Sad man sitting at table with alcohol and holding cigarette

Even as the problem of legal and illegal drug abuse dominates headlines, the reality of unhealthy alcohol consumption as a public health problem remains. Too many people remain unaware of the health effects of dangerous drinking, especially what happens if they try to stop without medical help. The signs and symptoms of alcohol withdrawal range from the embarrassing to the life-threatening, and they should not be taken lightly.

How Does Alcohol Work?

Billions of people around the world can stop taking alcohol without missing a beat; however, this is not an easy prospect for many others. Alcohol increases the production of endorphins, the natural painkillers produced by the human brain, that also regulate feelings of pleasure and reward. Endorphins tend to gather in the regions of the brain linked to addictive behaviors, which is a key way that the threads of alcohol dependence are formed.

The National Institute on Alcohol Abuse and Alcoholism explains that “alcohol can make the brain tell lies.” Even though there is no external and objective cause for the pleasurable reaction when alcohol is consumed, the brain still perceives a significantly enjoyable activity in progress during drinking. While this happens, alcohol deactivates portions of the brain that control other critical functions, such as decision-making and impulse control. In combination, the chemical chain reaction can compel rising amounts of consumption.

McGill University points out that the region of the brain at play here is the nucleus accumbens, which is the core of the reward pathways. The functioning of the nucleus accumbens is responsible for the production of two vital neurotransmitters (chemical messengers): dopamine, which creates feelings of desire and pleasure, and serotonin, which promotes satisfaction and inhibition. The more endorphins that are released in the nucleus accumbens, the more pleasure experienced. This could be the result of anything from partaking in a desirable activity to consuming chemical substances that artificially stimulate endorphin production. Many drugs do this, and so does alcohol, which also increases dopamine production.

Research has found that heavy drinkers experience significantly pronounced endorphin production, more so than moderate drinkers experience. This is why heavy drinkers also feel greater degrees of pleasure, which, in turn, contributes to greater levels of intoxication. It is a cycle that feeds itself, and it explains how heavy drinkers are locked into it.

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The Mechanism of Alcohol Withdrawal

For people who drink heavily for long periods of time (anything from weeks to years), there are mental and physical problems that arise when they stop or cut down on the amount they drink. These problems are symptoms of a complex medical process known as withdrawal, with the severity of the symptoms ranging from the inconvenient to the serious, depending on the nature of the drinking and the drinker’s unique physiology.

For example, a person who only drinks occasionally, and does not struggle with the compulsion to drink more, can probably go without alcohol for a long time without incurring any withdrawal symptoms. On the other hand, a person who has experienced the full brunt of what alcohol can do will probably feel the effects of trying to quit suddenly.

This is because alcohol is a depressant, so it has a depressive effect on the brain and central nervous system. It slows down the function of the brain and changes how nerves communicate. This has the result of impairing both physical and psychological activity. As a depressant, alcohol blocks the communication between nerve receptors and the brain, affecting a drinker’s decisions, perceptions, emotions, and movements. Depressants do not make a person feel “depressed”; rather, they “depress” the central nervous system. Despite the name, depressants can make a person feel relaxed, more sociable, and even happy. This is why alcohol has been used as a social lubricant throughout history.

When used properly, alcohol and other central nervous system depressants are very useful, even therapeutic, in this way. However, when used improperly, there are wide-ranging effects on physical and psychological wellbeing. In the case of alcohol, these intoxicating effects demonstrate its depressant nature. Reflexes are slowed, motor skills are impaired, cognitive functioning is reduced, and blood pressure, heart rate, and breathing are all slowed.

For people who drink occasionally, these effects are temporary. For heavy drinkers, however, the central nervous system adapts to the constant presence of alcohol. The body is forced to keep the brain in an unnatural state of alertness and to keep the nerves communicating with one another. When the alcohol is taken away—either because supplies dry up or because the drinker tries to quit—the brain remains in this hyperactive state. The inability to return to normal functioning in the absence of alcohol is what causes withdrawal, as the brain sends out frenzied levels of hormones and neurotransmitters in a desperate attempt to regain balance.

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Signs and Symptoms of Alcohol Withdrawal

The first signs and symptoms of alcohol withdrawal usually start around eight hours after the last drink was taken, but this depends on a number of factors: how heavy the drinking has been and for how long it has been going on, the person’s unique physiology, if there is a family history of substance abuse, if other drugs are present, and environmental and lifestyle conditions, among others. Typically, the symptoms peak 72 hours into the process and then slowly abate over the next 3–4 days. It is not unheard of for alcohol withdrawal to last for weeks in the cases of those who are severe drinkers.

Common symptoms of alcohol withdrawal include:

  • Periods of anxiety or agitation
  • Depression
  • Fatigue
  • Trembling in the extremities
  • Unpredictable mood swings
  • Poor sleep or insomnia
  • Difficulty concentrating

Chronic drinkers might experience sweaty skin, dilated pupils, a loss of appetite, nausea and vomiting, and an irregular (rapid) heart rate.

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Hallucinations and Malnourishment

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All degrees of drinkers experience some form of psychological distress as part of their withdrawal, but the heaviest of drinkers might struggle with hallucinations and psychosis, severe mental disorientation, and the possibility of seizures. These symptoms will only present in very specific circumstances, depending on the individual’s drinking history and health, but they present the most risk to the person’s wellbeing. As many as 25% of alcohol-dependent individuals who do not receive detox treatment can experience grand mal seizures, also known as generalized tonic-clonic seizures (caused by abnormal electrical activity throughout the brain) in the first five days of withdrawal.

