Post-Acute Withdrawal Syndrome (PAWS)

What Is PAWS?

PAWS is an acronym that stands for post-acute withdrawal syndrome. It describes the symptoms felt after the acute withdrawal process. While acute withdrawal is typically the most painful period of detox, PAWS symptoms can last weeks, months, or even years. It’s typically associated with heavy drug or alcohol abuse, but its severity all depends on a person’s addiction, genetics, and someone’s overall mental health.

While the initial withdrawal exhibits mostly physical symptoms, PAWS manifests itself as strictly psychological symptoms. Though no physical symptoms are felt, psychological symptoms can be just as difficult. PAWS can make recovery difficult, and can even lead a person back to drugs or alcohol.

What Causes PAWS?

PAWS is a long-lasting condition in which the brain is trying to restore function to neurotransmitter pathways that were disrupted through chronic drug or alcohol use. Neurotransmitters are chemicals used to send signals in the brain, and the “rewiring” that occurs after chronic drug or alcohol use can lead to a variety of mental health issues such as depression, anxiety, and psychosis. The brain is capable of restoring balance, but this process takes time; sometimes many months or even years. The subjective experience during this recovery process can be mentally uncomfortable while the brain is working to heal itself.

Common PAWS Symptoms

The exact symptoms of post-acute withdrawal syndrome will vary in intensity, sometimes greatly, between people. That being said, the imbalances produced through chronic, heavy drug or alcohol use have some very similar results in many people. While these may vary in intensity and duration, the most common symptoms of PAWS include:

• Strong Cravings
• Mood Swings and Emotional Outbursts
• Depression
• Anxiety
• Insomnia
• Strange and Vivid Dreams or Nightmares
• Low Energy and Lethargy
• Short Term Memory Issues
• Decision Making and Problem Solving Difficulties
• Issues with Managing Stress
• Dizziness

This experience of PAWS is typically characterized by a highly aroused mental state, combined with a very bleak outlook on the present and future. Someone may be so overcome with anxiety that they are scared to be around other people, or even to go outside. At the same time, they may be extremely depressed and lonely. This leads to a very dangerous mental space of wanting to do something to calm their anxiety, but being too depressed and scared to reach out to others for help.

Drugs Commonly Associated With PAWS

Almost every habit-forming substance is capable of producing PAWS, the only difference is in the specific symptoms and possibly their intensity. PAWS is technically a psychological condition resulting from suddenly losing such a powerful, albeit unhealthy coping mechanism. That being said, some substances are known for particularly intense symptoms and issues, and these are often most closely associated with a post-acute withdrawal syndrome.

Some of the substances which most often produce PAWS issues include:

• Alcohol: Severe anxiety, insomnia, and depression are common during PAWS from alcohol. This often takes several months or even years to fully resolve.
• Opiates: Such as heroin and oxycodone, the most common symptoms of PAWS include deep depression and social anxiety. Sleep disturbances are quite common as well, and these symptoms commonly take many months to resolve.
• Benzodiazepines: Such as Xanax and Klonopin, these drugs produce severe anxiety and stress management issues during PAWS. This can take the form of social anxiety, a fixation on problems, and issues controlling anger or frustration. This may take many months, or sometimes even years for someone to fully recover.
• Stimulants: Drugs such as crystal meth, cocaine, or Adderall can produce some of the most long-lasting post-acute withdrawal syndrome issues out of any known drug. These symptoms commonly include cognitive and memory problems, deep emotional instabilities, a loss of interest in life, and perceptual distortions which may persist for many months, and commonly last a year or more.

How is PAWS Treated?

There are a variety of effective treatments for PAWS and they are most effective when used in combination. A multifaceted approach including medication, therapy, social support, and exercise can be extremely effective at making it through PAWS while reducing the intensity of the symptoms.

Medication

Medications can be extremely useful in helping someone deal with the symptoms of PAWS. The medications which are most frequently used are ones that are non-habit forming, as someone experiencing post-acute withdrawal syndrome has already demonstrated a substance abuse problem in the form of heavy, chronic drug or alcohol use. These medications are not a solution, but they can give someone the mental stability to begin to build a solid foundation in recovery.

Some of the most commonly used medications for PAWS include medication classes such as:

• Antidepressants: Such as selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs). These medications mainly work on serotonin (SSRI) or serotonin and norepinephrine (TCAs) by increasing the levels which are available in the brain. Serotonin is a major neurotransmitter responsible for regulating mood and emotions. Norepinephrine is a powerful neurotransmitter in the brain and a hormone in the blood. In the brain, it is mainly responsible for attention, learning, and emotions. These medications can help to restore balance and reduce the negative symptoms of PAWS by helping to elevate and stabilize mood, increase motivation, and reduce fatigue.
• Blood Pressure Medications: Such as propranolol (a ꞵ-blocker) or clonidine (an ɑ-agonist), these medications may reduce blood pressure as well as reduce excitability. Both of these medication types are thought to act by reducing adrenaline activity which has a cascade effect of lowering blood pressure and heart rate as well as reducing anxiety.
• Anti Anxiety Medications: Typically non-narcotic and non-habit forming medications such as buspirone (Buspar) may be used. These medications can reduce anxiety but require time to start working, sometimes for several weeks. Medications like buspirone will not produce euphoria and have no potential for abuse. Because it has a highly selective mechanism of action, buspirone can reduce symptoms of anxiety without producing euphoria, tolerance, or dependence.
• Sleep Aids: Specifically non-habit forming sleep aids such as melatonin or diphenhydramine, these medications may reduce insomnia, thus promoting healthier sleeping patterns and help the brain better heal the damage done through chronic substance abuse.

Therapy

While medications will help reduce the symptoms, there are a variety of therapies that may help the underlying psychological causes of these symptoms. Throughout addiction, many addicts or alcoholics will isolate and avoid dealing with feelings in healthy ways, keeping emotions strictly to themselves. Learning new, more productive ways to handle these inner issues will go a long way towards achieving some relief during PAWS. Some of the commonly used therapies in this regard include:

• Individual Therapy: Discussing emotional issues with a trained professional who may be able to provide strategies or healthy coping mechanisms. This can take the form of a counselor, social worker, or therapist and having someone to provide solutions to the problems someone may face can help reduce some of the depression, fear, and anxiety experienced during post-acute withdrawal syndrome.
• Inpatient or Outpatient Therapy: Usually drug or alcohol-specific programs, these can be very effective at helping someone to develop healthy habits in early recovery. Not only do these programs include a variety of trained addiction recovery specialists, but there are also other people early in recovery with whom someone may be able to relate and connect.
• Physical Exercise: Exercise can play a hugely positive role in recovery from addiction of any sort. It can be especially useful in reducing symptoms of anxiety and depression which are commonly felt during PAWS. Dopamine, serotonin, and norepinephrine production can be stimulated through strenuous physical activity, and exercising these systems in a natural way can help lessen the time until full recovery. Likewise, the natural opioid system of the brain is activated during and after exercise which may also help to reduce anxiety and depression.
• Social Support: Either in the form of friends and family or through something more active like a 12 step program. Particularly in the case of 12 step programs, having people around who can relate and share their experiences can be a great benefit. Proof that there is life after drugs or alcohol can help to reduce anxiety, depression, and help someone feel more purposeful and hopeful in their recovery.

Post-acute withdrawal syndrome is different for everyone, and certain treatments may be more beneficial than others. It’s up to each individual going through this to reach out for help, and to try some different approaches until they find what best suits their unique needs. PAWS is unpleasant, to be sure, but it will get better if someone can stay sober. This will require help but it is possible, and there is life after addiction if someone is willing to reach out.