There are several barriers to addiction treatment, both real and perceived. These barriers can include the cost, the availability of treatment, denial that there is a problem, not being ready to stop using, or being afraid of what will happen when they stop using.
Addiction encourages you to continue using your drug of choice on many different fronts. Emotional addiction causes you to lean on a chemical substance in times of struggle to better deal with trauma or mental disorders. Physical addiction causes you to have painful or unpleasant symptoms when you try to quit or cut back.
In many cases, persistent negative symptoms can drive you back into drug use even after you’ve gotten the drug out of your system. These symptoms are a result of Post-acute withdrawal syndrome or PAWS. This phenomenon causes uncomfortable emotional, cognitive, and physical symptoms all accompanied by powerful drug cravings. It can act as both a barrier to seeking treatment and a potential cause of relapse.
Though PAWS is a significant challenge in addiction recovery, it can be treated. In addiction recovery, you can receive medical treatment that can safeguard your sobriety after detox. Then, through therapy and addiction counseling, you can learn positive, effective coping skills to address underlying issues and prevent relapse in the future.
Understanding PAWS and the problems it presents can help you overcome it as a barrier to getting the treatment you need. The following guide will go through the signs and symptoms of PAWS, the drugs that cause withdrawal, and how it can be treated.
What is Post-Acute Withdrawal Syndrome?
In the hours and days after you stop using addictive substances, you may begin to feel uncomfortable symptoms. Acute withdrawal is the immediate onset of symptoms you experience when your body no longer gets a steady supply of a chemically addictive substance. When you become dependent on a chemical substance, your body will adjust to the levels of the foreign chemicals that you regularly introduce. For instance, in the case of cocaine addiction, the body will release less dopamine because of cocaine’s effect on the brain. If you suddenly stop doing cocaine, your body will experience an immediate lack of dopamine. The lack of this chemical will produce unpleasant symptoms almost immediately.
However, even after you’ve gone through acute withdrawal and broken your body’s dependence on drugs, you may still experience symptoms as your body adjusts. Post-acute withdrawal refers to the persistent symptoms that continue to occur for days or weeks after the initial withdrawal phase. It takes time for your brain to adapt to new neurochemical levels and there may be a period of time when you experience unbalanced brain chemistry. This can manifest in physical, cognitive, and emotional symptoms.
While we understand that withdrawal symptoms generally have to do with your body adapting to the loss of a chemically addictive substance, we don’t know exactly how or why PAWS occurs. Psychologists, doctors, and researchers have different theories but no one agrees conclusively as to the cause of post-acute withdrawal.
Some suggest that psychological adaptations cause persisting symptoms. In some cases, the underlying issues that lead to initial substance use and addiction return after a person goes through detox, which worsens withdrawal symptoms and causes intense cravings. In medical detox settings, medical staff and clinicians help clients avoid triggers that can exacerbate symptoms.
Signs and Symptoms of Post-Acute Withdrawal
The symptoms, intensity, and duration of withdrawal symptoms depend on a number of factors and may be different for each person. Certain drugs may cause specific sets of symptoms and your mind and body’s reaction to withdrawal may be unique. Different drugs work on different neurotransmitters that affect different brain functions. That being said, there are a few common symptoms that can occur in withdrawal from most addictive substances.
Symptoms can come and go, fluctuating in severity. While there are some drugs that can manifest in physical symptoms in the post-acute phase, most symptoms will be cognitive or emotional. Symptoms can include:
- Depression
- Anxiety
- Obsessive-compulsive behavior
- Feelings of guilt or shame
- Lack of concentration
- Problems with memory
- Panic disorder
- Insomnia
- Sleep disturbances
- Coordination issues
- Irritability
In some cases, physical withdrawal symptoms can occur even after the acute phase. Central nervous system depressants like benzodiazepines can cause seizures, even a few weeks after you’ve gone through acute withdrawals and the drug has left your body.
Because symptoms aren’t constant, some people in recovery assume they are finished with withdrawal after the acute withdrawal phase. However, PAWS can be triggered at any moment and one of the most common symptoms is an intense desire for your drug of choice. In many cases, people relapse a few weeks after the initial cessation because of these cravings and symptoms. Triggers often make symptoms worse and, outside the bounds of a structured treatment environment, triggers might be difficult to deal with.
Addiction is often caused by an underlying issue that can resurface after detox. For instance, if you have undiagnosed depression, and you have been self-medicating with alcohol to mask symptoms, stopping alcohol use can cause them to return. In many cases, the return of negative emotions can lead to crisis for people in recovery and drive them toward relapse. However, with help from counselors and clinicians, you can learn coping skills that help you avoid crisis and relapse. Plus, you’ll have the support of a team that’s experienced in treating addiction.