Malnourishment is a big problem during alcohol withdrawal. The process of withdrawal can cause gastrointestinal distress and appetite loss, which can be very dangerous when they occur against the backdrop of detoxification. On its own, alcohol can starve the body of key nutrients and vitamins, which are not immediately replenished when a person stops drinking. This makes the body exceptionally vulnerable and weak during withdrawal, and people will likely suffer significant weight loss and specific mental and physical disabilities as a result of vitamin deficiencies.

Similarly, many individuals struggle with dehydration as part of the alcohol withdrawal process and suffer a severe electrolyte imbalance. Even on its own, alcohol dehydrates the body, and the nausea, vomiting and diarrhea of withdrawal compound the loss of fluids. The loss of electrolytes leads to fatigue, problems with heartbeat, and muscle problems, along with psychological symptoms like anxiety, headaches, and confusion. In severe cases, dehydration can cause long-term damage to the autonomic nervous system, affecting body temperature and breathing rate.

At its most life-threatening, alcohol withdrawal can cause delirium tremens, a collection of symptoms that range from uncontrollable shaking, seizures, and hallucinations to dangerously high heart rate and blood pressure. If left untreated, delirium tremens can be fatal to people undergoing alcohol withdrawal, or it can cause permanent disabilities.

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Medications to Assist with Alcohol Withdrawal

Alcohol withdrawal is a necessary step in the process of recovery, but it is not without its risks. Fortunately, there are many medications that can be administered to help individuals endure the most stressful parts of the experience, and to protect them from the most violent reactions to purging their bodies of long-term alcohol reliance.

The main class of drugs that is used for this purpose is the benzodiazepine class. Benzodiazepines are held up as the first choice for treating alcohol withdrawal. They are typically administered at high doses early in the detox process before being weaned down as the person gradually overcomes the physical need for more alcohol. There are many different kinds of benzodiazepines (some of them household names like Xanax and Valium), all with their own properties. Xanax (or alprazolam, if it is used in its generic formulation), for example, is effective in reducing some of the physical symptoms of withdrawal. Valium (generic name diazepam) has a long-half life (how long it takes for half of the dose to be worked out of the bloodstream), so it is effective in that it does not need to be frequently administered in order for it to control withdrawal symptoms. Ativan (lorazepam in its generic form) is usually prescribed for anxiety, but it can reduce the risk of seizures in those who might develop delirium tremens during withdrawal.

Other benzodiazepines for alcohol withdrawal include oxazepam (sold as Serax), which has a relatively slow absorption rate and a shorter half-life than other benzodiazepines, so it is usually prescribed only for mild to moderate alcohol detox; it would not be an effective medication to use for severe withdrawal. Nonetheless, oxazepam has been successfully used for recovering alcohol users who have experienced liver failure.

Another benzodiazepine option is clorazepate (also known as Tranxene). Clorazepate is formulated to treat anxiety and seizures. This characteristic of calming electrical excitation in the brain makes it a useful remedy for some of the mood and behavioral disorders that present during alcohol withdrawal. A study of the drug in 1987 showed none of the 226 patients who received the medication experiencing any convulsions, leading researchers to recommend clorazepate for “countering convulsive and other manifestations of alcohol withdrawal syndrome.”

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Anticonvulsants

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Clorazepate is an anticonvulsant benzodiazepine, but there are other anticonvulsants that are not benzodiazepines that can be used to mitigate the symptoms of alcohol withdrawal. Because there is the potential for patients to develop a dependence on benzodiazepines, anticonvulsants have emerged as an alternative to benzodiazepines in Europe; however, benzodiazepines remain the primary course of alcohol withdrawal treatment in the United States. An example of an anticonvulsant used for alcohol detox is carbamazepine, administered only for mild to moderate symptoms. Some studies have indicated that carbamazepine is preferable over benzodiazepines for deterring early relapse. A study conducted as far back as 1982 found that carbamazepine offered faster relief of symptoms than a comparison drug and “demonstrated a preferential action on symptoms like fear and hallucinations.

Another anticonvulsant is gabapentin (brand name Neurontin), which has been found to be of equal effectiveness as benzodiazepines for helping patients manage their withdrawal symptoms. In 2015, the JAMA Internal Medicine journal noted that gabapentin was especially useful in treating insomnia, dysphoria (general unease and dissatisfaction), and cravings during withdrawal. Researchers suggested that increasing gabapentin implementation for the treatment of alcohol withdrawal symptoms could provide a major benefit as a primary care option.

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Continuing Treatment

The medications used to treat the symptoms of alcohol withdrawal will help a patient through the physical effects of the alcohol purge and, if completed, will help the person not feel the physical need for alcohol. However, it is vital that the patient follows this up with therapy to address the psychological damage caused by the alcohol abuse and to learn how to cope with the mental desire for alcohol. This entails one-on-one and group therapy sessions, family therapy, and aftercare support groups, like Alcoholics Anonymous or another peer-led 12-step program.

Withdrawing from alcohol can be a very difficult and stressful process, but it is only the first part of a long undertaking. With the right care, work, and medications, people who struggled with problematic drinking or an unhealthy dependence on alcohol will be able to lead long, rich, and fulfilling lives.

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