The National Institute on Drug Abuse (NIDA) reports that alcohol abuse exerts a significant financial burden in the United States. Approximately 17 million people have issues with alcohol that qualify them for diagnosis of an alcohol use disorder, and the cost of alcohol abuse and use in the country is estimated to be significantly over $200 million yearly. This places the burden on society as a result of alcohol abuse second only to the abuse of tobacco products.
A significant portion of the costs associated with alcohol use disorders are due to medical complications associated with moderate to heavy alcohol use. For individuals in recovery from an alcohol use disorder, a significant portion of their initial success involves being able to deal with the complications associated with physical dependence on alcohol. The physical dependence that occurs as a result of having a moderate to severe alcohol use disorder can result in severe withdrawal symptoms that can be fatal. Intensive medical interventions are often required to help the person maintain their abstinence from alcohol in the early stages of recovery.
Physical Dependence on Alcohol
The American Psychiatric Association (APA) establishes the diagnostic criteria that are used to diagnose mental disorders, such as an alcohol use disorder. However, APA does not specify the specific standards of treatment for mental disorders in its diagnostic manual, the DSM-5. Instead, organizations like the American Society for Addiction Medicine (ASAM), the largest formal organization of addiction medicine physicians in the United States, sets the standards and guidelines for the major medical treatment protocols associated with substance use disorders. This includes the medical procedures used to negotiate issues with physical dependence on drugs and alcohol.
Physical dependence consists of both the syndromes of tolerance (a process of habituation to the use of a drug or medication, such that an individual needs to take a larger amount of the drug over time in order to get the effects they once experienced at smaller amounts) and withdrawal (a process that occurs when an individual’s system adjusts itself to the presence of alcohol or a drug, and is thrown out of balance when the levels of that substance decline in the system).
ASAM, APA, and the World Health Organization (WHO) have distinguished between the notions of detoxification and withdrawal management. These organizations recognize that the process of detoxification as a natural process that occurs in the body as it attempts to rid the system of waste products and toxins, whereas withdrawal management refers to a directed process that attempts to deal with withdrawal symptoms that occur when an individual stops using certain drugs or alcohol. When the withdrawal management process is supervised by a physician, it is often referred to as physician-assisted withdrawal management; in some instances, treatment facilities may refer to it as medical detox. Whatever term is used, the accepted protocol for managing withdrawal symptoms from alcohol or detoxing from alcohol is established by organizations like ASAM and WHO.
Alcohol Withdrawal (Alcohol Discontinuation Syndrome)
Most sources now agree with previous research that the withdrawal process from alcohol can be roughly divided into mild alcohol withdrawal syndromes and moderate to severe alcohol withdrawal syndromes. The ability of treatment providers to predict who will actually develop a mild or severe alcohol withdrawal syndrome is limited, but it is often done on the basis of the severity of their alcohol use disorder (as defined by the DSM-5) or by the withdrawal syndrome the individual expressed previously when they attempted to discontinue their use of alcohol.
Individuals who have more severe alcohol use disorders (who express more symptoms), or have a history of complicated or severe withdrawal, are more likely to express a complicated or severe withdrawal syndrome than individuals with fewer symptoms or a history of mild withdrawal. There may be quite a bit of variability between individuals with the same general overall presentation and within the same individual over different attempts to stop using alcohol.
The factors that determine whether an individual who discontinues their use of alcohol will experience mild withdrawal symptoms or more severe withdrawal symptoms can be variable but typically include the following:
- The individual’s genetic makeup, which can include variations in metabolism
- The extent and severity of an individual’s alcohol use, such that individuals who abused alcohol for longer periods of time and/or in greater amounts are at a higher risk to develop more severe withdrawal symptoms
- The method of stopping use, such that individuals who immediately abstain from alcohol use (suddenly just stop drinking altogether) are more likely to experience more severe withdrawal symptoms than individuals who slowly taper off the substance (NOTE: It is not recommended that individuals attempt to taper alcohol use on their own as continued abuse is likely; instead, medical assistance is recommended.)
- Other individual variables, such as an individual’s body weight, gender, age, and even their psychological state
- The severity of the alcohol use disorder as rated by APA, with those with moderate to severe alcohol use disorders having more complicated withdrawal symptoms as a rule
- The abuse of other substances in conjunction with alcohol, with polydrug abuse resulting in more severe instances of withdrawal
The symptoms that occur as a result of alcohol withdrawal can be divided into general clusters of symptoms.
- Physical or somatic symptoms: changes in heart rate or body temperature as well as nausea, vomiting, dilated pupils, increased perspiration, feelings of shakiness, etc.
- Behavioral changes: restlessness, insomnia, appetite loss, and states of hyperarousal (heightened sensitivity to environmental stimuli)
- Psychological symptoms: depression, anxiety, mood swings, and even psychosis (hallucinations and/or delusions)
- Neurological manifestations: tremors, headache, disorientation, cognitive issues, and/or seizures
The major differences that occur in individuals who develop mild alcohol withdrawal symptoms compared to moderate to severe alcohol withdrawal symptoms are categorized according to their onset, the length of time the symptoms last, the overall presentation of the individual, and any complications that occur.
Mild alcohol withdrawal
- The onset of symptoms will often occur several hours after they stop using alcohol (often within 3-6 hours).
- The average duration of the symptoms is 24-48 hours. The majority of individuals with mild alcohol withdrawal will experience a peak of their symptoms between 12 and 24 hours after they stop drinking.
- The most common symptoms are issues with restlessness, accelerated heartbeat, some mild feeling of jitteriness, nausea, potential vomiting, headache, some issues with quality of sleep, and mild issues with mood, such as anxiety or depression.
