Post-Acute Withdrawal (PAW): The Symptoms

By Terence T. Gorski

Post Acute Withdrawal (PAW) is a cluster of symptoms that occur in recovering addicts and alcoholics. PAW symptoms usually begin to occur between seven and fourteen days after the acute period of withdrawal, and usually peak between three and six months after the start of abstinence.

Post-Acute Withdrawal (PAW) Syndrome is also referred to as:

– The protracted withdrawal syndrome,

– Chronic brain toxicity,

– Long-term neuropsychological impairment

– Long-term neuro-cognitive impairment

Acute withdrawal (AW) is composed of physical symptoms that occur as a result of stopping the use of a drug after the addict has develop tolerance and dependence.

– Tolerance means that the body adapts to the constant use of large quantities of the primary drug of choice. As a result it takes more and more of the drug to experience the desired effect from taking the drug.

– Dependence means that the body learns to function normally with a high dose of the drug. When they stop taking the drug they experience symptoms of acute withdrawal.

– Symptoms of Acute Withdrawal (AW) includes shakes, vomiting, chills, muscle soreness and cramps, headaches, diarrhea or constipation, extreme skin sensitivity, sensitivity to light, and more. PAW begins to emerge as AW symptoms begin to subside.

PAW is a bio-psycho-social syndrome that results from the combination of damage to the nervous system caused by alcohol or drugs and the psychosocial stress of coping with life without drugs or alcohol.

PAW symptoms can be divided into the following six groups or clusters:

1.  Difficulty Thinking Clearly:  PAW causes recovering people to have difficulty recognizing and solving usually simple problems, making decisions, concentrating, understanding abstract concepts, and stopping rigid and repetitive ways of thinking.

2.  Difficulty Managing Feelings: PAW creates the tendency to vacillate between emotional overreactions or emotional numbness;

3.  Difficulty Remembering Things: PAW causes people to have difficulty remembering what they learn and understand. The memories tend to fade after several hours something. It’s as if the memories are not shifted from short-term memory to long-term memory.

4.  Difficulty Sleeping Restfully: PAW causes sleep disturbances. Many recovering people have difficulty falling asleep and sleeping restfully. Their sleep is fitful; they awaken many times during the night, and do not feel rested after sleep.

5.  Problems With Physical Coordination: Recovering people often have difficulty with hand-eye coordination and controlling fine muscle movements. They also have problems with balance and can easily feel dizzy and disoriented.

6.  Stress Sensitivity: Recovering people tend to be stress sensitive. This means that a low level of stress can cause an exaggerated reaction on their brain and nervous system. Living in high stress, which is necessary in facing the challenges of early recovery, cause the problems with managing thoughts, feelings, memory, and sleep to become even more severe.

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16 Responses to Post-Acute Withdrawal (PAW): The Symptoms

  1. Carol Drogosz says:

    These still affect me! Amazing the great harm we do t ourselves in the guise of “gottas and havetos and shoulds”. I needed to rehear this this morning.

    • Terry Gorski says:

      PAW is present to some degree for life. The symptoms are stress sensitive. This means they are more easily activated, occur more frequently, are more severe, and last longer during stressful periods if life b

  2. Daniel Omell says:

    Note: After 17 years, I quit using. Discovered article listing PAWS within 1rst month of 8+ years of complete abstinence. Read the complete list each morning for “awhile” assuming in my reading that these symptoms were a foregone conclusion. They never materialized! Is their something to what I experienced. I attempted sharing my ‘discovery’ at meetings, and of course, the AA Traditions took precedence. I always wonder if I stumbled upon ……something. Nice to see PAWS survives. Dan Omell

    • Terry Gorski says:

      Not everyone gets PAW. Diet, exercise, stress management and a stable recovery are important.
      The severity of addiction and genetic history also play a role. Child abuse and neglect come into play.
      I am glad you missed this factor in recovery.

      • nitin says:

