What Is PAWS? What Is Its Role in Recovery?

When you first hear the word “PAWS,” the word might make you think of clumsy lion cubs or a big, furry Saint Bernard dog. But that’s where the cuteness ends. Unfortunately, PAWS, or post-acute withdrawal syndrome, refers to the not-so-cute psychological symptoms that often set in after an addictive substance has left our systems. They can persist for months. What are the post-acute withdrawal symptom, and what does PAWS recovery look like? Let’s see what science has to say.

What Is PAWS?

First, let’s clarify the difference between regular withdrawal syndrome and the post-acute withdrawal kind.

Defining Withdrawal

When we use a substance such as alcohol for a long period of time, our body and brain get used to it. Addiction hijacks the brain’s reward system, which relies on the feel-good neurotransmitter dopamine to steer us toward behaviors and substances that make us — yes — “feel good.” While it evolved to keep us alive by encouraging us to look for foods that taste good and to seek out romantic partners, the system is vulnerable to anything that provides instant gratification, such as drugs, gambling, or even excessive shopping. 

All of these activities flood the brain with “free” dopamine, and it starts to expect the constant supply as the new normal. With time, the body also gets used to the new state of things. As a result, if the supply of dopamine suddenly stops, the body and brain stage a revolt, which manifests as withdrawal symptoms.

• We might get nauseous and have trouble holding down food.
• Our heart rate might increase, and we might sweat more due to overstimulation of our autonomic nervous system.
• Our sleep gets disrupted.
• Our mood changes as the levels of feel-good neurotransmitters are depleted.
• Anxiety ramps up as dopamine levels plummet, and dynorphin levels ramp up.
• We might get intense cravings for alcohol (or whatever substance we’ve been using).
• In severe cases of alcohol withdrawal in particular, we might experience seizures and delirium tremens — the most serious (and potentially life-threatening) withdrawal effect.

How Is PAWS Different?

Unlike “acute” withdrawal symptoms, which set in around 24 hours after our last drink, peak for a couple of days, and dissipate within about a week, PAWS stages what feels like a sneak attack and can linger for months after there are no traces of the substance in our system. It’s not unique to alcohol — in fact, research shows that PAWS is associated with many different substances:

• Alcohol
• Opioids (heroin and prescription opioids)
• Benzodiazepines
• Stimulants (such as amphetamines) 
• Marijuana
• Nicotine
• Caffeine
• Antidepressants
• Antipsychotics

PAWS Symptoms and Causes

While less medically dangerous than the symptoms of acute withdrawal, the mixture of physical, mental, and emotional turmoil that PAWS can bring may be just as (if not more) distressing:

• Mood fluctuations. We might feel on top of the world one moment, down in the dumps the next, and irritated or angry shortly after. Mood changes are one of the most common symptoms of PAWS,  the direct result of the brain recovering from the neurotransmitter imbalances caused by addiction.
• Anhedonia. One of the most distressing symptoms of PAWS is the frequent inability to find joy in things that used to bring us pleasure. In the case of alcohol, this symptom tends to be at its worst during the first 30 days of abstinence.
  
  Like mood swings, this symptom is the result of neurotransmitter imbalances, with dopamine depletion playing a particularly significant role. Our brain needs time to read, and, in the meantime, activities that used to stimulate dopamine release naturally (such as meeting new people, engaging in creative tasks, reading, or spending time with loved ones) can feel unfulfilling. That “something is missing” feeling seems like it will never pass, although it certainly will.

• Stress sensitivity. Many people weathering PAWS find that their tolerance to stress plummets. A missed bus, a deadline at work — whatever the cause is, we might find ourselves easily going into full-blown panic mode. 
• Sleep disturbances and fatigue. PAWS can make us feel drained, disrupting our sleep patterns and leaving us feeling like we can never quite catch up. Even if we clock in the right amount of hours, we might feel like we’re running on empty.
• Difficulty concentrating. Our cognitive abilities might take a hit as well, making it harder to focus and keep our attention on tasks that require concentration. This is normal — it takes the brain some time to recalibrate. Though it might be frustrating to feel like we’re struggling to do tasks that came easily before, be patient. Our focus will return! 
• Anxiety and depression. We might feel our anxiety or depression ramp up as part of PAWS. It can be frustrating to deal with life without a chemical “crutch” to rely on (even though in reality, alcohol tends to worsen anxiety and depression in the long run). Especially after the acute withdrawal period is over, people might expect us to be “back to normal,” when in reality we still feel miles away from our former selves. It’s important to cut ourselves some slack in this case and be patient — we’ve been through a lot, and we need time to rest and recover.
• Cravings. Finally, cravings for alcohol (or the substance of choice) are a well-known symptom of PAWS. Even after physical dependence has ended, psychological dependence can persist for weeks, months, or even years. Once again, it’s important to be kind to ourselves when it comes to dealing with this understandably frustrating symptom. We’ll discuss some strategies on how to do so later on, but rest assured — there’s hope!

What Causes PAWS?

The cause of PAWS isn’t entirely clear. The brain is complex, and the simple truth is that it takes it a while to recover from the disarray caused by substance misuse. Certain genetic and environmental factors might also be at play.

