A Guide to Post-Acute Withdrawal Syndrome (PAWS)
Post-Acute Withdrawal Syndrome (PAWS) is a condition in which someone who has a prolonged history of substance abuse experiences severe withdrawal symptoms as a result of cutting their intake.
When someone becomes addicted to, or dependent on, a drug or other substances, the body becomes reliant on synthetic toxins. When the substance is suddenly halted, the body’s functions become confused at the change in chemicals, which gives rise to various withdrawal symptoms.
For those with a mild dependence, withdrawal stops there. This is the phase we call ‘acute withdrawal,’ which lasts for around weeks after the last substance was taken.
But for others who have more severe addictions, or who have been abusing substances for a longer period of time, withdrawal symptoms can continue to arise on and off for a long time. This is called Post-Acute-Withdrawal Syndrome or PAWS.
Withdrawal symptoms that occur weeks or even months after substance cessation are also known as post-withdrawal, prolonged withdrawal syndrome, protracted abstinence, and protracted withdrawal. Generally, these symptoms are more psychological than physical.
What to Expect from PAWS?
PAWS will not begin to appear until after the first stage of withdrawal is over. It may start to manifest within a few days, but it may take weeks or even months for the symptoms to appear.
Once the symptoms do appear, they may remain for months or even years after the person stops using the substance.
Symptoms of PAWS will vary depending on the drug or substance that has been abused, which we will look into below. If a combination of substances is in play, you can expect for the withdrawal symptoms to be more complex and intense.
Research indicates that PAWS symptoms can develop up to 2 months after cessation. There have also been reports that those recovering from substance abuse experience prolonged withdrawal symptoms for up to several years.
In rare cases, individuals who have a severely long history of substance abuse claim to experience PAWS symptoms for life.
This is not to say that someone who is prone to experiencing PAWS will live a life led entirely by unpleasant and debilitating symptoms. It is crucial to bear in mind that PAWS symptoms come and go in waves, and fluctuate over periods of days or weeks.
People suffering from PAWS do have respite periods, which are unfortunately difficult to predict. Fortunately, more research is currently being conducted into alleviating symptoms of PAWS to enhance the quality of life for those who experience its effects.
What Causes PAWS?
Although PAWS is a common and widely accepted medical condition among recovery experts, its exact cause is thoroughly debated among scientists. Some patients do not experience symptoms at all, while others suffer from fluctuating periods of PAWS symptoms for weeks and years.
Thus, research and testing the root cause of Post-Acute Withdrawal Syndrome is difficult.
One widely accepted notion is that exposure to substances for a prolonged period of time causes changes in the brain’s stress response area. Other theories of PAWS include:
1. Evolutionary Response
From an evolutionary perspective, PAWS can develop due to various systems ingrained into the human body through evolution that are supposed to cause a human to seek out natural rewards. Drugs can offer a quick and powerful reward in the form of a high.
Whether the drug produces the response of energy and excitement or causes the person to relax and calm down, the brain can become addicted to the response. Once the brain/body knows that taking the drug produces the reward, they will have a strong urge to use it again. 
2. Conditioned Response
The root of PAWS from a conditional perspective comes from Pavlov’s experiment. He used a bell and food to prove that dogs (or, in this case, humans) can have a psychological and physiological response to a cue.
When a person who is sober runs into certain cues, whether that be a specific person, environment, song, etc. their body may have both a psychological and physiological response. 
3. Neurological Response
PAWS can also be shown/measured with brain scans. Most substances actually change the chemical balance, and processes of the brain, which can be shown both before and after a person stops using a drug. Basically, the neurological explanation for PAWS is that substances actually change the brain.
Signs and Symptoms of PAWS
Below we have listed some of the most common physical and cognitive signs that indicate the Post-Acute Withdrawal phase:
- Depression and anxiety
- Low energy level
- Extreme fatigue
- Frequent or extreme mood swings
- Sleep problems (such as insomnia)
- Inability to focus
- Inability to think clearly
- Lack of a sex drive
- Chronic pain (this is rarer as most symptoms are more psychological)
Risk Factors for PAWS
There are several different things that can affect a person’s chance of developing PAWS. For instance, how much, how often, and how long they used the substance. The more a person uses a substance, the more likely they are to become severely dependent, and therefore they are more likely to develop PAWS.
Other factors, such as genetics and psychological conditions, can also play into whether or not a person is at risk for PAWS.
Which Substances Can Cause PAWS?
The severity of PAWS and how long symptoms last depends on the type of substance the individual has abused. Below is an extensive list of the types of substances that cause PAWS and how they occur:
Alcohol is one of the most common addictions and though it is legal (and therefore perceived to be less dangerous), the withdrawal symptoms associated with discontinued alcohol use can be severe.
Symptoms include psychosis, seizures, hallucinations, long-term cravings, and exhaustion.
This is not a common recreational drug, but people who have prescribed this type of drug can start to abuse it and become dependent on it. For this reason, if they stop taking it, they can have intense acute withdrawal that can develop into PAWS.
This is a drug that is used/prescribed to treat things like delirium, paranoia, and hallucinations. They are usually a fairly strong and brain-altering drug, so if someone stops using it cold-turkey and without the guidance of a doctor, they could have symptoms for months.
A doctor may prescribe this kind of drug to treat anxiety or panic disorders, but the brain can quickly become dependent on them. When someone stops taking benzodiazepines, the withdrawal symptoms can actually mimic the panic disorder; they were originally used to treat.
The PAWS symptoms that someone may experience due to this substance are insomnia, cravings, and fatigue.
