Post-Acute Withdrawal Syndrome (PAWS)

By Ioana Cozma

Last updated: 21 March 2024 & medically reviewed by Dr. Kimberly Langdon

What is post-acute withdrawal syndrome?

When an individual with substance use disorder (SUD) seeks addiction treatment, stopping substance use, they experience acute withdrawal symptoms. This initial withdrawal phase encompasses physical manifestations, such as nausea, headaches, chills, and psychological symptoms, such as anxiety, low mood, and cravings.^[1]

Post-acute withdrawal syndrome (PAWS), or protracted withdrawal, represents a host of new withdrawal symptoms that form after the acute withdrawal stage. PAWS symptoms are often psychological and may be mild or severe, lasting for months or years within recovery. Mental health symptoms of post-acute withdrawal syndrome may include poor memory, mood swings, and altered sleep, but these manifestations vary greatly between individuals.^[1]

Post-acute withdrawal syndrome is more common for people in benzodiazepine recovery, though withdrawing from other substances can trigger PAWS symptoms as well.^[2]

Additionally, though there is a growing body of literature and anecdotal evidence surrounding PAWS, the syndrome’s existence has not been proven scientifically.^[1]

When and why does post-acute withdrawal syndrome occur?

The prevalent explanation for post-acute withdrawal syndrome is that drugs and alcohol alter the brain’s ability to manage stress correctly. During drug use, brain chemistry is affected by either the consumption of psychoactive chemicals most commonly from stimulants or depressants. The level and production of neurotransmitters in the brain become dependent on the psychoactive substances consumed so the brain cannot return to normal levels immediately in withdrawal.^[2][3]

As a result of fluctuating levels of neurotransmitters during withdrawal, the brain experiences a reduced ability to deal with stress, translating into a state of “anhedonia,” which means an inability to feel pleasure.^[2][3]

Protracted withdrawal appears after the initial stage of acute withdrawal, which varies depending on how long each substance stays in the system. Cannabis (marijuana) has the shortest acute withdrawal timeframe, typically five days, while alcohol acute withdrawal symptoms last 5-7 days. The acute phase of opioid withdrawal may be experienced for 4-10 days, though methadone withdrawal may prolong for 14-21 days.^[3]

At the longer end of the spectrum, stimulants such as amphetamines, methamphetamine, and cocaine incur 1-2 weeks of acute withdrawal. Benzodiazepine withdrawal lasts between one and four weeks, though reducing the dose gradually, also known as tapering, can prolong these symptoms for 3-5 weeks. Nicotine, though a mild drug in terms of stimulant effects, comes with an acute withdrawal period of 2-4 weeks.^[3]

The common symptoms of PAWS

Psychoactive substances render different PAWS symptoms due to their distinct effects on the brain, so we will review them below.

Alcohol PAWS symptoms

The post-acute withdrawal syndrome from alcohol has well-documented symptoms, such as anxiety, anger, depression, mood swings, tiredness, problems sleeping, memory and cognitive impairment, low sexual drive, and unexplained physical pain.^[3]

Studies underline that sleep-related PAWS symptoms following alcohol misuse can last 1-3 years, even during complete alcohol abstinence. Individuals may experience sleep apnea, difficulty falling asleep, and lower sleep duration.^[4]

Opioid PAWS symptoms

PAWS symptoms following opioid misuse include mental health problems such as anxiety, depression, dysphoria, and irritability. Fatigue, decreased focus, and hindered executive control functions are likewise common occurrences during the post-acute withdrawal syndrome following opioid addiction.^[3]

Other sources note that protracted opioid withdrawal symptoms last up to six months, typically accompanied by low mood and strong opioid cravings.^[5]

Methamphetamine PAWS symptoms

Chronic methamphetamine abuse has shown significant functional consequences in brain imaging studies comparing regular methamphetamine users undergoing prolonged abstinence and subjects with no history of drug use. The differences are observable in the subjects’ cortical and limbic systems, underlining prolonged deficits in dopaminergic and serotonergic neurotransmitters for methamphetamine users, the markers of anhedonia.^[6]

Brain imaging studies additionally point out a decreased glucose metabolism, loss of gray matter, and cognitive deficits. These changes are connected to impaired executive control functions.^[6]

Other research notes that amphetamine withdrawal symptoms are typically non-life-threatening, including marked depression, fatigue, dysphoria, hunger, and drastic psychomotor retardation. Recovery from amphetamine use is prolonged, with depression symptoms extending for several weeks.^[7]

Cocaine PAWS symptoms

Cocaine withdrawal symptoms may include emotional regulation and impulse control issues. While emotional regulation issues typically improve within four weeks, with subjects gaining enhanced control of their emotions and developing healthy coping mechanisms, impulse control does not generally show improvements within four weeks of cocaine withdrawal.^[3]

Other studies note that post-acute withdrawal syndrome following prolonged cocaine echoes that of amphetamine due to both psychoactive substances being stimulants. Therefore, PAWS symptoms of cocaine misuse also include extreme tiredness, hunger, severe depression, dysphoria, and psychomotor retardation.^[7]

Marijuana (cannabis) PAWS symptoms

Post-acute withdrawal syndrome associated with marijuana misuse may trigger a host of symptoms, including marked sleep difficulties and strange dreams lasting for more than 45 days into abstinence.^[3]

Anxiety, irritability, headache, fluctuating appetite, and stomach pain may also accompany protracted cannabis withdrawal.^[8]

Benzodiazepine PAWS symptoms

Diagnosing PAWS symptoms from benzodiazepine misuse is challenging because they resemble symptom rebound or re-emergence. Symptom rebound defines a more intense return of initial benzodiazepine withdrawal symptoms, waning in time. Symptom re-emergence implies the same level of withdrawal symptoms returning, with no signs of abating.^[3]

In turn, PAWS symptoms during benzodiazepine withdrawal define new manifestations, such as increased anxiety, agitated depression, obsessive-compulsive episodes, and schizophrenia. These symptoms fluctuate in degree and can last for months, though they improve after prolonged abstinence.^[3]

Can PAWS be avoided?

There is a lack of scientific evidence on effective techniques to prevent post-acute withdrawal syndrome. The current body of evidence on PAWS suggests that the syndrome is a natural mechanism through which the brain corrects chemical imbalances caused by active addiction.^[8]

Additionally, not all individuals experience protracted withdrawal, which implies that additional factors can affect the emergence of PAWS, such as genetics, the type of substance used, the quantity and length of time, as well as individual brain chemistry.^[3]

Coping strategies to manage PAWS

While post-acute withdrawal syndrome cannot be actively prevented, individuals experiencing it can manage its manifestations. PAWS symptoms can be alleviated through self-care, support from loved ones, avoiding triggers, and taking the prescribed medication.^[1]

Alternative sources suggest physical and mental exercises, making to-do lists, establishing daily routines, celebrating accomplishments, and patience.^[3] Individual psychotherapy and group therapy are likewise useful strategies regardless of the psychoactive substance individuals withdraw from.^[2][5]

Interestingly, an effective coping strategy to handle post-acute withdrawal syndrome appears to be education, as understanding the causes, symptoms, and duration of PAWS helps patients’ expectations and planning.^[3][8]

What additional support is available for PAWS?

Additional support available for PAWS is available with the National Drug Helpline, SMART Recovery, the Substance Abuse and Mental Health Services Administration (SAMHSA), and the UCLA Dual Diagnosis Program.^[1][2]