Post-acute withdrawal syndrome (PAWS) involves symptoms that last or develop after the initial withdrawal from a substance. They can linger for months or years, and they can be severe. A range of treatments and self-care strategies can help.
If a person with substance misuse disorder abruptly stops using the substance, they may experience withdrawal symptoms. The initial symptoms may be relatively short-lived, but they can be very dangerous. They may include nausea and an increased heart rate, for example.
Withdrawal symptoms may linger or develop later on, possibly a few months into recovery from substance misuse disorder.
During this second or “post-acute” phase of withdrawal, a person may experience symptoms that are more psychological than physical. They may include trouble with sleep and memory, mood swings, and other symptoms of mental health conditions. A doctor may refer to this set of symptoms as PAWS.
PAWS is a hypothesized syndrome, not a scientifically proven entity. It is worth keeping in mind that the symptoms of withdrawal can vary greatly, depending on the substance and the person’s response.
Another name for PAWS is protracted withdrawal syndrome, or PWS. It refers to a group of symptoms that linger after the initial stage of withdrawal or that develop later on in recovery.
Acute withdrawal stage
Symptoms during immediate, or acute, withdrawal tend to be physical. They vary depending on the substance, but they can include:
- an increased heart rate
- muscle aches
During acute withdrawal, the body is healing from the substance misuse. The effects can be life threatening, and it is important to undergo acute withdrawal with medical supervision.
Post-acute withdrawal stage
Symptoms associated with PAWS may develop after the acute withdrawal stage. The specific symptoms may depend on the duration and intensity of the misuse.
The symptoms develop as the brain adjusts to life without active addiction. They vary, but they tend to be less physical and more psychological or emotional.
A person with PAWS might have:
- brain fog
- irritable or hostile behavior
- mood swings
- sleep problems
- memory difficulties
- lack of motivation
- problems with fine motor coordination
PAWS symptoms can be uncomfortable and distressing, and they can be risk factors for relapse. Having a strong self-care routine, working with medical professionals, and having support from people who understand can help. Symptoms develop because substance misuse disorder causes changes in the body, brain, and central nervous system.
In a person with an addiction to benzodiazepines, for example, lasting withdrawal symptoms can stem from functional changes to the neuroreceptors in the central nervous system. Up to 15% of people who have taken benzodiazepines long term experience PAWS.
For people in recovery from a substance misuse disorder, it may not be possible to prevent PAWS. However, adopting self-care strategies and working with healthcare professionals can help.
While experts are unsure of the precise causes, some risk factors include:
- an abrupt end to the misuse
- the duration of the misuse
- the intensity of the misuse
- other physical or mental health conditions
- some genetic factors
In addition, a person may have a higher risk of developing PAWS, or the symptoms may be more intense, when the misused substance was alcohol, opioids, or benzodiazepines.
Doctors may diagnose PAWS based on a person’s medical history and the findings of a physical examination. A urine test can help doctors rule out withdrawal from specific drugs or combinations.
To assess a person’s overall health and diagnose any complications, a doctor may perform:
- a complete blood count
- a metabolic panel
- liver function tests
- an arterial blood gas test
- a urinalysis
- a toxicology screening
PAWS can last from months to years. The duration can vary from person to person, and the substance involved may play a role.
For example, if a person tapers off benzodiazepine use, their withdrawal symptoms usually resolve within 6–18 months of the last dose. However, anecdotal reports suggest that some symptoms persist for up to a decade following cessation.
The Food and Drug Administration (FDA) confirms that benzodiazepine withdrawal symptoms can last weeks to years.
Regarding other prescribed medications, researchers behind a 2020 study found that people experiencing withdrawal from antidepressants may experience lasting, severe PAWS symptoms. The symptoms lasted from 6 months to more than 23 years, with a median of about 6.5 years.
Coping with PAWS and how to find help
After the acute phase of withdrawal, a person may still need professional medical care, as PAWS symptoms can be severe and affect the quality of life.
Others may prefer to rely on a strong self-care routine and support from loved ones and others in recovery.
Some strategies for coping with PAWS include:
Self-care: Eating well and getting enough sleep can help the body heal and recover.
Seeking support: Speaking with understanding friends and family members can help, and both in-person and online groups of people with shared experiences can provide guidance and emotional support.
Taking medications: If a doctor recommends this approach, it is important to take this medication as prescribed, even after the symptoms diminish.
Avoiding triggers: It is crucial to be aware of people, situations, and emotions that may trigger a relapse. Members of a support group, for example, can help a person develop effective ways to deal with these triggers when simply avoiding them is not an option.
Taking it one day at a time: It is important to avoid doing too much and worrying about the future or the past. It can be more helpful to focus on daily self-care and the successes that each day brings.
PAWS refers to symptoms of substance withdrawal that last past, or develop after, the initial withdrawal period.
They may be more psychological than physical, including mood swings and difficulty with sleep and memory, for example.
PAWS symptoms can last from months to years, and they may increase the risk of a relapse. Medications, support groups, and self-care are just some of the strategies that can help. Anyone looking for support can find resources above.