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Post-Acute Withdrawal Syndrome: Stages and Symptoms

Every addict in recovery must endure two stages of withdrawal before they can truly move beyond dependency on drugs or alcohol. The acute stage begins as soon as an addict stops using and continues for several weeks thereafter. During this time, physical cravings will be intense and persistent because the body has not yet adjusted to the absence of the drug it relied on for so long. In this stage of withdrawal, the desire for chemical relief from pain may be so overwhelming that addicts feel like they are dying. Most former substance abusers will reflect back on this stage of recovery and tell people it was the hardest thing they had ever experienced.

This is only the beginning of a long, arduous journey. Addicts pay a high price for their long history of usage. It may take up to two years before neurochemistry returns to something resembling a normal state. After the acute stage of withdrawal ends, the post-acute stage begins, with an array of troubling symptoms. This period can last for 20 months or longer and is often referred to as post-acute withdrawal syndrome (PAWS). Other terms include post-withdrawal, protracted withdrawal, prolonged withdrawal syndrome and protracted abstinence.1

Drugs Associated With PAWS

GABA-agonists such as alcohol and benzodiazepines, opiates and stimulants all lead to lasting changes in learning, motivation and pleasure. Drugs impact the neurotransmitters dopamine, glutamate, serotonin, GABA and opioid peptides, wreaking havoc on pathways involved in reward, pain relief, stress maintenance, sleep and arousal, learning and memory. The detrimental effects can last long beyond quitting.2 It is estimated that 90% of recovering opioid users and 75% of recovering alcohol and psychotropic drug abusers experience PAWS to some degree.3 While some drugs are more likely to cause PAWS than others, there is a paucity of scientific studies, so the following list is likely partial.

Alcohol: Many studies have analyzed PAWS in relationship to alcohol withdrawal. About 50% of people with alcohol dependence experience withdrawal symptoms. Severe alcohol withdrawal is often refractory to standard doses of medication and requires aggressive treatment. Alcohol withdrawal syndrome (AWS) is the term given to a cluster of symptoms that occur when somebody detoxes from alcohol. Withdrawal symptoms usually start about six hours after alcohol cessation. Although some strategies such as tapering work for AWS, they appear to be much less effective for the longer-lasting symptoms of PAWS.4

Benzodiazepines: As with alcohol, tapering strategies can help acute withdrawal, but are typically ineffective for PAWS. Many individuals take benzos for anxiety and panic disorders — as well as symptoms that mimic those associated with schizophrenia, depression and OCD1 — during PAWS.

Antidepressants: Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) raise the levels of one or both of the neurotransmitters serotonin and norepinephrine in the brain by blocking their reabsorption by nerve cells. The exact mechanism responsible for improving depression symptoms is unknown, although it is clear adaptive changes take place in the brain when people take SSRIs. Individuals who stop taking these drugs can experience long-term withdrawal symptoms.1

Opioids: Individuals recovering from opioid addictions often report PAWS symptoms. Both pharmaceutical and illicit opioid painkillers including oxycodone (OxyContin), hydrocodone (Vicodin), codeine and heroin can evoke symptoms such as anxiety, fatigue and sleep disturbances in addicted individuals when they stop taking these drugs.1

Stimulants: People who suddenly stop using stimulant drugs such as cocaine and amphetamine experience psychological symptoms of PAWS. These include paranoia, anxiety, impulse control problems, depression and other emotional regulation issues.1

PAWS Symptoms

While the physical cravings associated with chemical addiction begin to abate after the first few weeks, the abuse of alcohol and other drugs causes more than physical dependency. It is during the post-acute stage of addiction that emotional and psychological symptoms of withdrawal begin to emerge and become dominant, taking recovering addicts on a roller coaster ride of thoughts, feelings and reactions.

