How Long Does Post-Acute Withdrawal Syndrome Last
Many misconceptions surround the process of drug withdrawal. Although all substance-dependent individuals experience withdrawal symptoms that accompany the cessation of use, the severity and duration of those symptoms vary according to a multitude of factors. Habitual drug use involving either illicit or prescription drugs invariably triggers withdrawal symptoms, and the initial withdrawal period—usually the most intense—lasts anywhere from several days to two weeks. During this acute detoxification period, it is vital that clients receive medical supervision in a clinical setting in order to prevent “precipitated withdrawal”—the potentially deadly onslaught of withdrawal symptoms.
Even with proper management, however, certain mind-altering substances produce a protracted withdrawal process that can linger for months or even years before eventually resolving. In extreme cases where unrelenting and excessive drug abuse has occurred, it can last indefinitely. This process, known as post-acute withdrawal syndrome (PAWS), describes an ongoing cluster of withdrawal symptoms— the majority of which are psychological in nature and mood-based. Recent evidence-based research contradicts prior doubts about PAWS as a legitimate medical and psychological phenomenon. In a survey published by Recovery First, Inc., approximately 91 percent of addicts experience PAWS, with only 13 percent receiving PAWS-specific treatment.
Researchers and clinicians understand PAWS to be a complex syndrome without a singular cause and frequently disagree about the underlying reasons for the development of the condition. However, many agree that brain changes associated with addiction and the resulting stress response are a primary cause. Other theoretical causes include:
- Physiological Adaptation – when drugs are taken on a regular basis, particularly potent drugs like opiates, withdrawal symptoms appear as a result of the body trying to physiologically re-adapt. Many parts of the body become used to a regular influx of chemicals to help regulate various functions. Although the body tends to re-adapt quickly in most cases—within two weeks—sometimes this process is delayed. For example, a client detoxing from a long-term addiction to central nervous system (CNS) depressants may experience an accelerated heart rate for an extended period of time. This, in turn, causes symptoms of PAWS.
- Homeostatic Adjustment – physical dependence on drugs or alcohol alters brain chemistry. In its altered state, the brain depends upon drugs or alcohol to provide it with neurotransmitters, endorphins, and other vital neurochemicals. Without these chemicals, the brain cannot function properly on its own and experiences an extended return to homeostasis— a process which results in cravings, fatigue, mood swings, and other psychological symptoms.
- Habit – a major part of substance abuse treatment involves retraining the behaviors and responses associated with addiction. Although returning to a drug or alcohol habit after detoxification causes relapse, the absence of the habit also produces troubling psychological symptoms such as depression, anxiety, cravings, and fatigue— known characteristics of PAWS.
- Stress – quitting a drug or alcohol habit is extremely stressful—especially if done by quitting cold turkey under self-guided treatment. This heavy burden of psychological and physiological stress frequently leads to relapse or an extended withdrawal period.
DRUGS THAT TRIGGER PAWS AND ASSOCIATED MEDICATIONS
PAWS is known to be directly linked to drugs called GABA-agonists. This class of drugs, which includes benzodiazepines “benzos,” opiates, stimulants, and alcohol, leads to major brain changes in what is known as the “pleasure and reward system.” The impact of these drugs on neurotransmitters such as dopamine, serotonin, glutamate, GABA, and opiate peptides has a damaging effect on neural pathways that lasts well beyond the cessation of use. Although certain drugs more easily trigger PAWS symptoms than others, the following medications are all primary culprits:
- Benzos – although tapering schedules can definitely help during the acute withdrawal phase of detox, they are frequently ineffective in treating PAWS. Many clients take benzos during PAWS to help manage the intense anxiety and panic disorders that arise as a result.
- Opiates – recent studies implicate PAWS in approximately 90 percent of recovering opiate addicts. Illicit and legitimately prescribed painkillers including oxycodone, hydrocodone, heroin, and codeine are all known to produce symptoms including fatigue, insomnia, and intense anxiety.
- Antidepressants – commonly known as SSRIs, medications such as Zoloft, Prozac, and Lexapro artificially elevate the levels of serotonin and/or norepinephrine in the brain by blocking their reabsorption. Clients who stop taking these medications—especially after long-term use—experience protracted withdrawal symptoms.
- Alcohol – the majority of alcoholics experience PAWS symptoms. Typically, initial withdrawal symptoms begin within 6 hours of cessation. Although some tapering strategies may be effective, they usually do not work for the stubborn and lingering psychological symptoms associated with PAWS.
