Post-Acute Withdrawal Syndrome: What You Need to Know to Avoid Relapse

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Popsicle Sticks | Post-Acute Withdrawal Syndrome | The Hills

Post-Acute Withdrawal Syndrome may strike fear into the hearts of the recovering, but what is it, exactly? Is it really as bad as folks say? In this post, we’ll explore the dreaded PAWS at great length. Along the way, you’ll learn to differentiate between acute withdrawal and PAWS, and you’ll learn how PAWS manifests with specific drugs. You’ll also learn the leading theories on why PAWS occurs in the first place, why the condition is considered controversial by some and how it’s treated.

Read on.

Understanding Withdrawal

When you first quit taking an addictive drug or substance, you may experience acute withdrawal symptoms. This differs from  Post-Acute Withdrawal Syndrome, which we’ll cover shortly. Acute withdrawal symptoms may vary in severity from individual to individual. However, a given drug tends to produce predictable withdrawal symptoms. Both prescription and illicit drugs can cause withdrawal.

Acute withdrawal lasts anywhere from a few days to a few weeks.

Withdrawal syndrome is triggered by abruptly removing a substance from the body that the body has grown chemically dependent upon. You may have stopped taking the substance altogether, or perhaps you scaled your dose back significantly. In either case, withdrawal is the brain’s reaction to the change.

What’s Happening in the Brain?

When a drug is abused, the brain attempts to adapt by developing tolerance. The brain tries to become resistant to the drug’s effects which results in you having to take more of the drug to get the same high. If you persist through this phase, chemical dependency is often the next step. The brain comes to rely on the drug for release of certain neurotransmitters, such as dopamine.

At the same time, frequent use of the drug is either over-stimulating or depressing certain physiological brain functions—depending on the drug. For instance, cocaine is a potent stimulant, but diazepam—Benzodiazepine Medication— is a central nervous system depressant.

So, when you abruptly stop taking the drug, two things happen:

  • The brain reacts to lack of the compound, on which it has become dependent for release of certain neurotransmitters
  • But other brain and central nervous system functioning returns to normal

The two combined can make for some uncomfortable times ahead.

For instance, in addition to experiencing intense cravings, a recovering cocaine addict may feel lethargic, groggy or even exhausted. Someone recovering from Benzodiazepine Medication addiction, meanwhile, may experience tremors, anxiety and various neurological symptoms.

In either case, the body, now free of the drug’s effects, is trying to find equilibrium. This process can feel like overcompensation. In other words, you may feel as if you’re suddenly taking a drug that does the opposite of what the original drug did. Fortunately, this process is temporary.

The onset of withdrawal symptoms depends on the half-life of the drug. But generally, you can expect symptoms to begin between 4 and 72 hours of your last dose.

What Can I Do?

If you’re intending to go cold turkey, your best bet is to go through detox under medical supervision in an accredited rehabilitation facility. A doctor will work with you to manage your withdrawal symptoms.

You should never attempt to detox from a drug on your own.

Success is unlikely, and the process itself can be dangerous. Even detoxing from alcohol on your own is a risky proposition. In the case of alcohol, acute withdrawal symptoms appear within 6 to 12 hours after your last drink, and can include:

  • Sweating
  • Anxiety
  • Tremors
  • Vomiting
  • Headache
  • Insomnia
  • Mood swings

However, if you persist through these initial withdrawal symptoms, you can experience a host of more serious symptoms, including hallucinations, seizures—delirium tremens—and even heart failure. Though death is rare, you don’t know how your body will react to detox until you’re there. It’s always best to detox in a medically supervised environment.

Sadly, many people veer away from inpatient detox, either out of concerns over cost, fear of the process or a lack of information.

What is Post-Acute Withdrawal Syndrome?

