How to treat alcohol withdrawal
ARTICLE OVERVIEW: Drinkers who become physically dependent on alcohol will go through a period of withdrawal upon cessation or significantly lowered consumption of beer, wine, or spirits. Typically, most cases of alcohol withdrawal require a watch-and-wait supervision to treat symptoms as they occur. However, in cases of heavy or long-term drinking, medical intervention may be required to prevent very serious conditions: seizures or delirium tremens. In this article, we detail the basic protocol of how to withdraw from alcohol. Then, we invite your questions or comments about withdrawal treatment at the end.
TABLE OF CONTENTS
- Why Withdrawal Occurs
- Protracted Symptoms
- Main Treatments
- Mild to Moderate Cases
- Serious Cases
- Medications That Help
- Why Detox In A Clinic
- Detox At Home
- Signs Of A Drug Problem
- Who Uses Alcohol
- Dependence VS Addiction
- Your Questions
Why Withdrawal Occurs
According to the National Institute on Alcohol Abuse and Alcoholism, every year, more than 1.5 million people in the United States either enter alcoholism treatment or are admitted to a general hospital because of medical consequences resulting from alcohol dependence. These people, as well as a substantial number of others who try to detox at home, experience alcohol withdrawal. But what is withdrawal? Why does it happen?
Alcohol withdrawal is a clinical syndrome that affects people accustomed to regular alcohol intake who either decrease their alcohol consumption or stop drinking completely. In these people, the central nervous system has adjusted to the constant presence of alcohol in the body and compensates for alcohol’s depressive effects on both brain function and the communication among nerve cells (neurons). Consequently, when the alcohol level is suddenly lowered, the brain remains in a hyperactive, or hyperexcited, state, causing withdrawal syndrome.
How Long Does Alcohol Withdrawal Take?
Alcohol withdrawal symptoms usually occur within 8 hours after the last drink, but can last for many days. Symptoms usually peak by 24 – 48 hours and then diminish, but some symptoms persist for weeks. The most dangerous symptoms like delirium or seizures can occur a day or two after initial detox…so EVERY CASE OF ALCOHOL WITHDRAWAL SHOULD BE MEDICALLY SUPERVISED.
Symptoms that persist beyond the period of acute withdrawal (the first week or so of detox) are called “protracted” or “post-acute” withdrawal symptoms, and are usually related to sleeping or mood, disorders.
Many people who go through withdrawal from alcohol manifest a set of predictable, minor symptoms, also called a “syndrome”. Signals of alcohol withdrawal may include any combination of generalized hyperactivity, anxiety, tremor, sweating, nausea, retching, tachycardia, hypertension and mild pyrexia.
The most common effects of withdrawal from alcohol include:
- Anxiety or nervousness.
- Difficulty concentrating.
- Sensitivity to light and sound.
- Jumpiness or shakiness.
- Mood swings.
- Not thinking clearly.
NOTE HERE: Delirium tremens is the most intense and serious syndrome associated with alcohol withdrawal, is characterized by severe agitation; tremor; disorientation; persistent hallucinations (sensations and images that seem real though they are not); and large increases in heart rate, breathing rate, pulse, and blood pressure.
While treatable, serious withdrawal episodes may contribute to the development of negative health consequences. THIS IS WHY ALCOHOL WITHDRAWAL NEEDS TO MEDICALLY MANAGED! If you are dependent on alcohol, please seek professional help. There is no shame in asking for help. Alcohol dependence is a medical issue. It is treated medically.
The Substance Abuse and Mental Health Services Administration indicate that a protracted withdrawal syndrome may develop following alcohol withdrawal and can persist for up to 1 year after you stop drinking. Some symptoms may be masked as other health disorders, but are actually caused by delayed brain changes.
The symptoms of protracted alcohol withdrawal include:
- Depressive symptoms.
- Increased blood pressure and pulse.
- Increased body temperature
- Increased breathing rate.
- Sleep disruption.
Other symptoms of protracted withdrawal syndrome appear to oppose symptoms of alcohol withdrawal.
These symptoms of protracted withdrawal syndrome include:
- Decreased energy.
- Decreased overall metabolism.
