Post-Acute Withdrawal Syndrome (PAWS) Explained: Symptoms, Timeline, and Coping Strategies (Updated for 2024)
Post-Acute Withdrawal Syndrome (PAWS): The Overlooked Challenge in Addiction Recovery
If you or a loved one has battled substance addiction, you may think the hardest part is over once you've completed detox. But for many, the real struggle begins after the initial withdrawal phase, when a condition called Post-Acute Withdrawal Syndrome (PAWS) sets in.
PAWS is a set of persistent symptoms that can last for weeks or even months after quitting drugs or alcohol. It's a major reason why so many people relapse in the early stages of recovery.
In this comprehensive guide, we'll dive deep into what PAWS is, how to recognize its signs and symptoms, and most importantly, how to cope with it effectively to maintain your hard-earned sobriety.
What is Post-Acute Withdrawal Syndrome (PAWS)?
PAWS is a set of symptoms that can persist for weeks or months after the initial withdrawal from a substance
Common substances that can lead to PAWS include alcohol, opioids, benzodiazepines, and stimulants
The duration of PAWS is influenced by factors such as the length and severity of addiction, type of substance abused, and individual health and genetics
Post-Acute Withdrawal Syndrome (PAWS) is a complex condition that can occur following the initial withdrawal from a substance, particularly after long-term or heavy use. While the acute withdrawal symptoms typically subside within a few days to a couple of weeks, PAWS can persist for weeks, months, or even years, making the recovery process more challenging.
Common substances that can lead to PAWS
PAWS can develop after the cessation of various substances, including:
Alcohol: Chronic alcohol use can lead to significant changes in brain chemistry, and PAWS may occur during the recovery process. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), approximately 15.1 million adults in the United States have alcohol use disorder.
Opioids: Opioid addiction, whether to prescription painkillers or illicit drugs like heroin, can result in PAWS during the withdrawal and recovery phases. The Centers for Disease Control and Prevention (CDC) report that in 2020, there were over 47,000 opioid-related overdose deaths in the United States.
Benzodiazepines: Long-term use of benzodiazepines, such as Xanax or Valium, can cause PAWS when an individual attempts to stop using the medication. The Substance Abuse and Mental Health Services Administration (SAMHSA) notes that in 2019, approximately 5.4 million people in the United States misused benzodiazepines in the past year.
Stimulants: Stimulant drugs, including cocaine and methamphetamine, can also lead to PAWS during the recovery process. The National Institute on Drug Abuse (NIDA) reports that in 2019, approximately 1.6 million people in the United States had a stimulant use disorder.
It's important to note that not everyone who undergoes withdrawal from these substances will experience PAWS, but it is a relatively common occurrence among those with a history of prolonged or heavy substance use.
Factors that influence PAWS duration
The duration of PAWS can vary greatly from person to person and is influenced by several factors:
Length and severity of addiction
The longer an individual has been using a substance and the higher the doses consumed, the more likely they are to experience PAWS and the longer the symptoms may persist. Chronic substance use can cause significant changes in brain chemistry, which take time to reverse.
Type of substance
Different substances can have varying effects on the brain and body, and the duration of PAWS may depend on the specific substance used. For example, opioid and benzodiazepine withdrawal tend to have a longer PAWS duration compared to alcohol or stimulants.
Individual health and genetics
A person's overall physical and mental health, as well as their genetic makeup, can influence the severity and duration of PAWS. Those with pre-existing mental health conditions or a family history of addiction may be more susceptible to prolonged PAWS.
When does PAWS peak?
The timeline of PAWS can vary depending on the substance and individual factors, but it typically peaks within the first few months after the initial withdrawal. For some substances, such as opioids, the peak of PAWS may occur around 2-3 months into recovery, as noted by the American Society of Addiction Medicine (ASAM).
What are the side effects of PAWS?
PAWS can manifest in various ways, affecting an individual's physical, psychological, and emotional well-being. Some common side effects include:
Mood swings and irritability
Anxiety and depression
Insomnia or sleep disturbances
Fatigue and low energy levels
Difficulty concentrating or memory problems
Cravings for the substance
These side effects can fluctuate in intensity over time and may come and go in waves. It's essential for individuals experiencing PAWS to have a strong support system and coping strategies in place to manage these symptoms effectively.
