Withdrawal syndrome is a series of events that occur when a person who has developed a physical dependence to some substance suddenly stops taking the substance or suddenly cuts down on the amount of the substance that had been regularly used.
Physical dependence occurs with the use of certain types of substances or drugs. The individual’s system adjusts to the presence of the substance in the system in a manner that results in the person’s system needing more of a drug to produce the effects once produced at lower concentrations (tolerance) and only being able to function normally when certain levels of the drug are present (withdrawal). The syndrome of physical dependence consists of the development of both tolerance and withdrawal. It is extremely rare to observe withdrawal symptoms without tolerance being present.
Individuals who chronically use alcohol will inevitably develop some level of physical dependence on the substance. The development of physical dependence on alcohol is a serious situation because individuals who undergo alcohol withdrawal are in a potentially fatal situation.
What Happens during Alcohol Withdrawal?
The withdrawal syndrome associated with an alcohol use disorder depends on the amount of alcohol that was regularly used (this refers to the notion of the amount of pure alcohol the individual ingested in the form of alcoholic beverages), how often they regularly used alcohol, if they used alcohol in conjunction with other drugs, the presence of any other co-occurring psychological disorders like depression, and individual differences in physiological and even emotional makeup. The research suggests that there are differences in the withdrawal process from alcohol depending on the severity of the alcohol use disorder and other personal variables. Depending on the severity of the alcohol use disorder, some individuals will potentially experience severe withdrawal complications and others will not. Of course, using a medially assisted detox approach will also affect the withdrawal process.
For purposes of this article and to be consistent with research findings, the withdrawal syndromes from alcohol will be defined as a minor alcohol withdrawal syndrome where individuals do not typically experience severe complications and a severe alcohol withdrawal syndrome that is associated with a much more severe level of addiction and has potential life-threatening complications (see below).
Withdrawal from Alcohol
The diagnostic criteria for a withdrawal syndrome from alcohol are specified in the American Psychiatric Association’s current diagnostic manual, the DSM-5. The withdrawal syndrome must occur as a result of an individual who has had a prolonged history of alcohol use either suddenly stopping use of alcohol or significantly cutting down on the amount of alcohol consumed. In very heavy users, the withdrawal syndrome may appear relatively quickly once they stop drinking. These individuals may find that they must periodically drink alcohol around the clock to avoid experiencing the full withdrawal syndrome.
Many individuals with alcohol use disorders may not have the severe levels of physical dependence that are associated with potentially severe physically damaging symptoms, such as seizures and the development of delirium tremens. These individuals are more likely to have been moderate regular drinkers and experience a minor alcohol withdrawal syndrome. This syndrome consists of the following:
- Symptoms can occur within 6 hours after the discontinuation of alcohol use.
- For these individuals, the withdrawal syndrome will typically last 24-48 hours but may extend beyond 72 hours.
- Peak symptoms will occur 12-24 hours after last use of alcohol.
- Symptoms typically include nausea, vomiting, perspiring, shakiness or minor tremors, increased heart beat, loss of appetite, sleep difficulties, headache, and minor symptoms of anxiety and depression.
People who have developed a more severe alcohol use disorder due to extreme chronic use may experience the following:
- Withdrawal symptoms may occur while still intoxicated. This is because individuals with severe alcohol use disorders may have very high levels of alcohol in their blood. Once these levels begin to drop, the withdrawal syndrome is triggered. It is important to remember that the symptoms of moderate to severe alcohol withdrawal will occur once the alcohol blood levels drop sharply. The individual need not be sober.
- Symptoms can last up to a week or more.
- The symptoms that occur in the course of a minor withdrawal syndrome will also be experienced.
- Individuals can develop seizures within 6 hours of discontinuation of use of alcohol, and the potential to develop seizures will typically peak within 12-18 hours following the discontinuation of alcohol. The potential to develop seizures may still be viable for several days following discontinuation. The seizures associated with alcohol withdrawal can be potentially fatal and require immediate medical attention.
- Individuals can develop hallucinations, most often visual and auditory hallucinations, within 18 hours of discontinuation. Hallucinations may occur for up to one week following the discontinuation of alcohol.
- Others psychological symptoms, such as depression and anxiety, may be severe. This may lead to the potential for self-harm.
- In very severe withdrawal cases, the development of delirium tremens, often referred to as DTs, can occur with a sudden drop in alcohol blood level. In the popular media, it is often satirized with individuals seeing “pink elephants”; however, it is not a syndrome to be taken lightly. The syndrome includes severe cognitive impairment, such as disorientation, confusion, a loss of the sense of reality, vivid hallucinations, potential seizure development, and other associated symptoms, such as chills, sweating, vomiting, etc. If someone is going to develop delirium tremens, this will most often occur within 48-72 hours after they stop drinking; however, the potential for heavy users to develop delirium tremens can be present for up to two weeks following cessation of alcohol. Delirium tremens is a severe, potentially fatal syndrome that requires immediate medical attention.
