treatment copyThe development of physical dependence to certain classes of drugs can be symptomatic of having a substance use disorder; however, physical dependence (having both tolerance and withdrawal symptoms) is neither necessary nor sufficient to be diagnosed with a substance use disorder.
 
Many individuals who take certain medications under the supervision of a physician for medicinal reasons can develop physical dependence on them, but they do not have a substance use disorder.

Even though the withdrawal process will be slightly different for different people, there are general signs and symptoms that are associated with withdrawal. In addition, individuals undergoing withdrawal from drugs that they have used for medicinal reasons often do not experience many of the severe psychological and emotional issues that individuals with substance use disorders experience during withdrawal. This may well be because individuals who abuse drugs use them in far greater quantities and far more often than individuals with prescription typically do, or it may represent differences in the psychological effects of withdrawal associated with the two groups (abusers versus medicinal users).

Many of the symptoms of withdrawal for most drugs will have subsided or significantly attenuated within the first two weeks following discontinuation. For some drugs of abuse, such as individuals with severe alcohol use disorders, some potentially dangerous symptoms or the potential to develop certain symptoms can continue for several weeks following discontinuation, but the most severe symptoms typically occur within the first one to two weeks of the withdrawal process. Despite this, many individuals still continue to experience psychological and emotional issues many weeks following stopping use of the substance. Some clinicians have defined an additional phase of withdrawal, known as post-acute withdrawal syndrome, that extends for a much longer period of time.

What Is Post-Acute Withdrawal Syndrome?

Post-acute withdrawal syndrome (PAWS, also referred to by some sources as post – withdrawal syndrome, prolonged withdrawal syndrome, or protracted withdrawal syndrome) has been used to describe a set of persistent symptoms that are distressing and emotional draining, which occur after the formal physical withdrawal process from drugs has ceased. Every drug associated with some type of withdrawal process has been associated with the development of PAWS, although it appears that benzodiazepines are most often associated with this syndrome.

The syndrome appears to have been first described in the 1979 edition of the book Counseling for Relapse Prevention. As originally described in this book, the syndrome was believed to begin following 1-2 weeks after discontinuation from serious abuse of alcohol, peak within 1.5-2 months, and last for an additional 3 months. PAWS was believed to affect higher-level cognitive functioning, such as memory, and also produced an overreaction to stress and the display of more intense emotions associated with stress in people recovering from severe alcohol abuse. In its original conceptualization, PAWS was explained as a process that was associated only with relapse from alcohol abuse. The person begins recovery with intentions to stay sober, but as the PAWS progresses, the person’s ability to think clearly and remain focused is compromised. The person uses maladaptive coping methods to deal with triggers for relapse and other stressful situations, and ends up resuming use of alcohol as a coping method.


As clinicians began to have more experience with withdrawal from drugs like benzodiazepines, the syndrome appears to have been expanded to encompass a number of other drugs and a number of other symptoms.


There is research suggesting that there is PAWS associated with benzodiazepine withdrawal, but there is little formal research on the actual associated with PAWS (see below).

The duration of PAWS is also reported as being indefinite in a number of sources. It is reported as potentially lasting for months and even years following discontinuation in many sources. There is no general timeline reported for the symptoms occurring in PAWS, and a number of different symptoms are associated with different descriptions of the disorder. There are also no consistent PAWS symptoms associated with any particular substance despite what many online sources report. PAWS as a formal clinical syndrome appears to have many features that are similar to clinical myths that are often associated with a pseudoscientific approach to their validation.

Symptoms of PAWS

The most common symptoms of PAWS are reported as:

  • Alterations of the autonomic nervous system (increases in heart rate, respiration rate, etc.)
  • Depression
  • Anhedonia (difficulty experiencing the feeling of pleasure)
  • Having a pessimistic thoughts
  • Feelings of guilt
  • Amotivation (not feeling motivated or lack of initiative)
  • Prolonged feelings of pessimism
  • Apathy
  • Issues with anxiety
  • Panic attacks
  • Vivid dreams of using drugs
  • Insomnia
  • Obsessive-compulsive type behaviors
  • Impaired interpersonal skills
  • Social withdrawal
  • Issues with attention and concentration
  • Issues with memory
  • Problems with physical coordination
  • Increased sensitivity to pain
  • Increased reactions to stress
  • Feeling numb
  • Emotionally overreacting the things
  • Intermittent cravings for the drug of choice

 
 

Symptoms can come and go, and may present in wavelike occurrences where symptoms become very florid and distressing, and then the individual has periods of time where the symptoms are relatively minor or not present at all. This is not at all consistent with formally recognized withdrawal syndromes.

Explanations for PAWS include the theory that alternations in the central nervous system that result from chronically abusing drugs cause the syndrome; however, even in the literature investigating neurobiological associations of PAWS or protracted withdrawal, there is no formal designation of any specific syndrome that can be defined as post-acute withdrawal syndrome or protracted withdrawal.

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    Some Specific Considerations for Specific Drugs of Abuse and PAWS

    There are some symptoms that are more likely to be present for specific drugs of abuse:

     

    • Rebound effects: These refer to the return of symptoms that the drug was originally intended to control. For example, individuals who abuse benzodiazepines will often experience high levels of anxiety during withdrawal because benzodiazepines are primarily used in the treatment of anxiety. Individuals who abuse narcotic medications such as Vicodin or OxyContin may experience increased sensitivity to pain because these drugs are typically used for pain control.
    • Emotional numbness or oversensitivity: These issues may occur with drugs that dampen feelings, such as benzodiazepines, narcotic medications, alcohol, etc.
    • Cognitive effects: Many drugs will affect cognition. As a result of the chronic use of the drugs, the neurobiological pathways associated with certain cognitive functions, such as attention and memory, are altered permanently. This results in permanent issues with these cognitive functions.

    However, as mentioned above, there is no consistent pattern of PAWS symptoms reported for any specific class of drugs and no specific timeline.

The Take-Home Message

Just because the evidence that identifies PAWS as a valid syndrome of withdrawal is lacking, there is little reason to think that individuals who have been in recovery for substance use disorders are not vulnerable to certain triggers that can occur over the long-term. These triggers are real, but most likely do not represent a formal clinical aspect of a withdrawal syndrome. Instead, they represent part of the formal notion of what an addiction is, how it affects different people, and how it should be addressed in the short- and long-term. The take-home messages are:

  • Understand that if you are recovering from a substance use disorder, there will always be the potential for relapse.
  • Be aware of the specific triggers that affect you personally. Have a plan to identify, recognize, and address them.
  • Continue to be active in your own recovery plan. One way to do this is to remain involved in support groups.
  • A good support system goes a long way in assisting in recovery. Enlist the assistance of close friends and family.
  • Remember that cravings or urges are not failures of recovery but simply normal occurrences in the long-term recovery process. Likewise, if you relapse, use it as a learning tool to get stronger.
  • Approach the recovery process as a long-term process. Always be prepared to start over if things do not go as planned. Learn from mistakes, but do not dwell on them.
  • Many things that happen in life are out of our individual control, but we always have the ability to control how we react to these events. Learn to control what you are able to control.