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Post-Acute Withdrawal Syndrome (PAWS): Symptoms, Treatment & Types

When most people think of drug and alcohol withdrawal, they probably picture the initial withdrawal symptoms that occur when a person stops using drugs or alcohol and undergoes the detox process. While these initial withdrawal symptoms can be unpleasant and intense, another form of withdrawal comes later. According to the Semel Institute for Neuroscience and Human Behavior at UCLA, a second form of withdrawal, called post-acute withdrawal syndrome (PAWS), includes symptoms that occur for several weeks or even months after a person stops using drugs and alcohol. Other names for this condition include post-withdrawal syndrome, prolonged withdrawal syndrome, or protracted withdrawal syndrome, and it most often occurs with alcohol, benzodiazepine, and opiate abuse.

Symptoms of Post-Acute Withdrawal

Post-acute withdrawal symptoms may vary based upon the substance from which a person is withdrawing. According to a report in CNS Drugs, post-acute withdrawal syndrome for alcohol typically involves the following symptoms:

  • Anxiety
  • Depression
  • Sleep Disturbances
  • Difficulty Concentrating
  • Apathy

There is also a life threatening form of alcohol withdrawal called delirium tremens, and this can result in post-acute withdrawal symptoms, most notably altering between periods of wakefulness and sleepiness. The authors of the report in CNS Drugs have reported that this is fortunately rare.

Post-acute withdrawal syndrome resulting from benzodiazepines includes some of the same symptoms associated with prolonged alcohol withdrawal, but there are also differences. According to a report in Psychiatric Annals, benzodiazepine PAWS can last as long as six to 12 months and include the following symptoms:

  • Tingling Sensations in the Body
  • Sensitivity to Sights and Sounds
  • Muscle Spasms
  • Anxiety
  • Depression
  • Sleep Problems
  • Ringing in the Ears

Opiates also come with their own features of PAWS. Science Daily reports that post-acute withdrawal from opiate drugs, which include heroin and morphine, can cause people to feel unwell for weeks to months after acute withdrawal side effects subside. Symptoms of post-acute opiate withdrawal can include various signs related to depression, such as:

  • Concentration Problems
  • Lack of Energy
  • Disturbed Sleep
  • Lack of Pleasure in Usual Activities

Interestingly, Suboxone, a drug used to treat opiate withdrawal and cravings, can also create post-acute withdrawal symptoms when people stop taking it. This is especially true among people who abuse the drug instead of taking it under the care of a doctor. Ideally, when a person chooses to discontinue Suboxone use, his or her dose is gradually tapered, while a doctor supervises, to minimize withdrawal symptoms. When a person abuses the drug, on the other hand, withdrawal may be more uncomfortable.

A 2016 study published in African Health Sciences found that when people abused Suboxone, withdrawal was actually with a delayed onset and peaked 21 days after they stopped using the drug. Most of the users in the study injected the drug, and their withdrawal symptoms were mild. Post-acute Suboxone withdrawal may involve a milder version of typical protracted withdrawal from opiates, and those who are taking it for treatment of opiate addiction may be at increased risk of relapse when they discontinue Suboxone use.

Other Forms of Post-Acute Withdrawal Syndrome

Post-acute withdrawal syndrome is most often associated with alcohol, benzodiazepines, opiates, and Suboxone, but some people may experience prolonged withdrawal with seemingly harmless prescription drugs like antidepressants, which may be surprising. A 2018 study in the International Journal of Risk & Safety in Medicine found that post-acute withdrawal was common among people taking two types of anti-depressant drugs called selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). In fact, the average length of withdrawal for SSRI drugs was 21 months, and those coming off of SNRI medications experienced withdrawals lasting 12 months, on average. A quarter of those withdrawing from SSRIs experienced post-acute withdrawal for two years.

According to study results, the side effects of post-acute withdrawal from anti-depressant medications were numerous and included neurological and psychological symptoms as well as effects on various body systems, such as the gastrointestinal or cardiovascular systems.

