The body regularly cleans itself of toxins, waste products and other impurities mainly through the liver and excretory system. This detoxification, or “detox” for short, is a natural ongoing process that occurs in the body.
The terms “detoxification” and “detox” are also commonly used to denote the withdrawal process of someone who’s developed a dependency on drugs or alcohol.
In order to differentiate between the body’s natural cleansing and the professional management of someone who’s being treated for a dependency on a substance, the American Society for Addiction Medicine and other professional organizations involved in the treatment of substance use disorders no longer use the terms “detox” or “medical detoxification.” They now use the term “withdrawal management” to describe the medical and psychological series of interventions used to reduce the symptoms of withdrawal in individuals who have developed a physical dependency drugs or alcohol.1
Withdrawal management is only one part of adequately treating a person with a substance use disorder who wants to stop using the substance they have developed an addiction to.1
Alcohol Withdrawal Syndrome
When an individual drinks alcohol, the body—and specifically the liver—goes through its natural detoxification process to rid the body of alcohol and its byproducts. In heavy drinkers, however, the central nervous symptom of the body has adjusted to the constant presence of alcohol and naturally compensates for alcohol’s depressive effects.
When this occurs, the person has developed what’s called a “dependence.” Should the level of alcohol drop the body has a difficult time adjusting and symptoms of alcohol withdrawal begin to appear.2 The negative physical and emotional repercussions are referred to as “alcohol withdrawal syndrome.”
Anywhere from 90–98% of alcohol is metabolized by the liver, with a very small proportion excreted unchanged through the skin, breath, and urine.3 A number of factors affect the rate that different individuals will metabolize alcohol, such as the person’s weight, gender, individual metabolism, amount of food eaten, etc.;3 however, in general, it can be estimated that an “average” individual’s blood alcohol content (BAC) will decrease by about 0.015 per hour due to alcohol in the system being metabolized.4 Thus, if an individual with a BAC of 0.08 (the legal limit) drinks no more alcohol, it would take a little over five hours for their BAC to be lowered to 0.
Alcohol Withdrawal Timeline
Many factors affect the body’s ability to detoxify itself from alcohol. Individuals will experience withdrawal symptoms from alcohol if they have developed physiologic dependence on alcohol. (The timeline outlined in this article is based on a general estimate regarding alcohol withdrawal.)
Withdrawal symptoms begin 6 to 24 hours after a person’s last drink, or the marked reduction in quantity of alcohol that’s normally consumed.5 Symptoms range from minor symptoms such as insomnia to severe complications such as withdrawal seizures and delirium tremens.6
The symptoms experienced and their severity varies widely among individuals. Physicians and other licensed professionals who specialize in addiction medicine have evaluation tools to appropriately assess an individual’s withdrawal management needs.2 They include a physical examination, lab work, as well as an extensive history taking that includes quantity of alcohol intake and duration of alcohol use.2,6 They also take into consideration the presence of coexisting medical and psychiatric conditions, the severity of an individual’s withdrawal symptoms, and the risk the individual may experience potentially fatal withdrawal complications.2,6
Initial symptoms of alcohol withdrawal include tremor, anxiety, insomnia, restlessness, and nausea. For those who are only mildly dependent on alcohol, these symptoms may be the only ones experienced, and they may subside after a few days.7
Approximately 10% of individuals in alcohol withdrawal will experience more severe symptoms such as low-grade fever, rapid breathing, tremor, and profuse sweating. These individuals have a high risk of experiencing potentially deadly complications such as seizures or delirium tremens—a state of clouded consciousness where individuals experience marked confusion and disorientation to place and time.5,7 Episodes of delirium tremens have a mortality rate of 1–5%.6
Individuals who are diagnosed with an alcohol use disorder for the most part can expect to experience the appearance of withdrawal symptoms according to this general timeline:5,6
- 6–12 Hours: Minor withdrawal symptoms including insomnia, tremors, mild anxiety, upset stomach, headache, sweating, heart palpitations, lack of appetite.
- 12–24 Hours: Perceptual distortions or hallucinations in vision, sound and touch may be experienced. Visual hallucinations are most common and often involve seeing animals in the room.5
- 24–48 Hours: Withdrawal seizures peak at 24 hours after a person’s last drink and may be experienced as early as 2–8 hours.5,6 Seizures may be experienced in the absence of other withdrawal symptoms.5
- 72–96 Hours: Alcohol withdrawal delirium, also known as “delirium tremens” (DTs) may be experienced as early as 24 hours after the onset of withdrawal.2 (An individual experiencing DTs will see withdrawal symptoms worsen, and individuals develop marked tremor, fever, sweating and an increased pulse rate alongside hallucinations and a disorientation of time and place.5)
Individuals who develop issues with confusion, hallucinations, delusions, seizures, or display the syndrome of delirium tremens require immediate medical management. These individuals may become disoriented and engage in self-mutilation or even suicide.8 Seizures and delirium tremens can be potentially fatal.
Individuals who have undergone withdrawal from alcohol may continue to experience alcohol withdrawal symptoms (e.g., tremor, sleep disruptions, anxiety, depressive symptoms, as well as increased breathing rate, body temperature, blood pressure and pulse) during a protracted withdrawal syndrome which may persist for at least 1 year.7
A common medication used in withdrawal management from alcohol are benzodiazepines, which are drugs that produce similar physical effects to alcohol and also reduce the potential for issues with anxiety and seizures.5 A number of other medications, including anti-convulsants as well as thiamine and other vitamins, can be used for other issues, such as hallucinations, cravings, nausea, psychiatric distress, etc.5
The potential for dangerous symptoms during acute alcohol withdrawal syndrome is greatly reduced when individuals are closely supervised by trained medical professionals who can closely monitor them and ensure their condition remains stable.7
- American Society of Addiction Medicine. (2014). The ASAM Standards of Care: For The Addiction Specialist Physician.
- Saitz, R. (1998). Introduction to alcohol withdrawal. Alcohol Health and Research World, 22(1), 5–12.
- Jones, A.W. (2019). Alcohol, its absorption, distribution, metabolism, and excretion in the body and pharmacokinetic calculations. WIREs Forensic Sci, 1:e1340.
- National Highway Traffic Safety Administration. (2013). Sober Driving During the Holidays. Safety in Numbers, 1(9).
- Miller, S. C., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2019). The ASAM Principles of Addiction Medicine, Sixth Edition. Philadelphia: Wolters Kluwer.
- Bayard, M., Mcintyre, J., Hill, K.R., Woodside, J. (2004). Alcohol Withdrawal Syndrome. American Family Physician, 69(6): 1443–1450.
- Trevisan, L. A., Boutros, N., Petrakis, I. L., & Krystal, J. H. (1998). Complications of alcohol withdrawal: Pathophysiological insights. Alcohol Health and Research World, 22(1), 61–66.
- Chick, J. (2015.) Suicide, Self-Mutilation and Delirium Tremens. Alcohol and Alcoholism, 50(4), 377–378.