Post-Acute Withdrawal Syndrome (PAWS)
PAWS may be a condition with a cute acronym, but its symptoms are really ugly. Let’s set the scene. You’re a month or two into recovery, feeling better and starting to learn how to live sober. Out of nowhere, you start feeling different. Nothing horrible, just a little off, so to speak.
But the next day, it gets worse. Social situations become difficult to navigate. The work environment seems extra stressful. Sleep is evasive at best, and you have trouble with cognitive tasks. You may also find yourself daydreaming about executing a fatal judo-chop to the guy who gave you a “funny look.” Welcome to post-acute withdrawal syndrome.
Roughly 90% of those addicted to opiates, like heroin or prescription pain medication, experience this uncomfortable condition. 75% of those addicted to alcohol, benzodiazepines (Xanax, Klonopin) and amphetamine (Adderall, methamphetamine) also experience PAWS. It affects virtually everyone who gets sober from substance abuse at some point. And it might be the most underestimated cause of relapse.
I’ll start with some common symptoms and also relate some of my experience with post-acute withdrawal.
Insomnia doesn’t necessarily mean you are experiencing post-acute withdrawal, but it is often a tell-tale sign. You may notice your sleep cycle disturbed. You may endure nights of extremely restless sleep. Vivid dreams, often involving the use of alcohol and drugs, may also occur during this time.
In severe cases, you may go days without sleep despite months of sobriety. Stressful situations often trigger these episodes.
When I experienced bouts of PAWS, there were times where I had no sleep. This usually lasted one day, but sometimes it continued into the next day. There were also times where I’d have trouble going to sleep, and times where I’d wake up too early. I endured just about every form of insomnia possible. In almost every situation, stressful life circumstances brought about the sleeplessness.
The Big Book of Alcoholics Anonymous had a different word for anxiety when it was written decades ago. The drunks of old called it a “nervous disposition.” Today, we know it as anxiety.
Anxiety and insomnia seemed to be two sides of the same coin. The less I slept, the more anxious I was. The more I slept, the less anxious I was.
Worry and fear clouded my mental climate in early sobriety. I think everyone, to some extent, deals with anxiety when they get sober. But I feel opiate addicts, in particular, battle the soul-wrenching tension more so than substance abusers of different varieties.
Early on, anxiety informed almost all circumstances. I felt like the Tin Man with no oil when I was in a room full of people I barely knew. At first, I thought I was being humble by choosing a seat in the very back of a 12 step meeting while silently going about my business. It took awhile for me to realize I was consumed with anxiety and fear.
I’m certainly not opposed to prescription medication for those who genuinely need it. On the other hand, I felt that if I didn’t start learning how to meet these situations without an outside substance, I’d be doomed to addiction in some form or fashion.
If it wasn’t for the tools taught in 12 step programs, I wouldn’t have stayed sober. More on those later.
Heightened levels of stress and/or increased sensitivity to stress
Stress was never something I’d handled well. My mind amplified situations that shouldn’t have been that big of a deal. I think, to some extent, most people in early sobriety are accustomed to bringing unhealthy solutions to tumultuous events.
I remember battling some fairly crazy thoughts. I’d say something in a social situation and invent all kinds of goofy reasons why that was the wrong thing to say. I’d sit in a 12 step meeting and think the person sharing was indirectly referencing me in some negative way.
A variety of factors fueled this engine of stress. First, I’d never developed ways to take care of myself. Second, my mind invented fairytale perspectives, specifically relating to social situations. Third, I never learned how to say “no.” I often pushed myself to the breaking point, piling on responsibilities to an overwhelmed schedule.
Throw a little post-acute withdrawal in the mix, and you have a recipe for relapse. I was lucky that in the midst of magical journey of stressful innovation, I stayed active in a program of recovery. Between meetings, step work, sponsorship and fellowship, I found the support and growth necessary to walk through stress sober.
I also discovered I was going bald. That didn’t help things either.
