Alcohol Withdrawal

Alcohol withdrawal is a term used to describe the symptoms that occur after an individual suddenly stops drinking after prolonged and heavy exposure to alcohol. The condition is also termed alcohol withdrawal syndrome.

People who experience alcohol withdrawal often live with a chronic alcohol use disorder, which is sometimes referred to as alcohol abuse or dependency.

Roughly every second person living with an alcohol use disorder will develop symptoms due to alcohol withdrawal when drinking is strongly reduced or stopped. If symptoms occur, this usually happens between 6 to 24 hours after the last drink or when a strong reduction in drinking took place.

For most people with alcohol withdrawal, symptoms tend to be mild and include anxiety, restlessness, headaches, and a craving for alcohol. However, in about every fifth person with alcohol withdrawal, symptoms are more severe and may include hallucinosis, seizures, or even delirium.

There is a fixed set of criteria on which making the diagnosis is based. This requires a thorough medical history and physical examination. Other tests will be performed in order to evaluate the alcohol use disorder and check for complications. Treatment includes tranquilizers and close monitoring of the affected person. 1, 2, 3, 4, 5, 6, 7, 8

Symptoms of alcohol withdrawal are caused by stopping or strongly reducing alcohol consumption in a person living with a chronic alcohol use disorder. The latter is known to be caused by a combination of genetic, psychological, and social factors.

Generally, alcohol decreases the brain’s overall activity. If a person drinks large amounts of alcohol regularly, this can eventually result in a new balance between activating and inhibiting nerve pathways. If regular alcohol consumption then gets interrupted, overactivity is caused. This results in the typical symptoms of alcohol withdrawal. 1, 6, 7

However, only about every second person living with an alcohol use disorder will develop symptoms due to alcohol withdrawal when drinking is strongly reduced or stopped.

Factors that make this more likely include: 1

• Number of drinks consumed on each occasion
• Number of alcohol-related problems present
• The extent of the physiologic dependence- How strongly the body has adjusted to and thus requires alcohol
• No more than 24 hours have passed since the last drink

Genes may play a role in the risk for developing alcohol withdrawal, as well as in its severity. However, this is still being researched. 1

Symptoms of alcohol withdrawal can occur after a person suddenly stops drinking or suddenly strongly reduces drinking after prolonged and heavy exposure to alcohol.

The symptoms: 1, 6, 7, 8

• Only occurs in about every second person living with an alcohol use disorder after they suddenly stop drinking
• Typically occurs between 6 to 24 hours after the last drink or when a strong reduction in drinking took place
• Can be divided into two types: physical and psychological
• Tend to be mild for most people affected
• Are more severe and may include hallucinosis, seizures, or even delirium in about every fifth person affected.
• Last depending on the severity.

The symptoms of alcohol withdrawal include: 1, 2, 6, 7, 8

Mild withdrawal

• Onset: 6 to 36 hours after last drinkThe following symptoms last for one to two days.
• Anxiety
• Agitation
• Restlessness
• Trouble sleeping
• Shakiness
• Increased sweating
• Rapid heartbeat
• Headache
• Alcohol craving
• Loss of appetite
• Nausea
• Vomiting
• Hypertension

Alcohol hallucinosis

• Onset: 6 to 48 hours after last drink
• Symptoms last for one to two days
• May occur with or without symptoms of mild withdrawal (Usually visual hallucinations)
• Often seeing insects or animals in the room
• Auditory or tactile hallucinations may also occur
• Falsely hearing something or perceiving physical contact with an imaginary object

Withdrawal seizures

• Onset: 12 to 48 hours after last drink
• May occur with or without symptoms of mild withdrawal
• Occur in 10 to 30 percent of alcohol withdrawal cases
• Convulsions affecting the entire body – these can occur solitarily or in clusters of two or three

Withdrawal delirium

• Also called delirium tremens
• Medical emergency
• Onset: 48 to 96 hours after last drink
• Occurs in one to four percent of people with alcohol withdrawal who are in hospital care
• Disturbance of attention and cognition
• Rapid-onset
• Fluctuating course of disease

Sometimes accompanied by

• Hallucinations
• Agitation
• Fever
• Severely fastened heart rate
• Hypertension
• Major sweats

There is a fixed set of criteria on which the diagnosis of alcohol withdrawal is based. This requires a thorough medical history and physical examination. Other tests will be performed in order to evaluate the underlying alcohol use disorder, to check for possible complications, and to rule out other conditions. 1, 6, 7

The approach to diagnosis and assessment of the alcohol use disorder includes: 1, 6, 7

Medical history

• Extensive alcohol use in the past (Prior withdrawal syndromes, prior treatment approaches)
• Other drugs taken
• Psychiatric diseases
• Social situation and support
• Physical symptoms

