Post-Acute Withdrawal Syndrome (PAWS)

What You Should Know About PAWS

Post-Acute-Withdrawal Syndrome (PAWS) refers to a set of impairments that can persist for weeks or months after the abstaining from a substance of abuse. PAWS may also be referred to as post-withdrawal syndrome, prolonged withdrawal syndrome, or protracted withdrawal syndrome. The condition is marked by symptoms similar to those found in mood disorders and anxiety disorders, including mood swings, insomnia, and increased levels of anxiety even without any apparent stimulus.

PAWS symptoms most commonly manifest after a withdrawal period from alcohol, benzodiazepines and opioids, but have been known to occur with (cessation of) use of other psychoactive substances. It is estimated that 90 percent of recovering opioid users experience the syndrome to some degree as do 75 percent of recovering alcohol and psychotropic abusers. The precise mechanisms behind PAWS are still being investigated, but scientists believe the physical changes to the brain that occur during substance abuse and are responsible for increased tolerance to the substance are responsible for the recurring symptoms.

Signs And Symptoms

Symptoms of PAWS tend to fluctuate in severity, and may disappear altogether only to reappear at a later time. Some of the most common symptoms of PAWS include:

  • Difficulty with cognitive tasks, such as learning, problem solving, or memory recall
  • Irritability
  • Feelings of anxiety or panic
  • Depressed mood

Other symptoms may include:

  • Obsessive-compulsive behaviors
  • Difficulty maintaining social relationships
  • Craving originally abused substances
  • Apathy or pessimism
  • Disturbances in sleep patterns
  • Increased sensitivity to stress

These symptoms tend to increase in severity when triggered by stressful situations, but might flare up even without any clear stimulus.

Causes And Risk Factors

It is thought that PAWS is the result of physiologic changes that occur in the brain as a result of substance abuse. During drug abuse the brain makes adaptations to accommodate for the changes in available neurotransmitters, and these changes can result in excitability when levels of these neurotransmitters change during abstinence. Scientists hypothesize that that the brain’s capacity to deal with stress is reduced with prolonged substance abuse and the related withdrawal experiences. Infants born to mothers who have repeatedly abused substances are also at risk of developing PAWS.

PAWS can manifest after withdrawal from almost any abusive substance, but those abusing benzodiazepines seem to be the most at risk. There have been reports of benzodiazepine abusers experiencing symptoms of PAWS for years after final cessation of the abuse.


Treatment is generally administered over an extended period of time because the symptoms of PAWS can continue for months or years. Acamprosate, a drug commonly used to help recovering alcoholics, has been found to be somewhat effective in managing some PAWS symptoms. Other drugs may also be used. Most patients undergo psychotherapy as well, in the form of behavioral therapy, group therapy, or both to learn to cope with the symptoms.

PAWS can be challenging to deal with, especially after going through detox and then working to resist relapse. The unpredictable fluctuations of symptoms can be stressful, but a combination of drugs and therapy can help make those symptoms more manageable. The UCLA Dual Diagnosis Program can help you recover from addiction and co-occurring mental health conditions as well as deal with the ongoing symptoms of PAWS.