Completing detox is a major step in the right direction toward recovery. After going through detox and enduring the symptoms of withdrawal, it makes sense to expect to feel clear-headed and ready to move forward. But instead, some people may be surprised by the wave of emotional and cognitive setbacks that they experience.
It can be discouraging to get through detox and still struggle with certain symptoms. But this experience is common and may be part of a recognized phase of recovery called post-acute withdrawal syndrome or PAWS.
PAWS is sometimes nicknamed the “sober slump” because it occurs during sobriety in the days after detox. Understanding what PAWS is helps remove self-blame and fear. Instead, it allows you to view it as part of the recovery process.
What is PAWS?
PAWS involves a group of ongoing emotional, cognitive, psychological, and sometimes mild physical symptoms that may continue after acute withdrawal is over. Although detox removes the alcohol or drugs from the body, it does not immediately reverse the changes that occurred in the brain after long-term addiction.
Restoring healthy neurotransmitter balance and healthy communication between nerve cells in the brain can take weeks or months. Although it can become discouraging or frustrating, it is a common part of the recovery process.
In the past, the term “dry drunk syndrome” was used to describe someone who was no longer using a substance, but still had symptoms, such as mood swings or trouble concentrating. The term originated within the Alcoholics Anonymous circles. The theory was that the substance physically cleared the body, but the internal work during recovery was not done.
Today we know that this theory is false. Experts have a better understanding of the physiological effects that substances have on the body and brain that can lead to PAWS.
The challenges of PAWS are due to a neurological imbalance from substance abuse, not a lack of willpower or a moral failing.
The Neurobiology: Why PAWS Occurs
PAWS can develop due to various physiological changes within the brain. To understand why it occurs, it may be helpful to consider the following:
The Hijacked Brain
According to the National Institute on Drug Abuse, substance abuse alters brain chemical systems and neural circuitry. Certain areas of the brain are particularly impacted, such as the prefrontal cortex. This area of the brain is responsible for attention, decision-making, and impulse control.
In early recovery, the prefrontal cortex generally functions below its usual capacity. This can lead to poor concentration, forgetfulness, trouble managing emotions, and brain fog.
Prolonged substance use also affects the reward center of the brain, particularly the nucleus accumbens. Substances can increase dopamine release, leading to feelings of euphoria or pleasure. This can motivate an individual to repeat the behavior and seek that feeling again.
Recalibration Phase
Long-term drug or alcohol use can make the brain less responsive to GABA and dopamine. Specifically, dopamine activity may remain lower than normal. GABA activity is reduced. Simultaneously, glutamate levels may be elevated, leaving the brain in a hyperactive state. The brain needs time to adjust or recalibrate to establish healthy communication between nerve cells.
Sign of Active Healing
The good news is that the brain is remarkably adaptable. Over time, the healing process begins and gradually restores normal functioning. These changes are a normal part of the brain’s healing and repair process.
What PAWS Actually Feels Like: The Symptoms
As the brain begins and continues to heal, it may present with a variety of symptoms, including those listed below.
Cognitive Impairment (“Brain Fog”): This can include problems with short-term memory, problem-solving, and concentration, as well as feeling mentally cloudy. As mentioned above, long-term substance use can decrease the efficiency in the region of the brain involved in cognitive functioning.
Emotional Instability: After prolonged substance use, the amygdala, which is a part of the brain that processes emotions, may become hyperactive. This can lead to irritability, anxiety, depression, and mood swings.
Anhedonia: Anhedonia is the inability to feel excitement, pleasure, or joy. It can make an individual feel emotionally flat.
Physical and Somatic Complaints: Physical symptoms may also develop, including fatigue, nightmares, insomnia, body aches, and problems with fine motor coordination.
Stress Sensitivity: As the brain continues to heal, the stress tolerance threshold is lower. Minor daily inconveniences can lead to a significantly more intense stress reaction.
What is a Possible Timeline: Setting Realistic Expectations
It is helpful to understand that PAWS recovery is not typically a straight line. Symptoms may change and fluctuate in a “windows and waves” type pattern. The windows are periods of time where you have emotional clarity and stability. Waves of depression, fatigue, or mood swings can follow this.
