Individuals that have used any potent drug, particularly for a long-term and/or at high doses are known to experience significant short-term withdrawal symptoms. These symptoms may include things like dizziness, headaches, nausea, and vomiting. Over time, they usually lessen in severity as the nervous system and physiology adjusts to function without the presence of the drug.
Unfortunately, for many people the withdrawal period is not limited to a short-term. After the first couple weeks of discontinuation, individuals may find that their symptoms fail to lessen in severity for weeks, months, or in rare cases – years beyond when they were told they should be fully recovered from withdrawal. To add to their frustration, many medical professionals either fail to inform their patients or completely dismiss the possibility of protracted withdrawals.
This adds to the patient’s anxiety and often leads them to perceive that something more serious is wrong (e.g. a brain tumor) when their dizziness persists for months. Although it is important to always get a medical and neurological screening to rule out the possibility of something more serious, if symptoms emerge upon discontinuation from a drug – they are usually a result of withdrawal.
What is post-acute withdrawal syndrome (PAWS)?
Post-acute withdrawal syndrome (PAWS) refers to withdrawal symptoms that persist for an extended duration following drug discontinuation. Post-acute withdrawals are most commonly referenced among individuals discontinuing opioids. This is due to the fact that during opiate withdrawal, individuals often endure intense short-term symptoms and think that their withdrawals will be over after they “weather the storm.”
In many cases, the short-term symptoms lessen, but never seem to go away. In some cases, new symptoms may emerge and a person experiences long-term functional impairment. This long-term impairment may last for weeks, but often persists for months – and in some cases years – beyond the expected date of recovery.
The condition is not limited to those discontinuing opioids, it commonly occurs among those discontinuing alcohol, benzodiazepines, antidepressants, antipsychotics, and other psychoactive drugs. Although “post-acute withdrawal syndrome” is not recognized by the Diagnostic Statistical Manual of Mental Disorders (DSM) or by any medical associations, to deny or dismiss its existence is short-sighted.
- Source: https://www.ncbi.nlm.nih.gov/pubmed/8097618
Factors influencing Post-Acute Withdrawal Syndrome (PAWS)
If you are experiencing or have experienced post-acute withdrawal syndrome, it is important to consider the factors that may have influenced its duration. The factors listed below may play a role in influencing both the severity and number of symptoms you experience.
1. Time Span
In general, the longer the duration over which you’ve taken a drug, the greater the severity of withdrawal. Those that have been medicated for years, discontinue a drug, and expect to feel back to 100% within weeks are often deluded. Over a long-term, the drug has made changes to your physiology and brain that take a very long time to recover.
In fact, sometimes the recovery period may be longer than the term over which you used the drug. If you’ve been taking an antidepressant for 10 years, decide to stop, and hope that you’ll feel normal in just a couple weeks is completely misguided. Whatever chemical you had been supplying your body with for a long-term will result in a temporary deficiency upon discontinuation.
It can take awhile for your body (a complex system) to repair all of the changes that were made by the drug and re-learn how to manufacture an endogenous supply of neurotransmitters, hormones, etc. Those that had taken opioids for a long-term often experience “PAWS” because their body needs to re-learn how to manufacture its own, endogenous endorphins rather than rely on a synthetic drug.
Most individuals experiencing post-acute withdrawal syndrome are likely to have taken their drug on a daily basis or multiple times per day. The greater the frequency over which you took a particular drug, the more likely you’ll be to experience post-acute withdrawals. Someone who takes a drug once per week has a virtually zero percent chance of experiencing post-acute withdrawals.
This is due to the fact that most of the week a person is functioning without the drug. However, a person taking a benzodiazepine 4 times per day has essentially become both psychologically and physically adapted to the drug in order to function. Removing the drug from a person’s daily regimen, especially when used at a high frequency over an extended period of time is very likely to result in protracted or post-acute withdrawals.
If your body and nervous system have completely adapted to a drug that you’ve been administering at a high frequency for a long-term, it will probably take awhile to not only reverse changes made by that substance, but also restore homeostatic functioning. Those taking drugs that are active for 24 hours are at increased risk for post-acute withdrawal syndrome.
