Post-Acute Withdrawal Syndrome (PAWS)


Published On: April 5, 2023

Individuals coming out of substance use and detox will often experience what is called post-acute withdrawal syndrome, or ‘PAWS’.

This is characterised by intense and significant cravings for drugs and alcohol, along with withdrawal symptoms. [1] These stages of withdrawal and cravings will act as a trigger for relapse.

What is Withdrawal?

Woman under a blanket, lounging on the sofa

Withdrawal is the process that the body and mind go through following the cutting back or cessation (cutting out) of addictive substances or behaviours. [2]

Also known as detox or detoxification, withdrawal symptoms occur when you have developed a physical or mental dependence on drugs or alcohol.

The severity of the withdrawal can range from mild to severe, depending on the following factors:

  • What you are addicted to
  • How long you have been addicted for
  • Your age
  • Your gender
  • Physical health
  • Mental health
  • Method of withdrawal (e.g., medical detox vs cold turkey)

There is a difference between physical dependence and psychological dependence. Physical dependence is when you have been taking a drug or drinking alcohol for so long, that your body has become accustomed to it.

The body is used to functioning whilst the substance is in the system, so you will experience withdrawals if the substance isn’t taken.

Psychological dependence is used to describe the emotional and mental effects and processes associated with addiction. These cognitive aspects are linked to mental withdrawal symptoms, whilst they may not be life-threatening like the physical symptoms, mental withdrawals can significantly limit your quality of life.

What is Post-Acute Withdrawal Syndrome (PAWS)?

Man with his head in his hand, eyes closed, in a gesture of pain

Decades ago, post-acute withdrawal syndrome referred to mild but persistent withdrawal symptoms that have continued after individuals have discontinued benzodiazepine therapy.

The phrase has now become generalised, referring to all protracted courses of withdrawal symptoms from substances.

To help understand post-acute withdrawal syndrome, we must discuss the stages of detox and withdrawals.

The Stages of Detox and Withdrawal

Woman slumped in a chair, feeling nauseous

When someone is dependent or addicted to a substance, removing this substance sends the body and mind into shock. In order to break out of the cycle of addiction, withdrawal and detox are certain.

There are numerous stages of withdrawal and detox, each presenting with different symptoms and risks.

In the first few days and weeks following a limitation of substances, individuals may experience acute withdrawal symptoms. [3] [4]

Acute withdrawal is the first stage of detox, presenting mostly physical symptoms. These symptoms are immediate and can last for up to two weeks.

Acute withdrawal can present with life-threatening complications and consequences, especially if detox is not supervised or medicated.

Depending on the severity of withdrawals, the following are common symptoms of mild acute withdrawal:[5]

  • Headaches and nausea
  • Vomiting
  • A high temperature
  • Excessive sweating
  • Chills
  • Mild anxiety and/or depression

Severe withdrawals may present the following:

  • Ill mental health
  • Disorientation and confusion
  • Seizures, such as delirium tremens
  • Hallucinations
  • High fever
  • Rapid heart rate and high blood pressure

Due to the severity of withdrawal symptoms, you will be advised to detox using medical assistance rather than quitting substances on your own at home (home detox).

Post-acute withdrawal syndrome (PAWS) is the second stage of detox. This happens because the brain is re-calibrating itself following active addiction. The first stage of detox is primarily physical symptoms, whereas PAWS symptoms are mainly emotional and mental withdrawal symptoms.

Depending on the severity and length of addiction, PAWS is known to last for months, even up to 2 years. However, the intensity and frequency of the symptoms will lessen as time goes by.

Symptoms can appear randomly and sporadically, acting as a leading factor for relapse.

Regardless of the substance in question, the symptoms of PAWS tend to be the same for all individuals recovering from substance use disorders and alcohol use disorders.

The following are common post-acute withdrawal symptoms (or ‘PAWS symptoms’):

  • Insomnia and sleep disturbances
  • Irritability
  • Aggression and hostility
  • Depression
  • Severe anxiety
  • Panic attacks
  • Lack of motivation
  • Mood swings
  • Impaired concentration
  • Severely fatigued
  • Stressed
  • Alcohol cravings
  • Drug cravings

Following the acute withdrawal stage, post-acute withdrawal syndrome is a natural response as the brain slowly returns to normal following addiction.

During addiction, the brain rewires its neurotransmitters. Once the substance is removed, the chemicals in the brain have to regulate themselves as they attempt to return to a healthy balance. PAWS is the brain correcting these imbalances.

