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  • Writer's pictureDr. Harold Pierre

Understanding Post-Acute Withdrawal Syndrome (PAWS) and Why it Makes Sobriety Difficult

Updated: Jan 10

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

  • Genetic variability

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?

Man experiencing Post Acute Withdrawal Syndrome (PAWS) copy

Post-acute withdrawal symptoms involve physical, psychological, and emotional symptoms that fluctuate in severity and may come and go. Common symptoms include:

Physical symptoms:

  • Fatigue

  • Sleep disturbances like insomnia or hypersomnia

  • Muscle tension, aches and pains

  • Stomach upset, diarrhea

  • Sweating or chills

  • Lightheadedness

Psychological symptoms:

  • Irritability and mood swings

  • Anxiety or panic attacks

  • Problems with focus and concentration

  • Memory problems

  • Depression

Emotional symptoms:

  • Cravings

  • Feeling emotionally dull or numb

  • Lack of enjoyment of usual activities

  • Social isolation

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

  • Genetic differences

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?

Stop drug addiction. Drug addict hands try to come out of the pill bottle on gray background. Creative idea for support to help in drug rehabilitation. International day against drug abuse concept copy

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:

  • Gambling addiction

  • Compulsive sexual behavior

  • Shopping/spending addiction

  • Digital addictions like video games, social media, pornography

  • Workaholism

  • 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

  • Older age

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.

  • Lessens fatigue - Increases energy, improves stamina and counters low-motivation. Promotes higher quality sleep.

  • 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.

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