Post-Acute Withdrawal Syndrome: Everything You Need to Know

Post-Acute Withdrawal Syndrome

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When you quit alcohol or drugs, you may experience withdrawal symptoms for several days or weeks. These symptoms range from mild to severe based on the substance, quantity, frequency, and duration of use.

Sometimes, withdrawal symptoms can last much longer, for months or even years. This is known as post-acute withdrawal syndrome (PAWS). PAWS can make everyday tasks uncomfortable, and if an individual is dealing with addiction, it can cause relapses during recovery.

That is why individuals should not try to quit substance use alone. It is crucial to consult a healthcare provider to help manage withdrawal symptoms and prevent dangerous and potentially life-threatening complications.

Read this article to learn everything you need to know about post-acute withdrawal syndrome.

What Is Post-Acute Withdrawal Syndrome?

Post-Acute Withdrawal Syndrome (PAWS) entails a list of impairments lasting for weeks or even months after stopping using an addictive substance. PAWS is also known as protracted withdrawal syndrome or post-withdrawal syndrome.

The illness is characterized by signs and symptoms like anxiety disorders, such as mood swings, sleeplessness, and high anxiety levels, even without apparent triggers.

PAWS symptoms most frequently appear after withdrawal from opioids, alcohol, and benzodiazepines. However, PAWS symptoms are said to manifest with (cessation of) usage of other psychoactive drugs.

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Projections show that the condition affects 75% of recovering alcoholics and psychotropic drug users and 90% of recovering opioid addicts.

Although research into the specific processes underlying PAWS is ongoing, experts believe the recurrent symptoms result from physical brain changes that occur during drug misuse and lead to higher tolerance levels.

What Causes Post-Acute Withdrawal Syndrome?

The physiological changes occurring in the brain caused by drug addiction are assumed to cause PAWS. Substance abuse forces the brain to adjust to accommodate changes in the present neurotransmitters.

These changes may result in hyperactivity when the number of neurotransmitters changes during sobriety. Researchers hypothesize that continued drug use and the associated withdrawal symptoms reduce the brain’s ability to cope with stress.

PAWS can also occur in children whose mothers have a history of drug misuse.

PAWS can appear upon withdrawal from practically any addictive drug, although benzodiazepine users appear to be the most susceptible. Benzodiazepine addicts experience PAWS symptoms for years after stopping the substance.

Risk Factors for Post-Acute Withdrawal Syndrome

Recovering persons, even those with comparable drug backgrounds, report different and unique PAWS experiences.

The type of PAWS symptoms that appear and their severity may differ based on several factors, including:

  • Duration of the addiction
  • Genetics
  • The intensity of the drug use
  • A pattern of substance abuse
  • Physiology
  • Psychological makeup

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The most prevalent risk factor for PAWS is a past of drug abuse. PAWS symptoms are more likely to occur and be more severe in individuals who have used psychoactive drugs frequently, for extended periods, and at larger dosages.

But since PAWS could manifest distinctly in two people who have taken the same drug in the same way, genetics and physiological factors may come into play.

There has yet to be much study done on this syndrome. Therefore, it is impossible to know beforehand how someone may be impacted.

What Are the Most Common Symptoms Of PAWS?

Most undesirable emotions and sensations you suffer during the early stages of recovery might be signs of PAWS. It is crucial to understand this to reduce your risk of relapse.

You should also know that PAWS symptoms are not permanent. The most common symptoms include:

  • Anxiety or panic
  • Depression
  • Fatigue
  • Foggy thinking/trouble remembering
  • Impaired ability to focus
  • Irritability or hostility
  • Issues with fine motor coordination
  • Lack of initiative
  • Mood swings
  • Sleep disturbances – Insomnia or vivid dreams
  • Stress sensitivity
  • Urges and cravings

The severity of these symptoms tends to increase when triggered by stress, but they can flare up without any apparent trigger.

Common Drugs and Their Associated Post-Acute Withdrawal Symptoms

Some classes of drugs are more commonly linked with PAWS than others following prolonged abstinence from the drug.

However, very few scientific studies on the etiology of PAWS are available, so the following list of drugs said to cause this syndrome is not exhaustive.


Of all substances, PAWS from abstaining from alcohol has drawn the most scientific attention. Research exploring symptoms now linked to PAWS has been documented in medical publications since the 1990s.

Alcohol is a sedative substance that works partly by stimulating the brain’s gamma-aminobutyric acid (GABA) receptors.

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The brain adjusts to prevent persistent inhibition caused by increased GABA activity, suppressing total brain activity.

