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Updated on September 16, 2021

Post Acute Withdrawal Syndrome (PAWS)

What is Post Acute Withdrawal Syndrome (PAWS)?

PAWS stands for post-acute withdrawal syndrome. The days and weeks after someone stops drinking or quits substance abuse, they may experience acute withdrawal symptoms.

Post-acute withdrawal syndrome (PAWS) is a set of impairments that happen immediately after withdrawal from alcohol or other substances. It is the second stage of withdrawal when the brain tries to reach equilibrium, causing brain chemicals to fluctuate until they are stable. PAWS may be caused by the imbalance of neurotransmitters in the brain.

The term PAWS describes the group of ongoing withdrawal symptoms, most of which are mood-related, continuing after physical withdrawal symptoms have stopped.

Common Symptoms of PAWS

PAWS symptoms are extremely uncomfortable and typically affect a person’s mental health and physical health. PAWS can sometimes feel like it comes on suddenly. The feelings of aggression, fatigue, and stress seem to appear abruptly out of thin air.

Post-acute withdrawal symptoms rarely involve aches, pains, nausea, cramping, and other physical symptoms. However, it can be just as intense as physical withdrawal symptoms and still puts the user at risk of relapsing to stop the discomfort. 

Common physical and psychological symptoms of PAWS include:

  • Irritability and hostility
  • Feelings of anxiety or panic
  • Depression
  • Mood swings
  • Low energy and extreme fatigue
  • Sleep disruption, including insomnia
  • Limited ability to focus or think clearly
  • Lack of libido
  • Inexplicable chronic pain
  • Difficulty with cognitive tasks, such as learning, problem-solving, or memory recall
  • Obsessive-compulsive behaviors
  • Difficulty maintaining social relationships
  • Sleep disturbances 
  • Increased sensitivity to stress
  • Lack of impulse control
  • Elevated heart rate 
  • Panic attacks

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Alcohol Detox for Withdrawal and PAWS (Timeline)

Mild withdrawal symptoms, including intense cravings, nausea, vomiting, headaches, anxiety, and insomnia, may start within the first 6 to 24 hours after the person’s last drink. This is when the body starts detoxing.

Within 24 to 48 hours, the second stage of withdrawal starts, and symptoms will typically progress to irregular heartbeat, seizures, confusion, elevated body temperature, and hallucinations. 

48 to 96 hours after the person’s last drink, the most intense symptoms will set in, including severe itchiness, impulsive behaviors, depression, anxiety, disorientation, delirium, and seizures with tremors.

Who Does PAWS Affect?

Symptoms of PAWS most commonly appear in people who have misused or abused the following:

  • Alcohol
  • Antidepressants
  • Antipsychotics 
  • Benzodiazepines 
  • Marijuana 
  • Opioids and opiates
  • Stimulants
  • Xanax 

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Can PAWS Be Dangerous?

Alcohol withdrawal is one of the few withdrawal syndromes that come with potentially deadly side effects.

Withdrawal can make detox a painful experience. PAWS is a significant threat to someone’s recovery because of its severe side effects. Post-acute withdrawal syndrome exacerbates the cravings that addicts going through the recovery process continue to experience, making it extremely difficult for them to productively participate in their counseling sessions.  

One of the most dangerous aspects of post-acute withdrawal syndrome is that some symptoms can come back months or even years after clinical treatments are complete.

These symptoms are the prime cause of relapse for rehab patients, and they can even cause those who have been sober for years to return to drug use. People who experience unexpected, massive cravings are sometimes left feeling powerless to handle them.

How to Manage Symptoms of Post-Acute Withdrawal Syndrome

Here are 10 tips that may help manage the symptoms of PAWS:

  • Seek help from mental health professionals
  • Practice self-care through a healthy diet, exercise, avoiding triggers, and establishing healthy relationships with the people around you
  • Talk about what you're going through with people you trust and who will not judge you based on your circumstances
  • Determine what triggered the flare-up of your PAWS symptoms so you will know what to do next time
  • Document your experiences through a journal
  • Keep yourself busy
  • Set reminders or write things down if you're having difficulty remembering things
  • If you're having a hard time sleeping, cut down on caffeine especially before bedtime
  • Establish a sleep-wake routine
  • Be gentle to yourself and don't rush things
  • Acknowledge that there will be bad days (if you fall, get up and start again)

PAWS: Common Questions and Answers

Here are answers to some of the most common questions asked about PAWS:

How long does post acute withdrawal syndrome last?

