Post-Acute Withdrawal Syndrome (PAWS)

What is Post-Acute Withdrawal Syndrome (PAWS)?

Post-acute withdrawal syndrome (PAWS) is a collection of symptoms that emerge after the typical withdrawal period has ended. Some of the general symptoms of post-acute withdrawal include anxiety, sleep problems, memory and attention issues, cravings, and depression. However, the effects and timeline can differ depending on the substance used, the severity of drug dependence, and the presence of co-occurring medical, mental health, or polysubstance abuse problems.

Relative to other substances, people who abuse opiates, alcohol, and benzodiazepines have a greater risk of experiencing post-acute withdrawal.

PAWS and its effects are generally less severe and, in the case of opioids and sedatives, less immediately life-threatening than those experienced during the normal or acute withdrawal period. Still, they can jeopardize recovery and may require professional treatment.

How is Post-Acute Withdrawal Different?

In many cases, acute withdrawal consists of a characteristic set of symptoms that a physically dependent person will experience when they suddenly stop or reduce use of that substance.^1,2,3 For most substances, acute withdrawal symptoms begin within a few hours or days after last use and typically resolve within a month.³

In contrast, post-acute withdrawal symptoms appear after the acute phase and can last much longer, on average. These symptoms can significantly affect someone in recovery and increase the risk of relapse, especially when the person is uninformed or unprepared for them.

Post-Acute Withdrawal Syndrome Symptoms

Some common post-acute withdrawal syndrome symptoms include:³

• Anxiety.
• Problems sleeping.
• Memory, attention, and decision-making issues.
• Feeling tired, with low motivation.
• Cravings for more of the substance.
• Depression and low mood.
• Irritability.
• Aches and pains.
• Low sexual desire.

However, signs of post-acute withdrawal can vary between substances and between people, with differences in onset, intensity, and duration.³

PAWS in Opioids

Heroin and prescription pain medications are widely abused substances that are known to trigger post-acute withdrawal symptoms.^3,7 Reports estimate that as many as 90% of recovering users will encounter some level of opioid post-acute withdrawal.⁴

Though the symptoms will vary with each person, PAWS symptoms for opioids include:^3,7

• Increased anxiety.
• Depression.
• Sleep problems.
• Low energy.
• Irritability.
• Weight gain.
• Increase in blood pressure.
• Quicker breathing.
• Menstrual changes.

Former heroin and other opioid users frequently report problems with attention, focus, and concentration levels during post-acute opioids withdrawal.³ Effects such as these can lead to interpersonal relationship issues and affect school and/or job performance.

PAWS in Alcohol

An alcohol-associated post-acute withdrawal syndrome is thought to affect about 75% of people recovering from alcohol dependence or alcoholism.⁴ The most frequently cited symptoms of post-acute alcohol withdrawal are:^3,6,7

• Anxiety.
• Anger and aggression.
• Irritability.
• Depression.
• Frequent or sudden mood changes.
• Low energy.
• Poor ability to sleep.
• Problems with thinking, concentrating, and remembering.
• Increased levels of pain.
• Lack of sexual interest.
• Mild tremors.
• Dizziness.
• Coordination problems.

Sleep changes are some of the most long-lasting signs of alcohol post-acute withdrawal.³ For years after the last drink, people can be troubled by sleep apnea as well as difficulty falling and staying asleep.³

PAWS and Benzodiazepines

People dependent on this sedative class of medications experience post-acute benzodiazepine withdrawal effects at a rate similar to post-acute alcohol withdrawal.⁴ Benzodiazepine post-acute withdrawal symptoms include:⁷

• Depression.
• Anxiety.
• Panic attacks.
• Headaches.
• Dizziness.
• Ringing and other noises in the ears.

Post-acute benzodiazepine withdrawal symptoms are typically more difficult to identify because of several compounding factors:³

• Symptom rebound – the reappearance of acute withdrawal signs such as anxiety, insomnia, and restlessness. Rather than peaking and reducing in intensity over time, acute benzodiazepine withdrawal symptoms come and go inconsistently, which can make it difficult to tell when the acute phase is over.²
• Symptom reemergence – the return of the original symptoms of anxiety, physical tension, and poor sleep that someone had before they used a benzodiazepine. Symptom reemergence will feel uncomfortable, but it is unrelated to withdrawal or benzo post-acute withdrawal.

PAWS and Stimulants

In contrast to benzodiazepines, stimulant post-acute withdrawal symptoms are easier to distinguish and separate from acute withdrawal. Acute stimulant withdrawal only lasts for about 5 days, so symptoms beyond this timeframe are more likely to be part of a post-acute withdrawal syndrome.² Amphetamines and cocaine are the two most researched stimulants when it comes to post-acute withdrawal. Post-acute amphetamine withdrawal symptoms primarily include problems with executive functioning in the brain,³ including deficits to:

• Attention.
• Concentration.
• Memory.
• Problem-solving skills.
• Decision-making.

