Alcohol Withdrawal

What is 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 are often alcohol dependent. Alcohol dependence, or alcoholism, is characterized by a strong and often uncontrollable desire to drink. People with alcohol dependence will typically build up a resistance to alcohol, meaning they need a subsequent increase in their alcohol intake to reach the state of being intoxicated.[1]

The symptoms of alcohol withdrawal, which can be both physical and psychological, will normally begin to present themselves around three to eight hours after an individual stops drinking. The first-line treatment for alcohol dependency is complete abstinence, which usually involves a programme to provide the affected person with psychological support throughout the withdrawal process. This usually involves group support sessions, in order to ensure that people do not feel alone as they go through the experience.

For people who are struggling with the physical symptoms of detoxing in particular, a course of medication designed to alleviate these might be prescribed.[2]

Symptoms

The symptoms of alcohol withdrawal can be divided into two types: physical and psychological.

Physical symptoms of alcohol withdrawal include:[3][4]

  • Hand tremors (shaking)
  • Nausea
  • Thirstiness
  • Dry mouth
  • Abdominal pain
  • Headache
  • Increased sweating
  • Fever / increased body temperature
  • Excessive, purposeless physical activity
  • Hyperventilation (rapid breathing)
  • High blood pressure
  • Tachycardia (fast heart rate, with a pulse greater than 100 beats per minute)
  • Seizures, in severe cases

Psychological symptoms of alcohol withdrawal include:

  • Depression
  • Anxiety
  • Irritability and mood swings
  • Sleep disturbances, including frequent awakening, restless sleep, insomnia and night terrors
  • Confusion
  • Transient tactile, visual or auditory hallucinations or illusions
  • Poor focus
  • Restlessness

If an individual ceases to consume alcohol, most of these symptoms will decrease significantly after 10 days, but some might be present for longer.

Alcohol withdrawal timeline

The stages of alcohol withdrawal can be roughly broken down into three stages:

  • Stage 1 (8 hours after last drink): Anxiety, insomnia, abdominal pain and nausea are typically experienced during the first stage.
  • Stage 2 (24-72 hours after last drink): High blood pressure, high body temperature, unusually increased heart rate, rapid breathing and confusion are typical of this stage.
  • Stage 3 (72+ hours after last drink): Hallucinations, fever, agitation and seizures are typical of this stage.

This is a rough timeline – some individuals may experience a different timeline with differing symptoms.

Delirium tremens

Delirium tremens refers to a severe reaction to alcohol withdrawal. Symptoms will generally begin after around two to three days of ceasing drinking and may include:[5]

  • Severe trembling and agitation
  • Heavy sweating
  • Increased heart rate
  • Nightmares
  • Global confusion
  • Disorientation
  • Visual and auditory hallucinations
  • Fever
  • High blood pressure
  • Convulsions, in rare cases

These symptoms may appear suddenly, but they typically develop two to three days after the affected person stops drinking and are at their worst on the fourth or fifth day. Dehydration can also make delirium tremens worse. It is a serious condition which can in some cases be fatal. If any of these symptoms occur, immediate medical attention should be sought.

There are several factors that make the development of delirium tremens more likely. These include:

  • A history of heavy drinking
  • A history of delirium tremens
  • Being over the age of 30
  • Having another illness
  • Developing alcohol withdrawal after two or more days

Causes

The symptoms of alcohol withdrawal occur when a period of sustained and heavy alcohol consumption suddenly stops. Most people who experience alcohol withdrawal have an alcohol dependency.

Alcohol affects the part of the brain responsible for the fight-or-flight response. Alcohol suppresses this response, making us relaxed. When withdrawing from alcohol use, the chemical balance of the brain is adjusted, meaning individual’s enter this fight-or-flight state, even without the presence of danger. It is this state that causes both the physical and psychological symptoms of alcohol withdrawal.[6]

Diagnosis

A doctor will typically be able to diagnose alcohol withdrawal, after an individual answers a series of questions about their drinking habits and the symptoms which are being experienced, and once a physical examination has been performed.

Treatment

Mild symptoms of alcohol withdrawal can be managed at home, though it is recommended to get advice from a doctor before suddenly giving up alcohol, and urgently seek advice if any of the symptoms are troublesome. If the person withdrawing from alcohol develops any confusion or agitation, this could be a sign that they need urgent medical review and treatment in hospital while they withdraw from alcohol. The severe symptoms of alcohol withdrawal are treated with medications that prevent seizures and the nutritional supplement thiamine.