Marijuana is not generally considered a substance that would cause withdrawal, but when someone stops taking this drug, they could experience things like insomnia that could continue long enough to be considered PAWS.
Whether prescribed by a doctor or bought illegally, if someone does not stop taking this drug with the guidance of a medical professional, they could have an intense withdrawal and are significantly more likely to experience PAWS.
When someone is taking stimulants, they may experience symptoms such as twitching, paranoia, tremors, or aggression. The withdrawal symptoms (and the PAWS symptoms) are generally the opposite of that: fatigue, physical weakness, and depression.
How Long Does PAWS last?
There is a fairly large range for how long PAWS can last. It depends a lot on the substance a person used and the various other factors listed above under Risk Factors for Paws. For some people, PAWS only lasts for a couple of months, but for others, the symptoms can carry on for years after they get sober.
It is also important to note that PAWS symptoms are not persistent all the time. A person may go days or weeks without any symptoms and then suddenly start dealing with them again.
How Is PAWS treated?
PAWS is a serious medical condition and because of the risks they can impose, a detailed treatment plan that includes anticipating the symptoms is crucial. Each treatment plan will vary depending on the patient’s history of abuse, their background, age, gender, and any other mental or physical conditions.
Knowing that PAWS can exacerbate previously existing conditions is a vital point to bear in mind. For example, someone who suffers from anxiety, depression, or intrusive thoughts is highly likely to experience these feelings during the Post-Acute period, and to a greater intensity.
Due to the fact that most PAWS symptoms are psychological, long term therapy and counselling are some of the most successful and important treatment options.
Identifying a patient’s triggers of what caused the addiction to originally manifest is highly essential – this acknowledgment can be life-saving, allowing the therapist and patient to put into place an action plan for when those mental triggers occur, and how to minimize the risk of relapse or worse. 
During therapy, a person will learn what they should expect and how to overcome the various things they may face. A therapist will also be able to give a person the skillset needed to avoid relapse.
The Best Defence Against PAWS
Symptoms of PAWS can be unpleasant and sometimes scary – but take courage and pride in the fact that you are changing your life for the better. Knowing what could happen, and increasing your understanding of the topic puts you in the best position to combat any side effects that occur.
Below, we have listed some of the best methods to battle the symptoms of Post-Acute Withdrawal Syndrome:
While PAWS can make it hard to get regular sleep, it is important to do your best to put yourself on a healthy sleep schedule. Doing so will help the brain recover and operate optimally.
A good way to do so is by implementing a nighttime routine where you get ready for bed and put aside all other distractions. While a healthy sleep schedule is always important, when dealing with PAWS, it is especially important.
Exercise helps your body heal and also can improve your mood greatly as dopamine is released into your system naturally. Some people who exercise actually consider the feeling to be a “high”” of its own.
Regular exercise is a great way to deal with the psychological symptoms that can come along with PAWS, such as depression and anxiety. If you do not feel ready for an intense workout, you can take a simple 20-minute walk around your neighbourhood or block or do a 20-minute yoga video, both of which can be a great mood booster.
Try starting small and then build up. You will start to see the effects in no time.
For starters, though people in recovery tend to love caffeine, you should try to keep your intake to a minimum. Drinking energy drinks or large amounts of caffeine can trigger PAWS as it can trigger the drug craving part of your brain.
Beyond caffeine, keeping foods like sugar to a minimum can benefit your recovery greatly. When your body is healthier, you will be better able to recover mentally and stay sober. The better you feel, you will be able to avoid relapse easier.
Because of this, try to eat as healthy as possible, but it is, of course, okay to have a treat now and then.
A sober friend is a person that has also given up their addiction to a substance (preferably the same substance as you.) They will understand what you are experiencing and the importance of staying sober.
It is important that you stay away from situations that could make you feel tempted to relapse (especially in the beginning), and sober friends will support you in this in ways that friends who are still using cannot.
Meditation and, more specifically, mindfulness through meditation is a great way to overcome anxiety, agitation, and any other negative emotion. Taking a pause from the rest of life and focusing internally can really help someone refocus and get over negative feelings.
You can listen to a guided meditation or practice controlled breathing on your own. There are meditations you can find specifically to deal with PAWS or specific symptoms you are having.
Being aware of what to expect and signs & symptoms to look out for can be a great defence against PAWS. Enhancing your education on the physical processes and changes in the brain’s function can help you come to terms with PAWS, and may help you navigate your own recovery.
Of course, while being aware is key, it’s also important to not let yourself become immersed or obsessed with what may come. Having a heightened knowledge and understanding of the condition is great, but waiting around for symptoms to hit could increase your anxiety levels and overall have a negative impact on your mental health.
Remember The Positives
Always bear in mind why symptoms of PAWS occur – you have decided to make a change to your life for the better. Although the side effects of PAWS may be unpleasant, remember that they are so much better than the physical risks and dangers of prolonged substance abuse.
Not only are you stronger physically than what you would have been if you were still battling substance addiction, but you are also mentally stronger. Try not to lose perspective on the fact that you are in the process of transforming your life for the better.
Avoiding Relapse When Going Through PAWS
Because one of the symptoms are cravings and due to the desire to relieve the other symptoms, relapse can be common with those who suffer from PAWS. It is important to remind yourself why you are sober and build up both an internal and external support system.
Having the skills to avoid relapse (which are often learned through therapy) and having a support system of people you can turn to when the symptoms are particularly bad is one of the best ways to ensure that you avoid relapse.
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