How long does it take for PAWS to go away?
The duration of PAWS can vary significantly, ranging from a few weeks to several months or even years in some cases. However, for most people, the symptoms of PAWS tend to gradually improve over time as the brain and body heal from the effects of substance abuse.
While there is no definitive timeline for when PAWS will completely resolve, many individuals find that the severity and frequency of symptoms decrease within the first year of recovery. Engaging in ongoing treatment, therapy, and support groups can help manage PAWS symptoms and promote long-term recovery.
Recognizing the signs and symptoms of PAWS
PAWS can cause a range of mood, cognitive, and physical symptoms that may persist for weeks or months after stopping substance use
Recognizing these symptoms is crucial for managing recovery and preventing relapse
Understanding the different categories of PAWS symptoms can help individuals and their support systems better cope with the challenges of recovery
Mood-related PAWS symptoms
Individuals experiencing PAWS often struggle with significant mood disturbances. Irritability and agitation are common, as the brain adjusts to functioning without the substance. People may feel easily frustrated, quick to anger, and have a low tolerance for stress.
Depression and apathy are also prevalent. The absence of the substance can lead to feelings of sadness, hopelessness, and a lack of interest in previously enjoyable activities. Anhedonia, or the inability to feel pleasure, is a hallmark symptom of depression in PAWS.
Learn more about what causes anhedonia and how long this takes to go away in this episode.
Anxiety and panic attacks may occur as the body's stress response system becomes dysregulated. Individuals may feel a sense of impending doom, racing thoughts, and physical symptoms like rapid heartbeat and sweating.
Managing mood symptoms
Coping with mood-related PAWS symptoms requires a multifaceted approach. Engaging in regular exercise, practicing relaxation techniques like deep breathing and meditation, and maintaining a consistent sleep schedule can help regulate mood. Participating in support groups and individual therapy can provide valuable coping strategies and a sense of community.
Cognitive PAWS symptoms
PAWS can significantly impact cognitive functioning. Many individuals report difficulty concentrating, feeling mentally "foggy," and struggling to focus on tasks. This can be particularly challenging for those returning to work or school after addiction treatment.
Memory problems are also common, with both short-term and long-term memory affected. People may forget appointments, struggle to recall information, or have difficulty retaining new knowledge.
Decision-making abilities may be impaired, as the brain's executive functioning is still recovering. Individuals may feel indecisive, struggle with problem-solving, and make impulsive choices.
Learn more about brain fog and fatigue in this episode.
Physical PAWS symptoms
Physical symptoms of PAWS can be distressing and may interfere with daily functioning. Sleep disturbances are prevalent, with individuals experiencing insomnia, vivid dreams, or altered sleep patterns. This lack of quality sleep can exacerbate other PAWS symptoms.
Fatigue and low energy are common, as the body adjusts to functioning without the substance. People may feel physically exhausted, even after adequate rest, and struggle to maintain their usual level of activity.
Increased sensitivity to pain is another potential physical symptom. As the brain's reward system recovers, it may misinterpret normal sensations as painful. This can lead to heightened discomfort and a lower pain tolerance.
Coping with physical symptoms
Managing physical PAWS symptoms involves a combination of self-care strategies and professional support. Establishing a consistent sleep routine, engaging in gentle exercise, and practicing good nutrition can help regulate the body's systems. Pain management techniques, such as mindfulness, acupuncture, or massage therapy, may provide relief for those experiencing increased pain sensitivity.
Understanding the PAWS timeline
PAWS can last for several weeks to several months after acute withdrawal
The timeline varies based on factors like the severity of addiction and overall health
Understanding the timeline helps in developing effective coping strategies
Acute withdrawal phase
The acute withdrawal phase occurs immediately after an individual stops using a substance. The duration of this phase can vary depending on the specific substance and the severity of the addiction. For example, acute withdrawal from opioids like heroin may last for 7-10 days, while acute withdrawal from alcohol can last for several days to a week.