But Does the Brain Eventually Recover?

Yes! Rest assured,” to “Yes! Take heart, PAWS isn’t permanent. Research shows that it might take a few weeks to several months, but most people find their way back to their former selves within about a year. As far as alcohol-related PAWS, a recent review in the Journal of Studies on Alcohol and Drugs suggests that symptoms tend to last 4-6 months.

Can PAWS Be Avoided?

The best way to avoid PAWS is to approach the initial withdrawal process with care by going to a detox facility — especially for those of us who’ve been drinking (or using other substances) for a long time. A gradual detox process is much more gentle on the brain and body, and it can get the recovery process off to a good start. The treatment for alcohol usually involves benzodiazepines, which have an effect on the brain similar to alcohol. These medications can be administered in a medical setting and tapered off gradually over a few days, making the recovery process much more comfortable.

How Is PAWS Treated?

In general, treating PAWS calls for a highly individualized approach, and what works for one person might not work for another. Unlike acute withdrawal, PAWS doesn’t come with distinct physical symptoms that can be addressed with medication or specific types of therapy. Basically, there’s no universal protocol for treating PAWS other than providing support and possibly treating such symptoms as anxiety, depression, and insomnia with medications

That said, here are several things that people have found helpful in overcoming PAWS:

1. Understand where your symptoms are coming from. It seems simple, but it can make a huge difference. Symptoms such as anhedonia, in particular, can be difficult to grapple with and feel as if they’ll last forever. However, as we’ve already mentioned — you won’t feel like this forever! Little by little, you’ll start seeing sparks of excitement and authentic joy reappear in your life. 
2. Reframe the process as part of the journey. Try to see this as a chapter in your recovery story or as a sign that your body and mind are healing. The process might not always be easy, but look at it as a time of growth, change, and renewal. It will be worth it in the long run! Be kind to yourself and celebrate your recovery, even the parts that feel challenging. You’re moving forward!
3. Start practicing minfulness. Mindfulness is a science-backed way to rebalance your brain chemistry, and it can work wonders when it comes to getting through psychological challenges like cravings. All it takes is a few minutes a day of simply observing your mind without judgment. There are many different ways to do it — you can try deep breathing exercises, meditation, yoga practice, sound healing, or various brainwave meditations.
4. Nourish your body. Nutrition, hydration, and sleep — these three elements of healthy living go a long way toward minimizing the impact of PAWS symptoms on your life. When we’re not at our best emotionally, our eating and sleep habits tend to suffer. Keep your fridge stocked with plenty of fresh fruits and vegetables. Be sure to include healthy fats (such as salmon or avocados) in your diet to help your brain recover faster. 
5. Stay active. Exercise is amazing when it comes to restoring the levels of neurotransmitters depleted by alcohol use while releasing endorphins and lowering cortisol levels — all of which helps reduce stress. Pick an activity that you like, and stick with it. If going to the gym isn’t your thing — no problem! There are plenty of workout apps and YouTube channels with exercise videos to choose from. Some great ones to try? Popsugar Fitness and The Fitness Marshall have a little bit of everything. Heather Robertson is terrific for High Intensity Interval Training (HIIT), and The Studio by Jamie Kinkeade is full of fun dance workouts.
6. Talk to the pros. Connecting a therapist you connect with can make a huge difference in the recovery process as well. If you want to understand your thought patterns better, cognitive behavioral therapy (CBT) can help.
7. Make sure you have a support team around you. Supportive friends and family members are key to your recovery. It can also be incredibly helpful to join a recovery community to share stories and advice with people who are on the same path. (The Reframe forums are available 24/7 and filled with people ready to cheer you on!)
8. Find ways to boost dopamine naturally. While time is the best cure for restoring neurotransmitter levels that have been offset by alcohol, there are still ways we can speed this process along. One way is by forming authentic social connections — or reconnecting with old friends. It can be especially helpful to reestablish connections with people who remember the “real” you before alcohol got in the way. But building new bonds can work wonders as well! Now that you have access to your authentic emotions and personality (though it might not always feel like it quite yet), there’s so much to discover. Creative activities — anything that gets you in the so-called “flow” state — are great ways to boost dopamine naturally. Try whatever appeals to you — writing, gardening, learning a programming language, making quilts, making your own homemade granola — it doesn’t matter what it is as long as it gets your creative juices flowing.
9. Get excited about new opportunities. A big part of what makes the alcohol recovery journey — and PAWS in particular — so difficult is continuing to miss alcohol and its effects. It’s easy (and natural, brain-wise) to forget the bad parts and remember the “fun.” There’s even a name for it: euphoric recall. But you can be sure you’re not missing out on anything. In fact, it’s just the opposite! There’s a whole world of opportunities to discover, people to meet, and skills to learn. Try to look at this part of your life with appreciation and, most importantly, curiosity about the future. Who knows what you’ll discover without alcohol getting in the way?

Life After PAWS

Although it might not seem like it right now, there will be a time when PAWS will be behind you. Right now, you’re getting closer to that point every single day. It’s absolutely worth waiting for! Allow yourself to feel excited about the future and know that you’re on a journey to a more fulfilling, interesting, and meaningful life, and the weight of PAWS will start to lift sooner than you think.