A general timeline of recovery milestones includes the following:
Onset (Weeks 1 to 2): Symptoms of PAWS may begin to emerge as physical withdrawal symptoms decrease or subside.
Peak (Months 1 to 3): During months 1 to 3, symptoms usually reach their highest intensity. The focus of early treatment often shifts from managing physical symptoms to supporting ongoing recovery and symptoms of PAWS.
Gradual Softening (Months 3 to 6): During this period, the time between waves may become longer, and symptoms may be less intense. You may also have developed ways to manage symptoms to help reduce their severity.
Long-Term Healing (Months 6 to 24): During this stage, with ongoing sobriety, symptoms of PAWS usually resolve completely. It is possible to have a flare-up of symptoms when under significant stress, such as job loss, grief, or a physical illness.
Substance-Specific Nuances
The symptoms of PAWS may present differently depending on what the main substance of abuse was.
Substance-specific nuances may include the following:
Alcohol-Protracted Withdrawal: A systematic review published in the Journal of Studies on Alcohol and Drugs indicated that alcohol-related PAWS presents with anxiety, sleep disturbances, and cognitive cloudiness
Benzodiazepines: Benzodiazepines may cause the brain’s calming mechanism to work less efficiently. Benzodiazepines can lead to long-lasting and intense PAWS symptoms, such as tinnitus, severe anxiety, and muscle spasms.
Opioids: Opioid addiction changes the body’s ability to regulate pain and mood. Resulting PAWS symptoms may include severe sleep fragmentation, persistent fatigue, and a heightened sensitivity to physical pain.
Treatment and Self-Management Strategies
If you have symptoms of PAWS, there are ways to actively manage your symptoms instead of just waiting them out.
Medical and Therapeutic Interventions
Medications may be a good option, including the following:
Acamprosate (Campral): This is an FDA-approved medication for maintaining abstinence in people with alcohol use disorder who are already sober. According to the Substance Abuse and Mental Health Services Administration, Acamprosate helps restore natural neurotransmitter balance in the brain. It may help decrease insomnia, post-acute anxiety, and low-level cravings.
Naltrexone (Vivitrol): Naltrexone works by blocking opioid receptors involved in the pleasurable feelings associated with alcohol use. It subsequently reduces alcohol cravings and use.
Therapy and Mental Health Support: Cognitive behavioral therapy (CBT) can be especially helpful. CBT teaches individuals to recognize unhelpful thought patterns, identify triggers, replace them with healthier ways of thinking, and develop stress management strategies.
Mindfulness Practices: Techniques that promote relaxation, such as deep breathing and meditation, may also help reduce impulsive reactions and maintain emotional balance.
Non-Addictive Symptom Support: It may help to talk with your doctor about non-addictive options to treat sleep disturbances, such as low-dose melatonin or trazodone. Antidepressants to manage underlying mood disorders may also be useful.
Daily Holistic Protocols
Daily holistic habits can help support the brain’s recovery and may include:
Targeted Micronutrient Support: Although it’s always best to talk with your physician before starting supplements, certain micronutrients may help support the brain’s biochemistry, such as:
- Vitamin D to support nervous system health
- Omega-3 fatty acids to reduce neuroinflammation
- Magnesium at night to support sleep and GABA activity
Consistent Sleep Hygiene: Good sleep promotes healthy neurotransmitter balance, brain repair, and improves emotional regulation. Practice good sleep hygiene including:
- Maintain a consistent sleep/wake time
- Limit caffeine in late afternoon and evening
- Create a quiet, dark sleep environment
Low-Barrier Physical Activation: Exercise helps naturally improve mood. You don’t need an intense workout to benefit. In fact, hardcore workouts can trigger a stress response and spike cortisol. Instead, opt for:
- Taking a 15-minute daily walk in natural sunlight
- Attending a yoga class
- Performing gentle body weight exercises
Tracking Symptoms: Tracking symptoms in a journal can help you recognize patterns, identify triggers and understand that symptoms may ebb and flow in waves.
Utilizing Peer Networks: Staying connected to peer groups such as AA or NA and contact with counselors can help reduce stress and isolation. Social support also helps reinforce healthy behaviors and is associated with better long-term recovery outcomes.
