak energy times
How Does Exercise Help Improve PAWS Symptoms?
Exercise is a powerful tool for physical and mental health. Incorporating regular exercise helps improve many PAWS symptoms including:
Improves mood - Releases endorphins, elevates neurotransmitters impacted by substance abuse. Reduces depression and anxiety.
Reduces cravings - Provides a healthy outlet for stress and “substitute high”. Elevates dopamine which is depleted early in PAWS.
Enhances cognition - Stimulates brain plasticity and growth of new neurons. Improves circulation and oxygen to the brain.
Decreases stress - Lowers stress hormones like cortisol that are elevated in early recovery. Promotes relaxation.
Boosts self-esteem - A sense of accomplishment from meeting exercise goals and improving fitness. Provides confidence.
Supports routine - Provides structure and a healthy habit to look forward to each day.
Aim for a mix of cardiorespiratory exercise, strength training and flexibility work throughout the week. Even light activity like walking helps when starting out.
What Medications or Supplements Aid Sleep During PAWS?
Insomnia and disrupted sleep patterns are very common in PAWS. Some supplements and medications that can promote restorative sleep during PAWS include:
Melatonin - Helps reset circadian rhythm. Typical doses are 1-3mg.
Magnesium - Eases muscle tension and anxiety that disrupts sleep. Usual doses are 400mg before bed.
Valerian root - Herbal supplement that induces relaxation and drowsiness. May take 2-4 weeks to take effect.
Antihistamines - OTC medications like diphenhydramine promote drowsiness or prescribed hydroxyzine.
5-HTP - Precursor of serotonin that enhances sleep quality. Usual dose is 100-200mg with food 30mins before bed.
L-tryptophan - Another serotonin booster that promotes relaxation and sleepiness. Typical dose is 500-1000mg.
Phosphatidylserine - reduces the stress of withdrawal to help with sleep.
Chamomile tea - Widely used herbal sleep aid. Have a cup an hour before bedtime.
Improving sleep hygiene with a consistent bedtime routine is also essential. Avoid screens before bed, keep the room cool and dark, and use white noise if needed. If sleep problems persist, see a doctor to assess for underlying issues.
How Can Friends and Family Support Someone Experiencing PAWS?
A strong support system is invaluable in coping with PAWS. Friends and family of someone going through PAWS can help by:
Learning about PAWS to better understand what their loved one is experiencing
Offering encouragement and reassurance that symptoms do get better
Practicing compassion when PAWS causes irritability or mood swings
Helping create a low-stress home environment -Cooking nutritious meals and encouraging a healthy diet
Providing accountability for treatment plan adherence
Participating in healthy social activities together
Offering transportation to appointments or recovery meetings
Sharing uplifting stories of others who recovered from PAWS
Being patient and allowing time for the recovery process
Providing practical support with childcare, pets or chores
While loved ones cannot cure PAWS, their support makes the process easier to withstand.
Can PAWS Symptoms Re-emerge After a Later Relapse?
If substance abuse recurs after a period of recovery and sobriety, the neuroadaptations can restart as tolerance builds again. This means that after relapse, some PAWS symptoms may resurface upon withdrawing again.
The degree of symptoms returning depends on factors like:
Length of relapse period – Longer relapse increases likelihood of PAWS recurrence.
Level of use during relapse – Heavy use makes PAWS more likely to return.
Prior addictive behavior – Repeated cycles of addiction predicts recurrent PAWS.
While discouraging, the silver lining is that each cycle of recovery and sobriety strengthens future resilience and adaptability of the brain. So over time, the severity and duration of recurrent PAWS often decreases.
I am Here to Help
I lead a team with decades of experience, and a commitment to providing you with comfort, care, and respect as you navigate this challenging time in your life. Our office is located in Tulsa, Oklahoma. We also make treatment super convenient with hours of operation that extend from 0800 AM to 0900 PM, 7 days a week through scheduled appointments, accept most insurances, making addiction treatment accessible to practically all who call 918-518-1636. We are waiting for your call.
The Bottom Line
PAWS is a very real phenomenon arising from neurobiological changes during addiction. It requires compassion, understanding and proactive management. Patience and support from loved ones eases the recovery journey.
While PAWS symptoms can be uncomfortable, they are temporary and DO get better over time. Avoid relapse and continue applying healthy coping strategies. Each sober day allows more healing of the brain.
The brain and body have an amazing capacity to return to homeostasis when given the chance. With continued sobriety, the clouds of PAWS will eventually lift to reveal the open sky of recovery.
About the author:
Dr. Harold Pierre is a board-certified anesthesiologist and addiction medicine specialist with over 20 years of experience. He is board-certified by the American Board of Anesthesiology and the American Board of Preventive Medicine.
This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease, and those seeking personal medical advice should consult with a licensed physician or another qualified medical professional. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.