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PAWS: Post Acute Withdrawal Syndrome

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Over time, consistent use of alcohol or drugs can lead to the development of an addiction, or substance use disorder. Significant physiological dependence is a common component of addiction. Once you are dependent on a substance, acute withdrawal symptoms are likely to occur if use is stopped abruptly or drastically reduced.1,2

For many types of substances, the acute withdrawal syndrome is a well-known set of symptoms that follow a general timeline and can be expected to resolve in a matter of days or weeks.3 The length of time you experience withdrawal symptoms depends on a variety of factors, including the specific substance(s) used, the severity of the addiction, the average dose used, the frequency of use, and whether detoxing is done cold turkey or in a professional detox program using medication-assisted treatment or tapering.2,3 In some cases, symptoms of withdrawal may persist for a longer period of time than expected, and this is known as protracted withdrawal, or post-acute withdrawal.3,4

What Are PAWS?

For various substances, the post-acute withdrawal syndrome (PAWS) represents a pattern of symptoms that last or re-emerge beyond an established timeframe during which acute withdrawal has already resolved.3,4  Protracted withdrawal includes symptoms such as chronic fatigue, cravings, memory loss, and difficulty with concentration, decision-making, impulse control, and problem-solving.2,3,4 PAWS symptoms may overlap those commonly seen with mood or anxiety disorders, including anxiety, difficulty feeling pleasure, depressed mood, lack of interest in activities, irritability, or sleep cycle disturbances.2,3,4

Post-acute withdrawal symptoms are thought to be caused by changes in the brain as a result of chronic drug or alcohol abuse.3,4 These changes may be in response to alterations in normal levels of neurotransmitter activity. Neurotransmitters are signaling chemicals in the brain that normally help to control things like emotions and behavior. When the neurochemical “support” that chronically abused substances have been supplying is suddenly removed during abstinence, the individual may experience the effects of this new imbalance.4 Once substance use has been stopped or reduced, the brain needs to rebalance or adjust, but this process can take a variable amount of time from person to person. For some substances, this could mean that you’ll experience less of a response to behaviors or situations that normally elicit feelings of pleasure or happiness, such as listening to music, eating food, or spending time with loved ones. In other cases, it could mean that you’ll feel overly excitable or anxious without any discernable cause.3,4 There is a tendency for these symptoms to change in severity, and they can even go away only to return later on.4

Symptoms of PAWS are most common with abstinence from specific substances, such as opioids, alcohol, and benzodiazepines, but can occur after abstinence from other drugs as well.4 The unpredictable nature and long-lasting symptoms of PAWS can reduce your ability to manage stress effectively.4 It can make it more difficult to remain sober, leading some people to relapse in order to escape these distressing symptoms and feel better.3,4 The manifestation of protracted withdrawal symptoms can vary from person to person and are different depending on the substance or substances used.3

Opioids

Studies show that the vast majority (90%) of opioid users in recovery can expect to experience PAWS.4 The most common symptoms include:2,3,4

  • Anhedonia, or inability to feel pleasure.
  • Anxiety.
  • Depression.
  • Difficulty with focusing on tasks.
  • Dysphoria, or a general feeling of unease.
  • Fatigue.
  • Insomnia.

Alcohol

Approximately 75% of recovering alcoholics can expect to experience PAWS.4 Some of the more common symptoms of protracted alcohol withdrawal include:2-5

  • Anxiety.
  • Depression.
  • Fatigue.
  • Insomnia.
  • Mood instability.
  • Reduced interest in sex.
  • Difficulties concentrating and thinking.
  • Increased respiratory rate, pulse, blood pressure, body temperature.
  • Tremor.

Benzodiazepines

For people recovering from benzodiazepine addiction, it can be especially difficult to diagnose PAWS because of the phenomena of symptom rebound and reemergence.3 Rebound is when acute withdrawal symptoms reappear in a more intense fashion.3 Reemergence is when the symptoms benzodiazepines are prescribed to treat—anxiety, sleep difficulties, or muscle tension—return at levels equivalent to pre-treatment.3 PAWS occurs when new symptoms appear related to the withdrawal process, rather than symptom reemergence.3 Common symptoms of protracted withdrawal from benzodiazepines may resemble those of other mental health disorders, including:3,4

  • Agitated depression.
  • Generalized anxiety.
  • Obsessive-compulsive disorder.
  • Panic attacks.
  • Schizophrenia.

Stimulants

PAWS has also been identified for withdrawal from stimulants, including cocaine and methamphetamine.3 Protracted withdrawal symptoms for cocaine can include:3

  • Difficulty regulating emotions, including identifying them, expressing them appropriately, and utilizing coping skills.
  • Impulse control issues.