Commonly reported side effects of PAWS among anti-depressant users included:

  • Dizziness
  • Ringing in Ears
  • Restless Legs
  • Tremors
  • Blurred Vision
  • Anxiety
  • Depression
  • Suicidal Thoughts
  • Irritability
  • Anger
  • Sleep Problems
  • Memory and Concentration Issues
  • Paranoia
  • Panic
  • Erectile Dysfunction
  • Frequent Urination
  • Coughing
  • Runny Nose
  • Muscle Weakness
  • Body Aches
  • Chest Pain
  • Racing Heart
  • Vivid Dreams
  • Nausea
  • Bloating
  • Diarrhea
  • Constipation
  • Stomach Pain

It is noted that the participants in this particular study had been using anti-depressants for long periods of time, so their withdrawal symptoms may be more severe than what the average person experiences when discontinuing the use of these medications. Nonetheless, these findings show that it is possible to experience PAWS, even with proper use of a common prescription medication like antidepressants.

Additional Information about Post-Acute Withdrawal

Post-acute withdrawal syndrome can occur with multiple types of drugs and involve a variety of symptoms. Beyond this fact, The Semel Institute for Neuroscience and Human Behavior has reported the following information about PAWS:

  • It seems to be most likely among people who are withdrawing from benzodiazepines.
  • PAWS occurs because the brain changes when people abuse drugs and alcohol and then has difficulty adapting when a person becomes abstinent.
  • PAWS may appear to be over, but can return at a later date.
  • Symptoms of PAWS are not constant; they may be severe for a period of time, improve, and then become severe again.
  • People who are experiencing prolonged withdrawal may have difficulty with personal relationships and appear especially pessimistic or apathetic.
  • PAWS can involve cravings for a person’s drug of choice.
  • People may find that prolonged withdrawal symptoms worsen when they are under stress.

Treatment of Post-Acute Withdrawal Syndrome with Medication

The treatment for post-acute withdrawal can vary based upon a person’s drug of choice and the specific withdrawal symptoms he or she is experiencing. The ultimate goal of treatment is to make symptoms more manageable and to prevent a person from relapsing to drug or alcohol abuse. In some cases, this may be achieved with medication.

PAWS from Alcohol

For PAWS that occurs with alcohol addiction, medication may be necessary to manage symptoms. According to a report in Expert Opinion on Investigational Drugs, benzodiazepines have historically been the drug of choice for treating alcohol abuse, but they can be addictive themselves and cause problems, including relapse, for those recovering from alcohol addiction. The authors of the report indicated that other anti-seizure drugs, such as gabapentin and carbamazepine, have shown effectiveness for treating alcohol withdrawal and should be considered in its treatment.

The research supports this statement, as a clinical study in a 2014 edition of JAMA Internal Medicine showed that gabapentin treated protracted withdrawal symptoms including insomnia, low mood, and alcohol cravings. According to a report in Current Treatment Options in Neurology, acamprosate is also helpful in cases of alcohol-related PAWS, as it can reduce relapse and stabilize the body’s physiology during prolonged withdrawal. Medications can assist with alcohol-related PAWS side effects to make the process more manageable.

PAWS from Benzodiazepines

Benzodiazepine PAWS is sometimes treated with medication, but there is some controversy regarding this form of treatment for prolonged benzodiazepine withdrawal. For example, researchers writing for a 2016 edition of Current Psychiatry Reports have stated that anti-depressant SSRI drugs may be prescribed to treat benzodiazepine withdrawal, but this may not be ideal, given the fact that these drugs can come with their own form of PAWS.

A drug called pregabalin may be useful for reducing anxiety levels in people experiencing prolonged benzodiazepine withdrawal, and propranolol is another option for treating anxiety that occurs with PAWS. Finally, flumazenil is a potential medical treatment for severe and persistent benzodiazepine withdrawal. According to the study in Current Psychiatry Reports, it reduces cravings among people withdrawing from benzodiazepines, but it typically is administered in an inpatient setting, so it may not be feasible for everyone experiencing PAWS with benzodiazepines.

