Post-Acute Withdrawal Syndrome (PAWS) – What it is, Symptoms & Treatment

When people repeatedly use drugs or alcohol, they may become dependent upon these substances and develop an addiction to them. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, one of the criteria for an addiction is the experience of withdrawal, which involves uncomfortable symptoms that occur when a person abruptly stops using drugs or alcohol.

When most people think of drug and alcohol withdrawal, they probably imagine the unpleasant side effects that occur right after a person stops using drugs or drinking. While this is one form of withdrawal, there is a second presentation, called post-acute withdrawal syndrome, which lasts longer.

What is Acute Withdrawal?

Acute withdrawal involves the initial withdrawal side effects that begin rather quickly after a person stops using drugs or alcohol, and pass after a few days. The symptoms of acute withdrawal will vary depending upon the substance a person was using.

For example, as the World Health Organization has reported, withdrawal from opiates like heroin begins 8 to 24 hours after a person stops using and involves the following side effects:

  • Anxiety
  • Sleep problems
  • Hot flashes
  • Gastrointestinal symptoms like nausea and vomiting
  • Sweating
  • Cramping
  • Watery eyes
  • Runny Nose
  • Diarrhea

On the other hand, acute alcohol withdrawal symptoms can begin as early as six hours after a person stops drinking. More severe symptoms appear two to three days after the last drink. Initial alcohol withdrawal symptoms include nausea, vomiting, diarrhea, hand tremor, sleep disturbances, sweating, anxiety, and high blood pressure or heart rate. These acute withdrawal symptoms can progress to more severe complications, such as hallucinations, seizures, and a fatal condition called delirium tremens, in which a person becomes disoriented and has a variety of life-threatening physical symptoms.

Other forms of acute withdrawal may occur with benzodiazepines and stimulant drugs. When a person withdraws from benzodiazepines, which are typically used to treat anxiety and sleep problems, he or she will experience muscle pain, anxiety, sleep problems, irritable behavior, agitation, and concentration problems beginning a day or two after the last dose of drugs. Stimulant withdrawal tends to begin a day after a person stops using drugs like methamphetamine or cocaine, and it lasts for three to five days, per the World Health Organization. Stimulant withdrawal can involve symptoms like muscle pain, increased sleeping and eating, agitation, and depression. In some cases, people may become paranoid during acute stimulant withdrawal.

Post-Acute Withdrawal

As its name might suggest, post-acute withdrawal begins after acute withdrawal symptoms pass. According to the Semel Institute for Neuroscience and Human Behavior, some people may refer to this condition as prolonged withdrawal syndrome or protracted withdrawal syndrome. Symptoms appear similar to what might be seen with mood disorders like depression and anxiety, and they can last for weeks or even months after a person stops using drugs or alcohol.

People who are undergoing post-acute withdrawal syndrome may experience the following symptoms:

  • Depression
  • Anxiety
  • Difficulty with learning new things
  • Memory problems
  • Anxious mood
  • Panic
  • Drug cravings
  • Trouble coping with stress
  • Sleep problems
  • Negative mood
  • Obsessive behaviors
  • Relationship problems

These post-acute withdrawal symptoms can occur with any type of drug, but as the Semel Institute has explained, they are most common when withdrawing from alcohol, opiates, or benzodiazepines. In fact, 90 percent of people who stop using opiates will experience post-acute withdrawal, and 75 percent of those who give up alcohol or psychiatric drugs like benzodiazepines will undergo protracted withdrawal.

Specific Post-Acute Withdrawal Symptoms

While patients suffering from post-acute withdrawal tend to experience the general symptoms described above, there are some variations in protracted withdrawal symptoms depending on a person’s drug of choice. For example, as the World Health Organization has explained, when a person withdraws from opiates like heroin, post-acute withdrawal may persist for six months and involve severe cravings, relapse, and feelings of low well-being.

When a person stops using benzodiazepines, it is not unusual for psychological symptoms like anxiety or sleep disturbances, which benzodiazepines treat, to return. On the other hand, post-acute withdrawal syndrome involving stimulants can last for a month or two after a person stops using drugs, and symptoms include lethargy, mood swings, anxiety, irregular sleep schedules, and stimulant cravings.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), post-acute withdrawal syndrome after alcohol abuse includes the following symptoms:

  • Anxiety
  • Hostile behavior
  • Irritability
  • Depressed mood
  • Unstable emotions
  • Reduced sex drive
  • Pain
  • Concentration problems
  • Difficulty thinking
  • Fatigue
  • Sleep problems

Unfortunately, prolonged alcohol withdrawal can be persistent, as SAMHSA reports that symptoms can last for about two years, with sleep studies showing that patients may suffer from sleep disturbances for one to three years after giving up alcohol.

Treatment of Post-Acute Withdrawal Syndrome

Doctors and addiction professionals may treat acute withdrawal symptoms in a hospital or inpatient setting, by providing medications that alleviate withdrawal side effects and then slowly tapering medications as a patient detoxes. Medical staff may also monitor patients for complications and ensure that they receive proper nutrition.