During the acute withdrawal phase, individuals may experience intense physical and psychological symptoms. These can include tremors, nausea, vomiting, headaches, and severe cravings for the substance. It's crucial to seek medical supervision during this phase, as some withdrawal symptoms can be life-threatening.
PAWS onset and duration
Post-Acute Withdrawal Syndrome typically begins within 7-14 days after the completion of the acute withdrawal phase. However, the onset can vary from person to person. Some individuals may experience PAWS symptoms immediately after acute withdrawal, while others may have a delay of several weeks.
The duration of PAWS can also vary significantly. For some, the symptoms may last for a few weeks, while others may struggle with PAWS for several months or even years. PAWS symptoms can persist for up to 2 years after stopping substance use, particularly for individuals with a history of opioid addiction.
Please note: PAWS symptoms come and go and are usually triggered by stress. PAWS is not constant misery. If you are feeling anxious, tired, or angry constantly, then this is something to talk to a doctor or therapist about, or consider taking anger management class with me.
Factors affecting PAWS timeline
Several factors can influence the onset, duration, and severity of PAWS symptoms. Understanding these factors can help individuals and their support systems better prepare for the challenges of recovery.
Severity and duration of addiction
The length and intensity of an individual's substance abuse can significantly impact the PAWS timeline. Those who have struggled with addiction for many years or have used high doses of a substance may experience more severe and prolonged PAWS symptoms compared to those with a shorter history of addiction.
Overall health and support system
An individual's overall physical and mental health can also play a role in the PAWS timeline. Those with pre-existing health conditions or poor nutrition may have a harder time coping with PAWS symptoms. On the other hand, having a strong support system, including family, friends, and addiction professionals, can help individuals manage their symptoms more effectively.
Presence of co-occurring mental health disorders
Many individuals struggling with addiction also have co-occurring mental health disorders, such as depression, anxiety, or post-traumatic stress disorder (PTSD). These conditions can complicate the recovery process and extend the PAWS timeline. Addressing both the substance use disorder and any co-occurring mental health issues is crucial for successful long-term recovery.
Importance of understanding the PAWS timeline
Recognizing that PAWS is a normal part of the recovery process can help individuals and their loved ones maintain realistic expectations and avoid feelings of frustration or despair. It's essential to remember that progress is not always linear and that setbacks are a common part of the journey.
By understanding the factors that influence the PAWS timeline, individuals can work with their healthcare providers to develop personalized coping strategies and treatment plans. This may include a combination of therapy, support groups, and lifestyle changes to promote overall physical and mental well-being.
Benefits of understanding PAWS
Knowing what to expect during PAWS can improve recovery outcomes
Understanding PAWS helps loved ones provide better support
Healthcare providers can create more effective treatment plans when they understand PAWS
Improved recovery outcomes
Individuals in recovery who understand the symptoms and timeline of PAWS are better equipped to stay committed to their recovery journey. Knowing that symptoms like mood swings, insomnia, and anxiety are a normal part of the recovery process can prevent feelings of discouragement or thoughts of relapse. When individuals recognize these challenges as temporary and expected, they are more likely to push through difficult periods and maintain their sobriety.
According to a study published in the Journal of Substance Abuse Treatment, educating patients about PAWS during addiction treatment can significantly improve their chances of long-term recovery. The study found that patients who received education on PAWS had higher rates of treatment completion and were more likely to remain abstinent at follow-up compared to those who did not receive this education.
This is why I always encourage you to listen to my podcast. I explain the science of what’s going on and what to expect.
The role of realistic expectations
Setting realistic expectations is crucial for individuals in recovery. When they understand that the journey to recovery is not always a straight line and that setbacks are a normal part of the process, they are less likely to become discouraged or give up when faced with challenges. Educating individuals about PAWS helps them develop a more accurate and realistic view of the recovery process, which can ultimately lead to better outcomes.
Better support from loved ones
When family members and friends understand PAWS, they can provide more informed and effective support to their loved ones in recovery. Educating loved ones about the symptoms and timeline of PAWS can help reduce misunderstandings and conflicts that may arise during the recovery process. For example, if a family member knows that irritability and mood swings are common symptoms of PAWS, they may be more patient and understanding when their loved one exhibits these behaviors.