PAWS from Opiates

For post-acute withdrawal syndrome with opiate abuse, medications are often helpful. According to the Harvard Review of Psychiatry, methadone and buprenorphine/naloxone are the standard treatments for preventing relapse in opiate addiction. Other medications can also be beneficial. In fact, a study in Addictive Disorders & Their Treatment found that both memantine and amitriptyline were effective for reducing post-acute withdrawal symptoms like drug cravings, anxiety, depression, and lack of pleasure among people who had detoxed from heroin.

According to the National Institute on Drug Abuse (NIDA), memantine in particular can be especially beneficial for treating opiate addiction when used in combination with buprenorphine/naloxone. In a study where 30 mg of memantine per day was combined with buprenorphine/naloxone treatment, participants reduced their opiate use to zero and experienced fewer withdrawal symptoms when compared to those taking a placebo with buprenorphine/naloxone.

PAWS from Suboxone

There is less research available on the treatment of post-acute withdrawal from Suboxone. Given the fact that this drug is often used to treat opiate addiction and may be taken legally under the care of a doctor, prevention is likely the best approach for addressing prolonged Suboxone withdrawal. Those who take prescribed Suboxone and wish to come off of the drug should work with a doctor to gradually taper its use. Slowly reducing the dose over time can help the body to adjust so that withdrawal is more comfortable. For those who have been abusing Suboxone illicitly, medications typically used for prolonged opiate withdrawal may be beneficial.

Behavioral/Psychological Treatments for PAWS

While medical treatments may be effective for those undergoing PAWS from alcohol, benzodiazepines, and opiates, this is not the only treatment option available. Behavioral treatments, such as individual counseling and support groups can also be beneficial.

As the Semel Institute for Neuroscience and Human Behavior has explained, common symptoms of PAWS, regardless of the drug of abuse, include depression, anxiety, irritability, sensitivity to stress, and relationship problems. These symptoms can make the recovery process more difficult; people may feel that remaining abstinent is impossible, which can cause them to relapse to drug or alcohol abuse. Undergoing behavioral or psychological treatments can help people to cope with the unpleasant effects of PAWS.

There are several options for behavioral and psychological treatments for prolonged withdrawal:

  • Cognitive-Behavioral Therapy: In this form of counseling, people learn to replace unhelpful, negative thoughts with healthier ways of thinking. The theory behind this therapy modality is that thoughts, feelings, and behaviors influence each other. For instance, if a person feels that abstinence is too difficult, this can lead to relapse to drug use.  In addition, a person who is experiencing PAWS may think that the uncomfortable symptoms will last forever, and this thought can lead to depression. Those who undergo cognitive-behavioral therapy during PAWS will learn new ways of thinking that can help them to overcome depression and anxiety and have a more positive outlook that helps them to cope with stress.
  • Relapse Prevention Programs: PAWS can trigger a relapse, because people may begin to feel helpless, as if their lives were better off when they were using drugs or alcohol. Relapse prevention programs can help people to learn to identify these negative thoughts, as well as other triggers for relapse, and develop strategies for overcoming them. Relapse prevention programming can therefore be an important part of treatment for prolonged withdrawal.
  • Psychoeducation Programs: In psychoeducation programs, people who are experiencing post-acute withdrawal syndrome can gain knowledge about drug addiction and treatment and learn what to expect in terms of withdrawal symptoms and the treatment process. Someone who is experiencing PAWS may feel that something is seriously wrong, but learning that this is a normal part of the treatment process can be reassuring and provide people in recovery with additional coping tools.
  • Supports Groups: In addition to other behavioral treatments, people experiencing PAWS may benefit from attending support group programs like Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). In these programs, people can connect with others who are experiencing similar symptoms and share stories of recovery and healing. Having a support system in place can also make the unpleasant symptoms of PAWS seem more manageable.