Substances That Cause Post-Acute Withdrawal Syndrome
There are a variety of drugs that cause Post-acute withdrawal symptoms, some of which can be life-threateningly dangerous. Episodes can manifest in different symptoms that last for a few days at a time, and they may come and go at random. In some cases, symptoms can be felt intermittently for as long as a year. Without treatment, symptoms can get worse or last longer. Many psychoactive substances have side effects that last for a long time, but drugs that cause chemical addiction are often worse when it comes to long lasting effects.
The following drugs can produce PAWS symptoms that last for a significant length of time after treatment:
Alcohol
Alcohol is a nervous system depressant that can have profound effects on the brain depending on the amount that is abused and for how long. In some cases, cognitive impairments can be permanent, especially in people that engaged in long periods of regular binge drinking as adolescents. Alcohol can slow a developmental process called myelination, which occurs in people under 25 especially during the teenage years. Myelination is the process by which myelin sheaths form on the axons in nerve cells. These sheaths allow your brain to send signals faster and without them, you may experience memory and cognitive processing issues.
Alcohol, like other nervous system depressants can have dangerous withdrawal symptoms, especially when a user ceases drinking abruptly. The more you are tolerant and dependent on alcohol, the more likely you are to experience dangerous symptoms. Alcohol withdrawal can cause alcoholic hallucinosis, a symptom involving visual, auditory, or even tactile hallucinations that come and go. Untreated alcohol withdrawal has a chance of causing withdrawal seizures at some point within the first 48 hours after the cessation of alcohol consumption. These tonic-clonic seizures come in two phases: The tonic phase, which is when a person loses consciousness and the body seizes up. The clonic phase is when muscles rapidly contract and relax causing convulsions that can cause bruising and injuries.
Finally, alcohol withdrawal can come with Delirium tremens (DT), a potentially deadly symptom causes disorientation, tremors, hallucinations, and seizures. DT can be fatal in 25 percent of untreated cases. For more on this symptom, see the section on Delirium tremens.
The overall autonomic instability (impairment of the body’s system that responsible for automatic functions that control the heart, bladder, intestines, and other vital organs) makes alcohol withdrawal very dangerous outside of medical supervision. However, medical detoxification can help curb these symptoms and avoid serious medical complications.
Dry Drunk Syndrome (DDS)
Post-acute withdrawal syndrome may cause other PAWS symptoms that occur long after someone has stopped drinking alcohol. A person in this stage of recovery may experience dry drunk syndrome (DDS). This condition occurs when someone has been sober for some time but still acts as if they are still dependent on alcohol.
A person dealing with PAWs from alcohol has actively stopped drinking alcohol, but they have not done the emotional and behavioral work they need to do to deal with the emotional and psychological challenges that initially led them to abuse alcohol. Someone who is “dry drunk” and dealing with PAWs alcohol symptoms can exhibit the following symptoms:
- Little to no impulse control
- Increased anxiety and/or depression
- Increased social isolation
- Jealous of people who do not have an addiction or people who don’t struggle with one
- Remembering and glamorizing the times they used to drink
- Preoccupation with one’s self; feelings of superiority
- Trading addictions (such as sex, gambling, food, internet)
- Detachment from one’s reality
A person who is a “dry alcoholic” may strongly feel like they have failed in recovery. They also may not feel especially motivated to get back into treatment or attend support groups.
Carole Bennett, M.A., wrote a blog for Psychology Today on the topic, saying some of her clients wondered why their relationships with former drinkers were on rockier ground despite their loved ones being sober. Bennett writes that people with DDS must work on the internal stuff, too.
“Without working on (and realizing that this part of recovery needs as much work as the physical addiction does) the emotional/psychological portion, the alcoholic may become lazy, irritable, easily annoyed or quick to anger and will defend and justify at the slightest questioning or provocation.”
She also lists other issues that can arise from alcohol-related PAWs symptoms:
- Resentment toward the person who “made” the person with DDS stop drinking (e.g., a spouse or parent)
- Realization that previous goals, dreams, and potential may be lost because of alcohol abuse
- Annoyance that a person’s drinking days have to be put behind them for good
- Not taking healthy risks or seeking new adventures due to fear of failure
What to Do If You or a Loved One Has DDS
First, show yourself or your loved one some grace and realize that setbacks happen in recovery. The sooner you work to correct them, the sooner you can get back on track and address the issues properly. You may want to reach out to a 12-step group, such as Alcohol Anonymous, or another kind of support group, such as SMART® Recovery, where you can connect with like-minded people who understand where you are and where you’ve been. You can also talk with a counselor or therapist about your dry drunk syndrome challenges and get direction on what to do next.