Furthermore, loved ones who are informed about PAWS can help create a supportive environment that promotes recovery. They can encourage their loved one to stick to their treatment plan, attend support group meetings, and engage in healthy coping strategies. By providing a stable and understanding support system, loved ones can play a crucial role in helping individuals navigate the challenges of PAWS and maintain their recovery.
More effective treatment planning
When healthcare providers understand PAWS, they can create more tailored and effective treatment plans for individuals in recovery. By recognizing the specific symptoms and challenges associated with PAWS, providers can incorporate targeted interventions and coping strategies into their treatment approach.
For example, if a patient is struggling with insomnia during PAWS, a healthcare provider may recommend cognitive-behavioral therapy for insomnia (CBT-I) as part of their treatment plan. CBT-I is an evidence-based treatment that has been shown to be effective in improving sleep quality and duration in individuals with insomnia, including those in recovery from substance use disorders.
By tailoring treatment plans to address specific PAWS symptoms, healthcare providers can help individuals in recovery develop the skills and strategies they need to cope with these challenges and maintain their sobriety.
Increased engagement in aftercare services
When individuals understand PAWS, they may be more likely to engage in aftercare services and support groups. Recognizing that the recovery journey extends beyond initial treatment, individuals who are informed about PAWS may be more proactive in seeking ongoing support to help them navigate the challenges of long-term recovery.
Aftercare services, such as outpatient therapy, 12-step programs, online sober communities, and sober living homes, can provide individuals with the support and resources they need to maintain their recovery and cope with PAWS symptoms. Engaging in these services can help individuals build a strong support network, develop healthy coping strategies, and address any underlying mental health concerns that may be contributing to their substance use disorder.
Reduced risk of relapse
Ultimately, understanding PAWS can help reduce the risk of relapse for individuals in recovery. When individuals are prepared for the challenges of PAWS and have the tools and support they need to cope with symptoms, they are less likely to turn to substances as a means of self-medication or escape.
Learn more about self-medication in this episode and using alcohol to escape in this episode.
According to the National Institute on Drug Abuse (NIDA), the relapse rate for substance use disorders is estimated to be between 40-60%. However, by educating individuals about PAWS and providing them with comprehensive support and treatment, it is possible to reduce this rate and improve long-term recovery outcomes.
In addition to reducing the risk of relapse, understanding PAWS can also help individuals develop a greater sense of self-efficacy and control over their recovery. When they know what to expect and have the tools to cope with challenges, individuals may feel more empowered and confident in their ability to maintain their sobriety and build a fulfilling life in recovery.
Coping strategies for managing PAWS symptoms
TL;DR:
Establishing a consistent routine and engaging in regular exercise can help manage PAWS symptoms
Stress-reduction techniques and building a strong support network are crucial for coping with PAWS
Professional treatment plays a vital role in managing PAWS and promoting long-term recovery
Developing a consistent routine
Establishing a consistent daily routine is essential for individuals coping with PAWS. Structure and routine are critical for people in early recovery because it helps to reduce stress, increase predictability, and provide a sense of control over one's life. A structured routine should include regular sleep patterns, healthy eating habits, and scheduled activities.
Benefits of a consistent routine
Reduces stress and anxiety
Promotes better sleep quality
Helps regulate appetite and eating patterns
Provides a sense of purpose and accomplishment
Engaging in regular exercise
Regular physical activity is another key component of managing PAWS symptoms. Exercise releases endorphins, which are natural mood-boosters and stress-reducers.
Experts recommend engaging in at least 30 minutes of moderate-intensity exercise most days of the week. This can include activities such as walking, jogging, swimming, or cycling.
Practicing stress-reduction techniques
Stress-reduction techniques are essential for managing the emotional and psychological symptoms of PAWS. Mindfulness meditation and deep breathing exercises can help calm the mind and reduce anxiety.
Journaling and engaging in creative outlets, such as art or music therapy, can also be effective stress-reduction techniques.
