For many individuals recovering from a substance use disorder, as well as for their families and loved ones, the process can be long and arduous. For many, finally making the decision to stay away from drugs or alcohol can take years, and is sometimes the most difficult—and important—step towards recovery. However crucial this first step may be, it’s important for individuals and their families to understand what’s ahead, and to be patient and compassionate while seeking recovery.
Everyone knows that overcoming a drug or alcohol addiction is not an easy task, and is more complicated than waking up one morning and deciding to quit. Recovering from an addiction is a long and involved process, requiring near constant and ongoing diligence and understanding from both the individual and the people closest to them.
What Is Acute Withdrawal Syndrome?
Sometime during the initial few days or weeks after stopping use of an addictive substance, acute withdrawal symptoms usually set in. Acute withdrawal syndrome may include a variety of symptoms, including headache, nausea, muscle aches, and increased heart rate. For some, acute withdrawal can cause serious and even life-threatening physical reactions, which is why detox should always be done in a controlled and supervised environment.
In a supervised setting, doctors work with patients to help mitigate their withdrawal symptoms, while people choosing to detox on their own may struggle to manage their withdrawal symptoms and suffer a relapse, or could experience dangerous medical complications. For some, the physical withdrawal symptoms go away after a few days or weeks, depending on the type, quantity, and duration of drug use prior to detox. However, many people experience prolonged emotional and psychological symptoms long after the physical withdrawal symptoms have gone away. This type of prolonged withdrawal is called Post-Acute Withdrawal Syndrome, or PAWS, and can last for months or sometimes years.
What Is PAWS?
Recovering addicts experience acute withdrawal syndrome as their bodies try to adapt to the sudden absence of drugs. Withdrawal symptoms are caused by changes happening in your body as it tries to adjust. The symptoms caused by these physical changes are physical ones, often causing intense bodily discomfort, pain, and complications.
Post-Acute Withdrawal Syndrome (PAWS), on the other hand, is linked to the brain, rather than the body. After the body adjusts to not having drugs, it is the brain’s turn to adapt. As the brain attempts to recalibrate after detox, it undergoes some intense chemical fluctuation. These changes in chemical levels in the brain often lead to a period of psychological or emotional problems, known as PAWS. As the brain attempts to normalize, fluctuating chemical levels can cause individuals to experience a variety of symptoms associated with mood and psychological behavior, such as:
- Depression and sadness
- Aggressive or hostile behavior
- Low energy
- Severe mood swings
- Physical or mental fatigue
- Insomnia or vivid dreams
- Thought fog or trouble remembering
- Inability to focus
- Lack of sex drive
- Chronic pain
These symptoms can vary from person to person. The PAWS symptoms an individual experiences may vary depending on several factors.
- Type of substance used
- Duration and frequency of drug use
- Physical size of the individual
- Overall health
- Pre-existing mental condition
What Substances Cause PAWS?
Most addictive substances can cause PAWS, including alcohol, and prescription and recreational drugs. Research shows PAWS most often occurs among people recovering from addictions to any of the following substances:
Alcohol was one of the first substances discovered to cause PAWS. Suddenly stopping alcohol consumption can be dangerous, as alcohol withdrawal can cause severe tremors, seizures, delirium, and psychosis. When alcohol use is stopped abruptly and without supervision, it can also lead to long-term PAWS.
Many individuals use marijuana to relax, relieve anxiety, and induce sleep. As a result, it is not uncommon to experience insomnia and an inability to relax after stopping use of marijuana. Prolonged insomnia can lead to PAWS.
For many people recovering from an active meth addiction, impulse control can be an issue for months or even years after detox.
Few people abuse antidepressants, because they do not cause a rapid intoxication. However, abruptly stopping use of these drugs can greatly disrupt serotonin and other neurotransmitters in the brain, which could cause the individual to feel intensely depressed for weeks or months.
Antipsychotics bind to the dopamine receptors in the brain. When these drugs are discontinued, they could cause mood swings for months. PAWS symptoms may be more extreme if the antipsychotics are discontinued abruptly, without a taper.
These drugs are usually prescribed to help people manage anxiety and panic disorders. Benzodiazepines are usually only prescribed for short periods at a time because it is very easy for the brain to develop a dependency on these drugs. Acute withdrawal symptoms from benzos will mimic panic attacks they are prescribed to treat, while long-term PAWS symptoms may include insomnia, cravings, and fatigue. These symptoms may last for months.
Opioids, whether prescription versions or illegal recreational versions like heroin, can lead to intense acute withdrawal symptoms. Individuals who experienced the full intensity of physical opioid withdrawal symptoms are more likely to develop PAWS later on. PAWS may be especially strong in individuals who did not taper. PAWS symptoms after opioid use include cravings, cognitive impairment, fatigue, and exhaustion. These symptoms sometimes persist for a very long time after becoming sober.
How Long Does PAWS Last?
Unfortunately, there is no specific PAWS timeline. Just as there are many factors involved in determining who experiences PAWS, what symptoms they have, and how extreme the symptoms are, these same variables also affect how long PAWS will persist. When PAWS first sets in, it often feels like a roller coaster, with moods and feelings changing from minute to minute. Gradually, the time between changes gets longer. Later in the process, there may be weeks between symptoms. However, it’s important to be aware that even as the time between symptoms grows longer, bad episodes may still last for several days at a time.
