Medical detox is often the first step in addiction treatment, and generally, it’s believed that once medical detox is complete, the bulk of the physical withdrawal process is over. While this is true for many individuals, some people have lingering withdrawal, known as post-acute withdrawal syndrome (PAWS). For these individuals, the withdrawal process is more complex.
What Is Post-Acute Withdrawal Syndrome?
By definition, post-acute withdrawal syndrome – also called protracted withdrawal – is a series of symptoms that affect people after they experience acute withdrawal. Post-acute withdrawal syndrome goes by many other names, including prolonged withdrawal syndrome, protracted withdrawal syndrome, and long-term withdrawal.
The UCLA Dual Diagnosis Program states that post-acute withdrawal syndrome can last for weeks or even months. They also estimate that 90 percent of recovering opioid users experience the syndrome to some degree, as well as 75 percent of those recovering from addictions to alcohol and psychotropic medications.
There are many signs and symptoms of post-acute withdrawal syndrome, including, but not limited to:
- Anger and irritability
- Anxiety or panic
- Changes in appetite, attention span, memory, and sleep patterns, including insomnia
- Nightmares/strange dreams
- Drug cravings
- Lack of pleasure in activities, including sex
- Difficulty dealing with stress
- Decreased energy
- Difficulty with learning, problem-solving, and/or memory recall
- Difficulty with relationships
- Unexplained physical complaints
- Emotional outbursts/lack of emotion
What Causes PAWS?
In acute withdrawal, the brain goes through changes to remedy the damage that the substances have caused. While the brain does usually heal, it needs time – it doesn’t happen quickly. Because drug dependence affects the brain’s reward center, when the drug is stopped, the brain must essentially rewire itself to feel pleasure in activities while the person is no longer under the influence. For those who are dependent on opioids, sensitivity to pain may be increased while the brain reduces its endorphin production and increases the number of opioid receptors, according to an article by Psychology Today.
The autonomic nervous system is part of the peripheral nervous system, the part of the nervous system that delivers signals from the brain and spinal cord throughout the body. It controls most of the body’s organs and bodily functions that aren’t performed on a conscious level, such as digestion, blood pressure, heart rate, and others. Drug dependence causes an increase in activity from the autonomic nervous system, which activates the body’s “fight-or-flight” stress response, leaving the body in a continual state of stress. After withdrawing from a drug, the autonomic nervous system needs time to reset itself. This can be a long process, as this reset happens gradually.
Who Develops PAWS?
Each person who goes through a period of acute withdrawal from a substance is at risk for developing post-acute withdrawal syndrome. The symptoms vary between individuals, as does the severity. The Substance Abuse and Mental Health Services Administration states that some people may experience a period where symptoms clear up for the first month or so after acute withdrawal before the symptoms of post acute withdrawal syndrome begin.
Each substance may also produce different PAWS symptoms. For example, symptoms that a person may experience during PAWS for alcohol may be different than if the person had withdrawn from cocaine or heroin. The UCLA Dual Diagnosis Program states that those withdrawing from benzodiazepines seem to be at the highest risk. Also, Dr. Roger Weiss, Chief of the Alcohol and Drug Abuse Treatment Program at Harvard’s McLean Hospital, tells The Huffington Post that post-acute withdrawal syndrome occurring from alcohol and benzodiazepines can be similar due to their similarities in pharmacological actions. Those who used a substance for a longer period of time may experience longer lasting or more severe symptoms; however, this is not always the case.
The most obvious risk factor for PAWS is having recently withdrawn from a substance, as is the case for those who complete medical detox for drug dependence. As previously stated, the length of drug use may have a bearing on the length – or severity of – the person’s experience with PAWS. The person’s age may be a factor – older clients may have more extreme and longer-lasting symptoms than younger individuals.
Infants born to mothers with drug dependence may experience post-acute withdrawal syndrome, per UCLA.
How to Treat PAWS
The most important thing for a person to remember is that PAWS is a temporary obstacle on the road to recovery. Therefore, it’s imperative that individuals remain in treatment while they are experiencing these symptoms.
Therapy, both on an individual basis and in a group setting, can help people learn to effectively cope with PAWS symptoms. Also, since PAWS can be a trigger for relapse, therapy should address those feelings, as well as help the person learn to control impulses, solve problems, and make better decisions. Support groups can be of major benefit to those struggling with PAWS, as they encourage peer support and have been associated with longer periods of recovery.
Medications, such as antidepressants, may be helpful for some of the emotional symptoms of PAWS. If mood disorders and mental health issues are not treated, it will increase individuals’ risk of relapse. Natural interventions for managing anxiety and stress, such as meditation, yoga, and exercise, may also help to improve mood symptoms.
The University of Wisconsin Hospitals and Clinics Authority has created a list of ideas to support individuals as they deal with post-acute withdrawal syndrome:
- Identify the individual’s support system, and remind the individual to keep in contact with those people. This may include family members, friends, therapists, and other recovering individuals.
- Identify the individual’s emotional states that trigger the desire to use drugs and help the person find ways to work through those triggers. These emotions may include anger, boredom, loneliness, sadness, etc.
- Assist the individual in making a daily routine that allows time to rest and relax, as well as a routine sleep pattern. Encourage the individual to follow this routine on a daily basis.
- Encourage the individual to follow a balanced diet, including more healthy foods, such as fruits and vegetables. A healthy diet can help the body as it heals through recovery.
- Encourage exercise, as this will help to relieve stress and increase energy. Exercise, according to SAMHSA, can help individuals manage nervousness and distract from PAWS symptoms. Exercise can also improve sleep and promote a positive mental state. Mental exercises can have these same benefits.
- Encourage individuals to treat themselves with care, patience, and understanding. Offer reassurance that recovery is a process, and that these symptoms will not last forever.