Physical examination, in order to identify:

• Severity of withdrawal syndrome
• Additional or alternative conditions
• Chronic complications of alcohol use disorder

Laboratory tests

• Blood tests, particularly testing liver and kidney function, as well as glucose levels and the serum alcohol concentration

Urine drug testing

• Particularly checking for benzodiazepines, cocaine, and opioids

Other tests

• Electrocardiogram (ECG) – recommended for older people

Imaging tests

• CT scan (only necessary in people experiencing seizures for the first time, if withdrawal is different to previous withdrawal syndromes, if mental changes are not typical of a withdrawal syndrome, if a head trauma is likely).

Alcohol withdrawal requires both short-term and long-term treatment. The short-term treatment relates to managing a person’s physical and mental reactions that occur as part of the withdrawal syndrome. Treatment therefore aims at alleviating the symptoms, identifying and correcting possible metabolic derangements, as well as treating potential other complications.The long-term treatment focuses on providing support to help a person maintain their abstinence and manage the person’s underlying alcohol use disorder. 2, 3, 6, 7, 8

Only focusing on short-term treatment, which includes: 2, 3, 6, 7, 8

Supportive care – monitoring and frequent clinical reassessmentThis includes monitoring the vital signs, such as heart rate and blood pressure, as well as repeatedly checking glucose levels and alcohol concentration.

Admission to an intensive care unit can be considered in people:

• Over the age of 40
• With coexisting conditions
• With a history of complicated withdrawals
• Who do not react well to treatment
• Who have unstable vital signs
• Who have severe metabolic derangements
• Who have other complications

Metabolic derangements should be corrected.

Intravenous fluids: This is necessary in all people with alcohol withdrawal. Fluids are given via an intravenous access.

Nutritional supplementation: This should initially be done via an intravenous access because gastrointestinal absorption is reduced, and the person is at risk of vomit entering the airways and suffocating.Includes administration of:

• Thiamine (vitamin B1)
• Glucose
• Folate
• Multivitamins

Safe environment: This should be a quiet and protective place. In people with withdrawal delirium, temporary physical restraint may become necessary in order to prevent them from harming themselves and others. Any mechanical restraint should be removed as soon as sedation medication starts to work.

Medication: Benzodiazepines is necessary in all people with alcohol withdrawal in order to treat their agitation and to avoid complications. The treatment will work as a sedative and decrease the person’s neuronal overactivity.Benzodiazepines should never be taken long-term because of the high risk of getting addicted.

Alcohol withdrawal is caused by prolonged exposure to large amounts of alcohol and can therefore be prevented through abstaining from or at least strongly limiting one’s exposure to alcohol as to not develop an alcohol use disorder.

People living with alcohol use disorder should contact specialized treatment facilities in order to successfully manage their condition.In people developing signs of alcohol withdrawal, it is crucial to begin treatment as early as possible to avoid severe symptoms or complications. 7

People having experienced alcohol withdrawal may suffer from sleep problems or minor signs of an overactive nervous system, such as fastened heartbeat, agitation, or sweats, for a few months.

Half of people manage to stay abstinent from alcohol for a year. Chances of relapse can be decreased by undergoing long-term treatment of the underlying alcohol use disorder in a specialized treatment facility. 7

Alcohol hallucinosis, withdrawal seizures, and delirium (see above) are among the most typical complications of alcohol withdrawal. Other complications include: 1, 2, 6, 7

Over-sedation

• This can be a short-term result of high treatment doses

Electrolyte derangements

• Low magnesium levels
• Low potassium levels
• Low natrium levels

Increased mortality

• This is quite rare if adequate treatment is obtained

Other complications due to chronic alcohol use disorder.

Q: Can alcohol withdrawal cause diarrhea?
A: Yes, alcohol withdrawal can, in some cases, cause diarrhea. Other nonspecific symptoms of gastrointestinal upset, including indigestion, excess gas, bloating and constipation, may also occur. 8

Q: How long does alcohol withdrawal last?
A: Mild and moderate forms of alcohol withdrawal can usually be self-treated or subside after around 2-7 days. More severe cases usually require medical treatment. 9 The affected person should maintain their abstinence from alcohol for the rest of their lifetime, seeking help from available services whenever they feel the need to consume alcohol.

Q: Can alcohol withdrawal cause seizures?
A: Yes, in some cases, alcohol withdrawal can cause seizures. This is rare, however, and most people will not experience this symptom. Convulsions can also be a symptom of delirium tremens, a severe reaction to alcohol withdrawal. People experiencing seizures should seek urgent medical attention and are advised to call an ambulance to transport them to the hospital.