Post-Acute Withdrawal Syndrome (PAWS)

The withdrawal syndrome, often known in medical circles as a discontinuation syndrome, refers to an identified set of the symptoms that occur in individuals who have chronically used certain types of drugs. Withdrawal symptoms following chronic drug usage are a sign that the person has developed a syndrome of physical dependence. This syndrome of withdrawal occurs in conjunction with the development of tolerance to the drug (needing higher doses of a drug to achieve the effects that were once achieved at lower doses).

The risk of developing a withdrawal syndrome to a drug increases as one uses the drug for longer periods of time and increases dosages. There are a number of different drugs that have identified withdrawal syndromes associated with them. According to scholarly works, such as the book The Effects of Drug Abuse on the Human Nervous System:

  • The best known withdrawal syndrome occurs in individuals who chronically use alcohol.
  • Chronic use of opioid or narcotic medications/drugs, such as morphine, heroin, Vicodin, OxyContin, etc., results in a physical dependence that has an identified withdrawal syndrome associated with it.
  • Chronic use of benzodiazepines, such as Valium, Xanax, Klonopin, Ativan, etc., produces severe physical dependence, and there is an identified withdrawal syndrome associated with discontinuation.
  • Chronic use of cannabis appears to result in a formal withdrawal syndrome; however, the physical dependence associated with cannabis appears to be relatively mild compared to the above drugs of abuse, and many of symptoms appear to be emotional.
  • Chronic use of nicotine produces a mild physical dependence and severe emotional dependence, resulting in a withdrawal syndrome.
  • Stimulant medications, such as amphetamine and cocaine, can be associated with withdrawal symptoms when used chronically. The actual physical dependence associated with these medications appears to be relatively mild, and the withdrawal syndrome appears to consist primarily of emotional and psychological symptoms.
  • Individuals who use antidepressant medications can develop physical dependence on them, and this is associated with a recognized withdrawal syndrome.
  • Individuals treated with antipsychotic medications for severe psychiatric disorders are known to develop withdrawal symptoms when these are suddenly discontinued.

Symptoms and Withdrawal

Symptoms and Withdrawal
The withdrawal process occurs as a result of an individual’s system learning to operate efficiently only when a specific drug that has been taken for lengthy periods is present in the tissues of the system. The person’s system automatically adjusts to the presence of the drug and alters its normal level of homeostasis (balance) to accommodate for the effects of the drug. When an individual takes more of the drug to achieve effects that were once achieved that smaller doses (tolerance), the system continues to alter its normal range of functioning (the levels of hormones, neurotransmitters, and other substances) to accommodate for increasing levels of the drug. When the drug is suddenly stopped or the dosage cut sharply, the system’s sense of balance is thrown off, and this produces the withdrawal syndrome.

One of the ongoing distinctions regarding a withdrawal syndrome is the notion of psychological withdrawal versus physical withdrawal.

At one time, it was believed that certain classes of drugs, such as alcohol and opioid drugs, produced strong physical withdrawal syndromes that triggered relapse in individuals; however, when relapse rates for drugs that were considered to produce primary psychological withdrawal syndromes, such as cocaine, were compared with relapse rates for other “physically addicting” drugs, it was found that the relapse rates were comparable. In addition, behavioral addictions, such as gambling addiction, are noted to be associated with discomfort when the individual stops gambling and a higher rate of relapse. Thus, addictions that are both primarily physical or psychological in nature could result in high relapse rates due to a prolonged withdrawal syndrome.

The current thinking of the connection between the brain, emotions, and physical symptoms in the body reconceptualizes a combination of psychological and physical symptoms associated with the detoxification process from drugs. Nonetheless, it is generally recognized that withdrawal from certain types of substances, such as alcohol and benzodiazepines, can produce potentially fatal physical consequences as a result of physical dependence, whereas withdrawal from other types of substances does not carry the same risk. That being said, anyone who is emotionally distraught during the withdrawal process may be at risk for self-harm due to accidents or suicide attempts.

One popular syndrome that is seen quite often on a number of drug rehab forums and in some of the popular literature is the notion of post-acute withdrawal syndrome. This is sometimes also referred to as protracted withdrawal syndrome, protracted withdrawal, or prolonged withdrawal syndrome.

Post-Acute Withdrawal Syndrome (PAWS)

PAWS is associated with prolonged effects occurring after the formal detoxification process from drugs or alcohol is relatively completed.

All of the drugs listed above, as well as others, have been associated with the development of PAWS in a subset of individuals attempting to maintain recovery.

The notion of a protracted withdrawal syndrome was first associated with the drugs alcohol and benzodiazepines, where it was noted that recovering individuals who develop physical addictions to these drugs often have long-term issues with depression, anxiety, lack of motivation, apathy, and alternating periods of cravings to return to drug use with periods of relatively symptom-free functioning. Although there is no formal syndrome associated with PAWS, the literature does list a number of symptoms associated with it that appear to occur in individuals recovering from different types of substance use disorders.