Remember, too, that you can always reach out to a treatment center and enroll in its inpatient or outpatient program so that you can learn how to manage your alcohol-related PAW symptoms. Inpatient programs require staying at the facility full time while receiving therapy, medications, and more. Outpatient programs, on the other hand, offer more flexibility and do not require a facility stay. You will be responsible for attending your required therapy hours while you are in the program.
A treatment facility’s staff can assess your needs and determine how to treat them. You don’t have to deal with post-acute withdrawal symptoms on your own. Asking for help and receiving it from the right sources will help you combat DDS and others PAWs alcohol symptoms that arise.
Benzodiazepines
Benzodiazepines (or benzos) are another nervous system depressant used to treat anxiety, insomnia, and seizures. Like alcohol, benzos can cause potentially deadly symptoms that are dangerous outside of medical treatment. Benzos activate gamma-aminobutyric acid (GABA) receptors in the brain that causes sedation, anxiolytic (anti-anxiety) effects, and muscle relaxation. When the brain becomes dependent on benzos, which can happen when they are taken regularly for more than four weeks, you can develop a dependence on the drug.
If you stop taking benzos suddenly, your brain would not be equipped to handle the sudden loss of foreign, GABA activating substances, and you would have an unbalanced brain chemistry. You may experience a “rebounding effect,” which is when the symptoms a drug was intended to stop return. Therefore, withdrawal can come with intense anxiety, muscular stiffness, and insomnia.
Benzo withdrawal can also come with the following symptoms:
- Blurred vision
- Chest pains
- Severe depression
- Pupil dilation
- Hypertension
- Fatigue
- Nausea, diarrhea, vomiting
- Weight Loss
- Mood swings
- Paranoia
- Tachycardia
Like alcohol, benzos can cause more severe symptoms like serious catatonia that can result in stupor, or having little to no cognitive or physical activity, and a range of other strange symptoms. In a significant number of cases, catatonia can be deadly. Benzo withdrawal can also cause convulsions, coma, hyperthermia, mania, and Delirium tremens. Depression symptoms caused by benzo withdrawal can be severe to the point of suicidal thoughts and actions.
Altogether, benzodiazepines may be the most dangerous commonly abuse drugs to withdrawal from. If you believe that you’ve developed a dependence on benzos, don’t attempt to quit cold turkey without medical assistance. Call Ocean Breeze Recovery at 855-960-5341 to learn more about options to treat benzo addiction safely.
Opioids
Opioids like prescription painkillers, heroin, and illegally produced synthetic fentanyl are among the most addictive, commonly abused drugs available. They are the driving force behind the current epidemic of addiction and overdose in the United States. While opioid withdrawal is seldom fatal, symptoms can be incredibly uncomfortable. Symptoms can often mimic the flu with nausea, vomiting, diarrhea, and muscle and joint soreness. It’s often likened to a particularly bad case of the flu.
Other symptoms of opioid withdrawal can include mental or emotional symptoms like depression, anxiety, and irritability. Non-physical symptoms tend to last longer and symptoms like depression can be fairly severe. If depression symptoms become dangerous to the point of having suicidal thoughts, seek help immediately.
One of the most common symptoms of opioid withdrawal is intense drug cravings. While opioid withdrawal isn’t life-threatening, it often leads to relapse and it can be incredibly difficult to get through withdrawal on your own without using. If you or someone you know is struggling with opioid addiction and you’d like to become drug-free, call Ocean Breeze Recovery to learn more about recovering from opioid use.
Cocaine
Cocaine is a stimulant with powerful addiction potential. Like opioids, cocaine withdrawal symptoms aren’t likely to be fatal but they are extremely unpleasant and they can lead to relapse. Cocaine withdrawal symptoms can come on quickly and, in the case of cocaine binges, crash symptoms can manifest almost immediately after your last dose wears off. Unlike opioids, cocaine symptoms rarely ever manifest in physical symptoms. Typical cocaine symptoms include:
- Agitation, irritability
- Restlessness
- Fatigue
- Depression
- Discomfort
- Increased appetite
- Sleep disturbances, nightmares
- Lethargy
As a stimulant, cocaine causes a flood of dopamine to pour into the synapses between nerve cells. Then it blocks reuptake, the process of recycling unneeded neurotransmitters. This means that dopamine stays in the synapse, causing a rush of excitement, energy, and a feeling of power. When you stop drug use, your brain is suddenly left without that stimulus and you feel depressed, lethargic, and uncomfortable.
