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 Post subject: PAWS?
PostPosted: Sun Jun 14, 2009 6:13 pm 
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I've read about (and I think experienced) PAWS. I found this on Wikipedia, but was wondering if the cause is really a lack of an opiate or psychological.

Quote:
Symptoms can sometimes come and go with wave like reoccurrences or fluctuations in severity of symptoms. Common symptoms include impaired cognition, irritability, depressed mood, and anxiety; all of which may reach severe levels which can lead to relapse.

The protracted withdrawal syndrome from benzodiazepines can produce symptoms identical to generalised anxiety disorder as well as panic disorder. Due to the sometimes prolonged nature and severity of benzodiazepine withdrawal, abrupt withdrawal is not advised.

Common symptoms of post acute withdrawal syndrome are:[15][16][17][18]
Psychosocial dysfunction
Anhedonia[19]
Depression
Impaired interpersonal skills
Obsessive-compulsive behaviour
Feelings of guilt
Autonomic disturbances
Pessimistic thoughts
Impaired concentration
Lack of initiative
Craving
Inability to think clearly
Memory problems
Emotional overreactions or numbness
Sleep disturbances
Physical coordination problems
Stress sensitivity
Increased sensitivity to pain
Panic disorder
Generalised anxiety disorder

Symptoms occur intermittently, but are not always present. They are made worse by stress or other triggers and may arise at unexpected times and for no apparent reason. They may last for a short while or longer. Any of the following may trigger a temporary return or worsening of the symptoms of post acute withdrawal syndrome:

Stressful and/or frustrating situations
Multitasking
Feelings of anxiety, fearfulness or anger
Social Conflicts
Unrealistic expectations of oneself
Too much on your to-do list


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PostPosted: Sun Jun 14, 2009 8:48 pm 
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While I've of course heard about longer acting opiates causing more prolonged/severe PAWS I've experienced very long lasting PAWS from short acting opiates. The last time I went through in patient treatment they slowly tapered me down and a few days before I got out I was off of everything. For the next 4 and 1/2 months or so I experienced extreme sleep problems, anxiety, and concentration problems. I had a hard time carrying on a conversation and I couldn't hardly sit still in class I was constantly uncomfortable. I used to fantasize about just getting to the point where I felt halfway content. I was practicing martyrdom then and wouldn't even take anything to help with sleep so I wouldn't doubt that my body was probably taking longer than normal to repair but it was really aweful. Maybe I'm just a little girl when it comes to PAWS lol

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 Post subject: response to PAWS
PostPosted: Fri Aug 14, 2009 3:39 pm 
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Aah yes, good ol PAWS (post acute withdrawal syndrome). Generally speaking, the most common symptoms of PAWS are unclear thinking, difficult emotions, difficult physical coordination, sleep disturbances, and stress. When I was in rehab last year, every day during group we would start with how we were each doing mentally, physically, emotionally, and spiritually? I realized that our responses to these questions helped our counselors gauge the degree of PAWS we were each going through.

There are two stages of withdrawal for addictive chemicals. The first stage is the acute, intense and immediate withdrawal that occurs directly after stopping use. The second stage is the long-term effects of withdrawal symptoms that occur after initial withdrawal symptoms. These symptoms comprise PAWS.

When we stop taking our drugs, we enter this first acute withdrawal stage. These symptoms are due to the imbalance of neurotransmitters and neurochemical pathways in the brain, which were drastically changed by our use. For example, a chronic opiate user develops tolerance and dependence on the drug. As more exogenous (from the outside) opiates are being introduced to the brain, more opiate receptors must be produced in order to keep up with the increasing amounts of opiates coming in. The binding of opiates to opiate receptors causes a myriad of effects, from euphoria, miosis (pupil contriction), inhibition of cough reflexes, constipation, dry mucus membranes, urinary retention, nausea, pruritis (itching), fatigue, bradycardia (low heart rate), hypotension (low blood pressure), respiratory depression, and the most important of them all, PAIN RELIEF. When the drug is no longer introduced to those receptors, and the receptors remain unbound, the symptoms of acute withdrawal kick in. And the majority of them are the exact opposite of what the drugs actually do to the body. Instead of constipation, you get diarrhea; instead of euphoria, you get dysphoric and depressed, anxious, and irritable; instead of miosis, you get pupillary dilation; instead of dry mucus membranes, you get increased salivation, lacrimation (tears), rhinorrhea (runny nose); instead of fatigue, you get restless; instead of bradycardia, hypotension, and respiratory depression, you get increased heart rate, increased blood pressure, and breath faster and harder; and most of all, instead of pain relief, you get PAIN. Before you ever introduced these exogenous opiates to your system, your body had a balance of natural endorphins and opiate receptors. But when these receptors got mass produced, there is no way your natural endorphins and endogenous opiates can keep up, that's why you have to keep taking more and more of the drug to get the desired effects, or just to feel normal and go on with your day, just to keep from getting sick. Our bodies now have become tolerant and dependent upon the exogenous opiates.

