Post-Acute Withdrawal Syndrome

If you are one of the 23.5 million people in the United States age 12 and over who need drug or alcohol rehab, you may be wondering what withdrawal is like. Tales from friends and others who’ve been through withdrawal can make it sound scarier, especially when you hear about post-acute withdrawal syndrome. What is it? What are the symptoms?

Post-acute withdrawal syndrome refers to a phase of withdrawal from drug and alcohol abuse that some people go through. Note that some people go through it, but not everyone. You’re more likely to experience post acute withdrawal syndrome in recovery from certain drugs like alcohol, benzodiazepines and opiates than with other drugs, although it’s possible to experience the symptoms from any kind of drug.

Despite the scary long name, post-acute withdrawal syndrome isn’t even officially classified as a mental disorder or recognized in the Diagnostic and Statistical Manual (DSM), the handbook mental health professionals use to officially diagnose mental illness.

The best way to counteract any kind of fear is through information. By looking at the facts about post-acute withdrawal syndrome, you can understand where it comes from, what it’s like, the symptoms, treatment and recovery process.

Causes of Withdrawal

Drugs, including alcohol, change how the brain’s neurons process and transmit chemical messengers. Some drugs block neurotransmitters. Others cause the neurons to release a flood of specific chemicals.

When you take drugs or drink heavily for long periods of time, your brain adapts to the higher levels of chemicals flooding into your body by changing the amounts and kinds of neurotransmitters it releases. Over time, you crave more drugs to achieve the same “high” because your brain has actually adapted to the different amounts of neurotransmitters in your system.

Withdrawal occurs when you stop taking drugs, because as the chemicals found in drugs and alcohol are removed from your system, your brain actually has to rebalance its chemistry. Neurons may be seeking higher amounts of specific chemicals, but the drugs that signaled your body to release them aren’t there anymore.

Most drugs affect the brain chemical called dopamine. Dopamine is the “pleasure” chemical. High amounts make you feel good. When you stop taking drugs, the dopamine drop can make you feel depressed or anxious. This is just one example of what happens during withdrawal with one specific drug, but it gives you an idea of how the body responds to drugs through withdrawal.

As your body looks for the chemicals in the drugs or alcohol that were removed and doesn’t find them, it may send you signals to “get more.” That’s why during the initial stages of withdrawal, there’s a strong level of cravings and discomfort during the first 24-48 hours after your last binge. Your body gives you signals to find more drugs or alcohol quickly to offset the discomfort caused by cravings, which are in turn caused by the imbalances in brain chemistry.

These imbalances can cause many symptoms. The exact symptoms differ according to both the unique combination of drugs and alcohol your body is used to and your own specific chemical make-up. Common symptoms include:

• Headaches
• Anxiety
• Irritability
• Nausea
• Shaking
• Feeling tired, or the opposite — feeling “wired”
• Insomnia
• Hallucinations
• Paranoia
• Itching skin
• Increased heart rate
• Muscle or joint pain

These symptoms are temporary, but some may be life-threatening. That’s why you should never try to detox from drugs or alcohol on your own. Abruptly stopping certain drugs can cause your heart to race or cause other medical problems that can lead to death. When you withdraw from drugs in a rehabilitation center or detox facility, you are monitored by the staff and given medications to see you safely through the initial stages of withdrawal.

After Acute Withdrawal: Post-Acute Withdrawal Syndrome (PAWS)

After the initial discomfort of withdrawal passes, some people move into what is known as Post-Acute Withdrawal Syndrome (PAWS). During PAWS, your body has finished the initial detox process and you are starting to recover. But there may be some lingering effects, especially after years of heavy drinking or drug abuse.

Think of PAWS this way: During the initial withdrawal, your body had a lot of work to do to detox your system from drugs. After the physical effects are finished, the psychological and emotional effects also need to heal. PAWS is the healing of the psychological and emotional aspects of an individual after the acute stage of withdrawal is complete.

What Are the Symptoms of Post-Acute Withdrawal Syndrome?

It would be great to have a checklist that every person in recovery follows, but as with anything involving human health and wellness, it’s not that simple.

PAWS can begin immediately after physical detox. It can be sudden or creep in gradually over the course of weeks or months. Symptoms vary according to the individual.

The symptoms of PAWS include:

• Mood swings
• Anxiety
• Irritability
• Tiredness
• Low enthusiasm or feeling “numb” at times
• Trouble sleeping, including bad dreams
• Difficulty concentrating

Many people describe PAWS as feeling like they’re on an emotional roller coaster. One day they feel happy and optimistic — the next day they feel sad and pessimistic.

At first, PAWS episodes last for several days or weeks. Generally, at the start of recovery, the bad stretches outnumber the good. As you continue in recovery, the balance will shift, and good periods outnumber the bad. This is the typical pattern.