Unfortunately, there is no set time frame for how long PAWS will last. Several factors can impact how long PAWS will last, including:

  • The type of substance used
  • How long the substance use persisted
  • The physical health of the person in recovery

Some people may experience minor withdrawal symptoms that can last for days or just a few weeks, while others will continue to experience PAWS symptoms for years.

While PAWS can be severe, an individual with a substance use disorder can control the symptoms with professional oversight and medical intervention at a treatment center. 

Stopping alcohol use cold-turkey or attempting to recover from drug addiction is not recommended. Due to the severity of PAWS symptoms, people often feel as if they have to use to make the symptoms go away. When you are in a treatment center, working with substance use specialists will offer you methods and medication to combat PAWS symptoms.

For the best relapse prevention chances, people should seek treatment at a detox or treatment center.

What is the difference between PAWS and initial withdrawal symptoms?

There are two stages of detox or withdrawal symptoms:

The withdrawal symptoms associated with the first stage of detox, called acute withdrawal, are primarily physical. 

Acute withdrawal can create even more severe health consequences—even life-threatening complications—if detox isn’t completed in a supervised setting. This is especially true for people in the acute withdrawal stage of alcohol, benzodiazepines, and barbiturates, because substances have higher risks of complications without medical supervision, including seizures or coma.  

The second stage of detox, called post-acute withdrawal syndrome (PAWS), happens as the brain re-calibrates after active addiction. Unlike acute withdrawal, which consists of primarily physical withdrawal symptoms, post-acute withdrawal symptoms are mostly psychological and emotional symptoms. Post-acute withdrawal is known to last for several months, depending on the intensity and duration of drug use and alcohol addiction.

What does PAWS feel like?

PAWS is not a pleasant experience. The emotional and mental distress caused by PAWS can be extremely difficult for most people to bear, even for those without a previous history of mental health problems.

PAWS typically comes in unexpected waves. For example, a person in recovery may wake up in the morning feeling tired and extremely irritable for no apparent reason. Others may find themselves suddenly unable to balance and have no coordination. The symptoms can appear and disappear in as short as an hour.

As recovery progresses, the symptoms become more cyclical. They will generally last for several days at a time, disappear for weeks or months, and then come back. As time passes, the symptoms will happen less frequently and fade faster.

Can withdrawal symptoms be permanent?

PAWS symptoms usually start within seven to 14 days after the acute period of withdrawal. These symptoms will typically reach their peak between three to six months after the start of abstinence and may continue for as long as two years after the acute withdrawal period begins.

It’s important to remember that the symptoms are not permanent. They will come and go. As time goes on, you will experience PAWS symptoms less and less, and eventually, the symptoms will disappear completely.

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Post-Acute Withdrawal Syndrome (PAWS).” Semel Institute for Neuroscience and Human Behavior.

Hoffman A.L. (1986). "Relationship Between Severity of Alcohol Dependence and Protracted Alcohol Withdrawal Symptoms." Drugs and Alcohol, Medicolegal Library, vol 6. Springer, Berlin. Heidelberg. 

Heilig, Markus et al. “Acute withdrawal, protracted abstinence and negative affect in alcoholism: are they linked?.” Addiction biology vol. 15,2 (2010): 169-84. doi:10.1111/j.1369-1600.2009.00194.

"Post-Acute Withdrawal Syndrome: The lingering effects of alcohol or drug withdrawal and how you can manage them." University of Texas Health Science Center at Houston.

Swanson, Jeanene. "The Condition Many Recovering Addicts And Alcoholics Don't Know About." HuffPost.

"Post Acute Withdrawal Syndrome: Causes, Symptoms, Treatment." Mental Health Daily.

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