The second stage, PAWS, is due to persistent physiological adaptations in the brain, manifested in the form of continuing but slowly reversing the tolerance and dependence. Your receptors are beginning to downregulate, because they notice there's no more exogenous drug coming in, so they adapt. But this takes time. Following acute withdrawal, (not PAWS), there is a huge disturbance and imbalance in neurotransmitters. Many of drugs we take, from opiates, to uppers, downers, etc, all effect certain neural pathways in the brain, specifically ones involving serotonin and dopamine. Levels of these neurotransmitters increase dramatically during active drug use and the body tries to compensate by increasing the activity of opposing neurotransmitters, in the hopes to achieve a sort of balance. When the drug is removed, the balance is unopposed and many of these neuronal pathways become hyperexcitable. For example, an alcoholic changes his/her brain chemistry by increasing activity of GABA neurotransmitter (same as benzo's). So the body compensates by increasing activity of glutamate, an excitatory neurotransmitter, not an inhibitory one like GABA. When the alcoholic stops drinking, the levels of GABA decrease, but the brain had been kicking in so much glutamate to offset the action of GABA. With all this glutamate now being unopposed, guess what happens... PAWS! It takes time for our neurochemistry to come back to normal. But the underlying message is that eventually it will, things will get restored to how they were, and balance and homeostasis will ensue, and all those symptoms of PAWS will vanish.

I used oxycodone and hydrocodone for a year and a half, and pretty high doses, about 500mg/day, and it took me about 4-5 months for me to feel "normal" again. I had a lot of those PAWS symptoms, but the severe ones died out in a bout a week or two. The dysphoria's the tough one to handle. Another interesting point is that PAWS is cyclic, meaning some days symptoms may be more pronounced than other days.

It's also very important to note that stressful situations arise in early recovery, and the symptoms of PAWS produce further stress. So it's vital to avoid or deal with the triggers that make post acute withdrawal worse. That's why they say in early recovery, if you're not working, don't work for a few months, don't make major geographical moves, don't start a new relationship, etc. I laughed when they told me all these as I was being discharged from a treatment facility a year ago. But the fact is, it's a science, and it all comes down to restoring the natural physiology of our central nervous systems, and stress won't help.

Hope that helps explain PAWS a bit more. Again, my apologies for any mistakes or errors. Points to remember, PAWS will happen, it will suck, and it will go away.

Be well.


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PostPosted: Mon Oct 31, 2011 8:55 pm 
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Woulld drinking a little alcohol help? even if im on klonnpin???


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 Post subject:
PostPosted: Tue Nov 01, 2011 7:27 am 
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Does PAWS relate to just the symptoms we experience from the brain normalising, or also the symptoms of getting over the stuff we experienced in addiction?

I'm not doubting the existence of PAWS in any way. I spent 6 months in a rehab with another 30+ very sick recovering addicts, and it was a circus. At the end of the 6 months we almost felt able to pick the different PAWS symptoms for different drugs. The crystal meth fiends were always really impulsive, had jagged movements, quick to anger that took months to get manageable. Us heroin folk were moody, anxious, poor memories with really insidious cravings. Alcoholics seemed the most "damaged" upstairs, strangely. Everyone was in weird shape. One of the really important symptoms I think of PAWS is that there was always a lack of insight into how crazy we really were, especially in the first few months. It wasn't until I was 9-12 months clean that I realised how insane I really was.

But it's so hard to tell what is a symptom of the drugs, and what is the natural result of experiencing the things we put ourselves through. One of those symptoms in the PAWS list was "Feelings of guilt". It would have been extremely abnormal for me to have no guilty feelings after a relapse.

My personal choice in my early recovery would be to try and forget I have PAWS, but rather remind myself that I'm still "finding my feet". Given I already have bipolar disorder, and so many of its symptoms overlap with PAWS, I really don't want something else to pathologize my life with. I just wanna enjoy the insanity of early recovery. I have some really fond memories of my poor 'impulse control' in early recovery. :lol: But that is my personal choice.

Doc, given we that we do eventually recover from PAWS, do you think we should use medication to relieve its symptoms?


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 Post subject: great article
PostPosted: Tue Nov 01, 2011 11:55 am 
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Doc...one main thing with the H addicts was /is sugar in PAWS- any insight on the changes of the brain that addiction causes is so fascinating! being bipolar ive always heard the term 'neurotransmitters' and rapid firing thrown around in some way or another... id like to know more about the role they play in BPD...im quite sure that answer would be much more lengthy but if anyone can answer , why sugar?


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 Post subject: Looking back
PostPosted: Tue Nov 01, 2011 12:20 pm 
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on my 5 failed re-hab stints; PAWS got me everytime- the nurses and docs would say , "oxycontin will be out of your system in 3 days" then id piss clean after 4 and wonder why it was so difficult to do the easiest tasks- i couldn't carry on a conversation, id always lose my train of thought. I figured I'd be like this for life so I started using again. I wish one of those rehabs would have mentioned it would take another6-7 months after the 4 day acute kick.....hrrrmm, maybe i wouldn't have picked up after 2 months- PS-methadone PAWS are the WORST!


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Fond Du Lac Psychiatry
Dr. Jeffrey Junig, M.D., Ph.D.

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