The development of physical dependence (expressing both tolerance and withdrawal) on alcohol can be a significant barrier to recovery for an individual who has an alcohol use disorder. Both tolerance to alcohol and the development of withdrawal symptoms when one stops using alcohol are potential diagnostic symptoms in individuals who are suspected of having alcohol use disorders, according to the diagnostic criteria put forth by the American Psychiatric Association (APA) to diagnose an alcohol use disorder (the clinical term used to signify issues with alcohol abuse and alcoholism).
When an individual is attempting to recover from an alcohol use disorder and begins to engage in a program of abstinence from alcohol, the development of withdrawal symptoms can result in rapid relapse to alcohol abuse. The initial treatment of an individual with an alcohol use disorder should attempt to identify the potential severity of any withdrawal symptoms that they express and treat the symptoms in order to ensure that the individual can focus on their initial attempts at recovery. The withdrawal process from alcohol can be quite variable, and depending on the symptoms the individual expresses, the person may only require simple medical monitoring and mild intervention, or may require placement in an inpatient unit.
The Withdrawal Syndrome from Alcohol
APA lists formal diagnostic criteria to determine if an individual is undergoing withdrawal from alcohol. In order for an individual to be diagnosed with alcohol withdrawal, they must:
- Display withdrawal symptoms after they have stopped using alcohol (typically following prolonged alcohol use)
- Display two or more of several listed symptoms within several hours to several days after they’ve either stopped using alcohol or significantly cut down on their use
Symptoms must cause significant distress or impair functioning in some way and cannot be due to some other psychological disorder, medical condition, or better explained as withdrawal symptoms from some other substance. The symptoms include autonomic nervous system hyperactivity, which often consists of issues like sweating or accelerated pulse rate, insomnia, hand tremors, nausea and/or vomiting, psychomotor agitation (jitteriness, restlessness, etc.), anxiety, periodic hallucinations (most often visual but can also be auditory or tactile), and seizures (most often, generalized seizures).
Individuals who experience complicated withdrawal issues often experience hallucinations, confusion, and/or seizures. Previous research has divided the presentation of alcohol withdrawal symptoms into mild alcohol withdrawal symptoms and moderate to severe alcohol withdrawal symptoms. Individuals with mild alcohol withdrawal symptoms have a slower onset of their symptoms; the symptoms typically peak rapidly and resolve within one or two days; and the symptoms do not present significant impairment in their functioning or distress, although individuals may be relatively ill for a short period of time. Moderate to severe alcohol withdrawal symptoms typically occur more rapidly; they may last for days to weeks; and they may present with significant functional impairment and distress (potentially life-threatening distress if seizures are present).
Individuals who have moderate to severe alcohol withdrawal or prolonged alcohol withdrawal symptoms are typically older than 30 and/or have histories of chronic and heavy alcohol abuse. Individuals who have moderate to severe alcohol symptoms may also express complicated withdrawal from alcohol and the syndrome known as delirium tremens (significant mental confusion, disorientation, visual or other hallucinations, and potential for seizures). This syndrome typically appears in individuals with histories of very chronic and heavy alcohol abuse.
The treatment of the withdrawal syndrome from alcohol is based on the presentation of the symptoms expressed by the individual. Mild alcohol withdrawal may only require the use of specific medications to treat headaches, nausea, irritability, insomnia, etc., whereas moderate to severe alcohol withdrawal symptoms may require 24-hour monitoring and significant medical intervention.
Medications Used to Treat Withdrawal from Alcohol
Due to the potential occurrence of seizures as a result of alcohol withdrawal, it is strongly recommended that any individual who is attempting to become abstinent from their use of alcohol and diagnosed with an alcohol use disorder consult with a physician before stopping their use of alcohol. Most individuals will not develop seizures as a result of alcohol withdrawal; however, as the onset of seizures can result in a potentially fatal situation, it is far better to be safe in this situation. Individuals who have been using or abusing alcohol for several years, have experienced issues with nausea, shakiness, sweating, etc., when they stop using alcohol, and continue to use alcohol regularly to avoid these symptoms are at particular risk; however, there is no surefire manner to predict who will develop significant medical issues associated with alcohol withdrawal. Thus, anyone who has used alcohol on a regular basis and is planning to quit using alcohol should consult with their physician.
While medications alone are not sufficient to treat potential relapse and the symptoms of alcohol use disorder, medications can help an individual negotiate the withdrawal process and avoid relapse early in recovery. There are some medications that are commonly used in the treatment of alcohol use disorder.
Medications Approved by the FDA
At the time of this writing, there are only three medications that are approved by the FDA to treat alcohol abuse issues, and none of these directly address withdrawal symptoms.
Antabuse (disulfiram) is a medication that is used to discourage individuals from using alcohol. When an individual takes the drug and drinks alcohol, it results in a severe reaction that makes the individual violently ill. The principle that drives the use of Antabuse is the principle of aversion therapy from behavioral psychology. This principle uses punishment (the application of a noxious condition or stimulus) to decrease the probability that an individual will repeat a specific behavior (drinking alcohol).
