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Post-acute withdrawal syndrome (PAWS) and PTSD share many of the same symptoms.

PTSD is often mistaken for PAWS in addiction treatment contexts.

Treatment professionals should carefully assess for PTSD.

Almost all Americans are familiar with posttraumatic stress disorder (PTSD) and its long-term, sometimes devastating effects on people’s lives—crippling anxiety, depression, disturbing flashbacks, sleep problems, irritability, concentration difficulties, and much, much more.

About 70 percent of U.S. adults have experienced at least one major life trauma. The fact that so many of us experience trauma makes it easier to empathize with the 10 or so percent of people who go on to develop PTSD. This explains why PTSD is far less stigmatized than disorders like schizophrenia, bipolar disorder, and addiction, which far fewer people experience firsthand.

Post-Acute Withdrawal Syndrome

Americans are much less familiar with post-acute withdrawal syndrome (PAWS) than with PTSD. PAWS describes a collection of symptoms that occur after people with addiction quit using and enter recovery. PAWS symptoms, such as anxiety, depression, sleep problems, cravings, cognitive impairment, and irritability, can last for months to years after initial withdrawal from any number of drugs. These include alcohol, benzodiazepines, crack, marijuana, methamphetamine, and opioids.

PAWS isn’t an official medical diagnosis, yet there’s little question it exists. In some cases, physiological causes are well understood. People who are addicted to methamphetamine or crack, for example, can do long-term damage to their brain’s dopamine systems, making it difficult to experience pleasure. Some people’s dopamine systems are so damaged that they experience low-grade depression for life.

In many cases, however, symptoms we attribute to PAWS are caused by PTSD instead. Given so many shared symptoms, differentiating between PAWS and PTSD can be difficult. How are we to distinguish them in practice, where proper diagnosis of PTSD in particular is essential for effective treatment?

Diagnosing PAWS often hinges solely on whether or not a person is recovering from addiction. For those with substance use disorders, attributing symptoms to PAWS is often automatic. Trauma, if considered at all, becomes an afterthought. For people without addiction, the same symptoms are attributed directly to PTSD, with careful assessment of trauma.

The consequences of mistaking PTSD for PAWS can be catastrophic. Instead of empathy, those with alcohol and drug use disorders are viewed as responsible for their symptoms, and at times, overtly blamed. Instead of being treated for PTSD, they’re told to “hang in there” until their symptoms subside. Sometimes their symptoms do subside, and sometimes they don’t, leading to relapse, self-medication, and risk of overdose and death.

Underdiagnosing PTSD among people with substance use disorders is highly ironic. Childhood trauma is a potent risk factor for substance use disorders, and people who are in active addiction are far more likely to experience major traumas than people without addiction, such as automobile accidents, domestic violence, sexual perpetrations, and witnessing the untoward effects of one’s own addictive behaviors on loved ones, including children. Flashbacks to these and other events are common among people in recovery, and getting over them can take years.

During my career, I’ve worked for the U.S. Veterans Administration (VA), on inpatient psychiatric wards, and in treatment programs for addiction. I’ve worked with homeless residents fighting fentanyl and crack addiction in some of Columbus, Ohio’s, poorest, most disadvantaged neighborhoods.

In these spaces, I’ve treated veterans with addiction who’ve witnessed the horrors of combat. I’ve treated patients suffering from addiction and schizophrenia, addiction and manic psychosis, and addiction and PTSD. I’ve worked with young women who’ve been raped and who’ve traded their bodies for drugs and protection from even greater violence. I’ve treated people who’ve witnessed murder and watched their friends die from overdoses. Trauma is the rule, not the exception, in these contexts, yet it’s rarely a focus of treatment outside the VA.

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Stigma and Misdiagnosis

Given how common trauma is among people struggling with addiction, treatment should, at the very least, include careful assessment for PTSD, and many people should be treated for it directly. For many traumatized people, abstinence is worse than continued alcohol and drug use, which at least dampens their PTSD symptoms.

Instead, many patients are taught about PAWS and told to wait it out. Many are prescribed addictive drugs that aren’t especially helpful and that reduce their long-term quality of life. Others relapse and self-medicate, just as they’ve done for years. Why is PTSD underappreciated, underdiagnosed, and undertreated among people with addiction?

Addiction is the most stigmatized of all mental disorders. People who struggle with addiction often become defined by it. In the eyes of many, often even family members, they’re addicts first and everything else second. All of their mistakes are attributed to addiction, and all of their actions are filtered through a stigma lens. Since they “chose” their life of drinking and using, addiction’s consequences are their choice, too. The very notion of self-elicited trauma may seem preposterous.

Though unfortunate, healthcare workers are just as susceptible as anyone in society to stigmatizing addiction in this way. Nora Volkow, director of the National Institute on Drug Abuse, describes stigma among healthcare workers in her calls for change.

This isn’t anyone’s fault. Healthcare workers are raised in the same culture as all of us, and like us, they’re human. Denouncing the very people who dedicate their lives to helping their fellow citizens isn’t constructive.

At the same time, healthcare workers can be educated about their biases, taught to assess for PTSD, and encouraged to carefully distinguish PTSD from PAWS. Treating both substance use disorders and PTSD, when indicated, produces more sustained recovery, saving lives and bringing hope to countless family members and other loved ones.

Given the prevalence of substance use disorders in America, even modest treatment improvements can affect the lives of many. Here, the costs of change aren’t high. When treating substance use disorders, we must see symptoms of PTSD for what they are.

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