In most cases, there is no obvious trigger for these episodes, so it can be impossible to predict when a post-acute withdrawal syndrome symptom may set in. For many people, this can be the most frustrating part. They can be having a great few days, feeling happy and healthy, and suddenly become irritable and depressed again for no seeable reason. It’s very important for individuals and families to know about PAWS, because these symptoms can be just as powerful as acute withdrawal symptoms and often cause people to relapse. Having the support and understanding of family and close friends while they experience PAWS is crucial.
How Is PAWS Treated?
The best way to manage and treat post-acute withdrawal syndrome is through continued support from counselors and therapists. Because PAWS encompasses a cluster of emotional and psychological symptoms, medical professionals help their clients by:
- Educating clients and their families about the possible effects of PAWS and what to expect from recovery.
- Encouraging patients during the process.
- Celebrating every accomplished step towards recovery.
- Helping the client find natural ways of promoting sleep.
- Encouraging or prescribing regular physical exercise.
- Encouraging clients to join emotional support groups.
- Providing tools for impulse control.
- Taking self-reported symptoms seriously and assessing potential co-occurring symptoms.
While many individuals have good medical supervision and support during the physical stages of acute withdrawal syndrome, during the post-acute withdrawal syndrome stage, family and friends are often the first—and only—line of support.
Controversy of PAWS
Post-acute withdrawal syndrome is a controversial topic among medical professionals and individuals. Despite the thousands of people experiencing PAWS every year; it is not an official medical diagnosis. The nature of PAWS makes it difficult to define. The symptoms vary greatly between individuals, while many of the symptoms are self-reported by individuals experiencing them. Without a medical definition, PAWS cannot be officially recognized by the medical community, even though many medical professionals know PAWS to be a real and potentially dangerous part of the recovery process.
Another reason why PAWS sparks so much controversy is because there is no clear consensus about what the syndrome is or what to do about it. Some people believe PAWS symptoms are just an excuse to relapse. Others believe it was invented by doctors within the medical industry to make more money off of prolonged treatment. Some medical practitioners argue that it is just another form of acute withdrawal.
How Can Families Help During PAWS?
As a family member, it’s important to be informed about the recovery process and to know what to expect during the PAWS stage. After seeing your loved one through detox and acute withdrawal symptoms, it’s difficult not to feel like the challenges have all been faced already, or to expect your loved one to be completely recovered after detox.
Learning about PAWS will enable you to be more supportive, understanding, and helpful to your loved one rather than reacting to their PAWS-induced behavior with suspicion, fear, or anger. Behavior caused by PAWS can sometimes look like a person’s behavior while using drugs or alcohol—inability to sleep, irritability, or mood swings—and often arouse suspicion in family members, who may think their loved one has had a relapse. Accepting these symptoms as a normal part of the process can greatly reduce your own stress and anxiety, and help you be a more effective support for your loved one.
How Families Can Survive PAWS
The most important thing to remember is to be patient. Recovery is a long, slow, and difficult process for all involved. The best thing you can do is to trust the process and take it one day at a time. Never try to hurry recovery.
Don’t Resent PAWS
It can be hard not to resent PAWS, especially when it causes your loved one to behave in ways you can’t understand. But if you react with frustration or resentment, both you and your loved one will start to feel exhausted, and the relationship strained.
Take Time for Yourself
While you may be tempted to devote all your time, efforts, and energy to supporting your loved one through their recovery, it’s important to take time for self-care so that you do not get burnt out. If you wear yourself down too far, you will no longer be able to provide the care and support your loved one needs. Part of this is learning to relax. Try to avoid dwelling incessantly on your loved one’s problems, and instead remind yourself often that what you are doing is enough.
Developing a consistent meditation practice can help you gain control over your thoughts and emotions and act more rationally in stressful situations. Sit comfortably with your eyes closed and begin to gently clear and empty your mind of all thoughts and distractions. It’s important—especially at first—that you don’t get frustrated when you feel your mind start to wander. This is a natural part of the process! When you notice your mind chasing after a certain thought or feeling, or getting swept up by distractions, gently call it back and resume your focus. You can start with five minutes a day, and gradually increase your time. Practicing meditation regularly for just a few minutes is more beneficial than attempting to sit in meditation for long periods, sporadically.
Get Regular Exercise
Getting regular exercise, whether it’s going for walks, taking a yoga class, doing some cycling—or whatever it is you enjoy—exercising for at least thirty minutes a day is another great way to gain mental clarity, sort through and control the thoughts, and manage stress.
Free Recovery Resources
It can be difficult to navigate PAWS, especially because it is impossible to predict exactly what symptoms will occur. Having strong family support can make the process more bearable, while seeking the help of counselors and therapists can help mitigate the symptoms and help reduce the chances of relapse.
ECHO Foundation provides support, tools, and resources for individuals seeking recovery, as well as information and answers for the families of people with mental health and substance use disorders. Visit our Free Treatment page for a list of resources you can use to find free and low-cost behavioral health services. There are also many resources available in the Harford County, Maryland community for those seeking addiction treatment and recovery support locally.
Experienced Chief Executive Addiction Recovery and Mental Health Professional
Business professional in the Addiction Recovery and Mental Health industry for the past 26 years. Caring, compassionate and strongly motivated to make a difference in the organizations I am affiliated with and welfare of the population we serve. Currently focused on advocating, educating and developing projects leveraging evidence based, real time technology to support individuals in recovery.