Post-Acute Withdrawal Syndrome (PAWS)

PAWS refers to a set of impairments that may persist for weeks, months, or even years after obtaining sobriety (i.e., substance-free)

What is post-acute withdrawal syndrome (Semel Institute for Neuroscience and Human Behavior, 2022)?

Post-acute withdrawal syndrome, often referred to as PAWS, is a set of impairments that may persist for weeks, months, or even years after obtaining sobriety (i.e., substance-free)
- The duration of PAWS that one experiences is dependent on the severity and duration of the substance abuse – typically symptoms of PAWS last for 1-2 years
- These set of impairments manifest after the withdrawal period

There are two stages of detox/withdrawal (Addiction Center, 2022)
- 1st stage – the actual withdrawal from the substance
- 2nd stage – involves your brain “re-calibrating” from addiction causing withdrawal-like symptoms and impairment in functioning (PAWS)

Scientists believe that PAWS occurs as a result of the physical changes in the brain that take place during active substance abuse

PAWS is most common after withdrawal from alcohol, benzodiazepines, and opioids, along with other psychoactive substances
- 90% of recovering opioid users and 75 % of recovering alcoholics will experience PAWS

What are symptoms of PAWS (Addiction Center, n.d.)?

Common symptoms of PAWS include, but are not limited to:
- Insomnia or other sleep disturbances
- Irritability
- Aggression
- Hostility
- Anxiety or panic attacks
- Depression
- Disrupted concentration
- Lack of motivation and enthusiasm
- Mood swings (extreme highs and lows)
- Fatigue/low energy
- Foggy thought process
- Poor memory and impulse control
- Stress sensitivity
- Substance use cravings
- Substance use dreams
- Apathy
- Decreased sex drive
- Chronic pain
- Tremors
- Obsessive-compulsive behaviors

Due to the symptoms and cravings for the preferred substance that PAWS manifests, those in recovery are at high risk for relapsing when experiencing PAWS (Hazelden Betty Ford Foundation, 2019)

Who is at risk for PAWS (Snipes, 2021)?

Anyone who is recovering from substance use is at risk of developing PAWS.

Underlying factors that play a role in the manifestation of PAWS includes:
- Physical health – poor overall physical health has been linked to increased risk for PAWS
- Underlying health issues – increases risk for paws or worsens symptoms
- Age – the younger the individual is, the more prone they are to PAWS and symptoms are more intense

Infants who have been repeatedly exposed to substance use in the womb are also at high risk of developing PAWS as well (Resnick Neuropsychiatric Hospital, n.d.)

Why does PAWS occur?

Researchers are still trying to determine the exact cause of PAWS but there are many theories regarding change in the brain’s neuroplasticity and overall structure

During chronic substance abuse, the brain begins to rely on the drug in order to maintain the high degree of pleasure associated with the high levels of neurotransmitters in the reward circuit (Resnick Neuropsychiatric Hospital, n.d.)

During drug abuse your brain adapts to the changes in available neurotransmitters resulting in physiological changes in the brain
- After maintaining sobriety, your brain tries to “recalibrate” the changes made
  - This “recalibration” often causes the brain to make new receptors which often causes the common symptoms of depression, anxiety, and substance cravings during PAWS. As new receptors grow to reach homeostasis, your brain is adjusting to these new receptors (Snipes, 2021)

Neuroplasticity is a process that involves the brain creating and changing neural pathways as we develop and learn (StoneRidge, n.d.)
- Frequent use of same circuits become “automatic” or habitual
  - During chronic substance use the brain often relies heavily on the pleasure-reward circuit
- Drugs and alcohol change the chemistry of the brain which therefore alters the neuroplasticity of the brain
  - When the brain’s neuroplasticity changes, this becomes the brain’s new “norm”
  - When someone becomes substance free, the brain feels it needs to “correct” any “imbalance”
    - i.e. The brain reduces the production of dopamine if a drug artificially creates dopamine-like effects. Once this adaption is the new “norm”, the brain will want to fix this “imbalance” when the substance is no longer present resulting in the brain going “haywire” (causing symptoms of PAWS)

How to cope with PAWS (Bridges of Hope, n.d.)?

As PAWS impacts an individual on both a psychological and emotional level, it is extremely important to have support from a therapist, counselor, or other mental health/addiction professional during this period of recovery.

Besides working with a professional on maintaining symptoms, below are some steps an individual can take to help manage PAWS symptoms:
- Practice self-care – eat a healthy diet, get regular exercise, avoid triggering places or people, surround yourself with supportive and positive relationships and influences
- Educate yourself on PAWS – knowing what to expect and not being caught off guard can make the PAWS period a little less scary
- Reflect on personal experiences – keeping a journal or reflecting on the events that led up to the substance use, and the consequences of the use has made will help you stay on the track of sobriety. Journaling can also be a useful tool for reflecting on alternative ways to handle difficult situations in the future
- Understand that recovery takes time – treating addiction cannot be rushed, having patience is a key component of recovery
- Have a plan in place – due to the severity and duration of PAWS symptoms, individuals often relapse during this time. Having a plan in place can help decrease the chances of relapse

Personal Success Story: Justin’s Story – A Reformed Drug User

I drank as a teenager in (my) 20’s, experimented with drugs as a late teenager and early 20’s. I got away from drugs because I got married, had a family, responsibilities and obligations. At about 38 years old I realized that alcohol was a problem. I actually realized I was an alcoholic. My parents were alcoholics. I just knew I was an alcoholic. But I enjoyed opiates and I always had that in the back of my mind (thinking) ‘I would like to do that again given the opportunity. Got sober at 40 years old and stayed sober for 10 years. I never addressed the drug thoughts with my sponsor at that time or anybody for that matter. Then I had an operation and got prescribed Vicodin. Did not drink but developed an affinity for opiates. Had the opportunity to purchase black market ‘percs’ (Percocet) and methadone, which would alleviate the withdrawals from the ‘percs’. I went on a 10 year run using opiates. I knew long before I sought help at 60 years old that I was addicted to the drugs. (My) personal relationships were falling apart with loved ones and family. Finances were becoming an issue and having trouble working. Couldn’t focus, didn’t have the stamina to work the hours I needed to work, having trouble completing tasks. (I) tended to isolate and withdraw, became non-supportive; marriage is a two-way street. If you don’t fulfill your obligations, it’s a problem. I turned to my family, to my spouse and to my children. I then went to someone in the recovery community and went to the rehab center. I think the most important thing was spending four months in a rehab center. It took me the 30 days to settle down a bit, then having three months of extended care really helped. We did the daily meetings, AA and NA, spiritual stuff, we did meditation, outings for comradery, we had responsibility and chores…it was a structured environment. But, it was the time; at the end of the day, it was the time- the four months spent up there to enable me to get a good start.

Today, what has helped is total immersion in the 12-step program, working the steps, big book, sponsorship, ongoing relationships with men with whom we talk recovery. We help each other and when able, give back. As I look back, I knew long before I asked for help, that I needed help. And if I had it to do over again, I would have asked for help long before I did. At the end of the day, the solution is not near as difficult to achieve as what my mind told me it was going to be. The fear was so great, but it wasn’t that bad. There is a solution. Any parent that recognizes a different child than what they are used to, you have to get involved and it had to be addressed. Go and don’t wait to get them help. To the community member, everybody has stuff; we all have friends, family members, acquaintances, that has some sort of problem. It’s not abnormal, it’s not unusual and the quicker we can respond and try to find a solution the better it will be for everybody.

Retrieved from: https://roadtorecovery.info/personalstories/

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