        First of all, your definition of PAWS seems to be the most widely accepted in all the online resources I have come across during the past month since I have begun my long, arduous journey in recovery. Just a bit of background, I began drinking and using various substances at a relatively young age, the most experimental stage occurred between the ages of 19-27. I smoked a lot of pot, drank rather heavily, indulged in psychedelics, dabbled in cocaine, ecstacy, amphetamines.. Never used heroin.. Substance use was a cornerstone of my lifestyle for a long time.. Up until recently.. I really began drinking more heavily and frequently the past year (largely due to work related stress). Finally on July 10th 2013 I had my first major (and last, thankfully) panic attack. I was at a friends house in s.f., we just got back from dinner where I had two beers and a cig, we smoked some pot and all of a sudden it hit me like a ton of bricks- tunnel vision, my heart rate increased to the degree I felt it was on the verge of bursting, my body temp went through the roof and I began to pace uncontrollably. I thought I was going to die. A few minutes later, I calmed down and my heart rate fell back to normal.. Since that day I have not been the same… I began to feel a little better within a few days of that episode, I diagnosed myself and felt it was the marijuana that was causing the anxiety. So I cut back drastically on my pot use. I then began drinking more, frequently engaging in “benders” days on end, getting damn near hammered after work.. Throughout most of this my anxiety continued, though much milder than the one major episode I had in July.. I would be sitting in traffic at rush hour and my body temp would rise, vision would begin to get worse and heart rate would begin to rise.. I controlled the burn through deep breathing and symptoms would subside… Mornings were a nightmare, id wake up feeling awful, anxiety, mild depression.. Eventually in the evenings I would find relief through drink. The next the cycle would repeat. Sound familiar to any of you? 🙂 I had my last bender on September 27th when I went out with some friends and drank heavily. I decided to finally give it up when I woke up the next morning without a hangover but a horrible sinking feeling of depression, and for the first time the thought of wanting to die crossed my mind. It freaked me out so much I knew something had to be done…

  3. nitin says:

    ….the first week of October I felt horrible, I was off the sauce and everything else. I was working but could barely function, drive, hold a conversation, hold one simple coherent thought.. I went to a physician (from my experiences, very few physicians know about PAWS) who looked at me and said I was not going through withdrawals, that I was more than likely clinically depressed/anxious.. I was in disbelief with her response and disillusioned by western medicine at this point… I knew there was something up and it had to do very much with substance abuse.. But because she didn’t notice tremors (externally), or any of the other acute withdrawal symptoms, she dismissed my belief that I was experiencing backlash from alcohol abuse.. She referred me to a psychiatrist/addiction specialist who prescribed me gabapentin, which I have to this day not taken.. I’m not quitting substances to form another addiction… The waves of emotion, the up and down of everyday, the pendulum of negative to positive thinking, the persistent nagging unwanted thoughts, the general difficulties of life amplified through the lens of sobriety… All of it has persisted for the past month and some change.. It does seem to get easier day to day week to week… But I’m constantly haunted by this uncertainty of well, anything, really.. I do my best to put one foot in front of the other and keep going but sometimes I feel like I’m going nuts… I guess why I’m posting this extremely long winded story has more to do with the fact that I’m seeking advice and validation, maybe some encouraging words of wisdom than anything else.. Its my first time posting on any forum regarding addiction recovery 🙂 and I’m doing what I can to defeat whatever is plaguing my mind. Thanks for reading

  4. […] Post Acute Withdrawals – PAWS lasts up to a year and there is no medication that can help manage these difficulties, some Doctors prescribe anti-depressants however they can create problems with natural brain chemistry and natural Dopamine production. […]

    • Terry Gorski says:

      I believe that there are treatments that can help manage PAW. In severe cases and when coexisting disorders especially depression are present, there are medications that can help. Here are the recommended steps in managing PAW:

      1. Accurate Information: Explain PAW and have the person do a self-evaluation of PAW and review the results. This will give them words and ideas to explain what they are experiencing. It will also help people to stop feeling crazy, judging themselves for having the symptoms, and being anxious and afraid because they don’t know what is happening.

      2. Stress management: relaxation and meditation. PAW is stress sensitive. This means the symptoms get more severe when experience high stress and less sever under low stress levels.

      3. Proper Diet: Have an alcohol and drug free diet. Eat a high protein, complex carbohydrate meal plan. The closest diet plan is is a hypoglycemic diet. Ask a nutritionist or look it up the internet. Avoid foods high in sugar and limit your caffeine intake. Supplement with multiple vitamins,Vitamin B-12, and broad spectrum amino acids.

      4. Aerobic Exercise: At least twenty minutes per day at least there-days per week in a heart-measured aerobic zone. (Subtract your age from 220. 80% of that number is you minimal training zone. 80% is the max). Too high or too low don’t seem to help much.

      5. A Recovery Program: Have a regular schedule of recovery activities that put you in places and around people who support your recovery and where you can honestly talk about yourself without judgment. It is also important to having a sponsor/mentor and therapist trained as an addiction professional.

      These practices stabilize brain chemistry. Don’t leave PAW management to chance. Get a plan. Work the plan. If it doesn’t work, get additional help.

      Please don’t spread the mistaken belief there is nothing that can be done to lower the severity PAW symptoms. THIS JUST IS NOT TRUE. The brain is plastic. It grows in response to experiences especially when stress in managed well during the experience.

