Post-Acute Withdrawal Syndrome (PAWS)

Table of Contents

The initial stages of alcohol or drug detox almost always include withdrawal symptoms. These symptoms can range from mild to moderate to extremely uncomfortable to life-threatening. This is why medical and psychiatric supervision is highly recommended for detox and recovery.

Most people are familiar with this first level of withdrawal symptoms. But many are unaware of the more long-term and lingering effects of drug or alcohol withdrawal. Post-Acute Withdrawal Syndrome, or “PAWS” for short, is the lingering effect of withdrawal.

Because PAWS symptoms can linger for months or even years, they can be a trigger for relapse. As a result, they seriously challenge the sobriety of a person recovering from addiction.

The good news is that these lingering PAWS withdrawal symptoms eventually disappear. However, people going through a detox process (and their loved ones) must understand and learn how to skillfully relate to them.

What Is Post-Acute Withdrawal Syndrome (PAWS)?

Post-Acute-Withdrawal Syndrome (PAWS) refers to withdrawal symptoms that appear after the acute phase of detox from alcohol, cocaine, opiates, benzodiazepines, or other highly addictive substances. PAWS is sometimes called a post-withdrawal syndrome, prolonged withdrawal syndrome, or protracted withdrawal syndrome.

An estimated 90% of recovering opioid users and 75% of recovering alcohol and psychotropic users experience PAWS.1

Acute vs. Post-Acute Withdrawal Symptoms

Most people undergoing drug or alcohol detox experience a period of physical discomfort known as acute withdrawal. Such acute symptoms can include nausea, headache, fatigue, bodily aches and pains, increased heart rate, and insomnia. But these physical symptoms are often just the first level of the detox process.

Acute withdrawal symptoms primarily reflect the healing process of the physical body. But the second layer of withdrawal symptoms—the post-acute symptoms of PAWS—typically reflect the withdrawal process’s more emotional and psychological aspects. 7 PAWS symptoms can be very similar to those of mood and anxiety disorders.

Depending on the intensity and duration of the alcohol or other drug addiction, these secondary post-acute withdrawal symptoms can appear a few weeks to a few months into the recovery process—and may continue for years. They can be highly uncomfortable and persist even after all physical traces of the substance have been eliminated from the body.

Though PAWS is a temporary condition, its symptoms can easily trigger a relapse if not dealt with properly.

Symptoms of PAWS

Post-acute withdrawal syndrome (PAWS) symptoms can fluctuate dramatically in frequency and severity. In the beginning, they may change minute-by-minute or hour-by-hour.

Later in the process, the PAWS symptoms may disappear entirely for a few weeks or months. However, they can also reappear in full force. The symptoms may be exacerbated by stress, while at other times may worsen for no apparent reason.

For these reasons, PAWS can feel like a rollercoaster of symptoms.

Typical PAWS symptoms include 2 :

  • Mood swings
  • Feelings of anxiety or panic
  • Irritability or hostility
  • Apathy or pessimism
  • Difficulties in learning or problem-solving
  • Impaired ability to focus
  • Inability to think clearly
  • Memory problems
  • Lack of initiative
  • Depression
  • Fatigue

Additional PAWS symptoms include:

  • Emotional overreactions or numbness
  • Physical coordination problems
  • Obsessive-compulsive behaviors
  • Difficulty maintaining social relationships
  • Craving the initially abused substances
  • Insomnia or other sleep disturbances
  • Increased sensitivity to stress

How Long Does PAWS Last?

The exact duration of PAWS is different for each person going through detox and recovery from substance abuse. The time that PAWS symptoms continue depends on how long, how much, and how often someone abuses the addictive substance.

That said, PAWS recovery usually takes between six and 24 months. This is the time it takes the person’s brain to regain its natural capacity to produce dopamine and endorphins.

What Triggers PAWS Symptoms?

Many people in recovery describe the symptoms of post-acute withdrawal syndrome as ebbing and flowing like ocean waves or rising and falling like a rollercoaster.

Sometimes, PAWS symptoms can be triggered by stressful situations. This includes situations involving people, places, or things that remind the individual of their addictive behavior. But, at other times, the symptoms can appear for no apparent reason.

What Causes PAWS?

The exact physiological mechanisms of post-acute withdrawal syndrome are still being investigated. However, scientists believe that changes to the brain during substance abuse are responsible for the recurring PAWS symptoms.

The addictive behavior alters the biochemistry of the brain. And then, in the withdrawal process, the brain has to recalibrate, to regain its original function. While the brain is correcting the chemical imbalances caused by the addiction, the PAWS symptoms appear.

The PAWS symptoms will no longer appear when the brain has completed this recalibration process.

PAWS Symptoms for Different Drugs

The symptoms of post-acute withdrawal syndrome can look different depending on which substance an individual has been using. The drugs most frequently cause PAWS symptoms include alcohol, marijuana, opioids, antidepressants, benzodiazepines, and stimulants.


