It’s a common misconception that substance-abuse withdrawal symptoms only occur once. People expect symptoms after detoxing from substances, but they are frequently unaware that symptoms can resurface after sobriety has been established. This phenomenon is called Post-Acute Withdrawal Syndrome (PAWS).

What is Post Acute Withdrawal Syndrome?

Research conducted at the Semel Institute for Neuroscience & Human Behavior refers to Post-Acute Withdrawal Syndrome (PAWS) as “a set of impairments that can persist for weeks or months after the obtaining from a substance of abuse.” Post-Acute Withdrawal Syndrome may also be called “post-withdrawal syndrome,” “prolonged withdrawal syndrome,” or “protracted withdrawal syndrome.”

People diagnosed with PAWS exhibit symptoms similar to those found in mood and anxiety disorders. Insomnia, mood swings, and heightened anxiety may emerge without any apparent trigger. While the cause for PAWS is unknown, symptoms usually arise after withdrawal from alcohol, benzos, or opioids, “but have been known to occur with (cessation of) use of other psychoactive substances.” Research shows that an estimated 90% of recovering opioid users and 75% of recovering alcohol and psychotropic abusers experience PAWS.

Unlike acute withdrawal symptoms that occur immediately when quitting a substance, Post-Acute Withdrawal Syndrome takes a long time to show up. Short-term withdrawal symptoms differ from person to person and depending on the drug used. PAWS symptoms “can vary and are dependent upon many factors, such as the type of dependency, physical size and gender, and overall health.”

How Different Drugs Affect PAWS

Some drugs are more likely to cause intense PAWS symptoms than others¹. Marijuana, cocaine, meth, opiates, and benzos can all cause symptoms of varying severity. Alcohol and most recreational drug use can also lead to PAWS.

Quitting marijuana use can cause insomnia, which, left untreated, can eventually lead to PAWS. For those people recovering from cocaine addiction, “for weeks and even months after becoming sober, prolonged symptoms of impulse control and depression are possible.” Recovering meth users may experience inhibited impulse control function, sometimes for years. Individuals recovering from opiate use may experience PAW symptoms for many months following their initial detox and withdrawal, experiencing symptoms like insomnia, anxiety, depression, and decreased impulse control.

Post Acute Withdrawal Syndrome From Benzodiazepines

Many people are prescribed benzodiazepines by health care professionals for depression, anxiety, or panic attacks. This increases the likelihood of an adverse reaction when they withdraw from drugs or alcohol. People prescribed benzos for mental health issues are especially at risk for side effects that can turn into PAWS. Unfortunately, PAWS can also exacerbate the original mental health issue. Research suggests that people in benzo recovery will experience panic attacks, extreme anxiety, or insomnia during their withdrawal period, requiring significant assistance from a therapist or doctor throughout their transition to sobriety. While PAWS can occur after quitting nearly every abusive substance, those people who are addicted to benzos appear to be at most at risk. Many recovering benzodiazepine users report experiencing symptoms of PAWS for years.

Signs and Symptoms of PAWS

Unfortunately, PAWS may appear after the individual in recovery has overcome the initial withdrawal symptoms. PAWS can jeopardize sobriety by interfering with the establishment of a new lifestyle. PAWS symptoms can include:

Irritability, aggression, or hostility
Depression
Anxiety
Abrupt mood swings
Lethargy
Fatigue
Insomnia
Clouded mind
Difficulty focusing
Loss of libido
Body aches and pain

Other symptoms reported by UCLA’s Semel Institute for Neuroscience & Human Behavior include:

Obsessive-compulsive behaviors
Difficulty maintaining social relationships
Craving originally abused substances
Apathy or pessimism
Disturbances in sleep patterns
Increased sensitivity to stress

Studies suggest that PAWS symptoms may intensify when triggered by stress, but they can also surface without any clear reason.

What Causes PAWS?

When a substance is used repeatedly, the body becomes dependent on it, resulting in acute withdrawal symptoms. This explains the withdrawal symptoms that occur after the initial absence. It doesn’t explain what causes symptoms to appear after someone has been sober a long time and after the body has already gone through a severe withdrawal.

According to the Semel Institute for Neuroscience & Human Behavior, “the precise mechanism behind PAWS is still being investigated.” Still, over the years, scientists have come to believe that “the physical changes to the brain that occur during substance abuse and are responsible for increased tolerance to the substance are responsible for the recurring symptoms.” The brain adapts and changes available levels of necessary neurotransmitters after years of consuming addictive substances. As a result, the body has trouble adjusting to abstinence. Another hypothesis is that “the brain’s capacity to deal with stress is reduced with prolonged substance abuse and related withdrawal experiences.” Sadly, infants born to mothers who have substance use disorders, whether in recovery or not, are at risk of developing PAWS.

How Long Does PAWS Last?

While acute withdrawal symptoms wane after the initial detox, “PAWS is unique as compared to other withdrawal issues because of how extensive it is; PAWS can last from six months up to two years after the person stops using the substance.” There is no definite timeline for PAWS, as it varies from user to user, substance to substance, duration of use, and overall wellness of an individual.

It is important to keep in mind that although PAWS introduces another obstacle to recovery from addictive substances, it is something that you can get through and will be worth any adverse experience. At Boardwalk Recovery Center, we give our clients lifelong support through foundational skills and healthy relationships. Our clients will be mentally and emotionally prepared to deal with any PAWS symptoms that arise during their recovery journey.

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