The effect of a drug is often dictated by the dosage administered. Taking the minimal effective dose is much less likely to result in a post-acute withdrawal than taking the maximum dose or a supratherapeutic dose. Certain drugs like opioids, benzodiazepines, and psychostimulants are associated with rapid-tolerance development.
This means that individuals often become tolerant to the effects of medically acceptable doses and find that they no longer offer any therapeutic benefit. At this point, an individual will find that they cannot function without the drug, but aren’t getting any benefit with their current dose. Some doctors and/or patients may end up taking supratherapeutic (higher than recommended doses) of drugs due to tolerance building.
These high doses produce even greater physiological change, resulting in more temporary relief. Before a patient knows it, they’ve dug themselves into an even deeper hole with this high dose. Discontinuing from supratherapeutic doses is regarded as the most difficult and most likely to produce post-acute withdrawal syndrome – especially if discontinued cold turkey.
4. Tapering vs. Cold Turkey
To minimize potential of experiencing post-acute withdrawal syndrome, it is always recommended to follow a tapering protocol. The speed by which you taper should be calculated based on your individual circumstances, the drug you’ve been taking, how long you’ve been taking it, and your dosage. As a general rule of thumb for antidepressants, dosing should be reduced by 10% per month, sometimes slower or quicker depending on the individual.
If you quit a drug cold turkey, your risk for post-acute withdrawal syndrome increases. This may be due to the fact that you were taking a high dose, and instead of allowing your nervous system to gradually adapt to receiving less of the drug, you strip the entire drug completely. By stripping your nervous system of a drug, it may experience shock and potential chaos.
A metaphor comes to mind associated with strength training. Think of tapering as gradually adding weight each week to help you get stronger. These gradual increases allows for slow adaptations. If you simply stop the drug cold turkey, it would be like loading up maximum plates on the bench press – it’s a lot tougher on your nervous system and you haven’t adapted to this weight.
To minimize the potential for post-acute withdrawal syndrome, it is always recommended to gradually taper off of whatever drug or substance you’ve been ingesting. This will allow your nervous system to slowly adapt to the changes rather than leaving it overwhelmed.
5. Individual factors
In some cases, two people may take the exact same drug, at the same dose, for the same period of time. However, one person may experience a withdrawal period that lasts 3 months, while another may experience a withdrawal period that lasts 9 months. What explains the difference between these two people? Individual factors.
Other factors that may influence the occurrence of post-acute withdrawal syndrome include: other drugs / supplements, environment, diet, genetics, exercise, stress, sleep, etc. If a person is taking supplements or other pharmaceutical medications, it may blunt their withdrawal symptoms. If a person is in a healthy environment, eating an optimal diet, practicing stress reduction, and getting quality sleep – they may recover quicker than a person in a polar opposite scenario.
It is also important to consider the fact that some people may have slightly superior genetics for recovery than others. Certain genetics may result in less severe withdrawal symptoms and promote quicker healing following long-term exposure to an exogenous substance.
What drugs cause post-acute withdrawal syndrome?
Drugs that have a significant effect on brain functioning are most likely to result in post-acute withdrawal syndrome. That said, theoretically any substance ingested over a long-term could result in noticeable protracted discontinuation effects. Below is a list of the drugs that are most commonly associated with post-acute withdrawals.
Alcohol: Protracted discontinuation effects have been associated with alcohol withdrawal since the 1990s. Although properly tapering off of alcohol may mitigate the potential of experiencing protracted symptoms, many people report withdrawal symptoms months after their last drink. It may take awhile for certain individuals to fully recover following a period of alcohol abuse or chronic alcohol consumption.
Antidepressants: Individuals taking antidepressants may experience post-acute withdrawals, especially if they discontinue “cold turkey.” Most popular antidepressants like SSRIs and SNRIs inhibit reuptake of the neurotransmitter serotonin. This reuptake is helpful over the short-term, but after awhile the drug stops working; this is due to tolerance. When a person discontinues antidepressants, their brain has to deal with the backlash of low serotonin and sort out an antidepressant-induced chemical imbalance – which can take a long time.
