Acute withdrawal may develop in people who have developed physical dependence to certain substances (such as alcohol) and then suddenly quit or cut down on the amount of the substance regularly used.
Physical dependence develops as a result of certain types of substance use. Neurochemical changes accompany the consistent presence of alcohol and certain other drugs in a manner that could leave a person feeling sick or unwell when this previously steady supply of substances stops. People with significant physiological dependence essentially come to “require” the substance in question to feel and/or function normally.1,2
Chronic drinkers will inevitably develop some level of alcohol dependence.3 Alcohol dependence and its associated risks can be quite serious—individuals commonly require close monitoring and medical intervention to keep them safe during the withdrawal management period.2
What Happens during Alcohol Withdrawal?
The character and severity of the acute alcohol withdrawal syndrome will be influenced by the amount of alcohol that was regularly used, the frequency of such use, whether drinking took place in addition to other chronic or compulsive drug use, the presence of any other co-occurring psychological disorders like anxiety and depression, as well as individual differences in terms of physical and emotional health.4
Depending on the magnitude of alcohol dependence, some individuals will potentially experience severe withdrawal symptoms and others will not. However, in many instances of early treatment for alcohol use disorders, medical detoxification and pharmaceutical withdrawal management will be the standard of care to mitigate the likelihood of a complicated and potentially lethal withdrawal.2,4
Withdrawal from Alcohol: Symptoms and Complications
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) includes alcohol withdrawal syndrome as one of several substance-related issues. Such a withdrawal syndrome—the diagnosis of which is made based on the presence of several criteria such as autonomic hyperactivity, anxiety, and nausea/vomiting—develops as a result of an individual with a prolonged history of alcohol use either suddenly not drinking anymore or significantly cutting down on the amount of alcohol consumed.5 In very heavy users, or when physiological dependence is otherwise quite pronounced, an unpleasant withdrawal syndrome may appear relatively shortly after drinking stops. Many individuals at risk of experiencing acute alcohol withdrawal will continue to drink to avoid an onslaught of unpleasant symptoms.3,6
In some cases of significant physical alcohol dependence, the associated withdrawal syndrome can be markedly severe. Severe withdrawal may be accompanied by potentially dangerous complications such as seizures and the development of delirium tremens.4
Other features of acute alcohol withdrawal include:4,5,7,8
- Symptoms may begin to manifest within 6 to 8 hours after the abrupt discontinuation or reduction in alcohol use.
- In many cases, symptoms will peak between 10 to 30 hours after the last drink; symptoms may begin to subside within 40 to 50 hours since last alcohol consumption.
- Acute symptom resolution may occur by the fourth or fifth day, though certain subacute, less intense symptoms of anxiety and insomnia may persist for several months, if not years, in some cases.
- Symptoms may include anxiety, insomnia, nausea, vomiting, racing pulse, increased blood pressure, fever, sweating, and shakiness or tremor.
More severe presentations of the acute alcohol withdrawal syndrome may include the following:4,6
- Seizures usually begin 24–48 hours after alcohol cessation. In clinical settings, caregivers will remain particularly vigilant for the onset of seizure activity for 48 hours. Should a second seizure occur, it is likely to happen with about 6 hours of the first. 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 12-24 hours.
- Less commonly, in very severe cases, people may develop grand mal seizures and/or an alcohol withdrawal delirium known as delirium tremens, or DTs.
Delirium tremens may include marked disorientation, confusion, delusions, vivid hallucinations, fever, sweating, tachycardia and, potentially, psychomotor agitation. If someone is going to develop delirium tremens, this will most often occur about 72 hours after the appearance of other alcohol withdrawal symptoms.6 Delirium tremens is a severe, potentially fatal syndrome that requires immediate medical attention.4
Managing Alcohol Withdrawal
Because of the risk of severe or complicated withdrawal, people with alcohol use disorders or who are otherwise contemplating sobriety after a period of consistent and/or excessive use would benefit from consultation 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.
Though not all individuals will experience life-threatening withdrawal complications, medications are often used to assist with the withdrawal process for several reasons, including:2,4,8
- It is difficult to predict whether an individual will experience severe withdrawal symptoms or develop complications during withdrawal.
- Medications can ease withdrawal symptom severity.
- Sedative detox medications can reduce agitation, halt withdrawal symptom progression, and minimize the likelihood of withdrawal seizures, DTs, and death.
