The Risks of Post-Acute Withdrawal Syndrome (PAWS)

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It takes tremendous courage to decide to stop using drugs or alcohol and begin the path toward recovery. However, the challenges of withdrawal don’t always end after the initial phase of stopping. Post-acute withdrawal Syndrome, also known as protracted withdrawal syndrome, can present a unique set of lingering challenges, ranging from mood swings to cravings, that can pose significant obstacles to continuing and maintaining your recovery.

Understanding the risks of PAWS is essential for developing effective strategies and seeking the ongoing support necessary for a resilient and successful recovery from substance abuse. In today’s blog, we’ll explore the facts of PAWS, illuminating its complexities and offering insights into strategies for overcoming these challenges in your recovery journey.

What is PAWS?

Post-Acute Withdrawal Syndrome, or PAWS, refers to a set of persistent symptoms that may occur after the immediate phase of withdrawal from certain substances, such as alcohol, opioids, or benzodiazepines.[1] While acute withdrawal symptoms typically occur shortly after discontinuing drug use and are more intense but short-lived, PAWS can last for an extended period, ranging from weeks to months (or even years).

These lingering symptoms often include mood swings, anxiety, and sleep disturbances, highlighting the importance of tailored treatment plans and ongoing support to promote sustained recovery.

How Does PAWS differ from acute withdrawal symptoms?

Both PAWS and acute withdrawal represent distinct phases in the process of recovering from substance dependence, and they differ in terms of timing, duration, and the nature of their symptoms:[2]

Timing

  • Acute withdrawal: The acute withdrawal stage occurs shortly after the cessation of drug use. Symptoms are often intense, immediate, and can begin within hours to a few days after the last use.
  • PAWS: PAWS typically follows the acute withdrawal phase and can begin days, weeks, or even months after stopping substance use. It represents a more protracted, prolonged period of adjustment.

 Duration

  • Acute withdrawal: Symptoms during acute withdrawal are generally more intense but shorter-lived, lasting for a few days to a couple of weeks. These symptoms often involve the body’s immediate response to the absence of the substance.
  • PAWS: PAWS symptoms can persist for an extended period, ranging from weeks to months. In some cases, PAWS can last for years, depending on factors such as the type of substance used, duration of usage, and individual differences.

 Nature of symptoms

  • Acute withdrawal: Symptoms during this phase are often more severe and include physical symptoms such as nausea, vomiting, sweating, tremors, anxiety, and irritability.
  • PAWS: Symptoms during PAWS can be more subtle than those seen in acute withdrawal, but can be persistent. They often include mood swings, cognitive difficulties, sleep disturbances, and cravings. While the acute withdrawal phase is characterized by the body’s immediate reaction to the absence of the substance, PAWS is more about the brain and body gradually adjusting to life without the substance.

 Intensity

  • Acute withdrawal: Symptoms are typically more severe and may require medical attention and/or supervised withdrawal management in some cases.
  • PAWS: Post acute withdrawal symptoms are generally less severe than those experienced during acute withdrawal but can still be challenging for individuals in their recovery process.

It’s important to note that not everyone who undergoes withdrawal will experience PAWS, and the specific symptoms they do experience can vary widely among individuals.

When Does PAWS Begin?

The onset of Post-Acute Withdrawal Syndrome can vary depending on several factors, including the type of substance used, the duration and intensity of use, individual differences, and the specific circumstances of withdrawal.[3] As noted above, PAWS typically follows the acute withdrawal phase, which is the initial period of more intense and immediate symptoms that occur shortly after discontinuing drug use.

For some substances, PAWS may begin shortly after the acute withdrawal phase, while for others, it might take some time for symptoms to emerge. In general, PAWS can start within a few days to a few weeks after the cessation of drug use. The duration of PAWS symptoms can also vary widely, lasting for weeks, months, or even longer.

What Does PAWS Look Like For Specific Substances?