Intense drug cravings are a common symptom of cocaine withdrawal and can make it incredibly difficult to quit on your own. In some cases, depression can lead to suicidal thoughts or actions. The safest, most effective way to detox from cocaine is to seek addiction treatment. Cocaine has a short half-life, which means that it leaves your system quickly and withdrawal can begin within 90 minutes of your last dose. Don’t hesitate to call as soon as you realize you need help.
Methamphetamines
Methamphetamines, or crystal meth, are other stimulants with high addiction potential and unpleasant withdrawal symptoms. Like cocaine and crack, meth offers an intense and immediate high that quickly fades. It also causes some users to engage in drug binges that can lead to deadly side effects, long-lasting cognitive impairments, and fatal overdose. After a binge, “comedowns,” or the feeling of the drug wearing off, can come with oppressive psychological symptoms.
Meth is a full agonist (a substance that activates a neurotransmitter) of multiple neurotransmitters in the brain including trace amine-associated receptor 1 (TARR1), which is responsible for controlling neurotransmitters like serotonin, dopamine, and norepinephrine. Those three neurotransmitters are three of the “feel good” chemicals that your brain releases. They cause you to feel happy, euphoric, and energized.
During a methamphetamine binge your brain will be flooded over and over with feel good chemicals with diminishing effects. The euphoria meth offers stops after the first few hits when your body runs out of endorphins and needs time to “recharge” so to speak. Still, people on a meth binge will continue to use trying to achieve the initial high. When you stop, the comedown is hard. The resulting brain chemistry imbalance and euphoria exhaustion can lead to an intense feeling of depression, hopelessness, and malaise.
Withdrawal symptoms begin within 24 hours after you stop using and withdrawal reaches its peak around the second week. PAWS symptoms can last up to a month. Symptoms can include paranoia, anxiety, confusion, insomnia, mood disturbances, and violent behavior. Some people in recovery from meth can display symptoms of psychosis like hallucinations, extreme paranoia, and delusions. In some cases, cognitive and psychotic effects can last for years.
Delirium Tremens
Delirium Tremens (DT) is among the most dangerous medical complications of withdrawal. It typically manifests within one to four hours after ceasing alcohol, benzodiazepine, or barbiturate use after developing a dependency. These three classes of addictive substances are in the category of central nervous system depressants, which create a relaxing or dulling effect in your brain. Depressants activate GABA receptors that cause relaxing, hypnotic, and sedative effects. In some cases, it can cause euphoria or a release of inhibition.
When you build up a tolerance and dependence to depressants, your brain will work overtime to try to correct the chemical imbalance that the foreign psychoactive substance is creating. It responds with its own excitatory effects. If you suddenly stop using a depressant, the floodgates are opened. The excitatory neurotransmitters are no longer fighting against the depressant and it overwhelms your brain with neurochemicals that cause anxiety, panic, aggression, and irritability.
People who have been heavily using depressants for extended periods of time have a greater chance of experiencing symptoms of DT. Signs and risk factors of DT include several earmarks. If the following factors apply to you, it’s important to seek medical help when you decide to quit alcohol or other depressants:
- Cessation of heavy alcohol/benzo use
- Autonomic hyperactivity, like a high pulse or excessive sweating
- Hand tremors
- Insomnia
- Visual, auditory, or tactile hallucinations
- Nausea and/or vomiting
- Psychomotor agitation, or excessive movement with no real purpose
- Anxiety
- Grand mal seizures (tonic clonic)
- Symptoms cause distress and get in the way of everyday life
- Symptoms can’t be explained by already existing medical conditions
DT is a risk for alcoholics even if they aren’t trying to quit alcohol use intentionally. For instance, if you have an alcohol use disorder but you have a scheduled surgery, you will need to stop drinking in the hours leading up to the surgery, as directed by your doctor (alcohol can act as a blood thinner, causing you to bleed excessively during surgery and obscuring the surgeon’s visibility and ability to perform the surgery correctly). Patients who are going into surgery that have an alcohol or depressant dependence are at risk for developing DT. Likewise, any life circumstance that gets in the way of drinking for four hours or more can trigger dangerous DT symptoms.
At its worst, DT can cause violently convulsive seizures, coma, catatonic state, disturbing hallucinations, and death. DT is reported as having anywhere between a five and a 25 percent chance of fatality without medical treatment, but it’s clear that medical treatment significantly decreases your likelihood of deadly symptoms. In medical detox, you would have 24/7 medically managed care and the necessary medical interventions to alleviate or avoid DT symptoms.