PAWS symptoms for methamphetamine can cause deficits in executive functioning, including problems with:3

  • Concentration.
  • Focusing on a task.
  • Learning.
  • Memory.
  • Solving problems.

Ongoing Support

Overcoming withdrawal and continuing with recovery can be difficult enough, but the symptoms of PAWS can be an additional stressor that may contribute to relapse, even after a period of sobriety.4 For this reason, it is especially important to continue with counseling and therapy as well as consistently attend support groups in order to learn how to cope with cravings and the distressing symptoms of PAWS.4

Individual therapy provides a forum to discuss issues in private and work on developing and practicing coping skills necessary to prevent relapse. Group therapy can help increase understanding of the experience of protracted withdrawal and normalize the process while providing support from peers who can share their knowledge and how they are dealing with it. Support groups can also provide this type of peer interaction to help you manage the challenge of PAWS while balancing the demands of a life in recovery.

There are various medications that can be prescribed to manage protracted withdrawal symptoms and reduce the impact they have on your recovery.3,4 Substance-specific medications are used, including:

  • Acamprosate (Campral) for alcohol: This medication can be used to manage post-acute withdrawal symptoms, such as anxiety, insomnia, alcohol cravings, and restlessness, and can be used for up to a year.6
  • Suboxone (buprenorphine/naloxone) for opioids: This is often prescribed to ease the symptoms of withdrawal and reduce cravings, helping people maintain sobriety and deal with both acute and post-acute withdrawal symptoms.13 Suboxone can be prescribed as a short taper to get you through the worst of withdrawal or for long-term use to prevent relapse.
  • Methadone for opioids: This is a well-known medication that has been used effectively for many years to manage symptoms of withdrawal and prevent relapse.3,7 Like Suboxone, methadone can be used in a short taper or for as long as needed to maintain sobriety.7

Community support groups meetings can be especially helpful for people in recovery from substance use, especially when experiencing unpredictable symptoms of PAWS.3 There is a wide variety of support groups, including:

  • Alcoholics Anonymous (AA): This was developed in the late 1930s as the first 12-step program based on spiritual principles to help members overcome alcoholism. Membership is free, and meetings are open to anyone who has a problem with alcohol and would like to get sober. Since establishment, AA meetings are held around the world and can be found daily in many areas.8
  • Narcotics Anonymous (NA): NA, which was developed as an offshoot of the AA program, was formed for people with drug addiction.9 NA is also a spiritual, 12-step program found in many areas of the world, hosting meetings for anyone who has an addiction and wants mutual support.9
  • SMART Recovery: This is a group that focuses on the use of evidence-based scientific techniques, such as Cognitive-Behavioral Therapy (CBT), to help members overcome their addictive behaviors involving alcohol, drugs, eating, gambling, etc. Meetings are held in-person, with online forums available as well.10
  • LifeRing: This group is not faith-based but rather it focuses on empowering each member to strengthen their Sober Self and attain abstinence. The concept of powerlessness found in 12-step meetings is absent in this type of support group, which hosts face-to-face meetings and online meetings, as well as offering an online forum for members.11
  • Secular Organizations for Sobriety (SOS): This is another strengths-based group that doesn’t focus on spiritual or religious tenets. Meetings provide an encouraging setting to get and stay abstinent while also reducing the sense of isolation associated with addiction.12

Sources

  1. American Society of Addiction Medicine. (2011). Definition of Addiction.
  2. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  3. Center for Substance Abuse Treatment.  (2010).  Protracted Withdrawal. Substance Abuse Treatment Advisory, 9(1).
  4. UCLA Dual Diagnosis Program. (2016). Post-Acute Withdrawal Syndrome (PAWS).
  5. Trevisan, L.A., Boutros, N., Petrakis, I.L., & Krystal, J.H. (1998). Complications of Alcohol Withdrawal: Pathophysiological Insights. Alcohol Health & Research World, 23(1), 61–66.
  6. Center for Substance Abuse Treatment. (2005). Acamprosate: A New Medication for Alcohol Use Disorders.
  7. Substance Abuse and Mental Health Services Administration. (2015). Medication and Counseling Treatment.
  8. Alcoholics Anonymous. (2017). What is AA?
  9. Narcotics Anonymous. (2016). Information About NA.
  10. SMART Recovery. (2017). Introduction to SMART Recovery.
  11. LifeRing Secular Recovery. (2017). New to LifeRing?
  12.  Secular Organizations for Sobriety. (2016). What We Do.
  13. Food and Drug Administration. (2002). Subutex and Suboxone Approved to Treat Opiate Dependence.

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