  • Psychological/emotional: The primary symptoms occurring in PAWS are reported as being of the psychological/emotional nature. These symptoms include depression, issues with anxiety ranging from mild anxiety to panic attacks, increased reactions to stress, problems with motivation, feelings of guilt, pessimism, empathy, intermittent periods of anhedonia (difficulty experiencing pleasure), social withdrawal, emotionally overreactions, and intermittent cravings for the prior drug of choice.
  • Autonomic nervous system: Some symptoms associated with autonomic nervous system functioning, such as changes in heart rate, changes in breathing rate, increased sensitivity to pain (although this could also be a psychological symptom), and periodic issues with perspiration and physical coordination have been listed.
  • Cognitive issues: Prolonged issues with attention, the inability to concentrate, issues with learning and memory, and issues with decision-making (although many of these are related to issues with relapse) are also reported.
  • Other: Issues with interpersonal skills, social isolation, feeling alone, and other issues with social functioning are also reported.

The duration of PAWS appears to be quite variable depending on the individual case. It can last for months to even years. There is no formally defined set of symptoms for PAWS (the formal definition of a syndrome) associated with any particular drug of abuse. The symptoms are wide-ranging, vary in intensity, appear to come and go intermittently, and are believed to result in an increased probability of relapse if not addressed.

Some Issues with PAWS

Is PAWS a valid syndrome? If one were to accept the notion that PAWS is not formally listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) even though it was considered for admission in the fourth edition and that most medical associations do not formally recognize PAWS as a syndrome, then the answer to this question is “no.”

It is interesting to note that the latest two editions of the DSM (DSM-IV; DSM-5) have been highly criticized for their lack of scientific rigor regarding the development of their diagnostic and classification system for mental health disorders, including disorders related to substance abuse and addiction. If PAWS was not included in this classification system by the American Psychiatric Association due to a lack of solid empirical evidence for its existence, a classification system that is harshly criticized by many professional medical organizations such as the National Institute of Mental Health, it can be reasoned that the research regarding the legitimacy of PAWS as a formal syndrome of withdrawal may be lacking in its methodology.

On the other hand, literature presented by a number of treatment centers for substance use disorders continually mentions PAWS as a valid and potentially dangerous syndrome that increases the potential for relapse in individuals if it is not addressed. The answer to this discrepancy is probably a lot simpler than arguing factions make it.
Issues with PAWS
From an investigative standpoint, the notion that the above symptoms that occur in individuals who recover from substance abuse represents a withdrawal syndrome that is associated with the detoxification of a drug or substance from the person’s system is not a valid notion. However, from an experiential standpoint based on the documented experiences of recovering individuals, it is clear that many people do experience many of the above symptoms associated with long-term recovery. Many of these symptoms may actually be the result of physical changes to the central nervous system that occurred as a result of chronic drug use. Other symptoms, such as cravings, may also be related to behavioral principles, such as priming (the activation of certain physiological responses by environmental cues that may not be overtly noticed or processed), classical conditioning (physical reactions that have been learned as a result of previous associations), and operant learning (the association of certain conditions with reinforcement, such as going to a bar, feeling relaxed, and wanting to drink alcohol).

Thus, while describing the issues that many individuals face during long-term recovery and abstinence may not represent a formal withdrawal syndrome, such as PAWS, it is clear that these are real issues that need to be addressed. Individuals in long-term recovery typically find that the longer they maintain their recovery program, the easier it becomes; however, many individuals still experience intermittent cravings, issues with stress, anxiety, pessimism, etc. Because individuals who have relatively long histories of using drugs as coping mechanisms have altered their physical systems, and in the past have also developed habitual patterns of behavior in response to stress, these individuals will always be at an increased risk for relapse. This increased risk does not necessarily represent some formal withdrawal syndrome but instead reflects current understandings of established principles of learned behavior and neurobiology.

Several important considerations can help individuals during long-term recovery:

  • Make appropriate changes: The process of recovery is not simply about quitting use of drugs or alcohol. It should also involve positive changes that will help you avoid issues with relapse. These include things like developing a long-term plan for recovery, associating with people who foster recovery, avoiding situations and places that have a high potential to lead to relapse, and getting rid of negativity and other issues that foster relapse.
  • Honesty is the best policy: Do not engage in deception, particularly in self-deception. Understand what your motivations are, the origin of your urges, and the types of excuses and rationalizations you make to explain away your behavior. Be honest with close friends and family, and certainly be honest with your treatment providers.
  • Ask for help: No one knows everything, and no one is in total control of all situations. Do not be afraid to ask for help or advice. Develop a support group you trust and confide in them when needed.
  • Take care of yourself: Take care of yourself before you attempt to take care of others. This also means trying to live a balanced life.
  • Stick to the plan: Adhere to the principles of recovery that were learned in therapy. Deviation from aftercare plans commonly results in relapse.
  • Take responsibility: Remember that the only thing you can consistently control is how you react to the situations that occur in your life. Take responsibility for your behavior, and avoid blame and resentment.