Post–acute withdrawal syndrome (PAWS) is symptoms that persist after the withdrawal from a drug or narcotic substance. PAWS refers to a set of symptoms that can occur after the initial stage of withdrawal from drugs or alcohol. It is not something that everyone experiences but for those who do, it can be challenging to deal with. These symptoms can last for weeks, months or even longer, depending on the individual.

Symptoms of post-acute withdrawal syndrome (PAWS) can vary widely, often presenting in waves that come and go with symptoms fluctuating in severity. Individuals may experience cognitive impairments, mood disturbances such as irritability, depression and anxiety, which can be intense enough to trigger a relapse. Extended withdrawal from substances like benzodiazepines, opioids and alcohol can mirror conditions such as generalized anxiety disorder and panic disorder making abrupt cessation inadvisable due to the severity of potential withdrawal symptoms.

Research into the prolonged withdrawal symptoms associated with substance abuse, particularly beyond alcohol, is limited and primarily consists of anecdotal evidence and clinical observations. For alcohol, protracted withdrawal symptoms are well-recognised and can include anxiety, irritability, mood swings, fatigue, insomnia, cognitive difficulties, reduced libido and physical pain with some symptoms potentially lasting over two years post-abstinence. Sleep issues specifically may continue for up to three years after ceasing alcohol intake.

In the case of benzodiazepines, distinguishing between protracted withdrawal and symptom rebound—where intensified symptoms reappear briefly after cessation—is challenging. However, protracted symptoms often fluctuate over time, presenting new challenges that gradually lessen with ongoing sobriety. Marijuana withdrawal can result in sleep problems and unusual dreams for over a month. Opioid detox may lead to enduring issues like sleep disruption, anxiety, depression and decreased mental sharpness. Cocaine withdrawal has been associated with ongoing struggles with impulse control weeks into abstinence. Across different substances, protracted withdrawal can manifest as irritability, depression, anxiety, low energy, sleep issues, memory problems, impaired concentration, cravings, diminished executive function, anhedonia, focus difficulties, decreased sexual desire and unexplained chronic pain.

The array of hypothesized symptoms associated with PAWS includes emotional and psychological challenges like psychosocial dysfunction, anhedonia, depression and feelings of guilt, as well as physical and cognitive issues such as sleep disturbances, extreme fatigue and memory problems. These symptoms may be triggered or exacerbated by stress, multitasking and social conflicts, among other factors. Notably, disturbances in mental function post-benzodiazepine withdrawal can persist for months or years with documented cases of protracted psychotic depression. Similarly, long-term use of dopamine agonists and subsequent withdrawal can lead to a range of symptoms including anxiety, depression and physical discomfort, which for some, may persist for an extended period, highlighting the complex and enduring nature of PAWS.

Acute withdrawal typically lasts for a shorter period of time and involves more intense physical symptoms like tremors, nausea and sweating. PAWS, on the other hand, is often characterised by more subtle but persistent psychological and emotional symptoms.

While the exact causes of PAWS are not fully understood, it is believed to be related to the impact of long-term substance use on the brain and nervous system. Prolonged exposure to drugs or alcohol can disrupt the normal functioning of neurotransmitters and other chemical messengers in the brain, leading to these withdrawal symptoms.

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