Antipsychotics: These drugs function primarily as dopamine receptor antagonists, meaning they bind to the receptors and inhibit stimulation from dopamine. This leads to a reduction in many of the positive symptoms of schizophrenia. They also elicit a broad range of effects on neurotransmission. When discontinued, withdrawal symptoms may linger for months (or years) before a person fully recovers.
Benzodiazepines: These primarily enhance the effect of GABA neurotransmission, leading to sedation and relaxation. Although they are the most potent anxiolytics, tolerance is rapidly established on benzodiazepines, leading users to end up on high doses. Should a person attempt to discontinue, they must taper as to avoid seizures and death. Even after tapering, withdrawal symptoms are often protracted, sometimes lasting years before full recovery is made.
Opioids: Regardless of whether you used illicit or pharmaceutical opioids, you may experience post-acute withdrawal syndrome following the acute-stage of withdrawal. Although the acute stage of withdrawal is regarded as the most severe, the functional impairment associated with protracted withdrawal may be difficult to cope with. The “PAWS” associated with discontinuation of opioids and opioid-related drugs may be due to reduced endogenous production of endorphins.
Psychostimulants: Those using psychostimulants for a long-term often build tolerance, end up taking high doses, and experience acute discontinuation effects. The acute symptoms are often followed by an extended post-acute withdrawal syndrome that persists for months after their last pill. This is due to downregulation of receptors and low dopamine stores that must be replenished. It can take a long time before the brain increases dopamine levels and receptor density.
Steroids: Anyone that’s been on corticosteroids for a long-term knows that the withdrawal can be serious. There are people that have taken drugs like Prednisone for years, attempt to discontinue, only to find that they experience protracted withdrawals. These protracted withdrawals may persist for years, often leading some patients to abandon the idea of considering withdrawal. For more information read various accounts of Prednisone withdrawal.
- Source: https://www.ncbi.nlm.nih.gov/pubmed/8040915
- Source: https://www.ncbi.nlm.nih.gov/pubmed/1675688
What causes post-acute withdrawal syndrome?
It is difficult to pinpoint the specifics behind each individual case of post-acute withdrawal syndrome. Some potential causes include: homeostatic adjustment, neural pathway adaptations, neurotransmitter levels, physiological adaptations, receptor densities, and stress.
- Homeostatic adjustment: Upon discontinuation of any drug or substance, the body attempts to function without it. It may have become well-adapted to receiving the chemical that it had been getting each day, but when the supply was cut, it still needed to function. It is attempting to restore biological homeostasis, which can take a long-term and be quite uncomfortable.
- Neural pathways: The neural pathways that you had used on the drug may be rendered relatively useless without the drug. New neural pathways are formed anytime a stimulus (including a drug is introduced). When the drug supply is cut, these neural pathways become weaker, leading you to form new neural pathways without the chemicals that you’ve been ingesting.
- Neurotransmitter levels: It is thought that most individuals experiencing PAWS have abnormal levels of certain neurotransmitters. These may be directly related to the neurotransmitters that were targeted by the drug they had been taking. For example, long-term amphetamine usage may have depleted certain dopamine stores.
- Physiological adaptations: The body is a complex system and to think otherwise is foolish. The longer you’ve taken a drug, the greater the number of physiological adaptations have taken place. This includes your gut bacteria, hormones, neurotransmitters, digestion, etc. During post-acute withdrawal syndrome, these adaptations must readjust and revert back to homeostasis, which can take a long time.
- Receptor densities: The densities of certain neurotransmitters may have been altered as a result of your drug use. For example, someone taking the drug Adderall may experience a dowregulation of dopamine receptors due to excess dopaminergic stimulation while on the drug. It can take an extended period of time before dopamine receptor density increases.
- Stress: One of the biggest culprits for post-acute withdrawal syndrome is that of stress. Many people become stressed because their withdrawal symptoms are highly severe and protracted, leading them to believe they have a more serious disease. To exacerbate things, their doctor tells them that withdrawal shouldn’t last longer than a week or two. High stress can extend withdrawal, impede recovery, and amplify the intensity of symptoms.