The significance of this cluster of symptoms has been debated. For example, protracted withdrawal syndrome could reflect the brain’s slow recovery from the reversible nerve cell damage common in alcoholism. Other experts are hesitant to claim that they even exist at all! Clinically, the symptoms of protracted withdrawal syndrome are important, because they may predispose abstinent alcoholics to relapse in an attempt to alleviate the symptoms.
So, what can you expect during an episode of alcohol detox? Here, we’ll cover the first few days and typical symptoms that manifest within that time.
Within 6 to 12 hours after alcohol cessation, the common symptoms include:
- Low-level stress or anxiety.
- Minor hand tremors.
- Sleep disturbances.
- Stomach upset/loss of appetite.
From 12 to 48 hours after alcohol cessation, a person may experience:
- General tonic-clonic seizures.
- Hallucinations that may involve sight, hearing or touch.
- Withdrawal seizures.
From 48 to 72 hours after alcohol cessation, the person may have:
- Delirium tremens (see above for more information).
- Further hallucinations, mostly involving sight.
- Increased heart rate, blood pressure and temperature.
Symptoms of alcohol withdrawal can range in severity from mild tremors to massive convulsions or withdrawal seizures. Mild alcohol withdrawal can cause pain and suffering; severe alcohol withdrawal can be life threatening.
The goals of alcohol withdrawal treatment are to:
- Relieve the person’s discomfort.
- Prevent the occurrence of more serious symptoms.
- Forestall cumulative effects that might worsen future withdrawals.
Withdrawal treatment also provides an opportunity to engage persons in long-term alcoholism treatment.
Any person going through alcohol withdrawal should receive a physical examination to detect conditions such as irregular heartbeat, inadequate heart function, liver disease, pancreatic disease, infectious diseases, digestive system bleeding, and nervous system impairment. Vital signs should be stabilized and disturbances of water and nutritional balances corrected.
Mild to Moderate Cases
Before you begin any alcohol detox, seek medical diagnosis. A doctor should follow clinical guidelines to manage withdrawal, such as these outlined in the 2013 article published in the medical journal, Indian Psychiatry. If the person the experience mild to moderate alcohol withdrawal symptoms, they can often be treated in an outpatient setting. If you fit into this category, you will need someone to commit to staying with you. It needs to be someone who can keep an eye on you.
Daily visits to the health care provider are often needed until you are stable. It is important that people who complete alcohol withdrawal can continue care in a living situation that helps support them in staying sober. Some areas have housing options that provide a supportive environment for those trying to stay sober.
The acute treatment for mild cases of alcohol withdrawal usually includes:
- Blood tests.
- Person and family counseling to discuss the long-term issue of alcoholism.
- Sedative drugs to help ease withdrawal symptoms.
- Testing and treatment for other medical problems linked to alcohol use.
Clinicians use numerous strategies to manage alcohol withdrawal, mainly relying on medications to help address symptoms. The Veteran’s Association’s withdrawal guidelines are published here, for example. Most often, doctor will first assess you using the Alcohol Withdrawal Scale, outlined in this 2015 article published in the medical journal, Drugs. This is why people with moderate to severe symptoms of alcohol withdrawal may need inpatient treatment at a hospital or other facility that treats alcohol withdrawal. The person will be watched closely for hallucinations and other signs of delirium tremens.
Treatment may include:
- Administration of fluids or medications through a vein (by IV).
- Monitoring of blood pressure, body temperature, heart rate, and blood levels of different chemicals in the body.
- Sedation using medication called benzodiazepines until withdrawal is complete.
So, should you seek a hospital, or not? ALWAYS SEEK PROFESSIONAL HELP IN ANY CASE OF ALCOHOL DETOX. More clinical guidelines for acute alcohol withdrawal from the Royal College of Physicians here.
Medications that Help
Pharmacological treatment is most frequently employed in moderate to severe alcohol withdrawal. Although more than 150 medications have been investigated for the treatment of alcohol withdrawal, clinicians disagree on the optimum medications and prescribing schedules. The following review describes some medications that have been recognized as potential treatments for alcohol withdrawal:
- Anti-anxiety drugs like benzodiazepines to reduce anxiety withdrawal symptoms.
- Anti-seizures drugs like Depakote.
- Beta-blockers which can slow the heart rate, reduce tremors and sometimes also helping with the craving for alcohol.
