Substance Use

What You Need to Know About Post-Acute Withdrawal Syndrome (PAWS)

Going through substance abuse recovery is a major milestone. However, it’s important to know the road doesn’t stop there. Post-acute withdrawal syndrome (PAWS) is a risk factor for anyone going through alcohol withdrawal or drug withdrawal, and it is a term used to describe an array of persistent symptoms after you stop using alcohol, opioids, benzodiazepines or other drugs. Symptoms and severity will vary from person to person, and educating yourself is important so you know what to expect.

Understanding PAWS

Acute withdrawal symptoms include typical detox side effects and physical and emotional effects that come from quitting your or a loved one’s substance of choice. Transitioning from typical detox symptoms to post-acute withdrawal syndrome (PAWS) is often not clear-cut and can happen in stages. Whereas acute withdrawal symptoms subside after a few days of being sober, PAWS emerges after the initial acute phase and can last for weeks, months or even years, depending on the severity of addiction that affects both your emotional and mental health. PAWS arises due to brain chemistry changes that occur from quitting a substance, especially after chronic, long-term use.

Alterations in Brain Chemistry

Dopamine, serotonin, and glutamate are all neurotransmitters in the brain that regulate mood, sleep, appetite, memory and more. Drugs can often enhance these neurotransmitters and when you go off the drug, the brain has an imbalance and needs time to reorient toward normal functioning. Chronic substance abuse can also lead to structural changes in the brain, such as reduced gray matter that helps with decision making, impulse control and reward. Lastly, substance use can lead to inflammation in the brain, which can lead to cognitive impairment and mood fluctuations.

Symptoms of PAWS

Substance use disorders come with acute withdrawal symptoms and may develop into PAWS in the weeks, months or even years following the addiction. Symptoms can also be triggered by uncomfortable situations where, typically, drugs or alcohol would numb those feelings. Common symptoms include:

Brain fog/difficulty remembering things
Urges and cravings
Fatigue
Irritability and hostility
Stress
Anxiety or panic
Depression
Lack of initiative
Concentration problems
Mood swings
Sleep disturbances (insomnia or vivid dreams)
Variable energy
Low enthusiasm

These symptoms can fluctuate and vary in intensity, depending on what triggered it and the individual. This, of course, can hinder how you feel every day, increasing the risk of relapse. It’s important to discuss all of this during your initial recovery to be prepared.

Duration and Variability

The length of PAWS episodes typically last a few days, but its intensity and length will depend on the person, what drug they were addicted to, and how severe the addiction was. It takes the brain six months to two years to heal and recalibrate. During this time, the brain will naturally begin to produce endorphins and dopamine.

Ways to Manage PAWS

Avoiding PAWS isn’t possible, but you can develop healthy coping strategies to manage the symptoms, including:

Finding a therapist who specializes in addiction or cognitive behavioral therapy (and psychiatry as needed)
Joining a support group
Practicing self-care, including a healthy diet, exercise regimen and lifestyle changes
Establishing supportive relationships
Journaling and reflecting on your journey
Limiting your time to focusing on one task for 15 minutes at a time if you struggle with concentrating
Writing things down or setting up reminders on your phone if you struggle with remembering things
Interrupting circular thinking or cravings by distracting yourself with something healthy, such as taking a walk, talking to a friend or listening to music or a podcast
If insomnia is an issue, limit caffeine intake, especially later in the day, establish a healthy bedtime routine and prioritize rest and sleep

Keep in mind: Be gentle with yourself and be realistic. This process takes time (it’s long-term recovery) and it’s best to not beat yourself up as your body and mind continue to heal. You’re on the right track — just keep going and don’t give up.

Challenges in Identifying and Treating PAWS

PAWS can be difficult to diagnose and treat because it is not cut and dry. Oftentimes, PAWS may mimic other symptoms that have to do with everyday life — mood swings, insomnia and being stressed, for example — are issues we all face, even without an addiction.

The symptoms of PAWS can dramatically spike or go away in as little as minutes, making it difficult to trace, especially in the initial phases. Many healthcare professionals are unaware of PAWS and may misdiagnose you, especially with varying symptoms with no predictability. Expect the unexpected when it comes to detoxification and drug addiction recovery in the long-term.

The Impact of PAWS on Recovery

The unpredictability of PAWS symptoms may become a trigger for some people to relapse. This is why arming yourself with a team of support is crucial for both your nervous system health and drug abuse prevention. Get a sponsor, find a counselor, and consider medications as prescribed by your doctor if needed to get you through the longer stages of substance abuse treatment. Going through PAWS can feel like a roller coaster of emotions, but know that with the right treatment programs and support, you can get through it and find yourself in a place of health, happiness and sobriety.

How Caron Can Help

Caron is the leading addiction treatment center on the East Coast, serving many communities, from young adults and teens to families to older adults, affluent individuals and the LBGTQIA+ community. We provide evidence-based therapies that combine traditional methods with holistic care to treat the whole person's mind, body and spirit so their well-being is cared for throughout the process. Contact us to learn more and talk to one of our experienced staff today.