Many people in recovery from substance abuse experience unpleasant symptoms after their initial acute withdrawal phase has completed—this is especially so for those recovering from alcohol, opioid, and benzodiazepine abuse. This is known as Post-Acute Withdrawal Syndrome (PAWS). It can last for weeks, months, or several years after achieving sobriety.
PAWS can pose a significant threat to recovery. If untreated, its symptoms may lead you to relapse into alcohol or drug use. Read on to learn more about PAWS, its symptoms, treatment, and things you can do for self-care.
What Are the Characteristics of PAWS?
Although PAWS is not a formal diagnosis of the DSM-5, the manual used by psychiatrists to diagnose mental health conditions, its existence is well established informally by substance abuse clinicians [1]. However, it is still controversial and there has been little recent formal study of its characteristics.
During PAWS, the brain is proposed to enter a relative state of hyperexcitability by activating central stress systems. PAWS is distinct from acute withdrawal, which typically occurs in the first two weeks after stopping substances and generally consists of physical symptoms. In contrast, PAWS symptoms are largely psychological and emotional in nature. But despite the discomfort, they are a sign that you are healing.
There is no precise agreed definition of PAWS in the medical and research community. But there is a definition of “protracted withdrawal” from the American Society of Addiction Medicine 2020 Clinical Practice Guidelines on Alcohol Withdrawal Management [2]. They define protracted withdrawal as a syndrome with persistent subacute symptoms of:
- Irritability
- Anxiety
- Sleep disturbances
The primary characteristics of PAWS include:
- Predominantly negative affect (mood disturbances)
- Onset during early abstinence
- Persistence for approximately 4-6 months, though duration can vary
One medical researcher has proposed a definition of PAWS (for consideration to be included in the DSM-5) [1]:
- A specific timeline for symptom onset and persistence i.e. the onset of symptoms within the first month after acute withdrawal that persists for greater than 1 month
- Specific symptoms that define PAWS i.e. three or more of the following:
- Irritability
- Depressed mood/anhedonia (the inability to feel pleasure)
- Anxiety
- Cravings
- Cognitive impairment (brain fog, memory problems, difficulty concentrating)
- Sleep impairment and fatigue
- Functional impairment
- Predisposing to substance relapse
For those with alcohol use disorder, PAWS has been informally recognized as a high-risk interval for return to alcohol consumption following abstinence.
Signs and Symptoms of PAWS
PAWS partially reverses with sustained alcohol (or other substance) abstinence. However, symptoms are often triggered by stress or by people, places, or things that remind you of using. Often, symptoms of PAWS are described as an ebb and flow like a wave or a roller coaster. The following table summarizes the main symptoms, with timelines [3]:
| Dimension | Timeline |
| Mood and anxiety symptoms | First 3 to 4 months following acute withdrawal, up to 10 years |
| Anhedonia (Inability to feel pleasure) | Most severe during the first 30 days of abstinence from alcohol |
| Cognitive impairment | Few weeks to a few months, with some residual effects lasting up to a year |
| Cravings for alcohol | Most severe during the first 3 weeks of abstinence from alcohol |
| Post-traumatic stress disorder symptoms | Decreasing severity during the first month of withdrawal, with the steppes decline during the first 2 weeks of abstinence |
| Sleep disturbance | Emerges during acute withdrawal, whereas prolonged insomnia can last up until approximately 6 months of abstinence |
Factors Impacting the Timeline
If you use drugs that can cause PAWS (such as alcohol, benzodiazepines, or opioids) there is a high risk of having PAWS. However, there are other factors that may impact the possibility of having PAWS in the longer term, including:
- How long you have misused: The longer this is, the more damage is done to brain cells, requiring longer recovery times.
- The amount of use: If you used large amounts of alcohol or drugs, your brain will likely need longer to recuperate.
- Your genes: Some people may be genetically predisposed to damage to brain cells, again needing longer to recover.
- Co-occurring mental health conditions: Experiencing anxiety or depression makes treating PAWS more complex.
How Is PAWS Treated?
In many studies of various medications for treating PAWS, none have had sufficient sample sizes or consistent research methods. Anticonvulsants (such as carbamazepine and oxcarbazepine) and gabapentinoids (such as gabapentin and pregabalin) appear to have more evidence than other categories of pharmaceutical therapy, but more and larger controlled studies are required.
There is currently a lack of controlled trials for nonpharmacological therapies for PAWS, so these cannot be clinically recommended.
Self-Care for PAWS
Nonetheless, there are important ways to cope with PAWS without medication. Among others, they include:
- Mindfulness meditation: Develop a daily practice to help manage the discomfort of PAWS symptoms.
- Exercise: Walking, jogging, movement, yoga, and working out are all highly beneficial ways to manage stress and other symptoms of PAWS.
- Nutrition: Eating a balanced diet with wholesome foods is a key way to manage your health and mental state.
- Journaling: Writing or drawing in a daily journal nourishes the soul and creates a living document of your feelings and thoughts, which you can reflect on.
- Anger management workshops: These can be very helpful to learn techniques to deal with strong emotions in a healthy manner.
- Work with your sponsor: Stay in touch regularly for sharing experiences and coping techniques.
- Therapy: Participating in ongoing therapy can be extremely constructive in identifying emotions and working with them as well as managing cravings.
Substance Abuse Disorder Treatment in Anaheim
Located in Anaheim, California, Restorations Health Care can help you or a loved one on the recovery from addiction and mental health issues. Our mission is all about saving lives.
We offer detox and inpatient treatment programs that help people get back on their feet. Our dedicated team of trained addiction professionals and licensed counselors provide individualized addiction treatment programs for recovery. Reach out to our Admissions team now.
Sources
[1] Bahji A, Crockford D, El-Guebaly N. Management of Post-Acute Alcohol Withdrawal: A Mixed-Studies Scoping Review. J Stud Alcohol Drugs. 2022 Jul;83(4):470-479
[2] The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management.
Journal of Addiction Medicine 14(3S):p 1-72, May/June 2020.
[3] Bahji A, Crockford D, El-Guebaly N. Neurobiology and Symptomatology of Post-Acute Alcohol Withdrawal: A Mixed-Studies Systematic Review. J Stud Alcohol Drugs. 2022 Jul;83(4):461-469.