- Adequate treatment decreases immediate relapse risks.
- Supplements can begin to correct any long-standing, drinking-related nutritional deficiencies.
Several medications may be used for medical detoxification. Though medically managed withdrawal protocols may vary, these may include:2,9
- Benzodiazepines: Commonly used as short-term anxiolytic agents, benzodiazepines are often also the first line of treatment for alcohol withdrawal. Benzodiazepine-facilitated detoxification helps reduce withdrawal symptom intensity, increase the comfort of the recovering individual, and prevent complications such as seizures and delirium tremens. Frequently used benzos include diazepam (Valium), clonazepam (Klonopin), and chlordiazepoxide (Librium). Because benzodiazepines themselves are also associated with 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 adequate doses and then tapered off as the withdrawal syndrome subsides; patients must be closely monitored as they go through this medically assisted intervention.
- Anticonvulsants: These medications are used for seizure control, and certain agents in this class may be considered for use in milder cases of alcohol withdrawal due to the fact that they elicit relatively lower levels of sedation and may have a somewhat lower potential for dependence and abuse than their benzodiazepine counterparts. Drugs in this class include carbamazepine (Tegretol) which, in addition to providing seizure prophylaxis, may decrease alcohol cravings after the withdrawal management period.
- Beta blockers / alpha agonists / calcium channel antagonists: Certain medications used to treat high blood pressure and issues with irregular heartbeat can also be useful adjuncts to other alcohol withdrawal management medications. Though they provide no protection against seizures, agents such as clonidine may be useful in managing extreme hypertension in association with withdrawal states.
- Other drugs: Medications for specific symptoms can be used at the discretion of the physician. One example would be antipsychotic medications for severe agitation, hallucinations, and delusions. Symptomatic medications may also be useful for reducing nausea and vomiting.
In addition to detox medications, additional supportive measures may be taken to help people to better negotiate the withdrawal process as well as promote their post-withdrawal recovery. These include:7,10
- 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 from symptoms 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. Making to-do lists or creating healthy habits can also help with memory and cognitive problems.
- Maintaining healthy personal relationships: Social support is a predictor of success in recovery, and family and friends play a huge role in this. Joining mutual help groups is a good option for getting extra support.
- Planning ahead: This may include distancing oneself from acquaintances who drink alcohol. Various therapeutic approaches have helped many to modify their thoughts and behaviors to best avoid triggers and other situations that previously reinforced substance use.
- Continuing on with a longer-term recovery program: Recovery should ideally extend far beyond the detox process. Ongoing alcoholism treatment efforts may include inpatient or outpatient rehabilitation. It is important to understand that successful withdrawal management does not guarantee sustained recovery from an alcohol use disorder. For many people, recovery is a long-term commitment and requires long-term involvement in treatment.
- National Institute on Drug Abuse. (2018). Is there a difference between physical dependence and addiction?
- Center for Substance Abuse Treatment. Detoxification and Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series, No. 45. HHS Publication No. (SMA) 15-4131. Rockville, MD: Center for Substance Abuse Treatment, 2006.
- Becker H. C. (2008). Alcohol dependence, withdrawal, and relapse. Alcohol research & health : the journal of the National Institute on Alcohol Abuse and Alcoholism, 31(4), 348–361.
- Saitz, Richard. (1998). Introduction to Alcohol Withdrawal. Alcohol Health & Research World, 22(1), 5–12.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
- Bayard, et. al. (2004). Alcohol Withdrawal Syndrome. Am Fam Physician, 69(6),1443-1450.
- Center for Substance Abuse Treatment. (2010). Protracted Withdrawal. Substance Abuse Treatment Advisory, Volume 9, Issue 1.
- National Clinical Guideline Centre (UK). Alcohol Use Disorders: Diagnosis and Clinical Management of Alcohol-Related Physical Complications [Internet]. London: Royal College of Physicians (UK); 2010. (NICE Clinical Guidelines, No. 100.) 2, Acute Alcohol Withdrawal.
- Kattimani, S., & Bharadwaj, B. (2013). Clinical management of alcohol withdrawal: A systematic review. Industrial psychiatry journal, 22(2), 100–108.
- Zgierska, A., Rabago, D., Zuelsdorff, M., Coe, C., Miller, M., & Fleming, M. (2008). Mindfulness meditation for alcohol relapse prevention: a feasibility pilot study. Journal of addiction medicine, 2(3), 165–173.