Understanding Post-Acute Withdrawal Syndrome (PAWS): Symptoms & What to Do

What is Post-Acute Withdrawal Syndrome (PAWS)?

Post-acute withdrawal syndrome (PAWS) refers to symptoms that persist for weeks or months after the initial withdrawal from alcohol or drugs. 

It’s also referred to as a post-withdrawal syndrome, prolonged withdrawal syndrome, and protracted withdrawal syndrome.

PAWS commonly happens with alcohol, opioids, and benzodiazepines. Around 90% of recovering opioid users and 75% of recovering alcoholics and psychotropic abusers experience PAWS.¹

Post-acute withdrawal symptoms are largely psychological rather than physical. They vary depending on the addictive substance and the person. Some changes in the brain take months to recover, while others never return to normal function.

Medications, therapy, self-care, and support groups can help people struggling with PAWS manage their symptoms and prevent relapse. 

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Acute Withdrawal vs. Post-Acute Withdrawal

When people suddenly stop using an addictive substance, they may undergo immediate or acute withdrawal. 

Acute withdrawal is usually composed of physical symptoms. They may be short-lived (several days to a week) but are often uncomfortable. Some are even life-threatening.  

Some common withdrawal symptoms include: 

• Headaches
• Nausea
• Vomiting
• Tremors
• Anxiety
• Depression
• Seizures
• Muscle aches
• Fatigue
• Mood swings
• Insomnia
• Irritability

Several symptoms may linger or develop past the initial withdrawal process. This can happen weeks or months after the last substance use and is referred to as the post-acute phase of withdrawal. 

What Causes PAWS?

The causes aren’t fully known and vary between people. But experts think PAWS is likely caused by ongoing adjustments in the brain and other parts of the central nervous system (CNS).  

These adjustments seek to correct or reverse conditions induced by substance abuse, including:^{2, 3, 4, 5}

• Altered brain chemistry
• Chemical imbalances
• Tolerance to alcohol or drugs 
• Hyperactivity of the nervous system 

During substance abuse, the brain makes several adjustments. One involves changing the levels of neurotransmitters like GABA, serotonin, norepinephrine, and dopamine. 

When the person stops using the substance, neurotransmitter levels change again. This leads to a hyperactive nervous system and manifests as withdrawal symptoms.¹

Symptoms usually resolve within 2 to 3 weeks. However, neurotransmitters and receptor activity may require more time to return to a normal state.⁶

Some symptoms, most of which are psychological, may persist or develop later on. If they appear, the person is now experiencing PAWS.

Experts also think withdrawal and long-term substance abuse can reduce the brain’s capacity to manage stress.¹

Take people with heroin addiction as an example. They may re-experience cravings and withdrawal symptoms when they are exposed to triggers. This may happen long after they abstained from using heroin.⁷

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What are the Symptoms of PAWS?

PAWS symptoms include:^{1, 5, 8, 9, 10}

• Insomnia and other sleep disturbances
• Mood swings
• Intense depression
• Aggressive behavior or hostility
• Anxiety or panic attacks
• Irritability
• Intense cravings for originally abused substances
• Difficulty learning or solving problems
• Foggy thinking
• Poor memory
• Increased sensitivity to stress
• Obsessive-compulsive behaviors
• Difficulty maintaining social relationships
• Apathy
• Pessimism
• Inability to concentrate
• Lack of initiative
• Poor impulse control
• Extreme fatigue
• Suicidal thoughts
• Sensory symptoms (like tinnitus, tingling, or numbness)
• Motor symptoms (like muscle pain, weakness, or tremors) 
• Gastrointestinal symptoms (like diarrhea or vomiting)

Symptoms tend to fluctuate in severity. In the first few weeks of early recovery, the symptoms can change every minute. As people move into long-term recovery, the symptoms appear less frequently.

Stressful situations reminiscent of substance abuse may trigger PAWS symptoms. But they may also appear without any triggers.¹

One danger of PAWS is that it can increase the risk of relapse. People usually hate the uncomfortable feelings associated with PAWS. This may push them to revert to substance use to avoid unpleasant symptoms.^{7, 11}

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When Does PAWS Set in?

The onset of PAWS varies. Some symptoms linger past the acute withdrawal stage, while others disappear then reappear after a few weeks or months. 

About 10 to 15% of benzodiazepine patients experience PAWS symptoms 2 to 4 weeks after their last use.⁵ Prolonged alcohol withdrawal may kick in more than 3 months after a person’s last drink.⁷

How Long Does PAWS Last? 

PAWS duration also varies. It depends on the person and the substance. PAWS may linger for months or even years. 

If a person tapers off benzodiazepine, withdrawal symptoms usually disappear within 6 to 18 months after their last dose. But there are also reports of symptoms lingering for up to a decade.⁵

With antidepressants, post-acute withdrawal symptoms last from 6 months to over 23 years.¹²

In people with alcohol use disorder (AUD), withdrawal symptoms usually disappear or become less intense 3 to 6 weeks after their last drink. However, the risk of relapse due to a lower stress threshold or cravings may persist beyond this period.⁷

How to Manage PAWS

Enduring PAWS can be challenging, especially with fluctuating symptoms. However, people can manage PAWS symptoms and prevent relapse by:¹

• Avoiding triggers: Recognize and avoid people, situations, and emotions that may trigger a relapse. For instance, recovering alcoholics should rarely, if ever, go to bars or places they used to drink.
• Managing stress: As stress can trigger PAWS, stress management can go a long way in preventing relapse. 
• Taking medications as prescribed: PAWS may persist for months or years, so medications have to be given over a long time. One medication is acamprosate, which can help with protracted alcohol withdrawal.  
• Receiving behavioral treatment: Cognitive behavioral therapy (CBT) is particularly helpful for learning coping skills when cravings are the dominant symptom.

• Practicing self-care: This includes eating healthy foods, getting enough sleep, exercising regularly, and drinking plenty of water each day. These simple activities can help counter several PAWS symptoms.
• Seeking support: Friends and family members can be significant sources of emotional support. Health professionals can provide medical assistance for symptoms like insomnia or depression. Support groups can also offer emotional support and guidance. 

In-person or online 12-step recovery groups: These are available worldwide. They’re also free and provide access to others who have experienced PAWS.