Post-acute withdrawal syndrome mechanisms
The specific mechanisms responsible for post-acute withdrawal syndrome are generally a result of the particular drug that a person is withdrawing from. A person experiencing PAWS from benzodiazepines may exhibit deficiencies in the neurotransmission of GABA, whereas a person experiencing PAWS from opioids likely has abnormally low levels of endorphins. If you want to pinpoint some specific mechanisms behind your PAWS, just look at the drug(s) that you were taking.
If you were taking an SSRI antidepressant, chances are that your brain is now failing to produce as much serotonin as it was getting while you were on the drug. In fact, your pre-drug baseline level of serotonin was likely greater than following your discontinuation. This is due to the fact that your brain became reliant on the drug for its serotonin supply and now needs to work harder to manufacture that particular neurotransmitter.
If you were taking multiple drugs, the mechanisms behind your PAWS may get more complicated. Theoretically it could be possible that someone taking high doses of amphetamines and high doses of opioids simultaneously over a long-term may exhibit PAWS as a result of both drugs. In this case, a dopaminergic depression as well as an endorphin depression may be experienced.
Post Acute Withdrawal Syndrome (Symptoms)
Below is a list of some common symptoms you may experience if you’re dealing with post-acute withdrawal syndrome. Keep in mind that the number of symptoms, type of symptoms, and intensity of symptoms – are all subject to individual variation. Many symptoms may reflect the specific type of drug that you’ve discontinued.
Also understand that symptoms may appear on an intermittent basis. In other words, you may feel well for a couple days, and then experience dizziness the next day. Certain symptoms may be more bothersome than others and nearly all symptoms can be exacerbated by stress.
- Anhedonia: Many people report that they don’t feel the same interest in life during PAWS compared to while they were on a medication or even pre-medication. It is especially common for individuals to experience prolonged anhedonia or inability to experience pleasure during post-acute amphetamine discontinuation. This anhedonia often stems from reduced production of neurotransmitters that help us experience pleasure.
- Anxiety: It is also very common to experience post-acute anxiety upon discontinuation of any medication. This post-acute anxiety is very common among benzodiazepine users who may note a severe spike in nervousness following medication discontinuation. In the case of benzo users, this is a result of decreased GABA functioning.
- Cognitive impairment: Some people feel as if they’re experiencing permanent brain damage as a result of the drug that they had discontinued. This is due to the fact that they aren’t able to think clearly and their cognitive performance is compromised. Although the cognitive impairment is not usually permanent, it can be frustrating to put up with poor executive functioning for months or years while your brain heals.
- Concentration problems: Most people will note that they cannot organize their thoughts or focus. Their concentration seems as if it has no hope of ever returning. This incessant “brain fog” is usually caused by neurotransmitter deficiencies, particularly dopamine. This is especially common among those who’ve used psychostimulants for a long-term and then discontinue only to find that their concentration is worse than before they took the medication.
- Cravings: During the post-acute phase of withdrawal, it is very common for people to experience cravings. They may crave the drug that they discontinued because they dislike the way they feel without it. They may also experience psychological cravings if they had withdrawn from one of the most addictive drugs (e.g. heroin). Cravings generally become less frequent the longer a person has remained abstinent from the drug that they discontinued.
- Depersonalization: Sometimes depersonalization may last for months or a full year during post-acute withdrawal. This is characterized as feeling unlike your “normal” self. You may feel as if you’re completely “numb” or as if your soul has been extracted only to never return. This is a result of neurotransmitter deficiencies and can be exacerbated by stress.
- Depression: It is common to experience a severe, moderate, or even low-grade depression during post-acute withdrawal. If you were taking an antidepressant, there are ways to distinguish withdrawal symptoms from the original mental illness returning. Many people will experience some depression during post-acute withdrawal syndrome, regardless of whether they were depressed prior to using the drug that they’ve discontinued.
- Emotional instability: You may find yourself increasingly angry or irritable during post-acute withdrawal. This may be related to dysfunctional neurotransmission and stress. If you feel as though every little thing triggers anxiety, anger, or irritability, just know that this is fairly normal. Over time it will usually subside, and can be mitigated with stress reduction exercises.
