According to the National Institute on Drug Abuse, the number of individuals abusing alcohol and the cost of alcohol abuse in this country are second only to tobacco use and abuse. It is estimated that nearly 17 million people in the United States have an alcohol abuse issue and that the overall cost of alcohol abuse is over $220 million annually, with much of this cost associated with the medical aspects of alcohol use.
One of the issues with alcohol abuse is its potential to produce physical dependence (tolerance and withdrawal). This article will discuss the withdrawal management, or medical detox, process from alcohol in individuals who have developed a moderate to severe alcohol use disorder.
Substance Dependence and Medical Detox
According to the American Psychiatric Association, which sets the standards regarding the clinical diagnostic criteria used in assessments of individuals with substance use disorders, and the American Society for Addiction Medicine, which outlines medical procedures in the treatment of substance use disorders, physical dependence consists of the development of tolerance and withdrawal, whereas detoxification (detox) and withdrawal management are separate entities.
- Tolerance: This is a relatively common occurrence when anyone takes a drug or medication on a regular basis. Quite frankly, it is very similar to sitting in a hot tub of water. At first, the water feels quite hot, but as your body habituates, it slowly feels less hot. Likewise, when individuals first began using medications or drugs, the effects may be very intense; however, over time, the individual no longer gets the same experience from the original dosage, and the person needs more of the drug to get similar effects that occurred early on. Tolerance becomes an issue when individuals begin taking extremely high doses of drugs that can be physically dangerous.
- Withdrawal: This occurs when an individual’s system has repeatedly been exposed to certain drugs and has learned to adjust so it only functions optimally when certain levels of the drug are present in its tissues. When these levels decrease, the person’s system is thrown out of balance and the functions of the system become disrupted. The individual begins to feel a number of negative and uncomfortable physical and emotional symptoms until they can replenish their system with the drug.
- Physical dependence: This is a condition that occurs when an individual has developed both tolerance and withdrawal symptoms as a result of their drug use. Physical dependence alone is not a sign that an individual has a substance use disorder. Many individuals who take certain types of medications under the supervision of a doctor and for medicinal reasons become physically dependent on these drugs; however, they are not abusing the drugs. An addiction, or substance use disorder, by definition requires that the individual is abusing the drug in some manner.
- Detoxification: This term applies to the natural process that the body uses to cleanse itself. Impurities, waste materials, and foreign drugs are eliminated from the system mostly through the liver. This is a natural, ongoing process that occurs constantly. The withdrawal syndrome represents a reaction to decreasing levels of the drug, that the individual has developed a physical dependence on, being removed from the system via natural detoxification.
- Withdrawal management: This term applies to the medical management of the withdrawal syndrome in individuals who have developed physical dependence on drugs or alcohol. A withdrawal management program is a specific protocol designed to alleviate withdrawal symptoms, avoid relapse, and eliminate or reduce any potential serious symptoms associated with withdrawal. The detox process is a natural process that occurs without medical intervention. Withdrawal management is a specific intervention targeted at reducing withdrawal symptoms.
The Withdrawal Process from Alcohol
The withdrawal symptoms that occur during alcohol withdrawal (sometimes termed alcohol discontinuation syndrome) will vary from individual to individual, depending on a number of different factors, such as how much alcohol an individual typically used, how long they abused alcohol, whether or not they commonly used alcohol in conjunction with other drugs, and individual differences in metabolism and psychological makeup.
A descriptive and informative article comes from American Family Physician articles was written in The American Family Physician regarding the symptoms and regarding the withdrawal process from alcohol. The withdrawal process consists of two syndromes, such that individuals who have mild forms of alcohol use disorders will most often experience mild withdrawal syndromes, whereas individuals who have moderate to severe alcohol use disorders will experience significantly more severe withdrawal symptoms. Typically, the designation of a mild, moderate, or severe alcohol use disorder is determined by the number of symptoms and the length of one’s period of abuse; however, sometimes individuals who would appear to have mild alcohol use disorders display severe withdrawal symptoms, and individuals with severe alcohol use disorders display milder withdrawal syndromes.