While PAWS symptoms can vary widely, many substances can display common withdrawal patterns:

Alcohol:[4]

  • Anxiety
  • Depression
  • Irritability
  • Fatigue
  • Sleep disturbances
  • Poor concentration
  • Mood swings

 Opioids (e.g., heroin, prescription painkillers):[5]

  • Anxiety
  • Depression
  • Fatigue
  • Insomnia
  • Mood swings
  • Cravings
  • Difficulty experiencing pleasure (anhedonia)

 Benzodiazepines (e.g., Xanax, Valium):[6]

  • Anxiety and panic attacks
  • Insomnia
  • Irritability
  • Poor concentration
  • Memory problems
  • Mood swings
  • Sensory hypersensitivity

 Stimulants (e.g., cocaine, amphetamines):[5]

  • Fatigue
  • Depression
  • Increased appetite
  • Disturbed sleep patterns
  • Difficulty concentrating
  • Cravings

 Cannabis:[5]

  • Insomnia
  • Anxiety
  • Irritability
  • Mood swings
  • Poor concentration
  • Cravings
  • Decreased appetite

If you or a loved one are experiencing persistent withdrawal symptoms then it’s recommended to seek professional help. Medical and psychological support can be beneficial in managing withdrawal and promoting long-term recovery.

What Are the Dangers of Relapse Regarding PAWS?

The dangers associated with PAWS and potential relapse can be significant, as individuals navigating the challenges of recovery may face several obstacles that could jeopardize their sobriety and ongoing recovery:

  • Increased vulnerability to relapse: PAWS can bring about persistent symptoms (such as anxiety, depression, and mood swings), making individuals more susceptible to the temptation of returning to substance use.
  • Impaired cognitive functioning: PAWS symptoms often include cognitive difficulties such as poor concentration and memory problems. These cognitive impairments can affect decision-making and coping mechanisms, making it harder for individuals to resist triggers and cravings that could contribute to relapse.
  • Higher levels of emotional distress: The emotional toll of PAWS, coupled with the challenges of adjusting to a sober lifestyle, can create intense emotional distress. Feelings of frustration, hopelessness, and anhedonia may drive individuals to seek solace in substances they once used to cope.
  • A loss of social support: Over time, the chronic nature of PAWS can strain relationships and support systems. If friends or family members don’t understand or recognize the ongoing struggles, individuals may feel more isolated, increasing their risk of relapse.
  • Underestimating the duration of recovery: Some individuals may underestimate the duration of PAWS and recovery, expecting their symptoms to resolve more quickly. When symptoms persist longer than anticipated, frustration and impatience may set in, potentially leading to a sense of defeat and an increased risk of relapse.
  • Co-occurring mental health conditions: PAWS can exacerbate or unmask underlying mental health conditions. If individuals are not receiving proper treatment for co-occurring disorders, such as depression or anxiety, the unaddressed mental health issues may contribute to relapse.
  • Disruption of daily functioning and activities: The cognitive and emotional challenges associated with PAWS can get in the way of your daily functioning, impacting work, relationships, and overall quality of life. This disruption can create stressors that, if not managed effectively, may increase the risk of turning to substances for relief.

Individuals in recovery need to be aware of the potential dangers of PAWS and take proactive steps to mitigate these risks. Regular engagement with a treatment team can help address emerging issues and prevent the escalation of difficulties that may lead to relapse and further potential consequences.

What Are My Treatment Options?

Post-Acute Withdrawal Syndrome can be extremely difficult to manage on your own. Fortunately, there are effective treatment options available to provide you with support and guidance:

Supervised Withdrawal Management

In a supervised medical setting, individuals can undergo detoxification to safely manage and alleviate any remaining acute and physical withdrawal symptoms. Medical professionals may administer medications to ease discomfort and monitor vital signs during this process, ensuring your comfort and your safety.

Mental health counseling

  • Individual counseling: One-on-one counseling sessions with a mental health professional can address specific challenges and provide personalized coping strategies, often as part of a holistic and comprehensive treatment plan.
  • Cognitive-Behavioral Therapy (CBT): CBT helps individuals identify and modify unhealthy thought patterns and behaviors, providing valuable tools for managing cravings and emotional distress.
  • Group therapy: Knowing that you’re going through things alone can be powerful, and group therapy helps to connect individuals who are struggling.