- Fatigue: Many people experience such extreme fatigue after withdrawal from a drug, that they may actually fit diagnostic criteria for chronic fatigue syndrome. This fatigue may persist for months following discontinuation of the medication and result in excess daytime sleepiness.
- Hypochondria: Since you are experiencing post-acute withdrawals, you may actually become a hypochondriac. Not only are you hypersensitive to every little sensation you experience, but your doctor may have told you that there’s “no way you’re still withdrawing.” Being told this is harmful due to the fact that it often leads to obsessing over the possibility that you may have some undiagnosed rare disease; after all, you still have these wicked symptoms.
- Hypersensitivity: Most people will report that lights are still too bright, sounds are too loud, and every tactile sensation is overwhelmingly painful. If you feel hypersensitive and as if you’d rather live in a bubble than function in the “real world” this is normal. Your nervous system is healing and is delicate to every little sensation.
- Insomnia: The most common impediment to sleep is that of insomnia. You may experience overwhelming insomnia characterized by an inability to fall asleep at night and/or an inability to stay asleep. As your brain continues to restore neurotransmitters, receptors, and parasympathetic activation, the insomnia should subside.
- Memory impairment: There is evidence that using benzodiazepines can cause dementia. That said, many people will experience some degree of memory impairment when they discontinue a drug. While memory impairment is most associated with benzodiazpines, it can occur during a protracted withdrawal phase from any drug. Over time, your memory should improve and the impairment will become less noticeable.
- Motivational deficits: Many people experience avolition or lack of motivation to complete work or school-related tasks upon discontinuation of their drug. The avolition may persist for months or up to a year after they’ve been abstinent. This often goes hand-in-hand with the PAWS symptom of fatigue.
- Obsessive-compulsive behaviors: Your thoughts may become obsessive and difficult to control. In fact, you may feel as if you’ve developed OCD during post-acute withdrawals. The obsessive-compulsive thoughts and behaviors may be a result of neurotransmitter abnormalities and are commonly associated with PAWS stemming from benzodiazepines.
- Panic attacks: Your nervous system feels shredded and you’re dealing with cortisol spikes. Your sympathetic nervous system dominating your parasympathetic functioning and epinephrine levels are through the roof. When your sympathetic nervous system is dominant and your neurotransmitters are at suboptimal levels, panic attacks may ensue.
- Social withdrawal: Many individuals withdraw from socializing as a result of post-acute withdrawal syndrome. Not only are they feeling anxious, depressed, emotionally unstable, and tired – they may feel as if they cannot even hold a conversation. Forcing yourself to interact with others in a low stress environment can actually expedite recovery.
- Suicidal thoughts: If you’re experiencing suicidal thoughts, it is recommended to work with a professional. A psychotherapist can be great for teaching you how to cope with these thoughts, but further intervention may be necessary. In my own experience, these thoughts were persistent for months after my withdrawal and took awhile before they lessened in severity.
Post-Acute Withdrawal Syndrome Treatment
If you want to reduce both the severity and number of symptoms you’re experiencing during withdrawal, you have some options. You could consult a psychiatrist, work with a psychotherapist, make healthy behavior changes (e.g. stress reduction), and consider supplementation.
- CBT: If you are dealing with post-acute withdrawal syndrome, a smart intervention is that of cognitive behavioral therapy. CBT will help you identify dysfunctional thinking and make behavioral changes to optimize your recovery. A licensed psychotherapist or psychologist may also provide you with much-needed emotional support during PAWS.
- Exercise: Partaking in light exercise such as daily walking may help speed recovery. Some exercise is known to promote healing, whereas too much exercise (e.g. excessive cardio) is a bad idea and will likely impede recovery.
- Nutrition: If you are shoveling down refined grains, processed foods, and sugars – PAWS may be exacerbated. Eat plenty of vegetables, healthy fats (e.g. MCT Oil), some protein, with some healthy carbohydrates and fruits. Making dietary adjustments can significantly reduce the intensity of your post-acute withdrawal syndrome.
- Pharmaceutical drugs: There may be some pharmaceutical drugs that could be prescribed to help mitigate post-acute withdrawal syndrome. You may want to work with a psychiatrist or specialist to help you come up with a treatment protocol. For example: Flumazenil has been thought to help with protracted benzodiazepine withdrawal and Acamprosate may help with certain post-acute alcohol discontinuation symptoms.