- Stimulants – clients who quit stimulants such as amphetamines and cocaine “cold turkey” frequently experience PAWS. Symptoms may include anxiety, depression, paranoia, impulse control problems, and emotional dysregulation.
PAWS produces a wide and somewhat unpredictable range of withdrawal symptoms. A client’s age, gender, height, weight, overall mental and physical health, duration and intensity of drug or alcohol use, and numerous other factors all combine to determine their individual symptoms and experience. Common symptoms may include:
- Anhedonia – this phenomenon describes the loss of pleasure and enjoyment of life activities. The chemical-boosting effect of mind-altering drugs is followed by a backlash effect that causes the depletion of these same “feel good” neurotransmitters. Until the brain eventually returns to equilibrium, clients may experience a lack of interest in activities or a loss of pleasure even while engaging in them.
- Insomnia – most psychoactive drugs disrupt normal sleep patterns after the brain adapts to chronic use. Upon quitting, it takes time for the body to gradually re-establish its nocturnal rhythm.
- Mood Swings – almost always result from the brain trying to re-balance proper levels of neurotransmitters and other vital neurochemicals. Many clients experience mood shifts for no apparent reason long after the acute withdrawal phase.
- Anxiety – quitting any habit can be psychologically unsettling, especially when it involves alcohol or benzos— substances which have an inhibitory effect on brain activity that results in arousal and excitability upon cessation.
- Depression and Fatigue – like anxiety, depression is the natural result of a backlash effect that occurs with cessation of use. Particularly after using opiates and alcohol—both of which induce euphoria—a depressed, lethargic state may occur.
- Cravings – PAWS is frequently characterized by intermittent cravings as the body re-adapts to its original state. Over time, these cravings gradually diminish and usually disappear entirely (except in very rare cases).
- Cognitive Impairment – difficulty concentrating, problems with long and short-term memory, and various other cognitive issues are commonplace and not necessarily indicative of permanent or even long-term damage.
COPING AND LONG-TERM MANAGEMENT
Although not usually as intense as the initial set of symptoms that accompany acute withdrawal, PAWS symptoms can be extremely uncomfortable and occasionally debilitating. Clients battling these symptoms benefit from the inclusion of coping strategies into their long-term recovery routine. The following are excellent examples:
- Regular Activity – a regular regimen of exercise and healthy physical activity helps the body and brain perform at optimal capacity and heal faster. It also enhances immune function, reduces anxiety and depression, and promotes better sleep— a critical aspect of healing.
- Self-Education – spending time actually studying and researching PAWS can help clients to better handle symptoms and prepare for possible complications.
- Positivity – maintaining a positive, relaxed frame of mind can go a long way toward helping someone manage PAWS and progress towards their goal of long-term sobriety.
- Avoidance of Triggers – the avoidance of social and environmental triggers is crucial. By first identifying what causes negative mental and emotional states, clients can better avoid them or at very least manage them more effectively whenever they arise.
- Healthy Dietary and Lifestyle Decisions – the importance of a nutritious, toxin-free diet and healthy lifestyle decisions cannot be underestimated. Maintaining a proper balance between all four foods groups and avoiding excessive sugar, fried or processed foods can help reboot a damaged system and significantly improve cognitive function. Building a strong sober support network, establishing community connections, and developing a personal spiritual program are all excellent ways to minimize PAWS symptoms and avoid relapse.
Remember, PAWS, like addiction, is a stubborn, lingering condition that responds favorably to aggressive treatment and intervention. If you or someone you love are struggling with symptoms of PAWS and are at risk of relapsing, call a substance abuse professional today. Although successfully completing initial detox and subsequent treatment are key ingredients of early recovery, they may not be enough to ensure long-term results. Many clients suffering from PAWS require ongoing treatment and support in order to eventually experience freedom from symptoms.
For more about PAWS and recovery, check out these related articles:
- “Key Elements of Relapse Prevention”
- “Relapse and the Path to Recovery”
- “How to Adjust to Sober Living”
- “How Mindfulness Exercises Aid Recovery”
- Yale Journal of Biology and Medicine (YJBM). Relapse Prevention and the Five Rules of Recovery. Sept, 2015.
- Addictive Biology. Acute Withdrawal, protracted abstinence and negative affect in alcoholism: Are they linked? April, 2010.
- Alternative and Complementary Therapies. Post-Acute Withdrawal Syndrome, Relapse Prevention, and Homeopathy. Dec, 2017.
- American Nurse Today. Understanding and managing alcohol withdrawal syndrome. June, 2013.