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Signs and Symptoms of Post-Acute Withdrawal Syndrome (PAWS)

post acute withdrawal syndrome symptoms

Post-acute withdrawal syndrome—PAWS, for short—refers to the symptoms that follow the acute phase of withdrawal from addictive substances. While the acute phase of withdrawal typically lasts for a few days up to a couple of weeks, post-acute withdrawal symptoms have been known to persist for weeks, months, even years after stopping substance use.

PAWS can be a challenging phase for individuals in recovery, significantly impacting their physical and mental well-being along with their ability to maintain sobriety. Understanding post-acute withdrawal symptoms is crucial for both people in recovery and healthcare professionals providing support.

Which Substances Trigger PAWS?

PAWS can occur with various substances, but some are more conducive to its triggering, due to their impact on the brain and body’s neurochemistry. Substances that primarily affect the brain’s neurotransmitter systems, particularly those involved in reward, pleasure, and stress response, have long been associated with PAWS. The following are some of the substances most conducive to users undergoing PAWS.


Long-term alcohol abuse disrupts neurotransmitter pathways, including those involving gamma-aminobutyric acid (GABA) and glutamate, leading to tolerance, dependence, and withdrawal symptoms. Alcohol-related PAWS can manifest in fluctuations of mood, anxiety, sleep disturbances, and cognitive impairment. These symptoms can last for months or even years after one has stopped drinking.


Opioids like heroin, morphine, prescription painkillers (oxycodone, hydrocodone), and synthetic opioids like fentanyl act on the brain’s opioid receptors. These receptors induce feelings of euphoria and pain relief. 

Therefore, prolonged opioid use can lead to neuroadaptation, tolerance, and dependence, resulting in withdrawal symptoms during cessation. PAWS from opioids may include mood swings, cravings, insomnia, and physical discomfort, lasting for an extended period.


Known as “benzos” for short, benzodiazepines like diazepam, alprazolam, and lorazepam are central nervous system depressants that enhance the effects of GABA, producing sedation, relaxation, and anxiolytic effects. Long-term benzo use leads to tolerance, dependence, and mental health symptoms like anxiety, insomnia, tremors, and cognitive impairment. PAWS associated with benzos may involve persistent anxiety, mood instability, and sleep disturbances.


Stimulants such as cocaine, amphetamines, and methamphetamine increase the levels of dopamine, norepinephrine, and serotonin in the brain, producing euphoria, increased energy, and heightened alertness. Chronic stimulant abuse can lead to neuroadaptation, tolerance, and withdrawal symptoms like depression, fatigue, cravings, and cognitive deficits. PAWS from stimulants may involve persistent dysphoria and difficulty concentrating.

Post-Acute Withdrawal: The Symptoms

Depending on the substance abused and such individual factors as genetics, overall physical makeup, and the duration and intensity of the substance abuse, PAWS can manifest differently for everyone. However, there some common signs and symptoms associated with PAWS across substances include:

Mood Swings

One of the hallmark symptoms of PAWS is wild mood swings. People can experience sudden shifts between feelings of euphoria and depression, irritability, or anxiety. Such mood fluctuations can be intense and unpredictable, making it challenging for individuals to regulate their emotions and healthcare professionals to prepare for outbursts.

Cognitive Impairment

One of the more debilitating post-acute withdrawal symptoms is the impairment of cognitive functions like memory, concentration, and decision-making. Some people struggle with forgetfulness, have trouble focusing on tasks, and experience confusion or mental fog. These cognitive impairments can impact daily functioning and productivity.

Sleep Disruption

Disrupted sleep patterns are common with PAWS. Those living with it may experience insomnia, hypersomnia—excessive sleepiness—vivid dreams, or nightmares. Meanwhile, disrupted sleep can exacerbate other symptoms of PAWS and contribute to fatigue and irritability during waking hours.

Physical Symptoms

PAWS manifests in various physical symptoms. These include headaches, muscle aches, tremors, gastrointestinal disturbances such as nausea, vomiting, or diarrhea, and noticeable changes in appetite or weight. These discomforts only add to the overall distress experienced during recovery.


Persistent cravings for one’s substance of abuse pose a significant challenge during PAWS. Even after the acute withdrawal phase has passed, individuals may continue to experience intense cravings, which can trigger relapse if not managed effectively. Cravings may be triggered by environment, stress, or heightened emotional duress.

Emotional Dysregulation

PAWS can disrupt the brain’s reward system and emotional regulation pathways, leading to heightened sensitivity to stress and difficulty coping with emotions. Individuals may struggle with managing anger, sadness, or frustration, and may resort to maladaptive coping mechanisms like relapse or self-harm if proper support is not there.


Anhedonia is the inability to experience pleasure or enjoyment from activities that were found fun or rewarding. PAWS has the capacity to dampen one’s ability to take pleasure from social interactions, hobbies, or other sources of fulfillment, contributing to feelings of emptiness or apathy.

Social Withdrawal

As a result of these post-acute withdrawal symptoms, individuals may withdraw from social interactions and isolate themselves from friends, family, and support networks during their recovery. This exacerbates feelings of loneliness, contribute to a vicious cycle of negative emotions.

Increased Sensitivity to Stress

PAWS can heighten sensitivity to stressors, making it difficult for people in recovery to cope with everyday challenges. Even minor stressors like misplacing one car keys, getting stuck in traffic, or minor kitchen mishaps tend to feel like the end of the world during this phase, increasing the risk of relapse as individuals seek escape.

Delayed Recovery

Pot-acute withdrawal syndrome prolongs the recovery process, delaying one’s ability to fully reintegrate into daily life and regain optimal functioning and wellness. This long phase of withdrawal can be disheartening for people in recovery, making them feel as though recovery will never get any easier. Of course, this only heightens the importance of patience and support.

The Importance of Support

With the right support systems in place—including medical supervision, therapy, group support, and modifications of lifestyle, those in recovery can successfully navigate PAWS to work towards long-term wellness. It’s therefore vital that healthcare professionals, loved ones, and individuals themselves work in unison to provide comprehensive support tailored to the unique needs of anyone living with PAWS.

To be successful, an addiction treatment must be tailored to address the specific alcohol or drug use patterns of the clients, as well as any drug-related physical and mental health concerns. Additional therapies like family counseling, individual therapy, and holistic practices like yoga also help people avoid relapse.

Find Help for Your Post-Acute Withdrawal Symptoms with Northpoint Recovery

Northpoint Recovery can help you or your loved one through the recovery journey, including the symptoms of PAWS. We offer CBT, DBT, and group support as part of our inpatient services for those in recovery. Of course, these services are fully customized to help support effective, individualized treatment. To enroll or find out more, call us today at 208.502.4867 or complete our online form.