Post-Acute Withdrawal Syndrome—or PAWS—refers to a cluster of symptoms that can occur after acute withdrawal has resolved. Some describe Post-Acute Withdrawal Syndrome as a roller-coaster that can strike at any time. An episode of PAWS can last several days, and episodes can occur on and off for a year or more. Post-Acute Withdrawal Syndrome is most strongly associated with the following drugs:

  • PAWS was first observed and officially described in individuals recovering from alcohol dependence in the 1990s.
  • Antidepressants change brain chemistry. Stopping them suddenly can change levels of serotonin and other neurotransmitters. This can lead to the overcompensation effect mentioned earlier, which can make any existing depression feel much worse. PAWS can last several months.
  • Anti-psychotics. These drugs seek to reduce hallucinations and relieve symptoms of psychosis by binding to dopamine receptors. If the individual stops taking them without tapering down, they may experience lingering post-acute withdrawal syndrome.
  • These drugs can help with anxiety, but the brain can easily become dependent on them. People recovering from benzodiazepine addiction may struggle with PAWS, especially when stressors and other triggers cause anxiety to resurface.
  • Many marijuana users become dependent on the drug to reach a state of relaxation. When they stop taking the drug, they may feel stressed, agitated, depressed or even paranoid. Insomnia is also common. These symptoms can easily morph from acute withdrawal into PAWS.
  • Use of any opioids, whether prescription or illicit, can quite easily lead to PAWS. Proper cessation requires a tapering off period, during which the body can adjust to the lower dose. Street opioids, like heroin, are particularly likely to cause PAWS. Opioid-related PAWS symptoms include irritability, intense cravings, exhaustion and cognitive impairment.
  • With meth, Post-Acute Withdrawal Syndrome can manifest as issues with executive control. This leads to Impulsivity and cognitive impairment. In the case of meth in particular, PAWS can be a long term condition.
  • Various stimulants, such as cocaine and Ritalin, can cause PAWS if initial withdrawal symptoms are not treated properly. For cocaine users, impulse control may be a symptom of PAWS.

Note that PAWS symptoms typically emerge after acute withdrawal symptoms fade. You may not experience PAWS at all, but it’s good to be aware of the possibility. Unfortunately, many people put their guard down when initial withdrawal resolve. This means, of course, that when PAWS hits, they’re unprepared. For many, this leads to relapse as they seek relief.

As noted, PAWS symptoms can vary from person to person and from drug to drug. However, the following symptoms are common:

  • Anxiety
  • Depression
  • Hostility
  • Irritability
  • Mood swings
  • Lack of libido
  • Insomnia
  • Cognitive impairment, trouble focusing
  • Lack of energy
  • Chronic pain


Unfortunately, there is no set duration for PAWS. Duration varies from individual to individual and may partially depend on the severity of the addiction and how long the person abused the drug. It’s also partially dependent  the overall health of the affected person.

The bottom line: some people may experience mild withdrawal effects that last days or a few weeks at most. Others may experience PAWS that lasts years.


PAWS is a very complex syndrome, and no medical professional can tell you precisely how long your symptoms will last. Experts aren’t sure why some people experience only minor withdrawal symptoms while others struggle with PAWS for years, and research into the matter is ongoing.

One area of consensus seems to be that addictive drugs permanently change brain function. Meth, in particular, is known to make persistent changes to brain structure. Once this occurs, on-going PAWS symptoms are likely as the cessation of drug abuse does not restore normal brain function.

However, psychologists and doctors don’t agree unanimously on the causes of Post-Acute Withdrawal Syndrome. For instance, some experts contend that PAWS symptoms are mainly due to stress responses that occur when someone stops abusing a drug. There are several theories, though. Let’s look at them one by one.

Homeostatic Adjustment

This theory states that drugs of abuse cause brain chemistry changes. Some drugs, like cocaine and marijuana, cause massive dopamine release in the brain. This massive neurotransmitter release is unusual, and the brain resists by developing tolerance. But if the individual persists, the brain seems to accept the new input. The result, of course, is that when the person stops taking the drug, the brain can no longer release dopamine, endorphins and other feel-good chemicals on its own. In other words, it can no longer reach equilibrium without the aid of an outside substance. Returning to normal brain function takes time.

In this model, PAWS is the result of the brain trying to reach homeostasis. The result can be temporary mood swings, exhaustion, cravings other psychological side effects.

Physiological Adaptations

This model stipulates that it’s not just the brain that’s causing PAWS. Other areas of the body, such as those involved in digestion or the production of certain hormones, may have a role to play too. Proponents of this model point to opioid withdrawal in particular as many of the symptoms are physical in nature. Folks struggling with opioid-related PAWS often complain of nausea, sweating, cramps and diarrhea. Central nervous symptom depressants are also known to cause physical withdrawal symptoms.