For the purposes of this article, we can classify the symptoms of alcohol withdrawal according to domains:
- Somatic symptoms: This group includes elevations in temperature, increased blood pressure, irregular heartbeat, sweating, nausea, vomiting, shakiness, and dilated pupils.
- Behavioral symptoms: This group of symptoms includes hyperarousal (extreme sensitivity to environmental changes), restlessness, irritability, and sleeping difficulties that often include insomnia.
- Psychological symptoms: This group of symptoms includes mood swings, depression, anxiety, the potential for paranoid thinking or paranoid delusions, and hallucinations.
- Neurological symptoms: This group of symptoms includes headache, tremors, confusion, disorientation, issues with memory, and the development of seizures. This category also includes the syndrome known as delirium tremens (see below).
The withdrawal process may differ depending on the severity of the alcohol use disorder, such that some individuals display a mild withdrawal syndrome whereas others display more severe withdrawal syndrome. The timeline for the withdrawal process from alcohol in individuals who are displaying a mild withdrawal syndrome follows:
- Initiation of symptoms: Individuals displaying a mild withdrawal syndrome from alcohol generally begin to experience symptoms several hours after discontinuation of use. The symptoms may begin 3-6 hours after one stops drinking.
- Length of symptoms: The average length of the symptoms is 24-48 hours. In some cases, it may be longer. For most individuals, the symptoms will peak 12-24 hours after discontinuation.
- Presentation: The major symptoms occurring in a mild withdrawal syndrome from alcohol include nausea, vomiting, mild shakiness, faster than normal heartbeat, headache, restlessness, some insomnia, and anxiety.
- Complications: There are typically no severe complications, such as seizures, hallucinations, or confusion, in a mild withdrawal syndrome.
Moderate to severe alcohol withdrawal will typically present differently:
- Initiation of symptoms: In some individuals with moderate to severe alcohol use disorders, symptoms may begin relatively quickly after the individual stops drinking. Some individuals may experience symptoms as soon as two hours after their last drink.
- Length of symptoms: On average, the symptoms will last 1-7 days; however, when there are severe complications, these may endure for 30 days or even longer. The onset of some symptoms, such as hallucinations or seizures, may be delayed for several weeks. When an individual continues to display what were thought to be withdrawal symptoms 30 days after their discontinuation of alcohol, a full assessment should be undertaken to ascertain if the symptoms represent alcohol withdrawal or some other condition.
- Presentation of symptoms: The presentation of symptoms during moderate to severe alcohol withdrawal can be quite varied. Individuals can display any number of symptoms from any of the groups mentioned above. Individuals will typically display many of the somatic symptoms, such as nausea, vomiting, and insomnia, and may display more serious psychological and neurological symptoms, such as delusions, hallucinations, and/or seizures. The development of seizures during alcohol withdrawal represents a potentially fatal condition that requires immediate medical attention.
- Complications: A number of complications can occur as a result of moderate to severe alcohol withdrawal. These include:
- Psychological symptoms: These may include delusions and hallucinations. If these occur, they typically begin anywhere 12-18 hours after discontinuation and can continue for several days.
- Seizures: These can develop 12-18 hours after discontinuation, and the potential to display seizures may be present for many days following discontinuation. Since these can be fatal, they require medical treatment.
- Delirium tremens (DTs): This is a severe syndrome that may occur in individuals with moderate to severe alcohol use disorders who experience a drastic drop in their blood alcohol level. The symptoms include severe issues with orientation (not knowing the date, year, where they are, familiar people, etc.), hallucinations (most often visual hallucinations), and the potential to develop severe seizures. In most cases, the syndrome will appear within 2-3 days after discontinuation and may continue for lengthy periods of time. Medical management is necessary for individuals displaying delirium tremens.