An Example of PAWS

Let’s use this fictitious example to understand the effect of PAWS on recovery. “Sheila” is a 26-year-old in recovery for prescription drug and alcohol abuse. After withdrawing from both, she goes to 12 Keys Rehab for recovery.

During her first week at 12 Keys, she’s just relieved to finally be free from her drug and alcohol addiction. She feels a growing sense of optimism that everything is going to be okay, that she’s finally in the right place. She gets along well with her counselors and is making new friends.

Yet in a few weeks, she starts to feel sad. Recovery seems a lot harder than she initially thought. Every time she feels cravings coming on, she wonders if she’s really going to get well.

During these “down” phases, Sheila has trouble sleeping. She doesn’t want to go to meetings or therapy. She just wants to stay home and lay on the couch watching reruns all day.

This is an example of the “roller coaster” effect of PAWS. If Sheila sticks with her recovery program, she’ll find that what goes down does indeed come back up. The blues she’s feeling after the initial relief of recovery will pass, and she’ll be back on track soon.

Dangers of PAWS

The main danger of PAWS episodes as in the example of “Sheila” above is that a recovering addict may give in to the feelings of despair, sadness and depression and return to drug or alcohol abuse.

It’s easy to reach for something familiar to comfort ourselves when we feel down. During depressive episodes, many addicts feel that they’ll never get well or that something is wrong with them. Without adequate support from their recovery friends and network, they may actually relapse.

PAWS is a very real danger to recovery. It’s not just the depressive phases of PAWS that can endanger recovery. During the optimistic phases or the PAWS roller coaster ride, some people get too self-confident. They feel as if they have recovery locked in and can stop following their program of recovery. They may stop going to meetings, cancel therapy appointments or dabble in their old substances of choice, feeling like they’re immune to addiction because they are “recovered.”

Recovery as a Continuum

Neither attitude is healthy. When PAWS symptoms strike, they are merely a signal that the healing process is continuing.

Drug and alcohol addiction is called a disease for a reason, but it’s important to remember that it is a chronic disease. Chronic diseases have periods of relapse and remission. Multiple sclerosis, for example, is an immune system disease that attacks the central nervous system. Patients with M.S. have a chronic disease that must be managed through medication, diet, exercise and lifestyle changes.

Alcoholics and drug addicts also have a chronic disease. It too must be managed through a combination of diet, exercise and lifestyle changes. Unlike having the mumps or the measles, alcoholics and addicts never fully recover from their disease. With the right lifestyle changes, the disease “goes into remission” like an M.S. patient who is adequately managing their symptoms. But the disease of addiction never fully goes away. It’s always waiting to be activated again.

Recovery, then, is a lifestyle change for the most part. This lifestyle change involves taking good care of yourself. It means learning how to manage the emotional highs and lows of living so you don’t need to turn to drugs or alcohol as a barrier against emotions. When you experience PAWS symptoms, it’s your mind/body’s method of letting you know that it too needs healing.

Recovery isn’t a race with a starting line at detox and a finish line the day you leave rehab. Instead, it’s a continuous journey of self-discovery and growth that lasts a lifetime.
When PAWS symptoms strike, it’s important to keep this in mind.

Managing PAWS

There are several things you can do to manage PAWS symptoms if and when they occur during recovery.

• Accept your feelings: Learning how to accept your feelings can be hard. We are taught from an early age that some feelings are acceptable and others are unacceptable. But feelings aren’t good or bad — they just are. How you express and deal with your emotions can have good or bad consequences. Returning to drugs or alcohol has detrimental consequences to your physical, emotional and spiritual health. Although it’s not easy, learning how to accept your feelings, whether you feel happy, sad, elated or gloomy, is part of learning to live life on life’s terms. Understanding that PAWS feelings are temporary, passing and part of the healing process can go a long way towards helping you accept your feelings.
• Continue your program of recovery: No matter how you feel about it, you should continue to follow your complete program of recovery. Avoid making changes to your program without talking them over with your sponsor or therapist. Go to meetings even if you don’t feel like leaving the house. Eat healthy meals and avoid binging on ice cream or other comfort foods, which can cause minor chemical imbalances that can worsen PAWS feelings — not to mention a snug pair of jeans, which can also be depressing! Get plenty of exercise and sleep, both of which help your mental state. Continue to work your program, work the steps and participate in therapy. Gradually, the PAWS symptoms will lessen as you continue to make progress in recovery.