Substances Associated with PAWS

Pills

Research has shown that there are certain substances that are associated with post-acute withdrawal syndrome, presenting with different symptoms:

  • Marijuana: insomnia, anxiety, headaches, irritability, and stomach pains
  • Methamphetamine: poor impulse control, insomnia, and irritability
  • Opioids: depression, anxiety, cravings, muscle tension, insomnia, and lack of impulse control
  • Cocaine: depression, lack of motivation, poor impulse control, and fatigue
  • Benzodiazepines: intense panic attacks, anxiety, irritability, insomnia, and sleep issues

These symptoms may persist for up to 2 years and can present themselves randomly. This is often a risk factor for relapse, defined as the return to substance use following a period of cutting down or cessation.

These symptoms are uncomfortable for everyone involved, so individuals should try different coping skills to help them recover and cope with them.

Coping Strategies for PAWS

Teenage boy walking down road with backpack, head down

The start of PAWS may be confusing due to the emotional rollercoaster and mood swings. These dramatic mood swings may be totally overwhelming, but they will get further apart and less intense as time goes on.

You may go a period of time without symptoms, but they may randomly appear after a month or two without them.

This unpredictability causes anxiety, but you must try to be patient as time will help you recover from PAWS. Managing PAWS is the only way to overcome these mental symptoms.

Self-Care and Education

A woman in an office smiling

Self-care is one of the most important aspects of managing PAWS that last for over a year. Take time to focus on yourself, including your mental and physical health. Self-care is not selfish, but it is taking care of yourself in order to be the best version of yourself that you can be.

The World Health Organisation defines self-care as “the ability of individuals, families, and communities to promote health, prevent disease, maintain health, and to cope with illness and disability with or without the support of a healthcare provider” [6].

Self-care involves steps to help individuals manage their stress levels and tension.

The following are commons steps involved in self-care:

  • Regular exercise
  • Good hygiene standards
  • Proper nutrition and healthy meals
  • Seek medical care if required
  • Be kind to yourself
  • Get enough sleep
  • Meditate
  • Spend time in nature
  • Grounding techniques
  • Take a break from electronics
  • Journaling
  • Practice positive affirmations
  • Chatting with friends and family about your feelings
  • Therapy

During active addiction, self-care often becomes less of a priority. It is also important to educate yourself about PAWS, addiction, and detoxification. This can help prepare you for any unexpected symptoms.

For example, you may go months without symptoms, and one day you may suffer from insomnia followed by extreme irritability and anger.

Without preparation and self-care, the symptoms presented may put you at risk of relapse. Start a journal and keep a notepad to write down your experiences.

This will help you develop an insight into your symptoms, and document coping mechanisms that have or haven’t worked for you.

This will make it easier to remember things and keep track of important information and feelings. This can also help remind you of important dates, appointments, and your daily schedule or routine.

Make sure you talk to friends, family, and other loved ones. Be kind to yourself, addiction is a mental disease, and it is not your fault nor is it a moral failing.

Try to avoid any known triggers, such as people you used to use with or places you used to use. Aim to avoid emotional situations that may provoke you, as this will help reduce the risk of relapse.

The recovery process for PAWS is long compared to other detox timelines, as the psychological symptoms can last up to two years, outlasting the physical withdrawal symptoms of acute withdrawal.

The long-term recovery of PAWS follows the acute withdrawal phase, moving from physical symptoms of withdrawal to psychological symptoms such as cognitive impairment. This happens following a period of prolonged substance abuse, withdrawal from alcohol, or cessation of drugs.

PAWS is the reconfiguration of brain activity and brain chemistry after being rewired by drugs or alcohol. This will have affected brain function, and possibly cause or exacerbate mental health conditions.

This can be helped naturally by improving your practice of self-care such as exercise and good nutrition. It can also be helped by mental health professionals, through different treatment programmes and behavioural therapy.

Healthcare professionals are able to treat your symptoms at whatever stage of recovery you are in, whether that is the acute phase of withdrawal or post-acute withdrawal syndrome presenting with severe symptoms.

Addiction recovery is never easy or simple, but the sooner you start, the more likely you are to receive the help you desperately need.

References

[1] Loretta Butehorn.Post–Acute Withdrawal Syndrome, Relapse Prevention, and Homeopathy.Alternative and Complementary Therapies.Dec 2017.228-230.brain activity

[2] https://www.cancer.gov/publications/dictionaries/cancer-terms/def/withdrawal

[3] Gupta M, Gokarakonda SB, Attia FN. Withdrawal Syndromes. (2022). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.

[4] Substance Abuse and Mental Health Services Administration. (2010). Substance Abuse Treatment Advisory: Protracted Withdrawal.

[5] Saitz R. Introduction to alcohol withdrawal. Alcohol Health Res World. 1998;22(1):5-12. PMID: 15706727; PMCID: PMC6761824.

[6] https://www.who.int/reproductivehealth/self-care-interventions/definitions/en/

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