Although everyone experiences PAWS a little differently, the following are commonly reported symptoms.1,3

  • Anxiety and panic attacks
  • Depression
  • Suicidal thoughts
  • Irritability
  • Sudden mood swings
  • Fatigue
  • Lack of motivation
  • Insomnia
  • Inability to concentrate
  • General cognitive impairment
  • Memory loss
  • Difficulty solving problems and thinking clearly
  • Obsessive thoughts
  • Fluctuating energy levels
  • Extreme drug cravings and obsessions
  • Anhedonia (the inability to feel pleasure from anything beyond use of the drug)

These states and conditions come and go throughout the duration of the post-acute stage, generally striking without warning. In the early days of PAWS, emotional and psychological turmoil is the norm. Due to rapidly cycling highs and lows, recovering addicts often feel like their lives are careening out of control. Recovering addicts will experience alternating periods of dysfunction and near-normality throughout the post-acute stage. As time passes, the duration of good times begins to increase. This is the result of the brain slowly re-organizing and re-balancing itself. Although the negative effects associated with PAWS remain a part of the equation for quite some time, recovering addicts can take heart, knowing that feelings of normalcy and stability will ultimately transition into a full-time state of being.

Coping With PAWS

Despite the intensity of the cravings in the acute stage, many addicts are able to resist them, only to relapse later during the post-acute stage. Substance abusers are often well-prepared for the strong physical symptoms that accompany abstinence, but they are not ready for the scary and unfamiliar emotions that suddenly confront them after the onset of PAWS. The following coping strategies can help.

Educate yourself: Knowledge is the most important defense an addict can have against PAWS. It is essential to gain an understanding of PAWS, be able to recognize the symptoms when they appear and have an action plan.5 Doing so can help people better cope with the various manifestations when they occur, such as the post-substance abuse blues.

Stay active: Physical activity and exercise help the body and brain heal quicker. Exercise boosts the immune system and restores a healthy balance to neurotransmitter levels. This in turn can reduce anxiety and stress and help recovering addicts sleep better.1

Be positive: When dealing with bouts of PAWS, recovering addicts should remain calm, relaxed, and accept that a high degree of inner turbulence is a natural and unavoidable consequence of getting clean and sober. Staying consistently focused on the positive goal of sobriety can help. It is wise to take care of your spiritual self and do things that bring you comfort.6

Identify and avoid triggers: Identifying situations that trigger anger, boredom, sadness, loneliness and stress can help you prevent these emotional states. If any of these are associated with people from your past who are still using, avoid them. Seek increased support when these situations arise.1,6

Eat healthy: All active alcoholics and most drug addicts suffer from malnutrition to some degree, and this often continues for months after adopting a healthier lifestyle. It is important to eat three balanced meals and three nutritious snacks every day (between meals and at bedtime) and avoid or limit sugar and caffeine. A diet should consist of a balanced mix of vegetables and fruit; carbohydrates such as potatoes, whole-grain rice and dark breads; protein; fats and dairy products.5

Above all, recovering addicts need the support of counselors and peers as they navigate post-acute withdrawal challenges. Regular appointments with therapists and weekly attendance at support group meetings are vital to recovery. There should be no hesitation on the part of the recovering addict to share details about the significant emotional repercussions associated with PAWS. The helpful advice, encouragement and compassion recovering addicts receive from support groups and counseling sessions are key to surviving this difficult stage — and ultimately staying clean and sober.

  1. What Is Post-Acute Withdrawal Syndrome? Drug Abuse website. http://drugabuse.com/library/post-acute-withdrawal-syndrome/ Accessed December 10, 2016.
  2. How to Isolate and Treat Protracted Withdrawal Symptoms. The Fix website. https://www.thefix.com/content/paws Published February 4, 2014. Accessed December 10, 2016.
  3. Post-Acute Withdrawal Syndrome (PAWS). Semel Institute UCLA Dual Diagnosis Program website. https://www.semel.ucla.edu/dual-diagnosis-program/News_and_Resources/PAWS  Accessed December 10, 2016.
  4. Schmidt KJ, Doshi MR, Holzhausen JM, Natavio A, Cadiz M, Winegardner JE. Treatment of Severe Alcohol Withdrawal. Ann Pharmacother. 2016 May;50(5):389-401. doi: 10.1177/1060028016629161. Epub 2016 Feb 9.
  5. P.A.W.S. What Me Sober website. https://whatmesober.com/post-acute-withdrawal-syndrome-paws-is-the-cause-of-a-lot-of-misery-and-relapse-in-early-recovery-it-pays-to-know-what-to-expect/ Accessed December 10, 2016.
  6. Post Acute Withdrawal Syndrome (PAWS). UW Health website. http://www.uwhealth.org/healthfacts/psychiatry/7228.pdf Accessed December 10, 2016.

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