Changes in Habit

Yet another explanation for PAWS is that as addicts change their habits, they experience psychological trauma. For instance, many heroin addicts think fondly back to cooking and injecting their drug of choice. It’s not that the act of cooking and shooting up itself was pleasurable. It’s simply that they associate the ritual with the intense high that followed.

Once they stop using, though, they don’t have any reason to undergo their ritual of cooking the drug and shooting up. But they still have to cook. They probably still use spoons in their day to day life, too. They may have occasion to use a needle. These triggers can cause psychological distress that can manifest as depression, anxiety, cravings or exhaustion.

A frequent marijuana user may come to associate overeating with their marijuana use. Then, when they quit, they may find themselves indulging in snacks for a completely unrelated reason. Still, the simple act of eating can act as a trigger, which can lead to cravings. The cravings can trigger happy memories of marijuana use. This in turn can lead to anxiety, mild depression, etc.


Under this model, PAWS is thought of as a side effect of stress induced by cravings. When a person goes cold turkey, they must manage these cravings on their own. The longer they ignore the cravings, the worse their PAWS symptoms will be. This model is somewhat older than the others and does not take into account the complex interplay of neurotransmitters involved in addiction.


While many people experience Post-Acute Withdrawal Syndrome, it’s not an official medical diagnosis. While there is some research on PAWS, it’s mostly a self-reported phenomenon. This means that PAWS symptoms are hard to measure and quantify. This, in turn, makes it hard to treat.

Because the condition has no official definition, it remains controversial. Some medical experts consider PAWS to be an excuse used by people when they relapse. Still others consider it a valid medical condition but caution that any treatment plan would need to be tailored to the individual, and that is best done under medical supervision.

The bottom line: some addiction experts consider withdrawal and PAWS to be the same thing, where PAWS merely represents the temporary return of withdrawal symptoms. These experts believe that the definition of withdrawal should be expanded to include Post-Acute Withdrawal Syndrome, cautioning that withdrawal can last months or years, not just weeks.

Post-Acute Withdrawal Syndrome—Treatment

In Therapy | Post-Acute Withdrawal Syndrome | The HillsHowever, with personalized care and long-term support, individuals struggling with PAWS can learn to manage the condition. Apart from a few cases, such as depressants and certain opioids, PAWS symptoms are largely emotional and psychological. If you suspect you’re struggling with PAWS, ongoing support from a therapist or addiction counselor may be a good idea.

A counselor or psychologist can:

  • Educate you about the realities of withdrawal, which can help you mentally prepare
  • Shift focus away from PAWS symptoms by helping you celebrate your sobriety and to take pride in your accomplishments
  • Encourage patience
  • Help you find natural ways to alleviate sleep problems or anxiety
  • Help you make exercise and diet changes that can positively impact sleep, mood and disposition
  • Help identify potential co-occurring disorders which may be hindering your recovery process
  • Help you learn to manage impulse control issues
  • Identify cravings in real time and practice mindfulness
  • Help you identify triggers

Regularly scheduled therapy or counseling sessions can be a real boon in managing withdrawal symptoms. Your counselor can help you learn powerful therapy modalities such as cognitive behavioral therapy. With CBT, you can learn to identify and become aware of powerful triggers that can lead to cravings. If you can anticipate these triggers, they may have less impact on you. Over time, CBT can help you gain powerful insights into your emotional state, which can help you prevent relapse.

In addition, your doctor can prescribe medications to help with withdrawal symptoms. For instance, naltrexone is available to help with opioid and alcohol withdrawal. Short-term use of antidepressants may be appropriate to stabilize mood, but only a mental health diagnosis can make that determination.

The bottom line: don’t go it alone, and don’t underestimate the potential severity of withdrawal symptoms. If you think your PAWS symptoms may lead to relapse, get help now.

If you’ve already slipped a time or two due to PAWS symptoms, consider inpatient rehab. It’s better to get help now than to let the situation worsen. If you’ve slipped once recently, you’re likely to slip again. A slip can turn into full blown relapse very easily. In rehab, you’ll detox from the drug in a safe, medically supervised environment, and then you can work with a counselor to gain insights into your emotional state that may have led to the relapse in the first place.

If you’re trying to get addiction treatment for yourself or for someone you love when it comes to dealing with PAWS, reach out to The Hills for comprehensive and caring treatment that will help patients detox and learn the skills to cope with their triggers.


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