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Withdrawal symptoms are common during the beginning stages of recovery from alcohol or drug addiction. The severity of symptoms can range anywhere from slightly inconvenient to severely uncomfortable.
Post-Acute Withdrawal Syndrome (PAWS) is characterized by withdrawal symptoms that show up and can stick around throughout the first few months of recovery.
Although these withdrawal symptoms eventually go away, it is essential to understand them and learn how to cope with them, as they can sometimes cause someone in recovery to relapse.
What is PAWS?
The withdrawal process consists of two phases. The first phase is characterized by acute withdrawal symptoms that occur alongside the detox of highly addictive substances. This stage includes mostly physical withdrawal symptoms and lasts around a few weeks 1.
Post-Acute Withdrawal Syndrome (PAWS) kicks in during the second phase of the withdrawal process. PAWS includes more emotional and psychological symptoms, while physical symptoms dissipate for the most part 1.
There are multiple addictive substances that, when abused and detoxed, can result in PAWS. For example, 90% of people recovering from opioid addiction experience PAWS to some extent, as do 75% of people recovering from alcohol and psychotropic drug abuse 2.
The severity of PAWS symptoms can range from mild to severe and may disappear, only to reappear later. Eventually, post-acute withdrawal symptoms will go away altogether.
Other symptoms include:
Stress can sometimes cause post-acute withdrawal symptoms to become more severe. Other times, symptoms can become temporarily severe, with no apparent cause 2.
PAWS for Different Drugs
While all PAWS symptoms generally fall under the above list, the PAWS symptoms associated with one drug may look different than those of another drug. Some of the most common drugs that result in PAWS symptoms include alcohol, antidepressants, benzodiazepines, marijuana, opioids, and stimulants.
Symptoms that are now known to be those of PAWS were first recognized in individuals recovering from alcohol addiction. Since the 1990s, medical journals have published studies that examine prolonged symptoms of alcoholism 3.
Alcohol works, in part, by activating the brain’s GABA symptoms, which inhibits brain activity. The brain then makes changes to avoid permanent or recurrent inhibition. These changes cause the nervous system to become overactive and easily excitable when the drinking stops 3.
PAWS symptoms related to alcohol include stress and anxiety, feeling sick, extreme exhaustion, and cravings that stick around for a long time.
While people tend not to use antidepressants recreationally, when someone stops taking them abruptly, they will usually experience PAWS symptoms.
Most antidepressant drugs work by targeting neurotransmitters in the brain and raising serotonin and norepinephrine levels. When someone stops taking antidepressants, the levels of these neurotransmitters change dramatically 4.
PAWS for antidepressants is usually characterized by prolonged and intense depression because of the drastic alteration in serotonin and norepinephrine once someone stops taking them.
Benzodiazepines include drugs like Valium and Xanax and work similarly to alcohol. However, those who use benzodiazepines seem to be at an extremely high risk of developing PAWS symptoms that can last for years 2.
PAWS symptoms associated with the use of benzodiazepines can also be very extreme. These symptoms can include anxiety, panic, obsessive-compulsive disorders, and even schizophrenia 5.
Many people who smoke marijuana use it to relax, and those addicted to it can become reliant upon it to feel normal. When someone stops using marijuana, they may become depressed, paranoid, and stressed.
PAWS symptoms associated with marijuana use can consist of the continuation of depression, paranoia, and stress. Symptoms also include difficulties with sleeping and abnormal dreams 5.
Opioids work by activating the opiate receptors located in the brain and spinal cord, which effectively blocks pain messages sent through the spinal cord to the brain 6. When taken in large doses, they can create a euphoric high.
PAWS symptoms associated with opioids typically include anxiety, depression, lack of focus, and sleep disturbances. They can also consist of feeling sad, extremely tired, and irritable 5.
PAWS symptoms associated with the use of stimulants include aggression, depression, extreme fatigue, lack of motivation, and issues with controlling impulses 5.
What Causes PAWS?