Short-term treatment

The first step in treating alcohol withdrawal will typically involve helping the affected person as they undergo a process of alcohol detoxification, commonly referred to as detox. This will usually be a supervised process, undertaken at a specialised treatment centre, in which individuals are helped to overcome the symptoms that may result from alcohol withdrawal. See the “Symptoms” section of this resource, above, for more information.

During the detox, people are recommended to:

  • Drink plenty of fluids
  • Eat regularly

Doctors will prescribe vitamin B1 (thiamine) in all cases of alcohol withdrawal. A deficiency of this vitamin affects around 80 percent of people who have experienced prolonged alcohol exposure.

If a person is experiencing particularly strong symptoms of alcohol withdrawal, medications may be prescribed. The medications most commonly prescribed to help alleviate the symptoms of alcohol withdrawal are called benzodiazepines. These can help prevent minor alcohol withdrawal symptoms from becoming worse, e.g. in people for whom delirium tremens is considered to be a risk. Medications are not usually part of a typical first-line treatment plan for alcohol withdrawal, and these medications will be administered at the discretion of the medical professionals who monitor the detox process.

The second step in treating alcohol withdrawal involves psychological evaluation to identify the underlying causes of a person’s alcohol dependency. These causes may be psychological, physical, biochemical and/or social. Doctors will work with the affected person to identify these causes and to devise a long-term treatment plan tailored to their needs in order to help them remain abstinent from alcohol on a long-term basis.

Long-term treatment

After the detox, people with a severe alcohol dependence will require the assistance of a qualified treatment centre, a rehabilitation centre, to help them recover from alcohol dependency. This period, which can last weeks or months, can be experienced as an inpatient or an outpatient, depending on the needs of the affected person. Most people with mild to moderate alcohol withdrawal symptoms will find treatment as an outpatient sufficient.[7]

To help people recover in the long-term, treatment centres will also provide advice on how to overcome alcohol dependency and on self-care and establishing living habits that promote their overall health and happiness. A person recovering from alcohol dependency may also be advised to attend support groups such as Alcoholics Anonymous to help them remain abstinent from alcohol.

Alcohol withdrawal prevention

Alcohol withdrawal is caused by prolonged exposure to large amounts of alcohol and can therefore be prevented through limiting one’s exposure to alcohol, so as not to develop an alcohol dependency. Methods of doing this include:

  • Quitting alcohol completely
  • Having frequent alcohol-free periods (days, weeks or months)
  • Not exceeding the recommended daily intake guidelines for alcohol. According to the US Department of Health, this is 1 drink per day for women and 2 drinks per day for men.

Alcohol withdrawal FAQs

Q: Is there a difference between alcohol withdrawal and a hangover?
A: Yes. Although the effects of a hangover are sometimes compared to mild alcohol withdrawal, there is a difference between the two. Alcohol withdrawal is a physical reaction to stopping drinking after prolonged and heavy consumption. People experiencing alcohol withdrawal will also typically be dependent on alcohol. A hangover, on the other hand, can be experienced by anyone, typically after a single bout of drinking alcohol. Alcohol withdrawal is a serious condition that can lead to acute and chronic complications, whereas a hangover is non-serious in the majority of cases.[4][8]

Q: How long does alcohol withdrawal last?
A: The symptoms of alcohol withdrawal will typically begin to subside after 10 days in most cases. The timeline of alcohol withdrawal can be roughly split into three stages, with differing symptoms in each (see: the alcohol withdrawal timeline). 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.

Other names for alcohol withdrawal

  • Alcohol withdrawal syndrome

  1. Medline Plus. “Alcohol withdrawal.” January 14, 2017. Accessed December 15, 2017.

  2. Patient. “Alcohol withdrawal (Alcohol detoxification).” December 11, 2017. Accessed December 15, 2017.

  3. Management of moderate to severe alcohol withdrawal syndromes.” UpToDate. 17 September 2017. Accessed: 27 February 2018.

  4. Complications of alcohol withdrawal.” Alcohol Health and Research World. 1998. Accessed: 27 February 2018.

  5. “Alcohol withdrawal (Alcohol detoxification).” Patient. December 11, 2017. Accessed December 15, 2017.

  6. Effects of alcohol dependence and withdrawal on stress responsiveness and alcohol consumption.” Alcohol Research: Current Reviews. 2012. Accessed: 27 February 2018.

  7. Comparative Effectiveness and Costs of Inpatient and Outpatient Detoxification of Patients with Mild-to-Moderate Alcohol Withdrawal Syndrome.” The New England Journal of Medicine. 09 February 1989. Accessed: 27 February 2018.

  8. What is alcohol withdrawal?” WebMD. 2018. Accessed: 27 February 2018.