Trouble with cognition/thinking
For a guy who remembered events as early as two years old, it was awkward asking someone to repeat what they just said to me. It was equally disturbing when I realized how simple the answer was to certain problems. Sometimes, my job required me to do simple math. 15+18 presented a mental challenge only Texas Instruments could solve.
I used to tackle Calculus with the precision of John Nash. Now, I felt like a middle school child learning the wonders of simple numbers all over again. Someone had slipped me a stupid pill.
Even complete sentences, at times, became a challenge. I secretly identified with Homer Simpson, but wouldn’t dare tell anyone. My friends appeared to have a pretty good handle on the English language. But as Andy James said, I felt like an alien returning to Earth.
Trouble with emotions (overreaction or little/no emotion)
I instigated a fight because I thought a guy had watched TV too long. That’s right. I was prepared to fisticuff with someone over a television. Fortunately, stronger heads prevailed, and peace eventually ruled the day.
I’d also cry in secret while riding in the van at Discovery Place when we passed Church signs. It didn’t have to be a particularly insightful sign either. A simple, “love is the answer when hate is the question,” was enough to rattle my emotion.
“What the hell is wrong with you,” I’d think to myself.
There were also times where I felt incapable of producing a single emotion – total emptiness. It went as far as me giving names to my emotions when they surfaced and feeling incredibly insightful that I had reached such a level of maturity.
Trouble in social settings
I think I’ve covered some of this already, but when you can substitute roughly 60% of what you say with durrrr, you might be having some trouble in society. I’m not trying to paint myself as a complete derelict, but I wasn’t that far off.
Granted, there wasn’t much social exercise occurring in the basement I occupied for a year using heroin and other drugs. My social skills were never that sharp anyway, and years of drug abuse really rounded out my awkwardness.
I’m almost hesitant to relate this story, though I feel it highlights just how hazardous it was to be around me in my early days of sobriety. I’m walking up to a 12 step meeting, and in the door’s reflection, I see two ladies walking up behind me. Tommy Boy said it best when he compared himself to “Jo Jo, the idiot circus boy.”
And the idiot circus boy was on full display that night. I held the door open for them, like the gentleman I was. But one lady, as she was thanking me, said, “How did you know we were behind you?” To which I replied, “I…just…did.”
When the awkward is so awkward you feel physical pain, it’s time to revamp your social skills.
Craving your drug of choice
My first month sober found me fantasizing about Heroin Mountain. It’s essentially what it sounds like – a mountain of heroin. By my second month sober, dreams of heroin hills disappeared, yet I continued to crave opiates. Cravings increased in pronunciation during cycles of post-acute withdrawal, especially when I had trouble sleeping.
I also noticed that if a situation or place reminded me of a time spent using, cravings usually followed. Fortunately I had the security of a long-term residential program. After 90-days in that program, I had begun to develop the skills needed to deal with both cravings and post-acute withdrawal.
The Best Defenses against PAWS
I believe meditation is the most underrated aspect of the 12 steps. It’s not talked about in 12 step meetings often. But you don’t have to wait until step 11 to start meditating. With some good direction, you can begin to calm your mind.
I prefer mindfulness meditation. Stress, anxiety and agitation melt away after 20 minutes of focus on breath and sound. When post-acute withdrawal flared, it was my go-to weapon.
You’ll notice some interesting aspects of your mental faculties too. It only takes a few seconds for my mind to wander off on some meaningless tangent, despite my best efforts to focus on breath and sound.
This is the general pattern I see: breathing… breathing… mind calming… I wonder what pair of pants I should wear today. The coffee brewing sure smells good. Wait, back to the breath.
Breathing… breathing… mind calming… Why did I say that to her last night? She probably thinks I’m a moron. Okay, back to the breath again. Breathing… breathing…
I’ve found the first five minutes of meditation to be the most difficult, as calming my mind is no small task. Generally, however, if I get through the clutter of the first five minutes, my brain begins to slow down. Eventually, I’ll find that blissful state monks on National Geographic possess. At least that’s what I tell myself.
