What is Post-Acute Withdrawal Syndrome (PAWS)?

What is Post-Acute Withdrawal Syndrome (PAWS)?

Post-Acute Withdrawal Syndrome (PAWS) refers to a collection of symptoms that continue for months or years after someone stops using an addictive substance. It differs from acute withdrawal syndrome in both symptoms and longevity. PAWS symptoms are similar to those of many mood disorders and include mood swings, insomnia, and increased anxiety levels.

Many drugs cause PAWS during recovery. The most common drugs that lead to PAWS are opioids and alcohol, but antidepressants, benzodiazepines, marijuana, and stimulants are also known to cause PAWS.

Treatment for PAWS includes individual and group therapy to learn coping strategies, and in some cases, Medication-Assisted Treatment (MAT) therapy can reduce symptom intensity.

What is PAWS?What is PAWS?

After stopping drug use, people go through two stages of withdrawal. The first stage is acute withdrawal. It is characterized by physical withdrawal symptoms, including nausea, vomiting, tremors, sweating, and fatigue. This stage usually lasts a few days to a couple of weeks, depending on the substance.

Once the acute withdrawal phase subsides, the second stage begins. Post-Acute Withdrawal Syndrome has few physical symptoms, but emotional and psychological withdrawal symptoms are predominant.

PAWS occurs because it takes time for brain chemistry to return to normal after drug use ceases. The gradual process involves fluctuating brain chemistry which results in PAWS symptoms.

Signs and Symptoms of PAWS

The symptoms of PAWS vary depending on the drug. The severity of PAWS symptoms is mild to severe, and they often disappear, only to return later. The most common symptoms of PAWS are:

  • Difficulty with mental tasks like memory, learning, and problem-solving
  • Irritability
  • Depressed mood
  • Feelings of anxiety or panic
  • Sleep pattern disturbances
  • Craving the initially abused substance
  • Obsessive-compulsive behaviors

PAWS symptoms come and go with significant intensity. In the beginning, the symptoms may come and go every hour. The time between symptoms increases as recovery continues, but the symptoms may keep their original intensity.

While symptoms are induced by stressful situations and the severity of the symptoms worsens with external stress, most PAWS episodes start with minimal external stress or no notable external event. After a time, the symptoms will go away. This amount of time depends on how often a user took an addictive substance, the length of the addiction, and the type of drug.

Different Drugs’ Effect on PAWS

The abused substance can impact the length, intensity, and type of PAWS symptoms. The following list of drugs causes PAWS and its symptoms.


The changes in the brain associated with alcohol addiction make the brain easily excitable when off the substance, by GABA and GABA-A neurotransmitters. This results in PAWS symptoms like stress and anxiety, extreme exhaustion, feeling sick, and long-lasting alcohol cravings.


Even though few people use antidepressants recreationally, abrupt stoppage commonly leads to PAWS. The primary symptom in antidepressant-related PAWS is prolonged and intense depression due to significant changes in norepinephrine and serotonin levels.


Benzodiazepines work on the brain similarly to alcohol. Between 10 and 15% of people taking benzodiazepines experience PAWS when ceasing the medication. Symptoms characteristic of this class of drugs include intense panic, anxiety, obsessive-compulsive disorders, and schizophrenia.


Marijuana affects brain chemistry to make users feel relaxed. While occasional recreational use has not been shown to elicit withdrawal symptoms, cessation can cause sleep difficulties, anxiety, paranoia, and stress if abused.


Opioids work by blocking pain signals in the brain. Once the drug is absent from the brain, PAWS symptoms like depression, insomnia, lack of focus, and irritability set in.


Stimulants like methamphetamine and cocaine change the brain’s functions, flooding the brain with dopamine and cortisol. This dramatic change in brain chemistry predisposes stimulant users for PAWS. Stimulant caused PAWS leads to extreme fatigue, difficulty controlling impulses, lack of motivation, and aggression.

PAWS TreatmentPAWS Treatment

There is no one drug or therapeutic practice known to cure PAWS, so treatment is based on managing symptoms to avoid relapse. This can take the form of individual therapy, group therapy, Medication-Assisted Treatment (MAT) therapy, and holistic approaches that include all three.

Individual therapy

Individual therapy, like psychotherapy and cognitive therapy, can help people with PAWS in many ways. Individual therapy can teach an individual about what PAWS is and how long it may last.

Since one of the most prevalent symptoms is increased cravings, individual therapy may focus on urge coping strategies. It can also give a therapist time to assess for a co-occurring disorder (COD), a mental disorder separate from PAWS that presents similarly. CODs may require different treatments, so determining their presence is important.

Individual therapy is personalized, so it will be different for everyone, but the goals are similar: Educate about PAWS, teach how to manage symptoms, and reduce the likelihood of relapse.

Group therapy

Group therapy has a certified therapist lead a group in judgment-free discussions surrounding specific addiction issues. It provides relief from isolation and is an opportunity to learn from others in similar circumstances.

There are group therapy sessions for every person with any addiction problem, so it is crucial to find one specific to your addiction and stage in recovery. For instance, if a person is doing MAT therapy, they need to find a group that accepts people using prescribed medicines as a treatment.

Medicated-Assisted Treatment

PAWS symptoms associated with alcohol and opioid addiction are receptive to treatment with medication. Methadone and buprenorphine may be suitable for people at high risk of relapse into opioid use.

Manage PAWS with Help From Right Path Addiction Centers

PAWS is a challenge for recovering addicts that can feel never-ending and hopeless. Just learning about PAWS is the first step to effectively managing the symptoms.

The Right Path Addiction Center staff can help you learn more about how to manage PAWS symptoms. With the help of holistic recovery programs that include many therapeutic options and MAT treatment, PAWS becomes a manageable step toward sustained recovery.

Written by Sergey Zhitar, MD Medical Director

Native of Moldova, Dr. Zhitar is Board Certified in Addiction Medicine as well as Internal Medicine and completed his training at UPMC Shadyside, Pittsburgh, PA in 2000.


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