The symptoms now associated with post-acute withdrawal syndrome were first observed in people recovering from alcohol use disorder. For the last thirty years, medical journals have published studies that examine post-acute symptoms of alcoholism. 3

PAWS symptoms appearing during alcohol detox and recovery include feelings of anxiety and stress, extreme exhaustion, and cravings for alcohol that persist for a long time.


Those who use marijuana often do so to relax. But people addicted to this drug can become reliant upon it to feel normal. And when they aren’t using it, they feel stressed, depressed, or paranoid.

The PAWS symptoms associated with marijuana detox and withdrawal are the continuation of feelings of paranoia, depression, and stress. People may also experience sleep disturbances and abnormal dreams.


Opioid pain medications activate opiate receptors in the brain and spinal cord. This has the effect of blocking pain signals sent through the spinal cord to the brain. This pain-blocking action can create a euphoric high. 4

The PAWS symptoms experienced in opioid withdrawal often include anxiety, depression, sleep disturbances, lack of focus, feelings of sadness, fatigue, and irritability.


Most antidepressant drugs work by raising the level of neurotransmitters serotonin and norepinephrine. When a person stops taking antidepressants, these neurotransmitters’ levels change dramatically, leading to PAWS symptoms. 5

The most common PAWS symptom in antidepressant withdrawal is prolonged and intense depression. This reaction is caused by the drastic decrease in serotonin and norepinephrine.


Benzodiazepines—including drugs such as Xanax and Valium—affect the body similarly to alcohol. Individuals who have abused and are now detoxing from benzodiazepines are at particularly high risk of experiencing post-acute withdrawal syndrome. They may experience PAWS for months or even years after their final drug use.

PAWS symptoms associated with benzodiazepine withdrawal can be very extreme, including anxiety, panic, obsessive-compulsive disorders, and schizophrenia.

Stimulants (e.g., cocaine and methamphetamine)

Stimulants such as cocaine and methamphetamine stimulate the body’s central nervous system and cause changes in how the brain functions.

PAWS symptoms commonly seen in withdrawal from stimulants include depression, extreme fatigue, lack of motivation, aggression, and impulse-control issues.

Treatment Strategies for PAWS

PAWS can be extremely challenging to deal with. Particularly after going through the acute phases of detox/withdrawal and then working to resist relapse. But once people understand what PAWS symptoms may look like, they’re in the best position to treat and manage them effectively.

While PAWS symptoms may not be avoidable, developing successful strategies for managing post-acute withdrawal symptoms can help the individual recovering from drug abuse feel better physically and psychologically. This can improve their self-esteem and reduce their risk of relapse.

So, as a first step, it’s essential to recognize PAWS symptoms—and to understand that they will eventually dissipate. And along the way, there are vital treatment strategies that individuals in recovery and their therapists can implement to help resolve PAWS symptoms and avoid relapse. 6 9 10

Since PAWS symptoms may linger for months or years, treatments are typically administered over an extended period. Such treatments may include psychotherapy and medication. Various forms of counseling and therapy can help the individual cope with the symptoms.

Tips for Managing PAWS

The unpredictable fluctuations of PAWS symptoms can be stressful. But a combination of therapy, medications, and these practical tips and strategies can help make these symptoms more manageable.

Some specific suggestions for skillfully navigating post-acute withdrawal syndrome include the following.

Practice Self-Care

It’s essential to take good care of one’s body and mind. People can practice self-care by eating well, exercising daily, and nurturing positive, supportive relationships.

Avoid trigger situations whenever possible. Reduce stress and enhance relaxation with yoga, meditation, tai-chi, a therapeutic massage, a warm bath, or time spent in the natural world.

Create a Support System

A good support system can include friends, family members, and a spiritual or religious group. It may consist of a 12-Step group and a psychologist or counselor familiar with PAWS symptoms. Find and cherish people who won’t minimize or criticize one’s experiences but will listen deeply and offer wise and kind support.

Avoid High-Risk Situations

It’s wise for people recovering from an alcohol or drug addiction to avoid people, places, and things associated with their previous substance abuse. It is best to avoid people who used to provide drugs or participate in drug use or locations where drugs were acquired or used. People should also prevent objects or activities that bring up memories of addictive behavior.

Therapy to Develop Coping Skills

It’s a good idea to make appointments with mental health professionals who can provide medication and counseling to help cope with PAWS symptoms. Cognitive behavioral therapy (CBT) and Mindfulness-based cognitive therapy (MBCT) are healing modalities that help them transform negative thinking patterns and develop skillful habits

Cultivate Self-Reflection

It is a good habit for someone recovering from addiction to review the events that preceded a flare-up of PAWS. And reflect on how they responded to the new symptoms. With increased awareness, they won’t be caught off-guard the next time a similar situation arises. They might consider maintaining a journal to document their PAWS experience and identify new ways of responding.

