Post-Acute Withdrawal Syndrome and Opioids

Medically Reviewed by Jennifer Casarella, MD on April 18, 2022
Written by Hope Winsborough
4 min read

When you are in the early stage of recovery from opioid use disorder or dependence, there’s a 90% chance that you will experience post-acute withdrawal syndrome, or PAWS. Knowing what to expect and how to manage the symptoms can help you feel better and, as a result, reduce your risk of relapse.

PAWS refers to a group of symptoms that appear after the “acute” stage of opioid withdrawal. Acute withdrawal, which happens after a medically supervised detox, can cause symptoms of physical discomfort like muscle aches, nausea, headaches, and increased heart rate, as well as life-threatening complications. These symptoms typically end after 2 weeks, at most.

PAWS refers to the more emotional and psychological symptoms that happen during the second stage of withdrawal. If you used a large amount of opioids for a long period of time, you are more likely to experience PAWS.

The most common symptoms are:

  • Foggy thinking or trouble remembering
  • Urges and cravings
  • Irritability or hostility
  • Sleep disturbances, including insomnia or vivid dreams
  • Fatigue
  • Issues with fine motor coordination
  • Stress sensitivity
  • Anxiety or panic
  • Depression
  • Lack of motivation
  • Less ability to focus
  • Mood swings

Post-acute withdrawal syndrome is normal and temporary. It can occur just a few weeks into recovery or months later. Whether your symptoms are mild or serious, if they pop up during the first months of recovery, they can increase your chances of relapse, or returning to opioid misuse.

Drug use changes the brain and its ability to deal with stress. Addiction experts describe PAWS as the brain’s way of correcting those changes, specifically the chemical imbalances that take place during active addiction.

Stressful situations can bring on PAWS episodes, and so can situations that remind you of using opioids. Your experience may be more difficult if you have other physical or mental health conditions. In certain cases, symptoms like cravings, exhaustion, and problems with thinking can take a longer time to go away.

When the PAWS process is over, however, your brain will once again be able to produce its own endorphins and dopamine. Dopamine and endorphins are “feel-good” hormones that occur naturally and control the way your body works as well as how you feel.

There isn’t an exact timeline for experiencing PAWS. You may have symptoms right after going through a medically supervised detoxification process, or “detox.” Or you may not have symptoms for years.

That said, PAWS symptoms typically appear after the acute phase is over and can last for a few days at a time. Each episode tends to come and go unexpectedly, and the episodes can continue for weeks, months, and even years after you stop taking opioids.

Many people describe PAWS episodes like a roller-coaster, when symptoms seem to change minute by minute. During long-term recovery, the symptoms become less common.

Many people who experience PAWS go to therapy, either by themselves or in groups, in order to help them deal with the symptoms. Other tips for managing symptoms include:

  • Practice self-care by eating well, exercising, and avoiding stressful situations when possible.
  • Establish and maintain positive, supportive relationships.
  • Think about what may have caused your last episode, then ask yourself if there’s anything you can do to react differently next time.
  • Start a journal to keep track of your PAWS experiences and to plan better ways to handle them next time.
  • If you’re having a hard time concentrating on something, take a break for 15 minutes.
  • If you find yourself obsessing over certain thoughts, stop yourself by trying something different–like listening to music, going for a walk, or calling a friend.
  • Make lists or set up reminders on your phone if you’re having trouble remembering things.
  • If you’re having trouble sleeping, limit caffeine and try to keep to a regular sleep schedule (going to bed and waking up at the same times each day).
  • Don’t be hard on yourself. Recovery takes time. Try to think of your PAWS symptoms as proof that you’re making progress.

If your PAWS symptoms seem overwhelming or dangerous, you should seek medical treatment. If you also have other mental health conditions, a doctor may be able to help you better manage all your symptoms. In some cases, medications can help normalize brain chemistry and prevent PAWS symptoms, which can help you with recovery. The treatment may continue for an extended period of time if symptoms continue. In addition to medical treatment resources, be sure to seek out relationships with people who support your recovery – like support groups and recovery coaches.

SAMHSA’s National Helpline is a free, confidential information service available round-the-clock that provides referrals to treatment facilities, support groups, and community-based organizations. Call 1-800-662-HELP (4357) or visit https://dpt2.samhsa.gov/treatment/directory.aspx for help locating an opioid treatment program.