Though the issues of both illegal and prescription drug abuse often dominate headlines, the reality of excessive alcohol consumption remains an enormous public health problem. Many people remain unaware of the health effects of problematic drinking, including the potential to develop physiological dependence and the risks of quitting without medical help. The signs and symptoms of alcohol withdrawal range from uncomfortable to life-threatening, and they should not be taken lightly.
What is Alcohol Withdrawal?
For people who drink heavily for sustained periods of time (anything from weeks to years), there are characteristic physical and mental/emotional changes that arise when attempts are made to cut down on the amount they drink or altogether quit drinking. Taken together, these adverse changes comprise the acute alcohol withdrawal syndrome1—the symptoms of which range from the inconvenient to the serious, depending on the nature of the drinking and the drinker’s individual physiological responses to abrupt abstinence.
Though the physiological details are quite complicated, at its most basic, the central nervous system adapts to the consistent presence of alcohol in heavy drinkers. Chronic, excessive drinking disrupts several neurochemical processes and the brain then works to restore balance via a phenomenon known as neuroadaptation.2 When the alcohol is taken away—either because supplies dry up or because the drinker tries to quit—the brain is thought to again become temporarily unbalanced, and the resulting over-excitatory brain signaling underlies many of the characteristic withdrawal symptoms.
Signs and Symptoms of Alcohol Withdrawal
In significantly physically dependent individuals, the first signs and symptoms of alcohol withdrawal often arrive around eight hours after the last drink3; however, the exact withdrawal timeline depends on a number of factors: for example, how heavy the drinking has been and for how long it has been going on, the person’s unique physiology, if other drugs have been used, and any previous withdrawal experiences. Symptoms often peak within 72 hours, however they sometimes persist for longer periods of time (e.g., weeks).3,4
Symptoms of acute alcohol withdrawal include:3,4
- Poor sleep or insomnia.
- Difficulty concentrating
- Changes in mood, including depression.
- Nausea and vomiting.
- Rapid heart rate.
Increasingly severe symptoms may include:3,4,5
- Hallucinations (visual, tactile, or auditory).
- Profound confusion.
Some people develop what is known as a protracted withdrawal syndrome that may last as long as a year following the more commonly experienced acute withdrawal period.6 Some of the symptoms of protracted withdrawal—such as insomnia and anxiety—resemble those experienced acutely, but their persistent, problematic presence can complicate recovery and make relapse prevention that much more difficult.
Complications of Alcohol Withdrawal
It is estimated that more than 5% of people who do not receive medical detox treatment will experience grand mal seizures—also known as generalized, tonic-clonic seizures—within the first few days of withdrawal (most within the first 48 hours, and less than 3 percent occurring 5 or more days after the last drink).6
In some instances of relatively severe withdrawal, people can develop a syndrome known as delirium tremens, or acute alcohol withdrawal delirium. When present, this complication typically arises 2 to 3 days after the last drink, and includes symptoms such as visual, tactile, and/or auditory hallucinations; marked confusion; and diminished level of consciousness in addition to severe autonomic hyperactivity (e.g., fever, sweating, tachycardia, anxiety, agitation, etc.).5
Other potential medical complications include:3,6,7
- Compromised nutritional status.
- Gastrointestinal bleeding.
- Dysregulation of body temperature, heart rate, and blood pressure.
- Alcohol-related arrhythmias.
- Worsening of any existing encephalopathy (e.g., Wernicke’s encephalopathy).
Medications to Assist with Alcohol Withdrawal
For many who struggle with alcohol use disorders, navigating the period of alcohol withdrawal is a necessary early part of recovery, but it is not without its risks. Fortunately, there are several medications that can be administered as part of a supervised medical detox to help individuals through this often-unpleasant and potentially stressful period, and to minimize the risks of certain complications, such as seizures.
Benzodiazepine medications are the first line of treatment for acute alcohol withdrawal management and effective seizure prophylaxis.6,7,8,Valium (generic name diazepam) is indicated for use to relieve acute agitation, tremor, hallucinations, and delirium tremens associated with alcohol withdrawal.8 Similarly, chlordiazepoxide (trade name Librium) is also commonly used in the pharmacologic management of acute alcohol withdrawal.7,8
Another benzodiazepine that may be considered for alcohol withdrawal is oxazepam. Oxazepam has a relatively slow absorption rate and a shorter half-life than some other first-line treatments, but is sometimes the favored agent used to manage withdrawal in people with hepatic insufficiency or liver failure.7
Other Withdrawal Management Medication
Though benzodiazepines remain the primary line of alcohol withdrawal treatment in the United States, other medications may be used in certain instances for symptomatic management. For example, anticonvulsant medications such as carbamazepine and valproic acid have shown efficacy in managing mild to moderate symptoms.7
The medications used to treat the symptoms of alcohol withdrawal will help a patient through the physical effects of abstinence in early recovery; important goals of successful withdrawal management include keeping an individual as safe and comfortable as possible and facilitating a closer focus on recovery work.7,8 Successfully navigating the detox and withdrawal management period is an important component of recovery, but it is vital that the patient follows this up with additional therapeutic interventions (e.g., behavioral therapies) to more closely address the psychosocial aspects of compulsive alcohol use and to better learn how to cope with any stressors, triggers, and cravings for alcohol.
Comprehensive rehabilitation efforts are often comprised of several components, such as medication-assisted treatment, ample one-on-one and group therapy sessions, family therapy, participation with peer support groups (such as Alcoholics Anonymous), and the development of a solid plan for aftercare prior to completion of the formal treatment 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.
- Becker, HC. (n.d.). National Institute on Alcohol Abuse and Alcoholism [website]. Alcohol Dependence, Withdrawal, and Relapse.
- Littleton, J. (1998). National Institute on Alcohol Abuse and Alcoholism [website]. Neurochemical Mechanisms Underlying Alcohol Withdrawal.
- MedlinePlus. (2019). Alcohol Withdrawal.
- Miller, S. C., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2019). The ASAM Principles of Addiction Medicine, Sixth Edition.Philadelphia: Wolters Kluwer.
- Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). (2013). Washington, D.C.: American Psychiatric Association.
- Trevisan, LA, Boutros, N, Petrakis, IL, Krystal, JH. (1998). National Institute on Alcohol Abuse and Alcoholism [website]. Complications of Alcohol Withdrawal; Pathophysiological Insights.
- Substance Abuse and Mental Health Services Administration. (2015). TIP 45: Detoxification and Substance Abuse Treatment.
- U.S. Department of Health and Human Services—Substance Abuse and Mental Health Services Administration. (2015). Medication for the Treatment of Alcohol Use Disorder, A Brief Guide.