Post Acute Withdrawal Syndrome (PAWS) – Does It Contribute to Relapse?

Post Acute Withdrawal Syndrome (PAWS) – what is it? Does it make staying sober difficult?

The following is a guest post by Todd Branston who has been working in the field of addictions for over 27 years. He has worked within the inpatient and outpatient settings, as well as in the Department of Corrections and as the Director of Counseling for a large chemical dependency hospital, where he’s currently employed doing in-home chemical dependency engagement with (mostly) seniors. He is part of an experts forum on chemical dependency and has a contract gig running the chemical dependency program for a long-term transitional program to support people to overcome homelessness. He currently runs a weekly podcast on addiction and mental health. Todd’s sense is that sobriety is a skill and that recovery looks different for everybody, and he invites readers to check out his podcasts at askanaddictioncounselor.com

Having a Difficult Time Staying Sober? It Could be Post Acute Withdrawal Syndrome (PAWS) by Todd Branston

Having a difficult time staying sober?  Maybe it’s not you – maybe it’s brain chemistry.

You know the drill: you have spent countless hours in meetings, on the phone with your sponsor asking endless questions about your desire to use.  You have worked the steps and you’ve even consulted specialists.  In a moment of desperation you found help by attending treatment.

You’re able to rack up six to twelve months, but eventually you find yourself in the throes of your addiction. None of this seems to work.  You find yourself questioning your commitment and ability to stay sober.  Maybe your sponsor was right when he said you lack willingness.

Not so fast….

What you are likely experiencing is Post Acute Withdrawal Syndrome or PAWS.

PAWS consist of a set of impairments that occur immediately and at times simultaneously after the withdrawal from alcohol or other substances.  These impairments affect three distinct areas of functioning and last six to eighteen months from the last use of alcohol or drugs as your brain tries to regain homeostasis.

Some of these impairments include cognitive problems like racing thoughts, rigidity, numbing of emotions, difficulty with abstract thinking and poor attention span, all of which are prevalent during this time. Emotional difficulties include shame and guilt, as well as difficulties with resentments. Depression is common during this time and may lead to relapse as the addict is generally not prepared to deal with the wealth of emotions they experience. Thedearth of emotions can lead people close to the addict to believe they might have relapsed.

While some counselors and organizations support 100% abstinence as the only way to resolve addictive behaviors, this approach tends to come across as a ‘one size fits all’ solution to dealing with these impairments.  While recovering from addictive behaviors it is remiss to not include an alternative approach without the mention of anti-craving medication as a treatment for PAWS.

Treating Post Acute Withdrawal Syndrome with  Anit-Craving Medications

Anti-craving medications may be appropriate for some individuals.  The use of medication does not represent a weakness in one’s ability to recover from addictive behaviors.  If anything, it should represent the idea that there is ‘another way’.

There are various medications that have been found to have efficacy in dealing with alcohol/drug cravings:

Prazosin is often prescribed to deal with PTSD and night terrors. It has been found to be successful among Opiate addicts and individuals using Cocaine and Methamphetamine.

Acamprosate is used to treat Alcohol cravings.  In addition to its apparent ability to help patients refrain from drinking, evidence suggests that Acamprosate is neuroprotective. It has been shown that it can protect neurons from damage and death caused by the effects of alcohol withdrawal.

Naltrexone has been prescribed for Opiate cravings but is largely recommended as a treatment for alcohol abuse. It is also available in a monthly injectable form under the trade name of Vivitrol.

Baclofen and Topiramate have found therapeutic utility for Cocaine and Alcohol cravings.

While Methadone and Antabuse have found success in treating addictive disorders, they are not seen as anti-craving medications.  Antabuse is a deterrent to drinking as it prevents the breakdown of alcohol. Some 5–10 minutes after alcohol intake, a person will experience the effects of a severe hangover for a period of 30 minutes up to several hours.

Methadone is a synthetic Opioid and has been used as part of an Opiate substitution regimen. The drug has found success in supporting long-term Heroin addicts to wean off the drug.  In addition, Methadone has been used as a pain management protocol due to its long duration of action.

There is a fair amount of controversy around Methadone for Opiate substitution as the detractors point to length of time a patient uses the drug, suggesting that addicts are essentially substituting one drug for the next. Conversely The Addiction Recovery Institute points out the following benefits of Methadone Maintenance Treatment:

  • Reduced or stopped use of injection drugs
  • Reduced risk of overdose and of acquiring or transmitting diseases such as HIV, hepatitis B or C, bacterial infections, endocarditis, soft tissue infections, thrombophlebitis, tuberculosis, and STDs
  • Reduced mortality – the median death rate of opiate-dependent individuals in MMT is 30 percent of the rate of those not in MMT
  • Possible reduction in sexual risk behaviors, although evidence on this point is conflicting
  • Reduced criminal activity
  • Improved family, employment and pregnancy outcomes

Bottom Line:  It is important to reinforce the notion that an approach of 100% abstinence as a singular modality is not for everyone.  Medications can provide additional support but they should not be seen as a complete solution.  The goal of the medication should be to offset cravings and free up “emotional space” for the newly recovering person to add support in the form mutual aid groups, group or individual therapy, connection with a community of faith, exercise or involvement in an alcohol and drug treatment program.

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4 Responses to Post Acute Withdrawal Syndrome (PAWS) – Does It Contribute to Relapse?

  1. I’ve heard that Naltexone is really effective for dealing with cravings, and it’s even been used effectively for treating obesity. Since drug addiction and the food-reward system both work via the dopamine pathway, it seems like a lot of the drugs which suppress drug cravings can also help other types of addicts.
    Also, have you heard of Suboxone? It’s a little newer than Methadone, but a lot of clinics are using it because it’s less addictive. Some people who go on Methadone end up getting even worse addictions than before.
    Here’s another great site about Post Acute Withdrawal Syndrome:
    http://www.squidoo.com/post-acute-withdrawal-syndrome

  2. Thanks for this post, Lisa and Todd. The fact of the matter is that Post Acute Withdrawal Syndrome is actually the single largest cause of relapse. Personally I’d argue that the condition is the ONLY cause of relapse, because in reality PAWS is simply an inactive state of the disease of addiction – a remission, if you will. Unfortunately, few have heard of this condition and so we have revolving door rehabs because we only focus on the short term – get sober, get out the door. I’ve recently conducted a large survey on PAWS and I am in the process of publishing the results – they are FASCINATING! I’ll report them back here. For more information, I run a website dedicated entirely to sufferers of Post Acute Withdrawal Syndrome: http://www.postacutewithdrawal.org/ Thanks again for helping to spread the word about the real cause of relapse among addicts and alcoholics! -James F. Davis, CAS, Board Certified Interventionist.
    James F. Davis recently posted…Why Drug Rehab Works – A Rebuttal to the New York TimesMy Profile

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