While this list of behavioral and psychological treatments for PAWS is not exhaustive, the point is that individual and group psychological interventions are useful for coping with prolonged withdrawal and staying clean. Other specific therapy techniques that are known to be effective for symptoms like anxiety and depression can also be helpful. In addition, it is important to remember that even if a person is taking medications to assist with withdrawal and remaining abstinent, it is also necessary to treat the underlying conditions that led to addiction. Psychological treatments are therefore necessary for recovery in general, even among people who are not experiencing post-acute withdrawal.

These treatments are also necessary for people who are struggling with post-acute withdrawal from medications like anti-depressants and benzodiazepines used to treat depression and anxiety. Through psychological treatments like counseling, people can learn ways to overcome these mental health conditions without medications. Additionally, it is also worth noting that some people with ongoing anxiety and depression may choose to remain on maintenance doses of medication over the long-term, instead of discontinuing use and struggling with post-acute withdrawal. The pros and cons of remaining on medication, as well as the suitability of doing so, can be determined via a discussion between patient and doctor.

FAQs of Post-Acute Withdrawal Syndrome (PAWS)

In general, post-acute withdrawal syndrome involves a variety of unpleasant symptoms, such as depression, anxiety, sleep disturbances, and general loss of pleasure after discontinuing the use of alcohol, benzodiazepines, opiates, or prescription medications like anti-depressants. The following FAQs provide additional insights into post-acute withdrawal:

When does post-acute withdrawal start?

The term “post-acute withdrawal” refers to any ongoing withdrawal symptoms that appear after a person has completed the initial detox from a drug of abuse or a medication that has caused dependence. For example, the World Health Organization reports that withdrawal from heroin typically subsides within 4-10 days. Post-acute withdrawal includes any symptoms that appear after this initial withdrawal phase.

Is post-acute withdrawal the same as initial withdrawal symptoms?

There can be some overlap between traditional withdrawal symptoms seen during acute detox phases and those that occur with prolonged withdrawal, but PAWS tends to be less severe than initial withdrawal. For example, people in the acute heroin withdrawal phase can experience highly unpleasant symptoms, such as nausea, vomiting, and chills, whereas post-acute heroin withdrawal tends to involve psychological symptoms like depression and concentration problems. While these symptoms can be distressing, they are usually not as disruptive as those that occur during acute withdrawal.

How long does post-acute withdrawal last?

The length of post-acute withdrawal will vary from person-to-person and based upon the specific substances a person abused. In some cases, PAWS may persist for several weeks or months, but as has been found with anti-depressants, symptoms may last for over a year.

How common is PAWS?

The Semel Institute for Neuroscience and Human Behavior reports that about 90 percent of people recovering from opiate addiction and 75 percent of those coming off of alcohol or psychiatric medications will experience prolonged withdrawal.

Why does post-acute withdrawal occur?

Initial withdrawal symptoms, such as insomnia, nausea, and vomiting occur as a person’s body rids itself of drugs and adjusts to operating without them. Post-acute withdrawal occurs because long-term drug and alcohol abuse alters the brain. Over time, the brain becomes dependent on the presence of drugs, and people will not experience typical levels of pleasure or happiness unless under the influence of the drugs. Once the drug use is discontinued, the brain must adjust to producing certain “feel good chemicals” on its own. Until the brain stabilizes, symptoms like depression, anxiety, and apathy are common.

Post-acute withdrawal syndrome can understandably lead people to feel rather unhappy and discouraged as they become abstinent from drugs or alcohol. Fortunately, medical and psychological treatments are available to assist people with PAWS. If you are struggling with symptoms of prolonged withdrawal, it is important to reach out for professional intervention and support to prevent relapse and learn healthy ways of coping.  

Sources & Resources

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