- Wernicke-Korsakoff syndrome: This syndrome occurs in individuals who chronically abuse alcohol and also severely neglect their diet. The disorder results is a lack of vitamin B1 and presents with a gate disturbance (difficulties walking), nystagmus (visual problems), and a very dense amnesia (memory loss). In many cases, the memory losses are so severe that individuals confabulate to try and cover up their inability to remember things. In some individuals, adjusting their diet and administering vitamin supplements may treat the symptoms; however, in chronic cases, some or all of the symptoms may be permanent.
Detox from Alcohol
Because of the potential danger that may exist for individuals withdrawing from chronic alcohol abuse, it is recommended that anyone diagnosed with an alcohol use disorder only discontinue use of alcohol under the supervision of a physician. The detox process typically involves administering medications, most often benzodiazepines, to assist in controlling the symptoms of withdrawal. A number of medications can be used in the withdrawal process for alcohol, including:
- Benzodiazepines: Benzodiazepines were developed for the treatment of anxiety and seizures. They have also been found to be extremely useful in the treatment of moderate to severe alcohol withdrawal, and they are considered the first-line treatments for withdrawal from alcohol. The type of benzodiazepine used in the specific case will depend on a number of factors, but drugs like Librium, Klonopin, Ativan, and Valium can be used. Benzodiazepines are typically administered on a tapering strategy, such that individuals receive subsequently lower doses of the drug at specific time intervals in order to wean them off the drug while at the same time controlling any withdrawal symptoms associated with alcohol abuse. It is important to understand that benzodiazepines are also highly addictive, can result in fatal overdoses, and when used chronically, result in physical dependence that is similar to the physical dependence that occurs with alcohol abuse. It is for this reason that withdrawal management using benzodiazepines should only be performed under the supervision of a licensed and trained addiction medicine physician or psychiatrist.
- Baclofen: Baclofen is a muscle relaxant that has been demonstrated to be useful in reducing cravings during the withdrawal process from alcohol. This medication may be included in the withdrawal management process.
- Beta blockers: These drugs are typically used to treat high blood pressure, but they are also useful for the treatment of alcohol withdrawal as they can control blood pressure and irregular heartbeat in individuals who develop these issues.
- Antabuse: Antabuse is a drug that results in a severe reaction in individuals who drink alcohol. While on the drug, individuals who drink alcohol become violently ill. As a result, the drug is sometimes used for individuals with severe alcohol use disorders to control their use of alcohol. It typically would not be used in an inpatient withdrawal management program where an individual would not have access alcohol, but might be used in an outpatient withdrawal management program for an individual who has experienced multiple relapses. However, this drug is not foolproof. Many individuals learn that they only need stop using Antabuse 24-48 hours before they plan to drink, and they will not experience the severe symptoms they would have experienced while using the drug.
- Anticonvulsants: These drugs are typically used to control or prevent seizures. While they are not typically used during alcohol withdrawal management programs, they are available for physicians who feel the need to use them.
- Specific drugs: Other medications can be added to the withdrawal management program, depending on the specific needs of the individual.
While the majority of individuals with alcohol use disorders will not experience potentially fatal or severe withdrawal symptoms when they discontinue their use of alcohol, it cannot be overemphasized that anyone with an alcohol use disorder who wishes to quit using alcohol should consult with a physician because it is very difficult to predict who will develop severe alcohol withdrawal symptoms. In addition, significant risk for potentially serious issues can occur as a result of emotional, psychological, or cognitive issues that occur during withdrawal and the use of a withdrawal management strategy makes the withdrawal process easier to negotiate. Using a withdrawal management strategy reduces symptom severity and any potential complications during the early stages of recovery, including the potential for relapse.
Finally, the withdrawal management process is only the first step in a full recovery program. Individuals who go through withdrawal management and do not get involved in a professional and structured program of recovery for their alcohol use disorder are at a very high potential for relapse. The reason for this is that these individuals have not learned to understand the issues that drove them to their substance use disorder, have not developed a relapse prevention program, and have not developed a positive social support group that will assist them in their recovery.