If you tell your doctor that you are having a problem with alcohol withdrawal s/he might also help you taper off with a benzodiazepine such as Valium or Librium. Typical detox regimens using these medications are as follows:
- Diazepam (Valium); 10 mg 3 or 4 times in first 24 hours, then 3 or 4 times daily as needed.
- Chlordiazepoxide (Librium); 50 mg every 6 hours for four doses, then 25 mg every 6 hours for eight doses.
This NIAAA introduction to Alcohol Withdrawal provides more details about medications to be used during detox. In addition, anyone who receives treatment for abstinence from alcohol should receive 100 mg of thiamine as soon as treatment begins. A magnesium supplement may also help improve general withdrawal symptoms, as well as an oral multivitamin formula that contains folic acid (for a few weeks).
Some people can just quit drinking alcohol cold turkey without having significant withdrawal symptoms. Other people, however, may suffer significant withdrawal symptoms when they suddenly stop drinking.
Alcohol withdrawal is potentially fatal, so if the person starts to experience significant alcohol withdrawal symptoms when they stop drinking then it is important to gradually detoxify from alcohol rather than quitting all at once “cold turkey”. They can gradually detoxify from alcohol by tapering off, by using alcohol itself or by using medications.
How to taper your drinking?
It all begins by reducing the number of drinks in a sitting, a day, a week, or whichever time frame works best. Tapering off alcohol is often a one-drink-at-a-time progression. Mixed drinks can be made with greater proportions of mixer to alcohol content or replaced with non-alcoholic drinks to mimic the act of alcohol consumption. If nothing else, drink alternatives like water between drinks because hydration is essential for detox.
In addition to quantity, the specific type of alcohol needs to be considered. Hard liquors, for example, contain higher alcohol-by-volume measures than other beverages. It is recommended when attempting to taper off alcohol that an person should substitute these stronger options for wine or beer — or at least hard liquor with a smaller proof.
Finally, when determining how to taper off alcohol, one must always remember the importance of setting. Users should avoid places where recreational or binge drinking is likely to occur, such as clubs, sporting events, parties, and more. Such a conclusion comes down to personal discretion — nobody knows the people and places that create potentially negative consequences like the person in question. This, of course, is easier said than done if drinking has become the crux of one’s social or romantic relationships. Experts advise surrounding oneself with positive influences whenever possible.
More tips for cutting down on drinking from the State of Wisconsin here.
Always remember that if the taper is not working for you or if you are having major withdrawal that it is safest to check into a medical detox because alcohol withdrawal can kill you.
After you complete your taper we recommend that you attempt a period of abstinence from alcohol. Thirty days is a reasonable amount of time to shoot for. This will give your body some time to reset back towards normal and also give you a chance to experience most of the situations where you used to drink without alcohol. Thirty days is just a suggestion; some people may choose a shorter period such as a week and others may opt for something longer such as 90 days. Some people might even find that they like abstinence from alcohol so much that they will opt for permanent abstinence once the trial period is up.
Why Detox In A Clinic?
Appropriate treatment of alcohol withdrawal can relieve the person’s discomfort, prevent the development of more serious symptoms, and forestall cumulative effects that might worsen future withdrawals. Hospital admission provides the safest setting for the treatment of alcohol withdrawal. Severe alcohol withdrawal requires pharmacological intervention. Although wide varieties of medications have been used for this purpose, clinicians disagree on the optimum medications and prescribing schedules.
Relative indications for inpatient alcohol detoxification include:
- History of severe withdrawal symptoms.
- History of alcohol withdrawal seizures or delirium tremens.
- Multiple past detoxifications.
- Concomitant medical or psychiatric illness.
- Recent high levels of alcohol consumption.
- Lack of reliable support network.
Detox At Home
Management of alcohol withdrawal at home could be considered if the person:
- Does not have a history of complicated withdrawal.
- Does not have a history of withdrawal seizures.
- Has an appropriate support person to monitor them and assist with medication administration.
- Has stable accommodation.
- Is experiencing mild withdrawal symptoms after 48 hours.
- Is medically and psychiatrically stable.
If you have been in an inpatient setting and want to leave early to continue to detox from home, please reconsider. You’ll need to be medically and/or psychiatrically reviewed and cleared as low risk of complications if managed in a home setting.
