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Alcohol Withdrawal

Detoxing from alcohol is often the first step in the rehabilitation process for people with significant levels of alcohol dependence. Left unmanaged, heavy alcohol users may experience uncomfortable and potentially severe alcohol withdrawal symptoms when attempting to quit.

The acute alcohol withdrawal syndrome may range from mild to physically dangerous, and may include symptoms such as irritability, anxiety, agitation, increased heart rate, high blood pressure, seizures and in rarer cases, delirium tremens. A supervised, medical detox can help people avoid unnecessary discomfort or life-threatening withdrawal complications.

What Causes Alcohol Withdrawal?

Alcohol interacts with special receptor complexes in the brain known as gamma-aminobutyric acid (GABA) receptors. These receptors are normally activated by the inhibitory GABA neurotransmitter—via an interaction that helps defines the baseline level of neural activity throughout the central nervous system (CNS). Alcohol modifies the responsiveness of these receptor proteins and, in doing so, enhances the inhibitory signaling power of GABA itself. After long-term use and consistently-decreased CNS excitability, the brain adjusts by down-regulating the number of GABA receptors. These neurochemical and structural changes underlie what is known as tolerance—a phenomenon which, once developed, leaves a person needing more alcohol to achieve the same effect.2

In somewhat related phenomena that frequently develop alongside of tolerance, certain central nervous system functions veer towards of state of overactivity in what essentially is a physiological effort to balance the artificially-bolstered inhibitory tone imparted by chronic and/or heavy alcohol use. A person may be said to have grown ‘dependent’ on alcohol to offset this new tendency toward excitable neural signaling; should alcohol use stop or slow during this period of neural over-excitation, unpleasant withdrawal symptoms may begin to appear.2

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Withdrawal Symptoms

When Will They Start?

Some relatively mild symptoms may be experienced as soon as 8 hours after the last time alcohol is consumed.2,3,6 Depending on the magnitude of physical dependence, additional withdrawal symptoms may continue to arise beyond 24 hours, with some potentially severe effects emerging in the range of 2 to 4 days after abstinence.6

Alcohol Withdrawal Symptom Severity6:

  • Mild—Anxiety, headache, insomnia, tremor, palpitations, gastrointestinal disturbances.
  • Moderate—In addition to the relatively mild symptoms above, some individuals may develop hyperthermia (elevated body temperature) and diaphoresis (sweating), tachycardia (rapid heartbeat), increased systolic blood pressure, tachypnea (rapid, shallow breathing), and some confusion.
  • Severe/Delirium Tremens—As symptoms progress in severity, individuals may begin to become disoriented and experience impaired attention, visual and/or auditory hallucinations, seizures.

How Long Will They Last?

A full range of alcohol withdrawal symptoms may persist for as little as a few hours up through several weeks after withdrawal has begun. The most severe symptoms commonly develop as many as two to three days after the last drink.1,3 In many cases, symptoms will largely begin to decrease and altogether resolve within 5-7 days.

What is Delirium Tremens?

In some instances of pronounced alcohol dependence and severe accompanying withdrawal, a person may develop what is known as delirium tremens (DTs)—a neurologic syndrome marked by autonomic nervous system excitation and changes in mental status. DTs are most commonly seen in those who’ve abused alcohol for more than 10 years, have a history of alcohol withdrawal, or drink daily, for months on end.4 Typically, DTs are present in only 5% of patients experiencing withdrawal.3

Delirium tremens symptoms may include:4

  • Fever.
  • Body tremors.
  • Sever confusion or disorientation.
  • Hallucinations.
  • Agitation.
  • Seizures.

If you suspect you or someone you know is experiencing this form of withdrawal, seek medical attention immediately.

Alcohol Withdrawal Treatment_4-19

Alcohol Withdrawal Treatment

The type of detox program or level of intensity needed for effective alcohol withdrawal management will depend on the severity of the addiction, the magnitude of alcohol dependence, and the risk of experiencing a complicated withdrawal. A doctor or other treatment professional may evaluate for the above factors prior to making a recommendation for the level of detox care needed to keep a person safe and comfortable.

Below are three potential treatment options for alcohol withdrawal management in ascending order of intensity:

Outpatient Detox

Outpatient detox for alcohol withdrawal may be an adequate level of care for people at low risk for severe withdrawal. Withdrawal progress is monitored through frequent check-up appointments within outpatient clinical settings (e.g., doctor’s office), allowing for the level of care to be escalated if needed.

Medically-Monitored Inpatient Detox

This level of care—often provided from a freestanding detox center, as opposed to a more intensive or acute care hospital setting—may be suited to people at risk for moderate to severe withdrawal and need 24-hour medically-supervised detox services.7 Staff at these detox programs will monitor recovery progress and regularly assess for any withdrawal complications to make sure the patient is not in danger. Benzodiazepines or other sedative medications may be administered during the process. Inpatient detoxification also serves as a way to keep individuals somewhat removed from potentially triggering social and environmental stimuli that might increase the risk of relapse.3

Medically-Managed, Inpatient Detox

Offering the most intensive level of care available, this detox option—which may include intensive care units in a hospital as well as acute psychiatric inpatient care settings—may be required for people at risk for, or already experiencing, severe withdrawal.7 Emphasis is placed on vigilant patient monitoring and the initiation and subsequent tapering of medications used to manage withdrawal and decrease the risk of complications.

Additional Treatment

 Following successful completion of detox, an inpatient or outpatient rehabilitation program may be recommended to allow further work toward recovery and relapse prevention. Group therapy, individual counseling, family counseling, support group meetings, wellness activities, and medication treatments may be included as part of a comprehensive treatment plan for alcohol use disorders. Behavioral therapies can help those struggling with alcohol abuse focus on avoiding old patterns and identify the root causes of addiction.

Sources:

[1]. Bayard, M., Mcintyre, J., Hill, K.R., Woodside, J. Alcohol Withdrawal SyndromeAmerican Family Physician 69(6): 1443-1450.

[2]. Kattimani, S. and Bharadwaj, B. (2013). Clinical Management of Alcohol Withdrawal: A Systematic ReviewInd Psychiatry; Jul-Dec 22 (2); 100-108.

[3]. Hugh Myrick, M.D., and Raymond F. Anton, M.D. (1998). Treatment of Alcohol Withdrawal. Alcohol Health & Research World 22(1): 38-43.

[4]. Rahman A, Paul M. (2018). Delirium Tremens (DT). U.S. National Library of Medicine.

[5]. Herbert L. Muncie Jr., M.D., Yasmin Yasinian, M.D. Linda Oge', M.D. (2013). Outpatient Management of Alcohol Withdrawal Syndrome. Am Fam Physician 88(9): 589-595.

[6]. MedlinePlus (2016). Alcohol Withdrawal.

[7]. Substance Abuse and Mental Health Services Administration. (2006). Detoxification and Substance Abuse. Treatment Improvement Protocol. (TIP) Series, No. 45. HHS Publication No. (SMA) 15-4131.