Post Acute Withdrawal Syndrome

An In-depth Guide

In-depth Guide to Post Acute Withdrawal Syndrome:  PAWS



Acute Withdrawal

When stopping the use of drugs or alcohol, many people experience symptoms of withdrawal.  This is the result of the effect toxic chemicals have on the brain and the body.  These symptoms typically appear within 24 to 48 hours of last use, although times vary depending upon the amount of substances used and the time frames of use.  Prescription medications, plant based medications and illicit substances can all produce this effect, and the symptoms can last anywhere from a few days to a few weeks.  This is called Acute Withdrawal.  

Some symptoms can be managed medically in either outpatient or inpatient settings by physicians; alcohol, benzodiazepines and opioids are commonly treated with other medications to minimize symptoms of withdrawal.  Other drugs take time.  Withdrawal symptoms can be uncomfortable at best, and some can be life threatening; it is always advised to seek medical advice before stopping any drug.  

Following the initial period of acute withdrawal, many drugs have a secondary or prolonged withdrawal as the body seeks to heal itself and the brain restores it’s balance.  This is called Post Acute Withdrawal Syndrome, and can last from a few weeks, months or a year or more.  


Post Acute Withdrawal


PAWS is a cluster of symptoms following the physical detox from substance.  These symptoms are primarily psychological (brain related) and impact moods.  They  produce insomnia, anxiety, depression, and difficulty in thinking, reading and concentrating.  Many people report ‘brain-fog’.  

Most physical pain has dissipated by this point, but the psychological symptoms can be just as devastating to the person, and a leading cause of returning to use to escape the pain.

PAWS symptoms come and go, creating a roller coaster effect.  They are difficult to describe, predict or treat.  Each ‘episode’ can last a few hours or a few days, and any drug that has an intoxicating effect can produce them.  PAWS symptoms have universal similarities between the substances used, but also are specific to the type of drug used, the amount of drug used, and the time frame of use, making them very individual to each person.  

In addition, when street drugs are used, any combination of substances can be ‘cut’ into the drug, such as bath salts, kratom, fentanyl, hallucinogens and a plethora of other toxic chemicals.  The combinations of these are endless and nearly impossible or extremely difficult to determine.  

People with co-occurring disorders of mental illness, emotional or behavioral issues and/or poor environmental support tend to have worsening symptoms. 


Common Symptoms of PAWS

The most common symptoms reported by people experiencing PAWS are:

  • Irritability and hostility
  • Depression
  • Anxiety
  • Mood swings
  • Low energy and fatigue
  • Sleep disruption, including insomnia
  • Limited ability to focus or think clearly
  • Lack of libido
  • Inexplicable chronic pain


PAWS Symptoms Associated With Substance Type


  • Alcohol: Though people have struggled to end alcohol addiction for much longer, the symptoms of PAWS were first defined for alcohol use disorder in the 1990s. Suddenly stopping alcohol consumption is dangerous, since it can cause delirium tremens (including seizures and psychosis) and can also increase the likelihood of PAWS.   Equilibrium, brain-fog, inability to concentrate, reading and short term memory are common complaints with alcohol PAWS, in addition to the symptoms above.   


  • Antidepressants: While few people abuse these drugs recreationally since they do not cause a rapid intoxication, stopping them suddenly can dramatically change the levels of serotonin and other neurotransmitters in the brain. Since people who struggle with depression are prescribed antidepressants, acute withdrawal will feel like intense depression; unfortunately, this experience could continue for months.


  • Antipsychotics: These drugs bind to dopamine receptors to decrease hallucinations and delirium. When they are discontinued, especially without a taper, the person could experience withdrawal symptoms like mood swings for months.


  • Benzodiazepines: Although these medicines help people with anxiety and panic disorders, they are very easy for the brain to develop a dependence on. Most prescriptions do not cover more than two weeks of regular use because they can be addictive. Withdrawal symptoms mimic panic disorders, making it harder to stop taking them. PAWS symptoms, like insomnia, fatigue, and cravings, can last for months after the physical dependence has ended.  People in recovery from benzodiazepine abuse and addiction often struggle with reemergence of the symptoms that originally created the need for the prescription in addition to post-acute withdrawal symptoms. Any new symptoms that occur during the post-acute detox period are generally identified as post-acute withdrawal, even if they occur after a long period of being asymptomatic. For example, extreme anxiety, panic, and symptoms that often look like other mental health disorders may wax and wane during the months following detox but gradually dissipate as long as abstinence is maintained.


  • Marijuana: Many people become reliant on marijuana to relax and feel normal; when they stop taking the drug, they can feel stressed, depressed, and paranoid. One of the most common withdrawal symptoms is insomnia, and without medical help, this could persist and become PAWS.  A number of studies support the existence of acute as well as post-acute withdrawal symptoms during marijuana detox. One study suggests that sleep disruption including intense dreams may persist up to 45 days or longer.