The widely agreed-upon cause of Post-Acute Withdrawal Syndrome (PAWS) is related to physiological changes that occur within the brain of someone who is addicted to a substance.
Drug addiction creates changes in available neurotransmitters, which causes the brain to alter itself to accommodate these changes. When someone stops taking an addictive drug, available neurotransmitters change again and can create excitability 2.
When someone uses a substance for a considerable amount of time, their brain loses some of its ability to deal with stress. Experiences during withdrawal also affect the brain’s capacity for stress 2.
Scientists believe that these physical changes are responsible for the recurring symptoms associated with PAWS. They also believe that these changes are what cause increased tolerance during active substance abuse 2.
How Long Does PAWS Last?
The duration of PAWS is different for each person recovering from substance abuse. The amount of time PAWS sticks around for generally depends on how long, how much, and how often someone uses an addictive substance 7.
PAWS can last a couple of weeks and may stick around for months or years. Symptoms of PAWS can be extremely uncomfortable and can persist even after physical traces of the substance no longer exist in the brain or body 7.
How to Deal with PAWS
PAWS tends to stick around for a while, and can even exist up to 2 years into the recovery process. These troublesome symptoms can create feelings of hopelessness in someone recovering from substance abuse and may cause them to believe that their only way out is to relapse.
It is imperative to recognize PAWS symptoms and understand that they do eventually go away. Additionally, there are vital strategies that someone in recovery should implement to reduce the chance of relapse.
Relapse Prevention Strategies
It is crucial to create a support system that includes an individual who can help recognize when someone is experiencing PAWS symptoms. This person may be a counselor or mental health professional 8.
A support system can also consist of friends, family, and perhaps a religious or spiritual group. However, the support system must only include those who want to help the recovering individual stay sober. This support system will ideally help them to cope with PAWS symptoms 8.
Avoid High-Risk Situations
It is best for an individual in recovery to avoid people, places, and things that are associated with previous substance abuse. For instance, they should avoid people who used to provide drugs or participate in drug use, places where drugs were taken or acquired, and things or activities that bring up memories of use 1.
Acquiring coping skills can help someone in recovery effectively deal with PAWS symptoms. Cognitive therapy is a great way to learn skills that can change negative thinking patterns and create more positive thoughts 1.
Seeking treatment is one of the best ways to prevent relapse due to PAWS symptoms. Since symptoms can last longer for those who engaged in excessive and persistent use, it may be wise for these individuals to seek longer-term treatment.
Treatment helps prevent relapse by offering medical assistance and providing a well-trained support system, a safe space free of high-risk people, places and things, and various coping skills acquired through therapy.
If you or someone you love is struggling to stay sober, it is vital to seek treatment as soon as possible. The admissions team at our San Diego Outpatient Rehab Center is available to answer any questions that you may have.
Medically Reviewed By:
Dr. Sanjai Thankachen
Dr. Sanjai Thankachen graduated from Adichunchanagiri Institute of Medicine in 2000. He completed his residency in psychiatry in 2008 at Creedmoor Psychiatric Center in New York. Dr. Thankachen is currently working with Pacific Neuropsychiatric Specialists in an outpatient practice, as well as working at multiple in-patient psychiatric and medical units bringing his patients the most advanced healthcare treatment in psychiatry. Dr. Thankachen sees patients with an array of disorders, including depression, bipolar illness, schizophrenia, anxiety, and dementia-related problems.
Edited for Clinical Accuracy By:
Sean Leonard is a board-certified psychiatric nurse practitioner. He received his master’s degree in adult geriatric primary care nurse practitioner from Walden University and a second postmaster specialty in psychiatry mental health nurse practitioner from Rocky Mountain University. Sean has experience working in various diverse settings, including an outpatient clinic, inpatient detox and rehab, psychiatric emergency, and dual diagnosis programs. His specialty areas include substance abuse, depression, anxiety, mood disorders, PTSD, ADHD, and OCD.
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