Identification and Evidence-Based Treatment of Post–Acute Withdrawal Syndrome

Published:January 10, 2022DOI:


      • Post–acute withdrawal syndrome is a risk factor for relapse in patients with a history of a substance use disorder.
      • Providers are in a prime position to identify and treat post–acute withdrawal syndrome in populations with a history of substance use disorder.
      • Literature on post–acute withdrawal syndrome is limited but growing, and the topic is well known in the recovery community.


      Post–acute withdrawal syndrome (PAWS) refers to a cluster of psychological and mood-related symptoms that can last for months to years after acute withdrawal from a substance and is a major contributing factor for relapse. PAWS symptoms exist for many individuals after withdrawal from alcohol, opioids, and benzodiazepines with underlying brain changes. Health care providers are in a prime position to identify and treat PAWS symptoms to decrease this risk of relapse. A synthesis of evidence on the state of the science of the limited but growing evidence on PAWS is explored. Patients experiencing PAWS need to be heard, supported, and appropriately treated by providers.


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        • Substance Abuse and Mental Health Services Administration
        Key substance use and mental health indicators in the United States: results from the 2018 national survey on drug use and health. 2019.
        • Substance Abuse and Mental Health Services Administration
        Detoxification and substance abuse treatment. 2016.
        • National Institute on Drug Abuse
        Drugs, brains, and behavior: the science of addiction. 2018.
        • Caputo F.
        • Cibin M.
        • Loche A.
        • De Giorgio R.
        • Zoli G.
        The recognition and management of protracted alcohol withdrawal may improve and modulate the pharmacological treatment of alcohol use disorder.
        J Psychopharmacol. 2020; 43: 1171-1175
        • American Addiction Centers
        Post-acute-withdrawal syndrome (PAWS): an in-depth guide. 2020.
        • Bayard M.
        • McIntyre J.
        • Hill K.R.
        • Woodside Jr., J.
        Alcohol withdrawal syndrome.
        Am Fam Physician. 2004; 69: 1443-1450
      1. Semel J, Semel T. Persistent withdrawal syndromes after detox dual diagnosis program. Semel Institute. UCLA Dual Diagnosis Program Information and Admissions, University of California, Los Angeles; 2020.

        • Blum K.
        • Braverman E.R.
        • Holder J.M.
        • Lubar J.F.
        • Monastra V.J.
        • Miller D.
        • et al.
        Reward deficiency syndrome. A biogenetic model for the diagnosis and treatment of impulsive, addictive, and compulsive behaviors.
        J Psychoactive Drugs. 2000; 32: 1-112
        • Aston-Jones G.
        • Harris G.C.
        Brain substrates for increased drug seeking during protracted withdrawal.
        Neuropharmacology. 2004; 47: 167-179
        • Angarita G.A.
        • Emadi N.
        • Hodges S.
        • Morgan P.T.
        Sleep abnormalities associated with alcohol, cannabix, cocaine, and opiate use: a comprehensive review.
        Addict Sci Clin Pract. 2016; 11 (article 9.
        • Watanabe K.
        • Ogihara-Hashizume A.
        • Kobayashi T.
        • Mitsushio H.
        • Komiyama T.
        Impaired sleep during the post-alcohol withdrawal period in alcoholic patients.
        Addict Biol. 2001; 6: 163-169
        • De Sousa Uva M.C.
        • Luminet O.
        • Cortesi M.
        • Constant E.
        • Derely M.
        • De Timary P.
        Cognitive and behavioural aspects distinct effects of protracted withdrawal on affect, craving, selective attention, and executive functions among alcohol-dependent patients.
        Alcohol Alcoholism. 2010; 45: 241-246
        • Martinotti G.
        • Di Nicola M.
        • Reina D.
        • Andreoli S.
        • Foca F.
        • Cunniff A.
        • et al.
        Treatment: withdrawal syndrome.
        Substance Use Misuse. 2008; 42: 172-284
        • De Timary P.
        • De Sousa Uva M.C.
        • Denoel C.
        • Hebborn L.
        • Derely M.
        • Desseilles M.
        • Luminet O.
        The association between self-consciousness, depressive state and craving to drink among alcohol dependent patients undergoing protracted withdrawal.
        PLOS One. 2013; 8e71560
        • Heilig M.
        • Egli M.
        • Crabbe J.C.
        • Becker H.
        Acute withdrawal, protracted abstinence and negative affect in alcoholism: are they linked?.
        Addiction Biol. 2010; 15: 169-184
        • Kaufling J.
        • Aston-Jones G.
        Persistent adaptations in the afferents to ventral tegmental dopamine neurons after opiate withdrawal.
        J Neurosci. 2015; 35: 10290-10303
        • Rapeli P.
        • Kivisaari R.
        • Autti T.
        • Kahkonen S.
        • Puuskari V.
        • Jokela O.
        • Kalska H.
        Cognitive function during early abstinence from opioid independence: a comparison to age, gender, and verbal intelligence matched control.
        BMC Psychiatry. 2006; 6: 9
        • Fu L.
        • Bi G.
        • Zou Z.
        • Wang Y.
        • Ye E.
        • Ma L.
        • et al.
        Impaired response inhibition function in abstinent heroin dependents: an fMRI study.
        Neurosci Lett. 2008; 438: 322-326
        • Hood S.D.
        • Norman A.
        • Hince D.A.
        • Melichar J.K.
        • Hulse G.K.
        Benzodiazepine dependence and its treatment with low dose flumazenil.
        Br J Clin Pharmacol. 2012; 77: 285-294
        • LaCorte S.
        How chronic administration of benzodiazepines leads to unexplained chronic illnesses: a hypothesis.
        Med Hypotheses. 2018; 118: 59-67
        • Ashton H.
        Protracted withdrawal syndromes from benzodiazepines.
        J Subst Abuse Treat. 1991; 8: 19-28
        • Modell J.G.
        Protracted benzodiazepine withdrawal syndrome mimicking psychotic depression.
        . 1997; 38: 1600161
      2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. 2013.

        • National Institute of Mental Health
        Substance use and co-occurring mental disorders. 2021.
        • Work Group on Major Depressive Disorder
        Practice guideline for the treatment of patients with major depressive disorder.
        3rd ed. American Psychiatric Association, 2010
        • Work Group on Panic Disorder
        Practice guideline for the treatment of patients with panic disorder.
        2nd ed. American Psychiatric Association, 2010
        • Zuckerbrot R.A.
        • Cheung A.
        • Jensen P.S.
        • Stein R.E.K.
        • Laraque D.
        Guidelines for adolescent depression in primary care (GLAD-PC): part I. practice preparation, identification, assessment, and initial management.
        Pediatrics. 2018; 141e20174081
        • Schutte-Rodin S.
        • Broch L.
        • Buysse D.
        • Dorsey C.
        • Sateia M.
        Clinical guideline for the evaluation and management of chronic insomnia in adults.
        J Clin Sleep Med. 2008; 04


      Brittany Haskell, DNP, PMHNP-BC, CNE, is an assistant professor of nursing at Vanderbilt University School of Nursing, Nashville, TN, and can be contacted at [email protected] .