How to Manage the Stages of Alcohol Withdrawal

Alcohol acts on both the central nervous system and brain chemistry that is related to pleasure and the stress response. As a central nervous system depressant, alcohol slows some of the autonomic functions of the body, including blood pressure, heart rate, respiration, and body temperature. Alcohol also interferes with the normal production, absorption, and transmission of some of the brain’s chemical messengers, or neurotransmitters.

Both excitatory and inhibitory neurotransmitters are impacted by alcohol, Forbes explains. For instance, the release of glutamate, an excitatory neurotransmitter that increases energy levels and brain activity, is suppressed by alcohol, and this accounts for declining cognitive functions as well as slowed and sluggish movements and thoughts. Production of the inhibitory neurotransmitter GABA (gamma-aminobutyric acid), which works as a natural tranquilizer in the body to lower anxiety and stress levels, is increased by alcohol. Another neurotransmitter that is responsible for pleasure, dopamine, is stimulated by the presence of alcohol as well, which is why alcohol can make people feel good.

When alcohol is consumed regularly, the brain gets used to its presence, and brain chemicals and circuitry are altered. Dependence then sets in.

When alcohol wears off, serious and even dangerous withdrawal symptoms can occur as the brain and central nervous system experience a rebound while they attempt to regulate themselves without it.

About one out of every 12 Americans suffers from alcohol addiction, as alcohol is the most frequently used addictive substance in the country, the National Council on Alcoholism and Drug Dependence (NCADD) publishes. Alcohol withdrawal can range from mild to severe, and the most severe form, delirium tremens (DTs), can even become life-threatening. Alcohol should therefore never be stopped “cold turkey.” Withdrawal should be managed through medical detox, a process by which medical professionals safely monitor alcohol withdrawal symptoms with the help of medications.

The Stages of Alcohol Withdrawal

The more significantly dependent on alcohol a person is (the longer it was used and the more of it that was consumed regularly), the more severe alcohol withdrawal will be. Other mitigating factors, such as metabolism, biology, genetic and environmental factors, polydrug abuse, and the presence of any co-occurring disorders, can also influence alcohol withdrawal – both the duration and the severity of the withdrawal symptoms.

The New York Times reports that alcohol withdrawal symptoms typically begin within about 6-48 hours after the last drink and peak in the first day or two. Side effects are usually at their worst during days two and three, and then start to decline. They usually mostly dissipate by the end of a week or so, although emotional symptoms and cravings may continue for longer.

Alcohol withdrawal may be either mild, moderate, or severe, and it can be progressive in nature. For instance, the New England Journal of Medicine (NEJM) publishes that the most significant form of alcohol withdrawal, DTs, may start after the third day of stopping drinking (particularly if withdrawal is untreated). Alcohol withdrawal symptoms generally progress through the following three stages as laid out by American Family Physician:

Mild Alcohol Withdrawal Symptoms: Days 1-2

  • Stomach upset (nausea, diarrhea, and vomiting)
  • Heart palpitations
  • Headache
  • Anxiety
  • Insomnia
  • Tremors
  • Restlessness and jumpiness
  • Depression
  • Irritability
  • Loss of appetite
  • Mood swings
  • Vivid dreams and/or nightmares

Moderate Alcohol Withdrawal Symptoms: Days 2-3

  • Tachycardia (irregular heart rate)
  • Hyperthermia (high body temperature) and sweating
  • Increased blood pressure
  • Chest pain after drinking
  • Mental confusion
  • Heightened respiration levels

Extreme Alcohol Withdrawal (Delirium Tremens): Day 3

  • Disorientation
  • Fever
  • Significant confusion and impaired attention
  • Auditory and visual hallucinations and delirium
  • Seizures

DTs can be fatal without swift intervention. NEJM warns that it develops as the most severe form of alcohol withdrawal about 3-5 percent of the time.

Tapering and Medications for Alcohol Withdrawal

Since alcohol withdrawal can be so significant, both physically and emotionally, it should not be stopped suddenly. Instead, some people attempt to slowly wean alcohol out of the body through a tapering schedule. This should not be attempted without direct medical supervision since the likely of relapse and subsequent alcohol poisoning is high. If dependence and withdrawal symptoms are milder, an outpatient detox program may be sufficient; however, if alcohol withdrawal is more intense, medical detox in an inpatient setting is often the ideal and safest option. During a taper, the amount of alcohol is slowly lowered every day through a set schedule. Just enough alcohol is consumed to keep the majority of the withdrawal symptoms at bay, and the amount can be reduced each day in a controlled manner in order to allow the brain time to restore balance without shocking the system. While this approach is not commonly used in medical detox programs, it is sometimes used in other formats.

  • During medical detox, medications are generally given to replace alcohol, with dosages slowly tapered over time. For example, benzodiazepine medications act on some of the same neurotransmitters in the brain to prevent overactivity of the central nervous system during withdrawal. The Industrial Psychiatry Journal publishes that lorazepam (Ativan), oxazepam (Serax), diazepam (Valium), and chlordiazepoxide (Librium) are common benzodiazepines used to treat alcohol withdrawal. Benzodiazepines are used to replace alcohol to minimize the severity of alcohol withdrawal and to prevent and manage DTs. These medications are tapered off during medical detox until they are no longer necessary. Benzodiazepine mediations do carry risk for addiction, especially if they are misused, and these drugs should be used under direct medical supervision and only as directed. They can be habit-forming and therefore are only recommended for short-term use.
  • Alternative medications may be used when necessary, such as other medications that suppress the autonomic nervous response, like anticonvulsant medications (Neurontin, Tegretol, or Depakene) or beta-blockers (Catapres or Inderal). These medications have less abuse and addictive potential, and they can be helpful in reducing some of the painful symptoms of alcohol withdrawal; however, they may not prevent deadly seizures.
    Anticonvulsants are often used after a short-term prescription of benzodiazepines during detox to further smooth the withdrawal process. Pharmacological care during medical detox often includes the use of medications to target specific symptoms of alcohol withdrawal too, such as gastrointestinal medications for stomach upset, antidepressants for low mood, nonsteroidal pain medications for physical pain, and sleep aids for insomnia and sleep difficulties. Co-occurring disorders are often managed pharmacologically as well.

The Importance of Medical Detox

In medical detox, a person is monitored around the clock to ensure that vital signs are stable and the severity of withdrawal is managed. Medications help to minimize physical and emotional pain as well as combat cravings during withdrawal.

Supportive care in a calm and stable environment can aid in reducing discomfort during medical detox and withdrawal as well. Vitamin supplements, such as thiamine (vitamin B1), and fluids are generally included during treatment since dehydration and malnutrition are often side effects of excessive alcohol consumption. Thiamine depletion due to heavy and long-term alcohol consumption can lead to the onset of Wernicke-Korsakoff syndrome, a severe mental health disorder that may not be completely reversible.

Behavioral therapies and counseling can reduce some of the emotional discomfort caused by alcohol withdrawal and also serve to help a person cope with and manage cravings. Medical detox typically lasts about 5-7 days on average. Ideally, it should be followed with a comprehensive addiction treatment program that supports long-term abstinence.

Getting Help with Withdrawal

Laguna Detox Hospital specializes in helping with the acute symptoms of alcohol withdrawal. Our team is here to ensure safe, medically supervised detox so recovery from alcohol abuse can start.

We are available to discuss options 24/7. Give us a call at or check your health insurance benefits below.