 Medication Management

  • Medications for cravings and mood stabilization: Depending on the substance of abuse, certain medications may be prescribed to help manage cravings and stabilize mood during the post-acute phase.
  • Medications for co-occurring disorders: If there are co-occurring mental health conditions present, medications may be prescribed to help address these issues and alleviate symptomatology.

 Support groups

  • Participating in support groups, such as 12-step programs (e.g., Alcoholics Anonymous, Narcotics Anonymous) can provide a further sense of community, shared experiences, and a platform for discussing your challenges and successes.
  • Psychoeducational groups: These groups focus on providing education about addiction, recovery, and relapse prevention strategies.

 The Importance of Aftercare Programs

After completing the initial stage of treatment, ongoing and comprehensive care is paramount for individuals on the path to recovery. Aftercare planning plays a crucial role in providing continued support and maintaining progress. This involves regular monitoring and follow-up with healthcare professionals and treatment providers to address emerging issues and ensure a dynamic and adaptable treatment plan that caters to individual needs and progress.

Outpatient Programs

Extended outpatient treatment programs offer a bridge between intensive treatment and independent living. Partial Hospitalization (PHP) and Intesive Outpatient (IOP) programs provide ongoing therapy, counseling, and support, enabling individuals to maintain valuable connections with treatment professionals while gradually reintegrating into their daily lives.

Community and Peer Support

Community and peer support are integral components of sustained recovery. Building a sober support network by connecting with individuals who comprehend the challenges of recovery is crucial for ongoing encouragement. Peer mentoring programs or mentor relationships can provide guidance and inspiration, drawing from the experiences of those who have successfully navigated similar challenges.

Learning More About Recovery

Education and awareness also play vital roles in long-term recovery. Understanding Post-Acute Withdrawal Syndrome (PAWS) is particularly important, as education about its symptoms helps individuals anticipate and cope with persistent withdrawal challenges. This knowledge reduces the risk of frustration and relapse, empowering individuals to navigate the complexities of PAWS with resilience and a proactive mindset.

Ready To Start Healing?

Clear is dedicated to providing personalized treatment plans, ongoing support, and the resources you need for a successful recovery. Your well-being is our top priority, and we’re here to help you reclaim control and build a foundation for lasting positive change. Call Clear Behavioral Health today to learn more about our inpatient substance abuse treatment programs and our outpatient programs for co-occurring disorders to start planning your path to recovery. Our compassionate and experienced team is ready to guide you through the journey of overcoming addiction.

 References:

  1. Grover, C., Sturgill, D., & Goldman, L. (2022). Post–acute Withdrawal Syndrome. Journal of Addiction Medicine, Publish Ahead of Print. https://doi.org/10.1097/adm.0000000000001047 on December 16th, 2023
  2. Bahji, A., Crockford, D., & El-Guebaly, N. (2022). Management of Post-Acute Alcohol Withdrawal: A Mixed-Studies Scoping Review. Journal of Studies on Alcohol and Drugs, 83(4), 470–479. https://doi.org/10.15288/jsad.2022.83.470 on December 17th, 2023
  3. Coping with post acute withdrawal syndrome. (2022, March 16). Www.medicalnewstoday.com. https://www.medicalnewstoday.com/articles/post-acute-withdrawal-syndrome on December 18, 2023
  4. Post-Acute Withdrawal Syndrome from Alcohol Ask your mental health clinician to learn more about post-acute withdrawal syndrome. RESOURCES Veteran’s Crisis Line VA Resources Rehabilitation resources for Veterans americanaddictioncenters.org/ rehab-guide/veterans-resources GC97277. (n.d.). https://www.mirecc.va.gov/visn16/docs/post-acute-withdrawal-syndrome-veteran-guide.pdf on December 18, 2023
  5. World Health Organization. (2009). Withdrawal Management. Nih.gov; World Health Organization. https://www.ncbi.nlm.nih.gov/books/NBK310652/ on December 18, 2023
  6. Haskell, B. (2022). Identification and Evidence-Based Treatment of Post–Acute Withdrawal Syndrome. The Journal for Nurse Practitioners, 18(3), 272–275. https://doi.org/10.1016/j.nurpra.2021.12.021 on December 18, 2023

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