Have you ever tried to learn a new skill and got it perfect the very first time? Maybe you took some tennis lessons and went out there and played your first match perfectly acing every serve. How about the first time you ever played golf, did you hit the ball straight or land a hole in one? Ok, maybe in mini golf.  How about the first time you played that guitar you bought a few years ago and you were instantly able to play all your favorite Zeppelin songs? Not likely, all of those skills take lots of practice. Sobriety is the same way. 

Relapse is Part of Recovery

It's pretty rare that someone succeeds at sobriety the very first time.  Not saying that it never has happened, sometimes making the decision to get sober is all someone needs to do to achieve their goal.  For most people however it requires lots of practice and some trial and error. It takes time to figure out what works and what doesn’t work. 

Relapse can be part of that process. If relapse happens you don’t give up.  Just learn from the mistakes and keep moving forward - “progress not perfection”. Alcohol and substance use disorders are chronic conditions characterized by a relapsing-remitting course, where understanding the determinants of relapse remains a formidable task.¹⁷

Relapse is fairly common even with treatment.  It is crucial to determine what some of the factors are contributing to relapse and develop relapse prevention planning. Nguyen has found that “at least 60% of individuals with Alcohol Use Disorder relapse to hazardous drinking within six months following treatment, highlighting the critical need to identify factors that contribute to this vulnerability”.¹⁵

Part of the sobriety journey is figuring out what are the factors that lead to relapse and make changes so it doesn’t happen again. That could involve avoiding “people, places, and things”.  Another factor could be Post-Acute Withdrawal Syndrome. Persistent Post-Acute Withdrawal Syndrome has emerged as a significant transdiagnostic phenomenon that may further compromise recovery by extending the period of physiological and psychological instability beyond the acute withdrawal phase.¹⁵

What is Post-Acute Withdrawal Syndrome (PAWS)?

Depending on the substance used and for how long, an individual may experience acute withdrawal symptoms. The acute withdrawal phase typically takes place within the first 12-48 hours and can last up to a few weeks depending on the substance.  Acute withdrawal can be very serious and potentially life threatening especially if it involves alcohol or benzodiazepines like Valium or Xanax. Post-Acute Withdrawal Syndrome (PAWS) is formally defined as a set of persistent symptoms and neurobiological alterations that continue beyond the resolution of acute withdrawal, typically extending for weeks or months into abstinence.²

There are a number of symptoms related to PAWS. PAWS encompasses a diverse array of psychological, cognitive, and physiological symptoms that persist well beyond the acute withdrawal phase, often manifesting as anxiety, depression, sleep disturbances, fatigue, dysphoria, irritability, and deficits in executive control that can endure for months or even years.¹⁴ After being sober for a few days or weeks these symptoms can arise causing the individual to question their sobriety. 

Just as all substances have varying degrees of acute withdrawal symptoms it’s the same with PAWS. Dysregulated affect, including anhedonia, irritability, anxiety, and dysphoric mood, as well as increased reactivity to stress and craving, are common symptoms of the abstinence symptomatology observed in post-withdrawal states from opiates, alcohol, cocaine, cannabis, stimulants, and polysubstance abuse.⁹ There are varying degrees of these symptoms and not everyone will experience them.  

So you get sober and stay sober for a while but just don’t feel right. That’s PAWS and can lead to thoughts of using again to feel “normal”. It's just your body getting used to not being poisoned by a substance anymore and it takes time to adjust.  

What Causes PAWS? 

Most substances are fatal in higher doses especially opiates, benzodiazepines, and alcohol.  Over the course of days, weeks, even years of use the body builds up tolerance basically to keep the person from overdosing. If you have ever used opiates you know how quickly tolerance can build even within a few days. With alcohol it sometimes takes a little longer but tolerance can build to unbelievable levels where someone is able to drink amounts that would be fatal for most people. 

PAWS is part of this tolerance building process. It is the body making adaptations to a substance which in higher amounts becomes toxic. There is the reward of ingesting the substance, i.e., the high, that reinforces further substance use. The pathophysiology of PAWS is rooted in long-term neuroadaptations that develop following repeated substance consumption and withdrawal episodes, which establish a chronic brain disease state characterized by persistent dysregulation of reward and stress pathways.¹⁶

As the body builds up tolerance to a substance, stopping the substance results in withdrawal symptoms. The body adapts to functioning with the substance in its system, and it takes time to relearn how to function without it. These adaptations involve a progressive impairment of reward systems recruited during intoxication, alongside an increasing engagement of aversion during withdrawal, which collectively enhance stress sensitivity and disrupt executive functions.¹⁸