Regular sleep schedule
This is fairly self-explanatory and really just entails consistent discipline. I feel like there are three critical elements in cultivation of healthy sleep habits.
The first element is diet. I can’t sleep when I’m hungry. I’ve found a snack shortly before bed silences the growls of an empty stomach.
The second element is target time. Set a window of time, say 10pm to 11pm, where you will start the bedtime routine. Brush and floss your teeth. Wash your face. Thank your Higher Power for another day sober. Put the cell phone on silent. Remove the distractions and drift off to dream.
The third element is a strict no napping policy. Obviously there are exceptions to this rule, but do your best to refrain from snoozing during the day. I’ve found it makes falling asleep at night much more difficult. And I’m guessing you will too.
It’s time to say goodbye to all those terrific people with whom you drank and did drugs. If you truly want to stay sober, you must shut the door on the “old playmates.” Despite what you think, I can almost guarantee you’ll have more fun.
Sober friendships add a layer of accountability to your program and provide people with whom you can confide in times of need. You must lean on these people when PAWS cycles start. Talk to them about how you’re feeling. Ask for direction and support.
This is something I still need to improve as I’ve definitely been a victim of the “sober 20” (packing on 20lbs in sobriety). Exercise helps your body heal faster and may shorten the amount of time spent experiencing post-acute withdrawal.
Even something as simple as a 20 minute walk can do wonders for your mood. As a reformed gentleman of leisure, I often find incredibly persuasive excuses for not exercising. None of them are valid. If I genuinely desire a healthy life, I must burn some calories on a regular basis. And you should too.
Most of us in recovery love caffeine. There’s a fine line between coffee connoisseur and Javier Gonzalez, lord of the Bolivian coffee underworld. I tend towards the latter.
It’s a good idea to keep caffeine to a minimum. These days, I’m a one or two cup guy. And I stay away from energy drinks like the plague. I attended a seminar on addiction by a medical professional who stated that energy drinks can trigger parts of the brain that crave drugs.
Sugar should be treated in like fashion. A candy bar here and there isn’t going to kill you. But if you’re like me and plunder the candy aisle at Kroger, it’s best to indulge on special occasions.
I’ve found on days I keep my meals restricted to eggs, chicken, oatmeal, fruits and vegetables, I feel fantastic. Like recovery, however, it doesn’t take much to throw me off the beam.
First rule of sponsorship – get a sponsor. Second rule of sponsorship – call your sponsor. Third rule of sponsorship – meet regularly and go through the literature.
Early in sobriety, I got this idea that my sponsor should be some type of Yoda, dispensing sage advice as I walked the path towards Jedi master. I really wish I could blame this on post-acute withdrawal syndrome. I can’t.
But a healthy, active relationship with your sponsor will shield you from a potential relapse due to PAWS. He or she is someone you can talk with confidentially and honestly. An authentic line of communication can go a long way in calming the unwelcome side effects of your body’s readjustment period.
A sponsor should also direct you through the steps. If completed as directed, the steps will change your perspective in ways too profound for words. Your entire relationship with people and the world will improve, as long as you do the work. Step work kept me accountable. Step work kept me sane. Step work helped me navigate post-acute withdrawal’s rocky terrain.
Taking time for yourself
There’s a reason the Big Book of Alcoholics Anonymous tells us to, “Relax and take it easy.” I always had this idea in my head that I was like the Dude from The Big Lewbowski. When the booze, pot and other party favors went away, I soon discovered that was not the case.
It took time for me to get comfortable with relaxation. I had this idea that even an hour or two watching TV made me a couch potato. Not true.
Take time to make nutritious meals, exercise, cultivate a clean living space and fellowship with friends. By finding time to unwind, you will help decrease the severity and frequency of post-acute withdrawal syndrome.