- Sleep: It may be tough to sleep during PAWS as lingering insomnia is a common symptom. There are many natural supplements like melatonin that may provide some benefit. Try to go to bed at the same time each night, and wake up the same time each morning – this helps your circadian rhythm.
- Stress reduction: Perhaps the most important treatment for PAWS is that of stress reduction. If you can manage to reduce your stress level and avoid freaking out each time you notice a symptom, you’ll likely have an easier time coping. For stress reduction, I’d recommend using an emWave2 or taking up a meditation practice for 20 minutes per day. This will help shut off your sympathetic nervous system and promote relaxation.
- Supplementation: There are many supplements that you could take during PAWS to help lessen symptoms and expedite recovery. I’ve written about the best supplements for antidepressant withdrawal, many of which also can be used during withdrawal from other drugs. I’d avoid a multivitamin and focus on nutrition and select supplements that you may need. A blood test may be advisable to help determine the most beneficial supplements.
- Tapering protocol: If you withdrew from a drug too quickly, you may want to go back on the drug, stabilize, and conduct a slower taper. Follow a tapering protocol, but make adjustments based on how you feel. Realize that some discomfort is inevitable with each consecutive dosage reduction. That said, a slower taper has potential to reduce the severity of your PAWS.
How long does post acute withdrawal syndrome last?
Everyone wants to know how long post-acute withdrawal syndrome will last, but there’s no definitive answer. There have been cases of individuals in the comments section of this site reporting that their post-acute withdrawal syndrome persisted for years. For most people, post-acute withdrawal syndrome will last somewhere between 6 months and 4 years.
A majority of post-acute withdrawal symptoms will clear up within the first year of discontinuation. That said, if someone was on a high dose of a drug for a long-term and didn’t properly taper, they may end up dealing with a much longer withdrawal period. A majority of individuals will notice that symptoms tend to fade in time.
Some individuals may notice that certain symptoms such as “brain zaps” may persist for years after drug usage. In these cases, nutritional, supplemental, and other physiological interventions may be advised. It is also important to consider the fact that exposure to stress, trauma, or unexpected life changes may extend the duration of post-acute withdrawal syndrome.
My Personal Experience with PAWS
I unknowingly had my first experience with PAWS following Paxil withdrawal. At the time I was 15 years old, and my doctor told me that my withdrawal from this medication shouldn’t last more than a couple weeks. The acute withdrawal was horrific, but I noticed several months after taking Paxil that I still felt absolutely awful.
Even a year after taking Paxil, I reported dizziness, headaches, hypersensitivity, and was socially withdrawn. Since the doctor said that I shouldn’t be experiencing withdrawal, I figured I must’ve been going crazy and that he must be right because he’s the professional. In reality, he was just going off of cherry-picked information given to him by the pharmaceutical reps.
It wasn’t until years later that people realized there was even such thing as “antidepressant withdrawal.” To make things worse, I would eventually end up going through Xanax withdrawal (the extended-release version) and my all-time worst nightmare of Cymbalta withdrawal. Withdrawal from the Cymbalta left me to experience a depersonalization and pushed me into a state of hypochondria that lasted years.
Without the help of a highly skilled therapist, I may have actually convinced myself that there was no such thing as PAWS, that my withdrawal symptoms were “all in my head,” and that my doctor was omniscient. Thankfully I survived PAWS coupled with PTSD which was the toughest thing I had ever done; my full recovery took well over 5 years from the combination. Had I not come to the realization that I was experiencing post-acute withdrawal syndrome, I may still be playing antidepressant roulette and making myself more mentally ill.
Have you experienced post-acute withdrawal syndrome?
If you’ve experienced post-acute withdrawal syndrome, feel free to share your experience in the comments section below. Mention the drug(s) you discontinued, how quickly you tapered, and how long your post-acute withdrawal syndrome lasted. Keep in mind that the duration and symptoms associated with post-acute withdrawal syndrome (PAWS) is subject to significant individual variation.