- There are no significant neurological or psychological complications in the majority of individuals who experience mild alcohol withdrawal. Some individuals may experience mild issues with mood, headache, shakiness, etc.
Moderate alcohol withdrawal
- The onset of symptoms with moderate alcohol withdrawal is significantly quicker than the onset of symptoms that occur during mild alcohol withdrawal. Individuals may experience symptoms 2-4 hours after their last drink.
- The length of the symptoms is also longer. The average length of symptoms for moderate to severe alcohol withdrawal lasts from one day to one week, but in many cases, the symptoms may endure for several weeks. Some symptoms of complicated withdrawal, such as hallucinations, delusions, or seizures, may appear relatively quickly after the individual has stopped using alcohol or may be delayed.
- The presentation that occurs during moderate to severe alcohol withdrawal varies from individual to individual. Most of these individuals display symptoms from all of the above clusters of symptoms to some extent.
- Individuals undergoing moderate to severe alcohol withdrawal can experience complicated withdrawal symptoms. Some individuals may present with hallucinations and/or delusions, which will often occur within 12-18 hours after the person has stopped using alcohol and may continue for days. The development of seizures in complicated withdrawal from alcohol can occur within 12 hours after the individual stopped using alcohol and may continue to occur for several days. In some cases, individuals may experience seizures several days after discontinuing alcohol.
The syndrome of delirium tremens may also occur in individuals with severe alcohol withdrawal as a result of the development of significant tolerance and a rapid decrease in blood alcohol concentration once they stop drinking. This disorder is most often associated with chronic heavy alcohol use. The symptoms of delirium tremens include confusion, disorientation, hallucinations (frequently visual hallucinations), and potential seizures. Very often, people who develop delirium tremens display symptoms rather quickly, within 2-3 days after they have discontinued alcohol, and the symptoms may last several days or longer.
Medical treatment is required for individuals who experience delirium tremens, hallucinations, delusions, or seizures. The seizures that occur as a result of alcohol withdrawal can be fatal and require prompt medical attention. Individuals who are seriously depressed, confused, or psychotic are also at significant risk for harm. Other complications as a result of dehydration or with pre-existing medical conditions may also lead to significant threats to a person’s health during the withdrawal process.
Some individuals who have chronically abused alcohol for significant periods of time and neglected their self-care, particularly their diet, may develop a syndrome known as Wernicke-Korsakoff syndrome. The syndrome is often associated with individuals with severe alcohol use disorders, but is actually caused by a lack of vitamin B1 (thiamine) as a result of severe neglect to one’s diet; this syndrome can also occur in individuals who have other conditions that affect their ability to absorb thiamine or who have extremely poor diets.
The symptoms of Wernicke-Korsakoff syndrome consist of visual problems (nystagmus), problems walking, and amnesia (memory loss). The amnesia is so dense that individuals often confabulate (make up stories) in order to cover for their inability to remember issues. If the syndrome is recognized early enough, it can be corrected by dietary changes and vitamin supplementation, but in chronic cases, some of the symptoms may not respond to treatment.
The Standard Protocol for Medical Detox (Withdrawal Management) from Alcohol
Professional organizations, such as ASAM and WHO, have established the protocols for withdrawal management (medical detox) from numerous drugs of abuse, including alcohol. The preferred intervention to help with withdrawal from alcohol is to prescribe a benzodiazepine like Valium (diazepam) to control the major symptoms of withdrawal. The physician monitors the recovering person’s condition and attempts to administer the benzodiazepine at a dosage that will result in the individual experiencing few or no withdrawal symptoms. Once this dosage is established, the physician will taper down the dosage at periodic intervals in order to wean the individual off the drug. Benzodiazepines can also produce physical dependence, and they are drugs of abuse, so the physician must continue to monitor the patient and their response to declining doses of the drug. In cases of moderate to severe alcohol withdrawal, this process is best accomplished in an inpatient unit where the person can receive 24-hour medical supervision until their situation is stabilized.
For individuals who have very mild alcohol withdrawal symptoms, no medical detox may be needed, or the physician can simply administer other medications to deal with specific symptoms and monitor the patient as an outpatient. Depending on the severity of the individual’s alcohol use disorder, it is often prudent to initially observe individuals very closely. Some individuals who have been diagnosed with mild alcohol use disorders according to APA diagnostic criteria may develop complicated withdrawal symptoms that need significant medical monitoring.
If individuals who are placed on a physician-assisted medical detox program for alcohol withdrawal continue to experience issues with nausea, headache, etc., the physician may administer specific medications to control these problems. A physician-assisted withdrawal management program takes longer to negotiate than if a person were to simply stop drinking altogether; however, the process is far safer. It also reduces the risk of relapse during the early stages of recovery significantly, as individuals who have moderate to severe withdrawal symptoms may return to alcohol to alleviate withdrawal symptoms.
It should be noted that successfully getting through the withdrawal period without relapsing is not enough. Individuals who simply go through the withdrawal syndrome and do not continue with addiction treatment will inevitably relapse. According to NIDA, relapse rates for all substance use disorders are high even for individuals who get involved in long-term recovery programs.
Individuals need to address the issues that promoted their use of alcohol, understand relapse prevention, develop a formal plan to address cravings and triggers, and develop a strong support system to maintain long-term sobriety. This can be done in a formal alcohol use disorder treatment program that includes continued medical management of any co-occurring issues, substance use disorder therapy, participation in support groups, and the assistance of friends and family.
ASAM and NIDA consistently report that overall success in recovery from any substance use disorder, including an alcohol use disorder, is strongly related to the length of time the person spends in treatment. Individuals who spend longer periods of time in treatment and treatment-related activities have greater rates of success in recovery.