Building a strong support network
Building a strong support network is crucial for individuals coping with PAWS. Attending support group meetings, such as 12-step programs or SMART Recovery, can provide a sense of community and connection with others who understand the challenges of recovery. Dr. Anna Lembke, Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic, emphasizes, "Social support is one of the most important factors in successful long-term recovery. Surrounding oneself with positive influences and people who understand the journey can make a significant difference."
Family therapy and couples counseling can also be beneficial for strengthening relationships and improving communication skills. Dr. Lembke notes, "Addiction and PAWS can strain relationships, so it's essential to work on rebuilding trust and fostering healthy connections with loved ones."
Check out my support community here.
The role of professional treatment in managing PAWS
Professional treatment is crucial for managing PAWS symptoms and preventing relapse
Medication-assisted treatment, cognitive-behavioral therapy, and aftercare support are key components
Treatment should be tailored to the individual's needs and recovery goals
Managing Post-Acute Withdrawal Syndrome (PAWS) can be challenging, and professional treatment plays a vital role in helping individuals navigate this difficult phase of recovery.
Medication-assisted treatment (MAT)
Medication-assisted treatment (MAT) is an evidence-based approach that combines medications with behavioral therapies to treat substance use disorders. In the context of PAWS, MAT can help manage cravings and withdrawal symptoms, making it easier for individuals to focus on their recovery.
Benefits of MAT in managing PAWS
Reduces cravings and withdrawal symptoms
Helps stabilize brain chemistry
Improves treatment retention and outcomes
Cognitive-behavioral therapy (CBT)
Cognitive-behavioral therapy (CBT) is a form of psychotherapy that helps individuals identify and change negative thought patterns and behaviors. In the context of PAWS, CBT can be particularly effective in managing symptoms such as anxiety, depression, and insomnia.
How CBT helps manage PAWS symptoms
Identifies and challenges negative thought patterns
Teaches coping skills for managing stress and triggers
Helps develop a positive mindset and self-image
Aftercare and ongoing support
Aftercare and ongoing support are essential components of a comprehensive PAWS management plan. These services help individuals maintain their recovery progress, prevent relapse, and build a strong support network.
Types of aftercare and ongoing support
Sober living homes
Alumni programs and peer support groups
Continuing therapy and counseling
Relapse prevention planning
The Importance of Self-Care During PAWS Recovery
Promotes physical and mental wellbeing
Helps manage PAWS symptoms effectively
Increases the likelihood of long-term recovery success
Self-care is a crucial aspect of the recovery process for individuals experiencing post-acute withdrawal syndrome (PAWS). While professional treatment plays a significant role in managing PAWS, incorporating self-care practices into daily life can greatly enhance the healing process and improve overall wellbeing.
Engaging in self-care activities helps individuals better cope with the challenges presented by PAWS, such as mood swings, sleep disturbances, and cognitive difficulties. By prioritizing self-care, those in recovery can build resilience, reduce stress, and create a strong foundation for long-term recovery success.
Learn more about developing a self-care routine in this episode.
Maintaining a Balanced Diet
Provides essential nutrients for brain health
Stabilizes mood and energy levels
The Role of Nutrition in PAWS Recovery
During PAWS recovery, the body and brain are healing from the effects of long-term substance use. Providing the body with essential nutrients through a balanced diet is crucial for supporting this healing process. A diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats can help restore brain chemistry and improve overall physical health.
Consuming regular, balanced meals throughout the day can also help stabilize mood and energy levels, which are often affected by PAWS. By maintaining stable blood sugar levels, individuals can reduce the likelihood of experiencing intense mood swings or fatigue, making it easier to manage PAWS symptoms.
Tips for Maintaining a Healthy Diet During PAWS Recovery
Plan meals in advance to ensure a variety of nutrient-dense foods are included.
Keep healthy snacks on hand, such as fresh fruits, vegetables, and nuts, to avoid reaching for processed or sugary foods during times of stress or cravings.
Stay hydrated by drinking plenty of water throughout the day, as dehydration can worsen PAWS symptoms.
Consider working with a nutritionist who specializes in addiction recovery to develop a personalized meal plan that meets your specific needs.