  • Opioids: Whether prescription opioids or illicit versions like heroin, these drugs can lead to post-acute withdrawal syndrome if they are not tapered off properly. People who experience the full intensity of acute withdrawal are more likely to develop PAWS, which includes cravings, exhaustion, and cognitive impairment that does not go away for a long time.  There are a number of post-acute withdrawal symptoms that have been reported in the weeks and months following opiate detox, including sleep disruption, anxiety, and depression, as well as decreased executive control functions.


  • Stimulants: Drugs from Ritalin to cocaine can cause post-acute withdrawal syndrome if withdrawal is not managed appropriately. Although a person taking stimulants may experience negative side effects like paranoia, twitching and tremors, and aggression, the opposite symptoms – extreme fatigue, deep depression, and physical weakness – can be harder to manage psychologically.
    • Cocaine:   Impulse control continued to be a struggle for study participants after four weeks of sobriety.
    • Methamphetamine: Long-term issues with executive control function were shown to be a persistent issue for people in recovery from methamphetamine abuse


Factors That Influence PAWS

PAWS is a complex disorder with no one specific cause. The absence of clearly defined timelines makes treatment difficult.   Some people will not experience any significant issues following acute detox while others will experience ongoing post-acute withdrawal symptoms for years, and still others will have periods of being symptomatic followed by periods of being symptom-free. 

Psychologists and doctors do not agree completely on reasons for PAWS, but many suggest that stress response and changes to that area of the brain during the course of addiction and alcoholism may contribute to the development of PAWS.   The 4 most common are:

  • Homeostatic Adjustment:  (stability, balance, or equilibrium)
    • A person’s physical dependence on drugs or alcohol leads to brain chemistry changes over time; when the body does not have the chemical flowing in, triggering neurotransmitters and endorphins to release, it cannot reach equilibrium on its own. The brain can take a long time to completely reach homeostasis without chemical help, and this can manifest in mood swings, exhaustion, cravings, and other psychological signs during PAWS.


  • Physiological Adaptations: (Normal Body Functions)
    • Other parts of the body may be used to an influx of drugs to regulate functions like digestion or hormones. Withdrawal symptoms reflect this – for example, nausea, stomach cramps, and diarrhea are common opioid withdrawal symptoms – but sometimes, these can take longer than two weeks to return to normal. For example, heart rate may be more rapid after overcoming an addiction to CNS depressants.


  • Stress: 
    • It is psychologically stressful to stop taking a drug, especially for people who try to do it cold turkey or alone. This stress may lead to relapse, or it could lead to a prolonged experience of withdrawal symptoms, as the individual tries to make sense of life without drugs or alcohol.  In addition, how we react to stress, what triggers our stress reaction, and how we process stress are extremely individual and culturally, environmentally, and genetically influenced.


  • Habit: (muscle memory)
    • Part of rehabilitation is to retrain behaviors and responses to drugs or alcohol. Recovering heroin addicts mention the ritual of cooking and injecting the drug, while people who overcame alcohol use disorder note the loss of social situations. Returning to habit leads to relapse, but the loss of the habit or tradition can enhance psychological symptoms like depression, cravings, anxiety, or exhaustion, leading to PAWS.  


Living With PAWS-Treatment and Support

Post Acute Withdrawal Syndrome occurs for a variety of reasons, but specifically, it is a result of stopping use of drugs or alcohol.  Your mind and your body are adjusting to the absence of the substance in your body.  It can be frightening, uncomfortable and disastrous if we use drugs or alcohol again.

Finding community support through 12-step groups, recovery groups and counseling can help us hearing from others, just like us, who have experienced similar problems.  An addiction trained (ASAM) psychiatric professional  should be consulted for all co-occurring mental health disorders, and be fully informed about your history of addiction or alcoholism.   A psychiatrist can assess potential co-occurring disorders, which may emerge or re-emerge.

While this may not help the symptoms to disappear, they will help you to understand what is going on with your mind and body, and help you get through this time.  It will pass.   

Supports can help :

  • Education about PAWS and what to expect (and not expect) in early recovery.
  • Celebrate every accomplished step in the process.
  • Encouragement.
  • Find natural ways to help with sleep problems.
  • Support exercise  by walking, biking, swimming, yoga with you.
  • Learn about nutrition and the role health eating can play in alleviating some symptoms.
  • Encourage joining other support groups.
  • Help to manage impulse control.
  • Take self-reported symptoms seriously.

Some medicines may help with specific drugs. For example:

  • methadone or buprenorphine is available to reduce cravings in people who are overcoming opioid addiction. This is not trading one drug for another-you don’t experience the euphoria that you have with opioids, and they allow you to reduce at your own pace, helping eliminate many of the depressing effects of a cold-turkey withdrawal.  (see the MAT section in this site, link below)
  • Antidepressants may help to stabilize mood for many people overcoming struggles with stimulants or psychoactive drugs. 


Need Some Answers?