Antabuse does not directly address withdrawal symptoms and requires significant compliance on the part of the user to be effective. Users must be motivated to stop drinking and continue to take Antabuse or the drug will not work. Many individuals can stop using the drug and drink alcohol 48-76 hours later without significant effects. The drug is primarily used for individuals who a have high incentive to stop drinking alcohol but may have had multiple unsuccessful attempts. Individuals undergoing withdrawal symptoms who are at risk to drink again may be prescribed Antabuse by a physician.
Campral (acamprosate) is believed to inhibit the actions of excitatory neurotransmitters (e.g., N-methyl-D-asparate) in the central nervous system. It is approved to reduce cravings for alcohol in individuals who are in a formal program for alcohol abuse recovery. Campral is most effective after the individual has already been abstinent from alcohol from several days to two weeks. The effectiveness of the drug in reducing or eliminating the use of alcohol is dependent on the individual’s motivation to quit using alcohol. It appears to affect an individual’s cravings, or desire to drink, but may not actually stop an individual from drinking altogether. The drug has no effect on withdrawal symptoms.
ReVia (naltrexone) is a drug that was originally used to reduce cravings for individuals with opiate use disorders (e.g., addictions to heroin, Vicodin, etc.). Research studies indicated that the drug can also reduce cravings for alcohol, and some studies suggest that it is more effective at reducing alcohol cravings than it is at reducing cravings for opioids. The drug does not address withdrawal symptoms in individuals who are in recovery from alcohol use disorders.
Other Medications Used for Withdrawal Management from Alcohol
Withdrawal management refers to the formal process that many individuals or organizations refer to as medical detox. Withdrawal management is a formal process designed to help an individual recovering from a substance use disorder, such as an alcohol use disorder, deal with withdrawal symptoms once they stop using their substance of choice. A physician-assisted withdrawal management program is essentially a medical detox program.
According to the American Society of Addiction Medicine (ASAM), the standard protocol to address withdrawal symptoms from alcohol is to use benzodiazepines. The primary medicinal use of benzodiazepines is to treat issues with anxiety, to control seizures, and to initiate sleep. Benzodiazepines can also be significant drugs of abuse and produce symptoms similar to alcohol intoxication when abused. Research studies have also indicated that benzodiazepines are effective in controlling even complicated withdrawal symptoms in individuals who are recovering from alcohol use disorders.
The process typically involves administering a dose of a particular benzodiazepine (e.g., Librium [chlordiazepoxide], Ativan [lorazepam], Valium [diazepam], or some other long-acting benzodiazepine) that controls the majority of the withdrawal symptoms an individual is experiencing. Then, at specific intervals, the physician slowly tapers down the dosage of the drug and weans the individual off the benzodiazepine. Over a period of several weeks to months, this process continues, depending on the severity of the individual’s withdrawal syndrome, and eventually, the individual is weaned off the benzodiazepine. Using this protocol, the majority of symptoms, including hallucinations, issues with anxiety, and seizures, can be controlled. If individuals experience minor nausea or other mild symptoms, they may be prescribed medications to address these issues. In some cases, there are several other medications that may be used, but the standard protocol is to use benzodiazepines as the major medication to manage alcohol withdrawal.
Certain types of antihypertensive medications, such as the drug Catapres (clonidine), have mild research evidence to support their use in treating alcohol withdrawal. The drug may assist in controlling mild or non-complicated alcohol withdrawal symptoms, including issues with mood, high blood pressure, sweating, tremors, irritability, and anxiety. Seizure control is best addressed by using benzodiazepines.
Certain types of anticonvulsant drugs may be useful in addressing some symptoms of alcohol withdrawal, including for seizure control. The drug Neurontin (gabapentin) has been used to treat seizures in individuals undergoing withdrawal from alcohol, and it may address some other symptoms, including tremors, anxiety, nausea, high blood pressure, etc. The drug Topiramate (topamax) has been approved by the FDA to treat seizures but has not been approved to treat issues associated with alcohol use disorders. Its mechanism of action is similar to the drug Campral, and it may help in controlling cravings for alcohol.
The drug Lioresal (baclofen) is a muscle relaxant that may also be useful in reducing cravings during the withdrawal process that occurs in individuals with alcohol use disorders.
Individuals who are experiencing hallucinations may be administered antipsychotic medications to control hallucinations initially until the condition is stabilized. Antipsychotic medications may be useful in managing individuals who are psychotic, irritable, and aggressive, and may allow treatment providers to initiate other medical procedures to stabilize them.
Finally, physicians often use other medications to address specific symptoms that occur during the withdrawal process. This can include issues with nausea, headaches, irritability, insomnia, etc. However, it cannot be stressed strongly enough that medications alone will not result in an individual recovering from alcohol use disorder. Individuals who successfully get through the withdrawal process need to become involved in a long-term treatment and aftercare program that typically will last for years. Many individuals remain involved in treatment-related activities, such as participation in 12-Step groups like Alcoholics Anonymous, for the rest of their lives in order to maintain abstinence from alcohol.