Coping with Withdrawal from Alcohol
Anyone who has an alcohol use disorder should consult with a physician before attempting to totally quit drinking. This cannot be stressed strong enough. Even though the majority of individuals who undergo the detox process associated with alcohol abuse will not experience potentially severe seizures or delirium tremens, it is far better to be cautious and err on the side of safety than to risk potentially serious medical complications.
Even though the majority of individuals will not experience severe withdrawal symptoms from alcohol, according to the American Society for Addiction Medicine (ASAM), medications are often used to assist with the withdrawal process for the following reasons:
- It is nearly impossible to predict whether an individual will experience severe withdrawal symptoms.
- There are significant issues with emotional adjustment, physical problems, and even long-term health risks associated with alcohol withdrawal.
- Symptom relief from the withdrawal symptoms is enhanced with the use of medications.
- Physicians find medications much more effective and easier to use than other strategies to assist individuals with withdrawal from alcohol.
ASAM lists a number of medications that can be used as components of medically assisted withdrawal from alcohol. These include:
- Benzodiazepines: This class of drugs is most often used as anti-anxiety medications, but they can be useful in the treatment of alcohol withdrawal. They reduce the symptoms of withdrawal, prevent seizures, and also prevent cravings. The particular benzodiazepine used will depend on the physician. Drugs in this class include Xanax, Valium, Ativan, Klonopin, and Librium. The use of benzodiazepines in the treatment of withdrawal from alcohol should only be attempted by an experienced licensed physician. It is not recommended that individuals attempt to use these medications without being under the care of a physician, as this practice can also result in potentially fatal complications. Because benzodiazepines can also produce serious physical dependence, physicians are careful when using them as aids for negotiating the withdrawal process from alcohol. These medications need to be administered in the right dosage, tapered off as the withdrawal syndrome subsides, and patients must be closely monitored as they go through this medically assisted intervention.
- Anticonvulsants: These medications are used for seizure control, and they may be used in the withdrawal process from alcohol depending on the physician. Many addiction medicine physicians will rely on benzodiazepines for seizure control; however, some cases may indicate the use of this class of drugs. Drugs in this class include Tegretol.
- Beta blockers: This class of medications is commonly used to treat high blood pressure and issues with irregular heartbeat. It can also be useful in the treatment of withdrawal from alcohol, especially for individuals who may develop irregular heartbeat or high blood pressure. Drugs in this class include propranolol.
- Bacolfen: This medication is a muscle relaxant that is been shown to be useful in reducing cravings for alcohol. It may be given during the withdrawal process.
- Antabuse: This medication is a drug that is commonly given to individuals in recovery to keep them from drinking alcohol. It produces a reaction in individuals when they drink alcohol, causing them to become violently ill. It will not address the symptoms of withdrawal, but could conceivably be used in some instances where the physician is concerned about an individual relapsing. While it may not directly affect the withdrawal syndrome, individuals who are taking it may be less prone to relapse because of the threat of becoming physically ill with drinking alcohol. However, many individuals find that they can stop taking the drug and drink alcohol without serious consequences after around 48 hours; thus, this drug offers no assurance that an individual will not stop drinking altogether. It can, however, serve as a deterrent to relapse.
- Other drugs: Medications for specific symptoms can be used at the discretion of the physician. These can include antipsychotic medications for severe hallucinations, antidepressants, medications to reduce nausea and vomiting, and medications to reduce other symptoms.
Individuals going through the detox process can adopt other strategies to assist with their ability to negotiate the withdrawal process. These include:
- Enrolling in a professional treatment program: Medical detox will ensure a person’s safety and comfort throughout the withdrawal process. A supervised program also ensures that the person will not relapse during detox.
- Maintaining a balanced and healthy diet: This includes staying hydrated and eating a balanced diet.
- Getting light exercise such as walking or yoga: Exercise can serve as a distraction and also prepare one for the long process of recovery.
- Meditation: In some cases, meditation may be useful in negotiating the withdrawal and recovery process. Learning to meditate under someone who is a certified instructor in meditation can be helpful.
- Keeping busy: The potential for relapse occurs most often in situations of stress or when the individual is bored and there is quite a bit of downtime. Keeping busy can lower the risk of relapse and also act as a psychological aid in reducing the severity of any withdrawal symptoms.
- Maintaining healthy personal relationships: Social support is a predictor of success in recovery, and family and friends play a huge role in this.
- Planning ahead: This may include isolating oneself from former friends who drink alcohol. Getting rid of old habits that fostered the substance use disorder and developing new habits as soon as possible are important.
- Committing to a long-term recovery program: This program should extends far beyond the detox process. It should include therapy, active participation in a 12-Step program such as Alcoholics Anonymous, getting family or group counseling, or whatever it takes to assist one in the recovery process. It is important to understand that just going through the withdrawal process will not result in a successful recovery from an alcohol use disorder. Recovery is a long-term commitment and requires long-term involvement in treatment.