• Avoid isolation: Addiction is a disease of isolation. Even during your using days, when you may have been surrounded by people, it’s still a lonely feeling to be addicted to drugs or alcohol. Addicts tend to isolate when confronted with emotional ups and downs like PAWS. Make sure that you still go to meetings, where you’ll be around caring people who understand PAWS and recovery symptoms. Go to sober clubs or on sober outings with program friends who will provide you with company without the temptation to take drugs or drink again. Whatever you do, avoid isolation, which can lead you into feeling even sadder during PAWS’ down phases.
• Tell someone: Some people suffering from the symptoms of PAWS are embarrassed about how they feel. Telling someone what you’re going through can be very helpful to your recovery. Talk to your program sponsor or therapist. Tell them how you’re feeling. Perhaps they can share their experience, strength and hope to help you get through the tougher times. It will make you feel less alone after you share your feelings with someone.

One word of caution: If at any time you start thinking about suicide, contemplating suicide or thinking about relapsing, get help immediately. Call someone. Call 12 Keys. Call your sponsor. Whatever you do, please reach out. No matter how bad you feel during a downswing, life gets better.

Preventing PAWS-Related Relapse

You may have noticed a trend among the tips on how to handle PAWS symptoms. These are also many of the strategies and techniques recommended for preventing relapse. That’s not a coincidence.

PAWS often leads to relapse, but it doesn’t have to. With awareness and strategies in place to counteract the emotional changes you’re undergoing during recovery, you can continue to learn, grow, change and adapt.

There are several steps you can take to prevent relapse related to PAWS. These include:

• Practicing good self-care: Self-care means taking care of yourself. Most people, especially recovering addicts, have to learn healthy self-care techniques. Good self-care means taking time for yourself. It means not overloading your schedule with must-dos and should-dos, but including plenty of time for adequate rest, relaxation and downtime to unwind. It means not beating yourself up over little things but accepting that you’re not perfect. Good sleep habits, eating and exercise habits are all part of self-care.
• Avoiding overloading your schedule: Along with good self-care, avoid overloading your schedule, even with recovery activities. Some recovering addicts pack their schedule with tasks in the hope of avoiding unpleasant emotions or thoughts of relapse. Although this can work temporarily, it can also backfire into feeling burdened and exhausted.
• Watching nostalgic thinking: Dwelling on your using days or thoughts of old drug pals can prompt you to starting hanging out with your old friends. If they’re still using, you’re setting yourself up for relapse. Instead, change your thoughts to the present day. Think about today and perhaps a little into tomorrow. Remember the slogan “One day at a time,” which means you stay sober one day at a time. It also refers to the fact that we are given one day at a time — no more, no less. Stay in the present moment and avoid dwelling on the past.
• Considering additional therapy: If your therapist believes that your PAWS symptoms are exacerbated by unpleasant memories or strong emotions related to memories, EMDR therapy and additional therapeutic methods may help you release these emotions and reprogram how you think about them. These may help you process memories to prevent potential relapse.

How Long Does PAWS Last?

PAWS can roll like waves or come and go like the seasons. For many addicts, symptoms of PAWS fade after the initial recovery period. They may experience some ups and downs during their first months or years of recovery, but gradually the good periods overtake the bad, and the symptoms of PAWS fade.

For others, it will take years to fully divest themselves of PAWS. And that’s perfectly normal. Although you may wish you could move on more quickly, if you need years to feel better, that’s what you need. When it comes to PAWS, there’s no right or wrong way to recover.

By incorporating many of these strategies to deal with PAWS during your recovery, recognizing the signs and symptoms and getting post acute withdrawal syndrome treatment, you can prevent relapse and remain in a strong, positive and progressive recovery.

Recovery at 12 Keys

At 12 Keys, we understand PAWS and the phases of withdrawal. We have worked with many addicts over the years and we understand all that comes along with recovery.

From the day you call us to your last day here, you’ll be surrounded by caring staff who know what it’s like to be in recovery. Many of us are addicts ourselves and have gone through withdrawal, including PAWS, and we know what it’s like. We’re here to listen when you need someone to talk to, and we’re here to help you when you’re not sure what to do next and your feelings threaten to overwhelm you.

If you’re considering where to go for rehab, please call us. 12 Keys offers recovering addicts a safe, comfortable and, yes, beautiful place to heal.

12 Keys is located along Florida’s waterfront, and it feels more like you’re visiting friends or family than being in rehab. Our clients have private or semi-private rooms and bathrooms, comfortable living rooms and gathering places for meeting or just hanging out, and outdoor spaces to relax, continue your recovery reading or talk to others about recovery.

At 12 Keys, we offer mind, body and spiritual healing. This is called holistic recovery, and we think it’s the best way for people to recover from drug and alcohol abuse. You’ll participate in individual and group therapy sessions, 12-step meetings and more. Additional activities like horseback riding, swimming and kayaking take advantage of Florida’s great weather and our location to give you new activities to try as well as healthy exercises and time to make friends.

Recovery starts at 12 Keys. Call us anytime, day or night, to talk to an admissions counselor. We’ll ask you a few questions and help you start on the road to recovery. Please contact us today.