Post-Acute Withdrawal Syndrome (PAWS)

PUSH for Recovery understands the challenges from post-acute withdrawal syndrome and we are here to help.

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    Post-Acute Withdrawal Syndrome (PAWS)

    Most clients in treatment for substance use disorder do not immediately feel better after stopping drugs or alcohol.  Even after completing post-acute withdrawal syndrome (PAWS), medications may persist for an extended period of time.  Everyone uniquely experiences the symptoms related to the effects of abusing substances for an extended period.  These symptoms with varying levels of intensity may be felt for weeks, months, or sometimes years.  Cravings, negative emotional states, and sleep disturbances are very common when the use of substances has stopped.  These symptoms may become so intense that the client seeks relief by returning to substance use, thus fueling the vicious cycle of relapse and recovery.

    Some clients in recovery also experience symptoms from co-occurring substance use and mental disorders. The SUD treatment provider's challenge is to determine which of a client's abstinence symptoms are substance-use related and will resolve over time, indicating a possible co-occurring disorder (COD) that calls for a thorough assessment by a mental health provider concurrent care.

    What is acute withdrawal?

    The American Society of Addiction Medicine defines withdrawal as "the onset of a predictable constellation of signs and symptoms following the abrupt discontinuation of, or rapid decrease in, the dosage of a psychoactive substance." Such signs and symptoms are generally the opposite of the intoxication effects of the substance.  These signs and symptoms begin within hours or days after the last use of the substance and gradually resolve.  For example, pupils constrict during opioid intoxication and dilate during acute withdrawal. The length of time symptoms last depends on the particular substance used.

    Substance Acute Withdrawal Timeframe
    Alcohol 5-7 Days
    Benzodiazepines 1-4 weeks; 3-5 weeks with tapering
    Cannabis 5 days
    Nicotine 2-4 weeks
    Opioids 4-10 days
    Stimulants 1-2 weeks
    Cocaine 1-2 weeks

    What is protracted withdrawal?

    Protracted withdrawal also knows as post-acute withdrawal syndrome (PAWS) is the presence of substance-specific signs and symptoms common during the acute withdrawal but lasting well beyond the acute withdrawal timeframe.  These protracted withdrawal symptoms may completely stop for periods of time and then suddenly return at varying levels of intensity.

    How do protracted withdrawal symptoms develop?

    Chronic abuse of drugs or alcohol causes molecular, cellular, and neurocircuitry changes to the brain that affect emotions and behavior and that persist after acute withdrawal has ended.   These adaptive changes in the central nervous system may lead to affective changes and withdrawal symptoms that persist for many weeks or longer beyond acute withdrawal.  For example, repeated use of a substance causes the brain to respond more readily to its effects but less readily to naturally rewarding activities.  As a result, the individual struggles to experience pleasurable experiences without the aid of substances. This state, in which a person's ability to experience pleasure is decreased, is called anhedonia.  In research on anhedonia, this phenomenon is linked to psychosocial factors in the lives of people recovering from SUDs and appeared to be a symptom of protracted withdrawal that was unrelated to other clinical and psychosocial features.   It takes time for the brain to normalize again and restore balance within the brain's molecular, cellular, and neurocircuitry.

    A variety of other symptoms have been attributed to protracted withdrawal, including:

    • anxiety,
    • depression
    • sleep difficulties,
    • problems with short-term memory,
    • persistent fatigue,
    • difficulty concentrating and making decisions,
    • alcohol or drug cravings,
    • impaired executive control (e.g., impulse control, solving problems)
    • difficulty focusing on a task
    • irritability
    • unexplained physical pain
    • reduced interest in sex

    Tips for Dealing with Post-Acute Withdrawal Syndrome (PAWS)

    Any treatment plan should take the person’s propensity for any particular symptom into account in treatment. For example, someone with a history of depression before or during their addiction will likely experience this PAWS symptom with greater intensity than someone else. Their treatment should explore the person’s history with depression, including any potential triggers, so they may be avoided during this stage of recovery. The same holds for symptoms such as anxiety, mood swings, and insomnia.

    In addition to a personal approach, an effective treatment plan should also include the following:

    • Stress avoidance – Stress can enhance PAWS symptoms, so it’s important for the person in recovery to take it easy and avoid stressful situations.
    • Continued therapy – Family and friends should play an important supportive role during this time.
    • Talk honestly about your symptoms and feelings with an understanding (non-using) friend or therapist.
    • Introduction of healthy habits – Healthy eating, exercise, and meditation are all helpful in this stage of recovery.
    • Advanced planning – Think about what a trigger could be and try to create a plan for handling the situation before it occurs.
    • Compassion – This is a difficult stage to endure, and it’s important for everyone to go easy on the person in active recovery, including the person herself.
    • Educate yourself about PAWS: Gaining knowledge and educating yourself on PAWS and recovery can help you deal with these unexpected withdrawal symptoms.  It is helpful to know that these feelings, emotions, and symptoms are normal during the first weeks and months of abstinence.  Focus on the little incremental progress that is being made.  It takes time to undo the damage from substance use but in many cases, with long-term abstinence, substance-induced brain changes reverse.
    • Explore spirituality. Most people have a spiritual side they may or may not know much about. You may find that your spirituality provides meaningful comfort during this difficult time.
    • Work toward moderation and balance in every area of your life.

    If you or someone you know is struggling to deal with the PAWS stage of recovery, please understand that you are not alone, and there is no shame in asking for help. Reach out to friends and family and talk to someone qualified to help you cope with symptoms as your brain is readjusting to its pre-substance state. Relapse can be very dangerous for your health, so be sure to get help and know that these symptoms are likely to subside before too long.

    Donate

    Donate to help the Life Recovery Society provide a safe, sober, supportive, and flexible way for individuals to earn an income while in treatment.  Life Recovery Society also plans to add a men's and women's sober living home in the Hilltop Community.

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