Post-Acute Withdrawal Syndrome (PAWS)

What Is Post-Acute Withdrawal Syndrome?

To understand Post-Acute Withdrawal Syndrome (PAWS), one must first understand the 2 stages of detox or withdrawal symptoms.

The first stage of detox, acute withdrawal, is primarily physical withdrawal symptoms that can last from a few days up to 2 weeks. Acute withdrawal symptoms are the immediate or initial withdrawal symptoms that occur upon sudden cessation or rapid reduction of the use of addictive substances, including alcohol.

Many people seek help through a medically supervised detox or by attempting to quit alone. Acute withdrawal can produce more dangerous health consequences—even life-threatening complications—if detox isn’t completed in a supervised setting. This is especially true of individuals who are in the acute withdrawal stage of alcohol, Benzodiazepines, and Barbiturates, as these substances have increased risk of complications without medical supervision, including seizures or coma. Due to the wide range of acute withdrawal symptoms that may occur, and the various addictive substances that may be used, it is always advised to seek medical assistance rather than quitting on your own.

The second stage of detox, known as post-acute withdrawal syndrome (PAWS), occurs as the brain re-calibrates after active addiction. Unlike acute withdrawal, which is primarily physical withdrawal symptoms, the symptoms of post-acute withdrawal are primarily psychological and emotional symptoms. Depending on the intensity and duration of alcohol or other drug use, post-acute withdrawal is known to last many months. Post-acute withdrawal symptoms typically last between 1 and 2 years; however, the severity and frequency of symptoms tend to dissipate as times goes by without the use of addictive substances.

Post-acute withdrawal syndrome can be not only discomforting, but symptoms can appear sporadically, making PAWS a driving factor for many individuals to relapse, despite how committed they are to staying clean and sober. Regardless of the addictive substance(s) used, PAWS are typically the same for most individuals in early recovery from substance use disorders (SUD).

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Common Post-Acute Withdrawal Symptoms

Some of the most common post-acute withdrawal symptoms include:

• Insomnia or other sleep disturbances
• Irritability, aggression, hostility
• Anxiety or panic attacks
• Depression
• Impaired concentration
• Lack of enthusiasm or motivation
• Mood swings (severe highs and lows in mood)
• Fatigue or low energy
• Foggy thought process
• Poor memory
• Poor impulse control
• Increased sensitivity to stress
• Alcohol or other drug cravings
• Alcohol or other drug dreams
• Apathy

Why Does Post-Acute Withdrawal Syndrome Occur?

Post-acute withdrawal syndrome occurs after the acute withdrawal stage and is a natural occurrence as the brain slowly returns back to normal over a period of time. As one’s brain chemicals begin to regulate, their post-acute withdrawal symptoms may fluctuate as the individual’s brain attempts to seek a healthy equilibrium. PAWS is the brain’s way of correcting chemical imbalances that it suffered from during active addiction. PAWS tends to occur more commonly and intensely among individuals with alcohol, Benzodiazepine, or Opioid addictions.

Common Drugs And Their Associated Post-Acute Withdrawal Symptoms

Certain drugs are known to result in more severe post-acute withdrawal symptoms, such as:

Marijuana

Several studies indicate that sudden discontinued use of Marijuana can result in post-acute withdrawal syndrome upon completion of acute detox. Common PAWS from Marijuana include insomnia, anxiety, irritability, headaches and other physical symptoms, such as stomach pain and changes in appetite.

Methamphetamine

Common PAWS for Methamphetamine include poor impulse control, disturbed sleep or insomnia, and irritability.

Opioids

Common PAWS from Opioids include insomnia, depression, anxiety, intense cravings, muscle tension, and poor impulse control.

Cocaine

Cocaine is known for various PAWS that last for prolonged periods of time. Many users report symptoms of depression, fatigue, low motivation, and poor impulse control.

Benzodiazepines

Benzodiazepines, such as Xanax, Ativan and Klonopin, are known for having common PAWS, including  intense anxiety, panic attacks, irritability, and severe sleep disturbances, including insomnia.