Getting Adequate Sleep
Promotes mental and physical healing
Improves emotional regulation and cognitive function
The Importance of Sleep During PAWS Recovery
Sleep is a critical component of the healing process during PAWS recovery. During sleep, the body and brain have the opportunity to repair and regenerate, which is essential for both physical and mental recovery. Adequate sleep can help improve cognitive function, emotional regulation, and overall mood, making it easier to manage PAWS symptoms during the day.
However, PAWS can often disrupt sleep patterns, leading to insomnia or other sleep disturbances. It's important to prioritize good sleep hygiene to ensure the body and mind are getting the rest they need to heal.
Tips for Improving Sleep During PAWS Recovery
Establish a consistent sleep schedule, going to bed and waking up at the same time each day, even on weekends.
Create a relaxing bedtime routine, such as taking a warm bath, reading a book, or practicing gentle stretching or meditation.
Ensure your sleep environment is comfortable, quiet, and dark, using blackout curtains, earplugs, or a white noise machine if necessary.
Avoid caffeine, nicotine, and heavy meals close to bedtime, as these can interfere with sleep quality.
If sleep disturbances persist, consult with a healthcare provider who may recommend additional strategies or treatments, such as cognitive-behavioral therapy for insomnia (CBT-I).
Engaging in Enjoyable Activities
Boosts self-esteem and sense of accomplishment
Helps replace substance use with positive experiences
The Benefits of Enjoyable Activities During PAWS Recovery
Engaging in enjoyable activities is an essential aspect of self-care during PAWS recovery. These activities can help boost self-esteem, provide a sense of accomplishment, and create positive experiences that replace the role substance use once played in an individual's life.
Enjoyable activities can also serve as healthy coping mechanisms during times of stress or when experiencing PAWS symptoms. By focusing on pleasurable pursuits, individuals can distract themselves from cravings or negative emotions, reducing the risk of relapse.
Examples of Enjoyable Activities to Incorporate into PAWS Recovery
Engage in physical activities that you enjoy, such as hiking, swimming, dancing, or yoga. Exercise can help reduce stress, improve mood, and promote better sleep.
Pursue creative hobbies, such as painting, writing, photography, or playing a musical instrument. Creative expression can be a powerful outlet for emotions and can provide a sense of accomplishment.
Spend time in nature, whether it's taking a walk in a park, gardening, or simply sitting outside and enjoying the fresh air. Nature can have a calming effect and help reduce stress and anxiety.
Connect with others through social activities, such as joining a support group, attending community events, or volunteering for a cause you care about. Social connection can provide a sense of belonging and purpose, which are important for recovery.
Practice mindfulness and relaxation techniques, such as meditation, deep breathing, or progressive muscle relaxation. These practices can help manage stress, reduce PAWS symptoms, and promote a sense of inner peace.
By incorporating a variety of enjoyable activities into daily life, individuals in PAWS recovery can create a well-rounded self-care routine that supports their physical, mental, and emotional wellbeing. Remember, self-care is not a one-size-fits-all approach, and what works for one person may not work for another. It's important to experiment with different activities and find what resonates with you personally, creating a sustainable and fulfilling self-care practice that supports your long-term recovery goals.
Taking Control of Your Recovery
PAWS is a challenging but manageable part of the recovery process. By understanding the symptoms, timeline, and coping strategies, you can better navigate this phase and maintain your progress. Remember, seeking professional help and building a strong support network are essential for long-term success.
Prioritize self-care activities like maintaining a balanced diet, getting adequate sleep, and engaging in enjoyable hobbies. These practices will help you manage stress, improve your overall well-being, and reduce the risk of relapse.
Are you currently experiencing PAWS symptoms, or do you know someone who is? Reach out to a trusted healthcare provider or support group for guidance and assistance. With the right tools and support, you can overcome PAWS and continue on your path to lasting recovery.
Get support to quit drinking
Here are some options:
Alcoholics anonymous (AA)
Therapy
Living a Sober Powered Life Community & virtual meetings
Smart Recovery
Recovery Dharma
Inpatient treatment
Outpatient treatment
Talking to your doctor about medication
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Fagugli RM, Taglioni C. Changes in the perceived epidemiology of primary hyperaldosteronism. Int J Hypertens. 2011;2011:162804.