Safety During Withdrawal
The best and the safety way to stop drinking after you develop physical dependence is under medical supervision. Neurologists, psychiatrists, and general physicians are trained in monitoring alcohol detox and identifying signs of complication and then treating them.
Appropriate treatment of alcohol withdrawal can ease discomfort, prevent the development of more serious symptoms, and put off cumulative effects that might worsen future withdrawals; and because alcohol withdrawal can quickly and unexpectedly take a serious turn for the worse, always seek medical help anytime you need to withdraw from alcohol.
Signs of an Alcohol Problem
To be diagnosed with alcohol use disorder, the persons must meet certain criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V).
To assess whether you or loved one may have alcohol use disorder, here are some questions to ask. In the past year, have you:
- Had times when you ended up drinking more, or longer, than you intended?
- More than once wanted to cut down or stop drinking, or tried to, but could not?
- Spent a lot of time drinking? Or being sick or getting over other aftereffects?
- Wanted a drink so badly you could not think of anything else?
- Found that drinking, or being sick from drinking, often interfered with taking care of your home or family? Or caused job troubles? Or school problems?
- Continued to drink even though it was causing trouble with your family or friends?
- Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink?
- More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)?
- Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout?
- Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before?
- Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart, or a seizure? Or sensed things that were not there?
The presence of at least 2 of these symptoms indicates an alcohol use disorder. The severity of the alcohol use disorder is defined as:
- Mild: The presence of 2 to 3 symptoms.
- Moderate: The presence of 4 to 5 symptoms.
- Severe: The presence of 6 or more symptoms.
Who Uses Alcohol?
According to the 2015 National Survey on Drug Use and Health (NSDUH), 86.4 percent of people ages 18 or older reported that they drank alcohol at some point in their lifetime; 70.1 percent reported that they drank in the past year; 56.0 percent reported that they drank in the past month.
In 2015, 26.9 percent of people ages 18 or older reported that they engaged in binge drinking in the past month; 7.0 percent reported that they engaged in heavy alcohol use in the past month. Even more, the same report documented that an estimated 15.1 million adults ages 18 and older (6.2 percent of this age group) had alcohol use disorder. This includes 9.8 million men (8.4 percent of men in this age group) and 5.3 million women (4.2 percent of women in this age group). Plus, an estimated 623,000 adolescents ages 12–17 (2.5 percent of this age group) had alcohol use disorder. This number includes 298,000 males (2.3 percent of males in this age group) and 325,000 females (2.7 percent of females in this age group).
However, not everyone who needs help gets it.
About 6.7 percent of adults who had alcohol use disorder in the past year received treatment. This includes 7.4 percent of males and 5.4 percent of females with alcohol use disorder in this age group. About 5.2 percent of youth who had alcohol use disorder in the past year received treatment. This includes 5.1 percent of males and 5.3 percent of females with alcohol use disorder in this age group.
As you can see by these statistics, you do not are the only one facing this problem.
Dependence vs. Addiction
Often the terms alcohol addiction and alcohol dependence are used interchangeably, which can lead to confusion.
Alcohol dependence refers to a physical dependence on alcohol and is characterized by tolerance to alcohol and alcohol withdrawal syndrome. Alcohol withdrawal syndrome can be life threatening and occurs when heavy drinkers stop drinking or drastically cut down their alcohol intake.
There is a fine line between the dependence on alcohol and alcohol addiction. Alcohol addiction is a primary condition characterized by the inability to stop using alcohol despite growing negative consequences. Uncontrollable cravings for alcohol, exceeding self-imposed limits, continued use despite physical, psychological, and social consequences, and an inability to stop drinking once one has started are all behaviors that signal addiction has developed.
We hope that you have found this article useful. If you still have questions about alcohol withdrawal and its treatment, please leave them in the section below. We will do our best to respond to all questions with a personal and prompt response.
Reference Sources: HAMS: Harm Reduction for Alcohol
MEDLINE PLUS: Alcohol withdrawal
NIAAA: Alcohol facts and statistics
NIAAA: Alcohol use disorder: A comparison between DSM–IV and DSM–5
NIAAA: Complications of alcohol withdrawal
NIAAA: Introduction of alcohol withdrawal
NIAA: Treatment of alcohol withdrawal
SA HEALTH: Ambulatory/home setting management of alcohol withdrawal
Photo credit: Kathea Pinto