Post Acute Withdrawal Syndrome (PAWS) in Addiction Recovery: Neurochemical Mechanisms and Coping Strategies

This podcast episode provides a comprehensive overview of Post Acute Withdrawal Syndrome (PAWS), distinguishing it from acute detoxification and explaining its neurobiological underpinnings. PAWS is defined as the protracted period of brain rehabilitation following substance misuse, characterized by intermittent symptom bursts that can last from one to two years. The severity and duration of PAWS are influenced by factors such as the intensity and chronicity of substance use, the individual's age at initiation (especially under 24 due to brain development), gender, overall physical health, and pre-existing mental health conditions that may involve neurochemical imbalances. Understanding these contributing factors is crucial for anticipating and managing the recovery process.\n\nThe episode delves into the specific neurochemical alterations caused by various substances. Cocaine, amphetamines, and alcohol, for instance, increase dopamine and glutamate availability while inhibiting monoamine oxidase (MAO), leading to an overstimulated reward system. When these substances are removed, the brain, having adapted by creating more receptors or altering its structure, experiences a "polar opposite" effect, resulting in depression, anhedonia, and intense cravings. Nicotine, opioids, and benzodiazepines also profoundly impact dopamine, GABA, serotonin, and pain receptors, further complicating the brain's rebalancing act during recovery. The host uses an analogy of a factory manager over-ordering raw materials (neurotransmitters) to illustrate how the brain adapts to excess and then struggles when the supply ceases.\n\nCommon symptoms of PAWS are thoroughly discussed, including emotional dysregulation (outbursts or anhedonia), anxiety, irritability, depression, persistent fatigue, sleep disturbances (strange dreams, altered patterns), cognitive impairments (memory problems, difficulty concentrating, decision-making, problem-solving), and physical symptoms like dizziness, balance issues, and delayed reflexes. These symptoms are presented as normal, albeit challenging, manifestations of the brain's healing process. The importance of psychoeducation is emphasized, preparing individuals for these expected fluctuations to prevent frustration and potential relapse, as these symptoms have historically triggered substance use.\n\nPractical interventions and coping strategies are highlighted, with a focus on self-regulation. The host introduces the concept of regulating the brain's "bath temperature" of neurotransmitters. Key recommendations include practicing meditation and focused breathing techniques (e.g., 4-4-4 breathing) to modulate the HPA axis and calm the nervous system. Developing distress tolerance and robust coping skills is paramount, often involving external support from sponsors, coaches, or friends during intense craving episodes. The discussion also extends to the impact of legal substances like cannabis and caffeine on neurotransmitter systems and PAWS, and underscores the heightened vulnerability of the developing brain to long-term alterations from early substance use, stressing the need for patience and consistent effort in the recovery journey.

PAWS is the result of changes in the brain that are either undoing themselves or rehabilitating after something happens.

People will experience little bursts of symptoms probably for up to a year sometimes two years depending on how intense and how chronic their use was.

Memories of substance use alter brain functioning so even just thinking about substance use can trigger some of those neurochemical reactions specifically sending that dopamine out and that dopamine says i want that i need that and triggers those cravings.

Our brain is geared to maintain a balance... it has actually altered its structure to try to rebalance itself.

During detox we see that as people move into later phases of recovery... there are going to be some days where people will just wake up and whatever symptoms they had during detox they may have those same symptoms again for a brief period.

Dopamine primarily is our go out and get it neurochemical it's the one that motivates us but dopamine is also responsible for energy.

Chronic stimulation by nicotine of the gabaergic neurons are desensitized and let and lose their ability to inhibit dopamine which reinforces the addiction by inducing craving.

In chronic substance abuse the brain comes to rely on the drug to maintain the high degree of pleasure associated with the artificially elevated levels of some neurotransmitters in the reward circuits.

The brain can even adapt to these high neurotransmitter levels by making new receptors which produces depression or anxiety and cravings if consumption ceases.

The developing brain is particularly vulnerable to the harmful effects of drugs of abuse... disruption of the nicotinic receptor development with early nicotine or drug use may influence the function and pharmacology of the receptors and alter the release of reward-related neurotransmitters.