      THE MIND IS A POWERFUL THING.

  5. […] PAWS or Post acute withdrawals sometimes can drag on for a year or more after the acute or first stage known as the “Crash” which lasts about a week. After this there are more subtle and long lasting symptoms such as low energy and depression or mood swings. […]

    • Terry Gorski says:

      In severe cases, PAW can persist for years. Since it is a stress sensitive bio psychological condition symptoms get worse during times of high stress. With proper management even people with severe PAW can learn symptom management skills that will allow them to live a normal life.
      We can always do something to get just a little but better. The mind is a powerful thing and the brain grows and changes in response to our experiences at all stages of life.

    • Terry Gorski says:

      Thank you for linking to my post. Please recommend to others who might be interested.

    • Terry Gorski says:

      PAW, when untreated, follows a slow pattern of recovery often marked by a periods of severe symptoms and cravings at 90 to 120 days of recovery. This is often called “hitting the wall.”

      Patients who follow the recovery suggestions in this PAW blog don’t follow the typical course of people who do nothing to learn PAW prevention and management skills. The severity and duration of PAW episodes really can be reduced with with proper lifestyle changes.

  6. […] addition to the physical detoxification process Post Acute Withdrawals or PAWS can last up to a year this includes many challenging symptoms and potential relapse […]

  7. Johnc626 says:

    Good blog! I really love how it is easy on my eyes and the data are well written. I am wondering how I could be notified whenever a new post has been made. I have subscribed to your feed which must do the trick! Have a nice day! ecgageceekbc

  8. AJS says:

    Hi I smoked marijuana from 14 – 29 years old every day, multiple times a day. I quit because I experienced a panic attack and I havnt looked back. Currently just passed my 1 year weed free mark. When I first quit the depression and anxiety were absolutely horrible. I went the first 8 months on a 2 week feeling ok and 2 week feeling like I can’t go on another minute cycle. Now Its more like every 2 months I hit a point where I just hit a wall for a few weeks then I bounce back. I still have a bit of anxiety during my good times but that’s probably just the real me I never let my self experience before. I am starting to get a bit discouraged after nearly 13 months and still going through this cycle. Would you say this is extreme for marijuana? I’m sure I can see improvements but it’s hard when you’re in the moment. It’s a painfully slow process. I’ve done all the right things, eat healthy, exercise 5 days a week, cbt therapy counselling. It’s very hard to find a professional who knows anything about paws. Most brush it off and treat it more like you’re suffering from a mental illness not withdrawal from marijuana. Would appreciate you’re insight. Thanks very much.

    • Hi ,AJS
      I also smoked weed from 14-36 years old.But much other drugs and alcohol.It was a surprise when I began to panic when I smoked.It seems to be happening to a lot of people.I had to stop but I kept trying for a few years.I finally quit everything,all at once then soon cigarettes as well.So the length you are experiencing for weed is on par with other stories.I know that a lot depends on the time and amount you used .Great work on the exercise and diet.I kept a journal and a little after 2 yrs there were no significant cycles.You are making really good progress as the cycles are getting farther apart.You smoked for 15 yrs so that is quite awhile.I know how hard it is.13 months is not extreme.What helped significantly for me was volunteering.When I do this it is hard to see myself negatively.I also focus on the generosity of the community.not what does not seem to work well.I also practiced relaxed breathing so when I got a panic attack or anxiety a few belly breaths would calm me.Relaxed breathing has basically cured my panic attacks.When I had success I wrote in my journal.I also got involved in sport.When I used to try and get clean I went to gym.This time I joined swim team .Then triathlon races for fun.Now I mountain bike race for fun.I also did recreational running races .These athletic groups are fun and friendly.
      So I challenged my esteem and negative thinking when it occured and so I would also backtrack to find out why this negativity kept happening,had a thought started it.I found myself feeling how I felt when I was much younger.I had OCD and low esteem because of it .So I challenged myself with small risks to fight social anxiety.I got out into the community.I got support but built myself by giving support in volunteering.If you do this ,don’t work hard ,just get to know everyone.So what I believe caused my drug use in the first place was there waiting for me when I quit.so through backtracking I isolated the emotion of esteem and seperation from others and then I set about it to change.
      I wrote down the changes I would make.I also put time limits to act toward my goal.Using a system of small steps.
      Keep up the good work.You are doing the right thing to ventilate and reality testing.Check out this site for more info.
      TERRY GORSKI’S BLOG-POST ACUTE WITHDRAWAL-A COMPREHENSIVE GUIDE.
      the link is just above the comment section on this page

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