Following treatment of acute withdrawal, ongoing care is necessary to treat post-acute withdrawal symptoms. According to SAMHSA, it is helpful for patients to understand that post-acute withdrawal is normal, and that they need to be patient and continue to aim for abstinence from drugs and/or alcohol.

One common treatment for post-acute withdrawal syndrome includes attending support groups. For example, patients may benefit from attending Alcoholics Anonymous (AA) meetings, where they can share their experiences with others who are undergoing the same challenges. Therapy may also be helpful to allow people to develop coping strategies and learn ways to control impulses. According to SAMHSA, a specific type of treatment called cognitive-behavioral therapy may be useful for helping patients to deal with the lasting effects that drugs have on the brain.

It is also important to lead a healthy lifestyle to help with post-acute withdrawal. This involves prioritizing sleep, following a nutritious diet, and staying physically active. As SAMHSA has explained, exercise can improve mood, reduce stress, and provide a distraction from drug cravings.

Relapse prevention can also be effective for treating post-acute withdrawal syndrome. Relapse prevention programs may involve attending educational groups, or working with an addiction counselor to develop a relapse prevention plan, in which patients identify situations or emotions that may trigger them to use drugs or alcohol and make a plan for what they will do when they encounter a trigger.

Prescription Medications for Post-Acute Withdrawal

SAMHSA reports that some people may take prescription drugs to help them cope with post-acute withdrawal symptoms. For instance, the medication acamprosate can help with protracted alcohol withdrawal, as it can reduce anxiety and sleep disturbances.

Those who are recovering from prolonged opiate withdrawal may take medications like buprenorphine or methadone. According to SAMHSA, these medications are safe for long-term use, ranging from several months to a lifetime. They work by reducing opiate cravings and stabilizing brain chemistry, suggesting that they can help post-acute withdrawal syndrome.

While there are specific medications used for prolonged withdrawal from opiates and alcohol, some people may benefit from taking psychiatric medications, such as antidepressants, during the post-acute withdrawal phase. These medications can help with general protracted withdrawal symptoms like depression, anxiety, and mood swings.

While post-acute withdrawal syndrome can be long-lasting and make it difficult to remain sober, there are steps a person can take to help with this condition. With medication and ongoing psychological care, people can find some relief from symptoms and learn to cope with a lifestyle that is free from drugs or alcohol.

Post-Acute Withdrawal FAQs

In addition to the above information, the following frequently-asked questions (FAQs), can make it easier to understand what to expect from post-acute withdrawal syndrome:

How long does post-acute withdrawal syndrome last?

In general, experts report that post-acute withdrawal syndrome lasts from several weeks to a few months, but the duration may vary based upon the substance. For example, experts have stated that post-acute heroin withdrawal can last for about six months, whereas prolonged stimulant withdrawal passes in a month or two. On the other hand, a person who is recovering from alcohol addiction may experience post-acute withdrawal symptoms for two or more years.

What causes post-acute withdrawal?

According to SAMHSA, ongoing drug and alcohol abuse changes the brain in ways that cause lasting effects on mood and behavior. For example, with ongoing drug use, a person may experience pleasure only when under the influence, which causes a lack of pleasure when a person stops using. This can lead to post-acute withdrawal symptoms like depressed mood and pessimism.

What helps post-acute withdrawal?

Both medication and psychological treatments can help with post-acute withdrawal. For example, doctors may prescribe medications that specifically treat the post-acute withdrawal symptoms associated with alcohol or heroin abstinence. Some people may take antidepressant drugs to help them cope with mood changes. In addition, psychological treatments, such as therapy, support groups, and relapse prevention programs can help people to manage symptoms of prolonged withdrawal and cope without turning to drugs or alcohol.

Is post-acute withdrawal real?

According to SAMHSA, there is clinical evidence that people experience withdrawal symptoms that extend beyond the typical acute withdrawal stage, suggesting that post-acute withdrawal syndrome is a legitimate condition. While symptoms may vary from person-to-person and based upon the type of drug a person was using, SAMHSA reports that common symptoms include anxiety, sleep disturbance, memory problems, cravings, difficulty with concentration, depression, irritable mood, and fatigue.

Post-acute withdrawal can be unpleasant, making it necessary for people to receive ongoing treatment and support after completing a detox program to treat acute withdrawal symptoms. Prolonged withdrawal is a normal part of the addiction treatment process, and support is available to help people cope so they can continue to remain abstinent from drugs and alcohol.

Sources & Resources:

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3767415/
  2. https://www.ncbi.nlm.nih.gov/books/NBK310652/
  3. https://www.semel.ucla.edu/dual-diagnosis-program/News_and_Resources/PAWS
  4. https://store.samhsa.gov/sites/default/files/d7/priv/sma10-4554.pdf
  5. https://www.samhsa.gov/medication-assisted-treatment