Post-Acute Withdrawal Syndrome (PAWS): Everything You Need to Know
Last Updated Dec 2, 2021
Post-acute withdrawal syndrome (or PAWS) is a set of symptoms that persist despite the absence of drugs and alcohol.
For example, someone may work through medical detoxification in a hospital setting, and when it is complete, that person can pass a drug or alcohol screening. No substances remain. Even so, that person feels desperately ill.
PAWS is dangerous, as some people find using again is the easiest way to ease pain. Treatment can help people lessen symptoms, deal with discomfort, or both.
What Causes PAWS?
Drugs and alcohol do not just change the way you feel. They can also change the way your mind and body work. Those physical changes can lead to uncomfortable symptoms that persist despite your sobriety.
PAWS begins with chemistry. Persistent drug use leads to changes in the:
- Basal ganglia. Dopamine is responsible for feelings of pleasure, and it works to train the brain to link situations (such as a backyard barbeque) with a craving (such as a deep need for a beer). When people stop abusing substances, the dopamine surge keeps suggesting relapse moments.
- Extended amygdala. This part of the brain regulates fight-or-flight responses. Dopamine changes here can make people feel distressed when drugs are not present. Some people even feel panicked when they can’t get the substance they’ve been abusing.
You may not see these changes in your body, but they can change the way you look at the world around you. They can also change the way you react in common situations.
PAWS symptoms can stay with you for weeks or even months. The length of your recovery and the intensity of your symptoms depend on the length and severity of your substance abuse.
Which Drugs Can Lead to PAWS?
Any substance that changes brain chemistry is capable of sparking PAWS. But some substances are closely linked to the phenomenon.
PAWS symptoms are common in people who abuse:
- Alcohol. Regular drinkers are likely to develop withdrawal symptoms when they stop abusing this substance.
- Benzodiazepines. Drugs like Valium, Xanax, and Ativan can cause PAWS. The syndrome does not discriminate, so symptoms happen in people with prescriptions and those who buy the drugs off the street. Stopping substance abuse quickly, without tapering the drug use, is closely tied to PAWS.
- Opioids. Prescription medications like Vicodin and street drugs like heroin both change brain chemistry. Protracted use and quick withdrawal can lead to PAWS.
The list above is not exhaustive. People taking other substances can and often do develop PAWS. But people with a history of abusing these three classifications of drugs should know what PAWS is.
What Does PAWS Look & Feel Like?
For years, people with PAWS were told that they had an underlying mental health issue causing their symptoms. Now, researchers know much more about what long-term withdrawal looks like and how it can make people feel.
Common PAWS symptoms include:
- Decline in mental function. You may struggle to learn new things, retain information, or solve problems.
- Poor emotional control. You may feel irritable or angry, even when you are in a safe or protected space. You may also feel depressed or sad.
- Panic. You may feel deep anxiety or fear when exposed to situations in which you once used drugs.
People with PAWS may also experience the following:
- Cravings for drugs
- Poor connections with others
- Disturbed sleep
- Low energy
Some people describe PAWS as wave-like. Symptoms wax and wane depending on what they are doing. If you are exposed to a trigger, your symptoms may intensify. But some people experience enhanced distress with no clear prompt.
How Long Does PAWS Treatment Last?
As long as you have PAWS symptoms, treatment may help. Teams build individualized programs, so there is no uniform start and stop date. You should get help as long as you need it.
Typically, people with PAWS stay in treatment for months. But sometimes, the help you get at the beginning of withdrawal dictates your recovery length.
For example, people given buprenorphine for opioid withdrawal in the emergency room are more likely to be in treatment a month later than those who do not receive buprenorphine. If your withdrawal program is sound, you may recover faster.
Some substances, including opioids, are responsive to medications. A tapering dose can help your brain adjust to sobriety. But almost everyone can benefit from therapy to help them understand their new brains and their symptoms.
Your therapist may help you pick up self-management skills to deal with symptoms such these:
- Muddled thinking: Determine your most focused time of day, and do your heavy mental work then. If you get caught in circular thinking, set a timer for 15 minutes. When the timer rings, find something else interesting and engaging to do.
- Emotional dysregulation: Tell your friends and family that you’re working on your recovery. Explain that you may seem to overreact in times of high emotion. Use meditation or focused breathing to help you calm down.
- Anxiety: Keep a “stress diary,” and make a note of situations that make you feel anxious or afraid. Work with a therapist on coping mechanisms for these events, if they can’t be avoided.
Why Should You Treat PAWS?
Your symptoms are a natural and normal part of the recovery process. In fact, they are signs that your brain is healing. But you do not need to live with them without help.
The longer your addiction lasted and the stronger your withdrawal symptoms, the harder long-term sobriety is to maintain. PAWS can make your life very difficult, and relapse can seem like a good option to make the symptoms go away.
You may feel:
- Angry. Why is this happening to me? Why am I unable to live a healthy life? Everyone else seems to have it easier. Why is it so hard for me?
- Depressed. I worked so hard to get sober, and now my brain is fighting me. I should give up.
- Fatalistic. I know I will relapse anyway. I may as well do it now.
These thoughts are understandable, normal, and common. But they are also very painful, and they can lead to relapse.
A relapse can be deadly. If you use as much in a relapse as you did while you were actively using, you can experience an overdose. Your brain is no longer accustomed to high drug doses, and you can overwhelm your system and stop your heart. Blocking an overdose is critical.
Handling your PAWS symptoms is one of the best ways to help you prevent a life-threatening overdose. A comprehensive addiction treatment program can help you address PAWS symptoms, so you can focus on your recovery. The lessons you learn in treatment can help you live a healthier life moving forward.
The Neurobiology of Substance Use, Misuse, and Addiction. (2016). U.S. Department of Health and Human Services.
The ‘Patient Voice:’ Patients Who Experience Antidepressant Withdrawal Symptoms Are Often Dismissed or Misdiagnosed with Relapse or a New Medical Condition. (2020). Therapeutic Advances in Psychopharmacology.
New Findings on Biological Factors Predicting Addiction Relapse Vulnerability. (June 2013). Current Psychiatry Reports.
Drugs, Brains, and Behavior: The Science of Addiction. (July 2020). National Institute on Drug Abuse.
Most Hospital ERs Won’t Treat Your Addiction. These Will. (September 2018). PEW.
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