When an alcohol-dependent person quits drinking, their nervous system becomes hyperactive. This hyperactivity may initially cause tremors and seizures, but mild symptoms like anxiety, mood swings, sleep disturbances, and loss of libido can last for months or even years.


Benzodiazepines (BZDs), which include diazepam (Valium) and alprazolam (Xanax), have a similar action mechanism to alcohol.

They are GABA receptor activators, and prolonged use may cause the brain to adapt by shifting to a hyperactive state. Even when used as prescribed by a doctor, these drugs can cause withdrawal symptoms.

The symptoms of prolonged benzodiazepine withdrawal might resemble those of other illnesses such as depression, panic attacks, schizophrenia, and obsessive-compulsive disorder (OCD).


Selective serotonin reuptake inhibitors (SSRIs), like fluoxetine (Prozac), and serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine (Effexor), make up the majority of today’s antidepressants.

They increase neurotransmitter (norepinephrine and serotonin) levels in the brain by inhibiting their reabsorption by nerve cells.

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It is unclear how exactly these medications manage depression in patients. But it probably involves adaptive changes in the brain since it takes several weeks before a patient starts feeling better after taking these drugs.

Therefore, it is not strange that patients who stop using their antidepressant prescriptions experience long-term effects.


People who are recovering from opioid addictions experience long-lasting opiate withdrawal symptoms. Addicts who quit using prescription and illegal opioids like oxycodone, hydrocodone, codeine, and heroin may have such PAWS symptoms as fatigue, anxiety, and sleep problems.

Opioids function by stimulating the opiate receptors in the brain and spinal cord, which reduces pain perception, promotes feelings of well-being, and, at high dosages, yields euphoria.

By expanding the number of opioid receptors on the surface of brain cells, the body adjusts to constant overstimulation of these receptors, making it necessary for opioid medications to activate more receptors to achieve the effect.

Besides, the number of endorphins – the natural compounds that activate opiate receptors- reduces in opioid addicts as the body adjusts to the overstimulation of this system.

These nerve system adjustments result in less opiate signaling to the brain and are associated with greater pain sensitivity and mood swings in opiate addicts.


The most substantial evidence that PAWS is a legitimate medical disorder and not just a prolonged acute withdrawal comes from stimulant substances like cocaine and amphetamine.

The psychological signs of PAWS, such as anxiety, paranoia, depression, impulse control issues, and related emotional control disorders, are typically observed in long-term stimulant addicts who stop using them abruptly.

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Like with other drugs, these stimulant withdrawal symptoms can last many months and are assumed to result from the brain’s adaptation to long-term stimulant usage.

Other drugs

It’s unknown that just specific drug classes fall under the purview of post-acute withdrawal syndrome.

PAWS may not be limited to specific categories of drugs. Theoretically, people who cease using marijuana, antipsychotic medicines, and anabolic steroids after prolonged chronic usage may also experience PAWS-like symptoms.

Although the examples above represent the PAWS’ most common causes, many doctors may overlook these cases since medical organizations and diagnostic manuals do not recognize PAWS as a disorder.

How is Post-Acute Withdrawal Syndrome Managed?

Since PAWS symptoms can last for months or even years, individuals often undergo treatment over a long period.

Acamprosate, a medication frequently prescribed for recovering addicts, is said to help treat some PAWS symptoms. Other drugs could also help.

Most patients also receive psychotherapy in group therapy or behavioral therapy to learn how to manage their symptoms.

Group problematic young people talking with guidance counselor.

Apart from these, there are steps you can take to cope with PAWS and improve your overall well-being during recovery. These include:

  • Educate yourself – Learn about acute and post-acute withdrawal to better prepare for it as you continue the recovery process.
  • Focus on positive changes and improvements – Most people focus on ongoing challenges caused by PAWS. But still, you should acknowledge how recovery is improving your life.
  • Stay active – Physical activity and exercise can help your body and mind recover quickly by boosting immune system function and reestablishing a healthy balance in neurotransmitter levels. They can also help have better sleep in the long run by lowering anxiety and stress levels.

Above all, be patient and be kind to yourself. Even though PAWS can take a toll on you and your family and friends, it will eventually fade away. Therefore, managing the symptoms and learning how to lead a healthy and fulfilling life in recovery requires empathy and patience.

Find the Help You Need Now!

Post-acute withdrawal syndrome may be challenging to manage, especially after detox and trying to avoid relapse.

Although the unpredictability of symptoms can be frustrating, combining therapy and medication can make these symptoms easier to cope with.

At CCIWA, we can help you find effective treatment programs for your PAWS symptoms. Contact us to get started today.

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