Research on post-acute cocaine withdrawal reports symptoms such as:^3,8

• Problems understanding and controlling feelings.
• Difficulty coping with stress and strong emotions.
• Poor impulse control, with reckless behaviors.
• Low mood.
• Cravings for more cocaine.

Though marijuana is not often associated with withdrawal, evidence suggests post-acute marijuana withdrawal symptoms arise after use ends.³ Sleep problems with abnormally strange dreams are the most significant post-acute marijuana withdrawal symptoms.³

Acute symptoms include:²

• Anxiety.
• Irritability.
• Poor sleep.
• Poor appetite.

Post-Acute Withdrawal Syndrome Timelines

Like the symptoms of PAWS, the post-acute withdrawal syndrome timeline will differ based on a number of factors, with the substance used being the primary factor.³

• Opioids/opiates. Acute withdrawal from opioids can last anywhere from 4–21 days depending on the substance used.³ Post-acute withdrawal symptoms will begin after these resolve and last as long as 9 months.⁷
• Alcohol. Following the end of alcohol dependence, acute symptoms can last for 5–7 days. But the alcohol post-acute withdrawal symptom timeline can be much longer. Most symptoms can last for more than 2 years after the person quits, with evidence showing that sleep problems can continue for 3 years of sobriety.³
• Benzodiazepines. The acute withdrawal timeline is between 1–5 weeks, depending on the method used to end benzodiazepine use.³ The post-acute withdrawal timeline varies greatly, with symptoms beginning after acute withdrawal and lasting months or even years following last use.^3,4
• Stimulants. Acute withdrawal symptoms from stimulants give way to post-acute withdrawal after a week or two. The emotional instability may improve after 4 weeks, but other withdrawal symptoms, such as poor impulse control, may persist.³
• Marijuana/cannabis. Acute withdrawal from marijuana use lasts for about 5 days. The post-acute withdrawal syndrome timeline may last for longer than 45 days.³

What Causes Post-Acute Withdrawal Syndrome?

When a person repeatedly uses a substance, the brain adapts to its presence.^3,4,5 A dependent person will eventually require the drug to feel and function normally. At the same time, natural rewards and previously pleasant activities may no longer be capable of eliciting feelings of happiness as robustly as before.³

When the drug is removed, the brain will struggle to regain equilibrium. The changes that occur from the brain’s adaptation to the drug persist long after the drug is removed from the system. Since it takes time for neurotransmitter activity to normalize and the brain to reestablish a new stability free from alcohol and other drugs, PAWS symptoms can emerge and last for weeks, months, and years.^3,5

Post-Acute Withdrawal Syndrome Risk Factors

It is impossible to tell which people in recovery will face acute withdrawal and post-acute withdrawal effects. Two similar people using the same dose and frequency of a substance can have very different symptoms.

However, certain characteristics can influence whether or not someone has withdrawal symptoms and how intense they will be, including:^1,3,6,7

• Age.
• Gender.
• Type of substance used (different drugs are more strongly associated with PAWS).
• Level of dependence on the substance.
• Co-occurring psychiatric issues.
• Co-occurring medical conditions.
• Multiple substance dependence.
• Social supports.
• Environmental conditions and stressors.
• Previous experience with substance withdrawal.
• Family history of addiction and dependence.

Even newborn babies are at risk for PAWS. Mothers that used alcohol and other drugs during their pregnancies put their children in danger of experiencing post-acute symptoms.⁴

How is PAWS Treated?

Post-acute withdrawal syndrome can seriously complicate a person’s ability to remain drug-free. To maintain recovery and limit the uncomfortable symptoms of PAWS, a person can:^3,4,6

• Gain reliable information about PAWS. This information can help someone set realistic goals and expectations about recovery.
• Stay physically and mentally active. In some cases, anxiety, stress, and low mood can be improved by engaging in physical activity. The same is true for attention, memory, and thinking problems. Eating well and prioritizing sleep can also help.
• Be social and join support groups. Spending time around people that are drug-free and emphasize the benefits of a drug-free lifestyle can aid in the management of PAWS symptoms.
• Seek professional treatment. Specialized treatment for addiction is important during any phase of recovery.⁵ A substance abuse treatment professional can help to:
  • Assess current status.
  • Evaluate for co-occurring disorders.
  • Teach effective coping skills.
  • Prescribe helpful medications.

Several medications can help treat PAWS, including:^3,5

• Acamprosate – can help by improving sleep and limiting anxiety linked to alcohol PAWS
• Methadone – treatment with methadone can reduce persistent opioid withdrawal symptoms and resolve cravings
• Buprenorphine – an opioid medication used in medication-assisted treatment that can also help reduce cravings and withdrawal symptoms (known as Suboxone when combined with naloxone)

These medications are most effective when combined with psychotherapy and other forms of behavioral treatment.⁵

---

---