Post-Acute Withdrawal Symptoms And Relapse

Post-acute withdrawal symptoms that persist or randomly occur during early recovery can become a risk factor for relapse. The symptoms can be discomforting, and without healthy coping skills, can lead to a relapse, no matter how committed one is to remaining clean and sober. Learning about the symptoms of post-acute withdrawal syndrome, along with implementing healthy coping strategies, is the most efficient way to prevent relapse.

Coping With PAWS

In the beginning, post-acute withdrawal symptoms may begin to feel as if you are on an emotional rollercoaster, with mood swings ranging from happy, to irritable, to sad. It can be overwhelming at first, but as you make progress in your recovery, symptoms of post-acute withdrawal syndrome begin to dissipate. After time, you may go a month without experiencing any PAWS and suddenly they will reappear unexpectedly. One of the hardest parts of PAWS is often the unpredictability of the occurrence of symptoms, making PAWS a major barrier for recovering from a substance use disorder (SUD).

Be patient and give it time, as the symptoms will decrease through time in severity and occurrence as long as there is continued abstinence. Learning healthy coping strategies for managing PAWS is one of the best ways to overcome the discomforting symptoms that may appear.

A few healthy coping strategies for PAWS include:

Practice Self-Care

Self-care is essential during the next 12 to 48 months while managing symptoms of post-acute withdrawal syndrome. Give yourself many breaks during the day, and remember to use positive affirmations, such as, “I am strong” or “I am worth it.” Most importantly, be good to yourself; mentally, physically, and spiritually.

Take time to focus on yourself while practicing healthy self-care practices, such as exercise, healthy meals, meditation, proper hygiene, establishing positive and supportive relationships, and expressing your emotions and feelings to a trusted family member, friend, or therapist. When in active addiction, self-care is often put on the back burner, making self-care vital while in recovery, as recovery is the opposite behavior as active addiction.

Educate Yourself On Post-Acute Withdrawal Symptoms

Gain as much education on symptoms of post-acute withdrawal in order to be prepared for unexpected symptoms appearing. You may go a few weeks with no PAWS, but wake up one morning after having disturbed, unrestful sleep, extreme fatigue, irritability and anger outbursts, as well as various mood swings. If you’re not prepared for it, you may find yourself at risk for relapse. Education is key in order to be prepared and learn how to manage the various symptoms.

Exercise

Being physically active helps reduce physical and mental tension, as well as anxiety, depression and other symptoms.

Start A Journal

Consider writing in a journal as a way to gain awareness and insight into your symptoms and document your experiences utilizing different coping skills. It is also a healthy way to express yourself and your feelings/emotions.

Keep A Notepad

If you have problems remembering things, keeping a notebook or pad of paper nearby can help you keep track of important information, such as your daily schedule, to-do lists, and other important information. Using your smart phone to schedule daily reminders of appointments or to complete tasks is also a great way to prevent forgetting responsibilities and commitments.

Talk About What You’re Experiencing

Sharing feelings, emotions, and any post-acute withdrawal symptoms you are experiencing with people you trust, such as family, peers in 12-step meetings, a counselor, or a close friend is useful in expressing yourself.

Be Kind To Yourself

Be good to yourself. Practice positive self-talk, including reminding yourself that what you are experiencing is normal and that “this too shall pass.” Be gentle with the thoughts you have, and be patient with yourself.

Avoid Triggers

Avoid situations, including triggers, that may initiate a craving to use, or situations that are anxiety-provoking, such as loud or crowded places. This will help reduce the trigger of or exasperation of post-acute withdrawal symptoms.

Practice Relaxation Techniques

Relaxation techniques, such as meditation, help reduce anxiety, tension, and overwhelming thoughts or emotions.

Help Is Available

Although post-acute withdrawal syndrome can be a very challenging process while the brain and body begin to heal and reorient itself to life without the use of alcohol or other drugs, help is available. There are many outpatient treatment programs available to guide you through the post-acute withdrawal phase during recovery to prevent relapse. Contact a treatment provider today to learn more about the various rehab options.