Diagnosis of PAWS

Some substances can mask symptoms of other disorders like depression and anxiety.  When someone gets sober these other symptoms can become more apparent. Accurate identification of PAWS is complicated by the overlap of its symptoms with those of primary psychiatric disorders and the natural course of acute withdrawal.  A comprehensive clinical evaluation that distinguishes protracted substance-induced phenomena from independent comorbid conditions is essential to understanding PAWS.¹¹

Distinguishing PAWS from independent psychiatric disorders requires clinicians to determine whether the affective disturbances, such as anxiety, depression, and anhedonia, are substance-induced or represent primary comorbid conditions, a distinction that is complicated by the shared symptomatology of mood and anxiety disorders ⁶. Having a comprehensive assessment by a clinician can be crucial to receiving adequate care and long term sobriety. There are many resources available that can assist with addressing these symptoms including medication.  

The Link Between PAWS and Relapse

Not being aware of the symptoms of PAWS can contribute to the possibility of relapse in many ways. Being sober for  some time and experiencing these symptoms can result in a person considering a return to substance use to feel better. The persistence of protracted withdrawal symptoms creates a chronic state of negative affect and physiological dysregulation that significantly undermines an individual's capacity to maintain sustained abstinence, thereby establishing a direct pathway to relapse.¹⁰

One of the main symptoms that could result in relapse is anhedonia or not getting pleasure from activities that used to be rewarding. This enduring state of anhedonia, often termed "Reward Deficiency Syndrome," diminishes motivation for natural rewards and heightens stress reactivity, compelling individuals to seek substance use as a means of alleviating acquired discomfort.sup>3</sup> It can also lead to boredom, one of the most common relapse triggers. 

Consequently, the desire to ameliorate these persistent negative affective states serves as a potent driving force for continued consumption, as substance use provides momentary relief from the distress associated with withdrawal while simultaneously perpetuating a vicious cycle that makes future abstinence increasingly difficult to maintain.⁴ This vicious cycle can result in repeated relapses where someone stays sober briefly but returns to use when discomfort increases. Here is where treatment can be beneficial to assist with getting over the discomfort of PAWS.

Ways to address PAWS and Prevent Relapse

Treatment approaches are designed to assist with addressing the various types of PAWS symptoms. Cognitive-behavioral interventions aim to equip individuals with coping mechanisms to manage the persistent negative affect and cravings characteristic of PAWS, thereby addressing the maladaptive thought patterns and emotional dysregulation that precipitate relapse.⁸ Many treatment programs incorporate Cognitive Behavioral Therapy (CBT). 

Complementary and integrative modalities, such as mindfulness-based stress reduction, exercise physiology, and nutritional optimization, target the underlying physiological dysregulation and stress reactivity associated with protracted withdrawal to support recovery.⁵  Mindfulness can include daily meditation. Nutrition and exercise can be beneficial in reducing the symptoms of PAWS. Additionally, Integrated treatment models combine pharmacological interventions, such as medication-assisted therapy, with psychotherapeutic and holistic strategies to simultaneously target the neurobiological adaptations, stress pathophysiology, and behavioral patterns that sustain addiction and increase relapse risk.⁷

Many individuals are unaware of what PAWS is and how it can be part of the process of sobriety.  Just being informed about what to expect in early recovery can be helpful.  Providing comprehensive education about the expected course, symptomatology, and duration of protracted withdrawal is essential for reducing distress and preventing premature discontinuation of treatment, as it empowers an individual and their support networks to distinguish between normal recovery processes and the emergence of comorbid psychiatric conditions.¹²

Addiction is also a disease of isolation. Sobriety can be one of the most difficult things a person can do but they do not have to do it alone. Peer support networks and community-based programs provide critical social reinforcement that mitigates the isolation and negative affect often experienced during protracted withdrawal, thereby offering a protective buffer against relapse.¹³

Conclusion

For some individuals, the dread of having to experience withdrawal prevents them from getting sober.  A person does not have to do it alone.  Seeking assistance from a medical provider can make the experience of acute withdrawal a lot more bearable.  Once the acute withdrawal phase has been completed there is the possibility of PAWS.  Here again, seeking help from a provider can make that experience a whole lot more manageable. Post-Acute Withdrawal Syndrome represents a critical, protracted phase of the addiction recovery process that necessitates comprehensive, integrated management strategies to address the persistent neurobiological dysregulation and negative affect that drive relapse.¹

The good news is that acute withdrawal and PAWS are both temporary.  Recovery is not just about stopping a substance. It is about giving the brain and body time to heal.  PAWS can make that healing period uncomfortable, but discomfort is not failure. With the right support, those symptoms pass. The hardest part is just reaching out. Developing a comprehensive, individualized strategy for sustained sobriety is essential to address the chronic nature of PAWS and mitigate the high risk of relapse.¹⁹  

References

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