Kindling
Kindling is another phenomenon that occurs with excessive alcohol, depressant, or sedative use and it often goes hand in hand with Delirium tremens. Kindling is a term used to describe the neurological condition of being more susceptible to dangerous withdrawal symptoms the more you go through periods of detox and relapse. For instance, someone you develop an alcohol use disorder and then goes into detox may only experience mild symptoms of PAWS. However, someone who has relapsed several times after detoxing from alcohol would be of specific concern to clinicians and has a higher likelihood of experiencing seizures or DT.
Kindling is believed to be caused by the changes in the brain that result from cycles of binge drinking and detox. The imbalance and rebalance of inhibitory and excitatory neurotransmitters cause changes in the way your brain releases certain neurotransmitters called monoamine neurotransmitters. This can contribute to an increase in neurotoxicity, or damaging effects to your brain. In some cases, the damage to your brain can be permanent, especially in adolescents and young adults. Studies suggest that excessive drinking and depressant use can affect your executive functions (abstract thinking, motivation, planning, attention span, and impulse control) and damage parts of your brain.
Essentially, the damaging effects of repeated cycles of abuse, detox, and relapse can make it so that electrical and chemical stimuli that used to have little to no effect on your body, now create intense effects including seizures as a response to an imbalanced brain chemistry. If you’ve relapsed several times, it may be even more important to seek medical help if you’ve started to experience withdrawal symptoms.
Neonatal Abstinence Syndrome
With the exponential growth of the opioid epidemic, the problem of neonatal abstinence syndrome (NAS) is becoming more widespread. NAS refers to the phenomenon of infants being born with drug dependence and withdrawal after being exposed to addictive substances in the womb. Women who are struggling with addiction often face a number of challenges during pregnancy. Using certain substances during pregnancy can increase the risk of premature birth, respiratory problems, sudden infant death syndrome, stillbirth, stunted fetal development, and other dangerous symptoms. Children born with opioid dependence are at greater risk of seizures, breathing problems, low birth weight, and death.
At the same time, withdrawal symptoms that put significant strain on mothers could potentially lead to other pregnancy problems. Plus, addicted mothers often avoid treatment for fear that it would result in a loss of custody or even that treatment could harm their baby.
Opioid addiction is also not easy to quit even when there are dire consequences on the line like pregnancy. Opioid addiction hijacks your reward center and rewrites the way your brain processes drugs and cravings. Your limbic system is designed to identify activities that are life-sustaining including physical factors like eating and sleeping, as well as social stimuli like a warm hug or a pleasant conversation. Opioids teach the limbic system to seek drugs like they are life-sustaining factors. People with opioid dependence may literally crave opioids like you would crave water in the dessert. Even when you know the consequences are high, opioid addiction is difficult to quit on your own.
However, research has shown that certain evidence-based treatments for opioid addiction and addiction to other substances that are harmful to pregnant women and their babies can be effective solutions for mothers that need help. Therapies and even some medications that are used to treat addiction and withdrawal have been approved by the FDA to treat pregnant women. With medical care and addiction treatment, the health of both mother and child can be improved.
Treating Post-Acute Withdrawal
PAWS symptoms are largely related to psychological effects of withdrawal like depression, anxiety, and the rebounding of symptoms and emotions you originally took the drug to suppress, either as medication or self-medication. In some cases, symptoms arise that are not so much a result of drug use as they are a result of a pre-existing unresolved issue that a substance was used to cover up. For instance, if a traumatic event occurred in your childhood and you were never able to deal with it before you started to use drugs to help suppress negative emotions, the negative feelings from that trauma may come flooding back.
One of the clearest dangers of emotional and psychological withdrawal symptoms is relapse. To avoid relapse and treat mental and emotional symptoms, support from experienced counselors and therapists is essential. Different withdrawal symptoms and individual needs require unique treatment options. Depending on your needs, you will be placed in a level of care that is best for where you are in recovery. If you have a potential for dangerous withdrawal symptoms or if you have other medical conditions that need medical care, you may be placed in a higher level of care. According to the criteria outlined be the American Society of Addiction Medicine, medically monitored or managed care is recommended for clients with a medical need.
To help you deal with the psychological effects brought on by PAWS, clinicians help through a variety of therapies, including cognitive behavioral therapy (CBT), which is based in building up your self-efficacy (your ability to cope with cravings in a healthy way). CBT is the most recommended treatment option for addiction treatment; however, each treatment plan is unique to the individual and based on your own personal needs and goals.