How to Manage Specific PAWS Symptoms

The following suggestions can help a person struggling with PAWS manage or respond to many common PAWS symptoms. 11

1. Difficulty Thinking Clearly

For PAWS, symptoms such as:

  • Difficulty concentrating
  • Abstract thinking problems
  • Circular thinking

Experiment with these strategies:  

  • Limit the time they spend on any task to no more than fifteen minutes, and increase the time only when they are consistently successful.
  • Permit themselves to be concrete thinkers for this period.
  • Interrupt the circular thinking cycle by doing something very different from their habitual activities (e.g., talking to a friend, listening to music, working out at the gym, or going on a hike).

2. Memory Problems

For PAWS, symptoms such as:

  • Short-term memory problems

Experiment with these strategies:  

  • Permit themselves sometimes not to be able to remember things for even fifteen minutes.
  • Tell their trusted friends about their memory problem, letting these people know it is a PAWS symptom.
  • If they have problems remembering, they can write things down or set up reminders on their phone.

3. Emotional Overreaction or Numbness

For PAWS, symptoms such as:

  • Unpredictable mood swings
  • Reactions that are disproportionate to events
  • Emotional numbness when emotionally overloaded

Experiment with these strategies:  

  • Recognize that frequent mood swings are a symptom of PAWS.
  • Discuss their overreaction with the people they live and work with, explaining that it is a PAWS symptom.  
  • Negotiate with trusted friends to be able to talk with them about the mood swings and provide reality checks.

4. Sleep Disturbances

For PAWS, symptoms such as:

  • Nightmares
  • Difficulty falling asleep or staying asleep
  • Changes in sleep patterns

Experiment with these strategies:  

  • Acknowledge sleep problems as a symptom of PAWS.
  • Trust that “this too shall pass.”
  • If insomnia is a problem, limit caffeine use before bedtime and establish a regular sleep routine.

5. Physical Coordination Problems

For PAWS, symptoms such as:

  • Dizziness
  • Balance problems
  • Sluggish reflexes
  • Impaired hand-eye coordination


Experiment with these strategies:  

  • Identify under what circumstances these symptoms occur and what has triggered them.
  • Avoid high-risk situations when experiencing these symptoms (e.g., operating a motor vehicle).
  • Tell their family and co-workers about these symptoms, so they don’t think the person has relapsed.

6. Stress Sensitivity

For PAWS, symptoms such as:

  • Difficulty managing stress
  • Increase in other PAWS symptoms during times of high stress

Experiment with these strategies:  

  • Get to know their stress triggers and stress threshold.
  • Do all they can to minimize their stress triggers.
  • Let trusted friends, family members, counselors, and their sponsor know about their stress triggers.
  • Be prepared to experience an increase in other PAWS symptoms if they’re in a high-stress situation

Treatment & Support from Inland Detox

Seeking treatment is one of the best ways to prevent a relapse related to PAWS symptoms. Since symptoms can last longer for those who engage in excessive and persistent use, it’s especially wise for such individuals to seek longer-term treatment.

A drug and alcohol treatment center such as Inland Detox can provide medical assistance and highly trained support staff in a safe space free from high-risk people, places, and things. In such a setting, detox and recovery—as well as the creation of a new life—become possible.

Inland Detox—Southern California’s leading drug and alcohol detoxification and rehabilitation services provider—is located in the peaceful and idyllic Temecula Valley in Riverside County, California.

Our modern, comfortable home is an ideal location for focusing on your recovery. Unlike many treatment providers, our home houses a maximum of six people. This ensures that clients receive the personal care and attention they deserve in a calm, peaceful environment.

Our skilled therapists and medical professionals support the detox and rehab process. This includes helping clients understand and navigate drug or alcohol withdrawal symptoms, including post-acute withdrawal syndrome (PAWS).

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  4. American Society of Anesthesiologists. What Are Opioids? 
  5. Harmer CJ, Duman RS, Cowen PJ. How do antidepressants work? New perspectives for refining future treatment approaches. Lancet Psychiatry. 2017 May;4(5):409-418.
  6. Protracted Withdrawal. Substance Abuse Treatment Advisory: July, 2010.
  7.  Mager, Dan. Detoxing After Detox: The Perils of Post-Acute Withdrawal. Psychology Today.
  8. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Chapter Four: Early Intervention, Treatment, and Management of Substance Use Disorders.
  9. Association of Intervention Specialists. What is the Johnson Model of Intervention?
  10. Association of Intervention Specialists. What is the Family Systemic Model?
  11. Carty, Bob. Post-Acute Withdrawal Syndrome. University of Texas. School of Biomedical Informatics.