Alcohol Withdrawal & Detox: Symptoms, Timeline & Treatment

Alcohol withdrawal is a dangerous process. It is important for people to be aware of the facts and potential complications before stopping alcohol use.

Alcoholism, or alcohol use disorder (AUD), is the inability to control alcohol use despite negative consequences. Those with AUD have a physical and mental dependence on alcohol.

When people who regularly use alcohol suddenly stop drinking, they usually develop uncomfortable and dangerous withdrawal symptoms. Alcohol detoxification (alcohol detox) is how the body rids itself of alcohol and its metabolites.

Alcohol withdrawal syndrome (AWS) is the collection of alcohol withdrawal symptoms that typically occur when people who drink alcohol regularly suddenly stop or reduce their alcohol intake.

Related Topic: Alcohol Use Disorder

What Causes Alcohol Withdrawal?

Alcohol causes drastic changes that affect sensitivity to many brain chemicals (neurotransmitters), especially GABA and glutamate. Both neurotransmitters help regulate the excitability of the brain. Because alcohol suppresses excitability, drinking alcohol causes a slowing of thinking, reaction time, speech and body movements.

Suppressed Neurotransmitter System

With prolonged alcohol use, this neurotransmitter system grows increasingly suppressed as tolerance develops and alcohol use increases. The brain tries to compensate for the alcohol-induced brain slowing by increasing its efforts at exciting the brain.

Hyper-Excitability in the Brain

When alcohol consumption is suddenly removed or reduced, a huge imbalance of  GABA and glutamate results in a “hyper-excitable” brain. This excitement causes rapid metabolism effects (increased heart rate, blood pressure and breathing rates), shaking, unstable movements and an over-active brain, as is seen in delirium tremens (DTs). In severe cases, this hyper-excitability can cause seizures.

Low Levels of Dopamine

Another important neurotransmitter affected by alcohol use is dopamine, which is a key part of the brain’s reward (feel-good) system. When intoxicated with alcohol, abnormally high dopamine levels are released, which is why people feel good for some time when drunk. This over-activation of the brain’s reward system is part of what makes people addicted to alcohol. The brain responds to the abnormally high dopamine levels from alcohol use by down-regulating dopamine production and the brain’s dopamine receptors. When alcohol use is stopped, the brain is left with very low dopamine levels, resulting in feeling depressed, tired and lethargic. It may take some time for the brain chemistry to return to normal, so these effects may persist for some time.

What Are the Symptoms of Withdrawal?

The symptoms of withdrawal are the effects the brain and body feel as the body rebounds to functioning without drinking after regular exposure to alcohol.

Some common alcohol withdrawal symptoms include:

• Muscle spasms
• Shaking
• Increased irritability
• Headache
• Feelings of anxiety and depression
• Diaphoresis (profuse sweating, cold sweats)
• Difficulty sleeping or insomnia
• Nausea and vomiting
• Hallucinations, confusion, jitteriness and agitation (common among people who drink heavily)

Types of Alcohol Withdrawal

Different types of withdrawal syndromes can occur:

• Initial withdrawal symptoms or a hangover
• Alcohol withdrawal seizures
• Delirium tremens (DTs)
• Post-acute withdrawal syndrome (PAWS)

People can experience some or all of these withdrawal symptoms after stopping or reducing their alcohol intake or following a binge-drinking episode.

Related Topic: Alcohol Withdrawal Symptoms

Acute Alcohol Withdrawal

Alcohol withdrawal syndrome usually starts with general hangover symptoms within 6–12 hours after the last drink. Symptoms may include nausea, vomiting, headaches, muscle spasms and sweating. Some people may also experience hallucinations.

The hallucinations in early withdrawal are different from the ones seen in the DTs and are referred to as alcoholic hallucinosis. These are usually predominantly auditory hallucinations (hearing things that aren’t there).

Seizures

About 24–48 hours after the last drink, the possibility of alcohol withdrawal seizures arises, and seizures may occur within two hours and up to 20 days after the last drink. People who experience these grand mal seizures may lose consciousness and fall. Their body stiffens, and the person may grunt, drool and froth at the mouth. They may also begin shaking violently. Alcohol withdrawal seizures are a medical emergency, so bystanders should call 911 immediately.

Delirium Tremens

A dangerous complication of AWS is delirium tremens (DTs), the most severe complication of alcohol withdrawal, which can be fatal.

The DTs are characterized by:

• Hallucinations (usually visual)
• Diaphoresis (drenching sweats)
• Severe confusion
• Anxiety
• Seizures
• Severe shaking
• High blood pressure, rapid heart rate and elevated body temperature

The DTs usually begin 48–72 hours after the last drink, peak at five days and last 4–12 days. Risk factors for DTs include:

• Previous episodes of withdrawal seizures
• Previous episodes of DTs
• Poor physical health
• Abnormal liver function
• Old age

Several factors dictate the severity of symptoms, most importantly, the degree of alcohol intake, length of time the individual has been using alcohol and previous episodes of detoxing from alcohol (this additive effect of episodes of detoxing is known as kindling).

As with seizures, the DTs are always a medical emergency, and bystanders should call 911 immediately.

Post-Acute Withdrawal Syndrome (PAWS)

Post-acute withdrawal syndrome (PAWS) is also called protracted withdrawal syndrome. This syndrome is a collection of symptoms that develop in some people following acute withdrawal and may persist for a year or more.

Many of the symptoms of PAWS are simply acute withdrawal symptoms that last longer than the usual duration, especially:

• Low energy, fatigue or apathy
• Anxiety
• Sleep disturbances
• Depressive symptoms
• High blood pressure, body temperature, heart rate or breathing rate

There is some debate within the research community about the validity of PAWS as a diagnosis, as many experts feel the symptoms are simply symptoms of mental health disorders, such as depression. However, it is widely agreed that protracted abstinence from alcohol after heavy and prolonged use can cause lasting symptoms due to brain effects from alcohol use.

It has been theorized that PAWS may play a role in relapse among people in recovery from AUD, although this has yet to be properly assessed by research.

How Is Withdrawal Diagnosed?

People with AUD are often secretive and even deny their alcohol use problems, so if they are having a seizure or DTs and are brought to the hospital, the cause may not be readily apparent. However, the cause is usually found after some simple investigations.

Withdrawal is anticipated in people stopping their alcohol intake, so diagnosis is generally not an issue in those forthcoming about their alcohol use.

Alcohol Withdrawal Timeline

The symptoms of AWS usually follow a timeline:

• Onset is anywhere from two hours to a few days after the last drink (the average onset time is about six to eight hours after the last drink).
• Peak at 24–72 hours.
• Symptoms usually improve and taper off by seven days, although they can last for weeks.
• The risk of DTs usually begins 48–72 hours after the last drink.
• If DTs occur, they usually peak at five days after the last drink and last from four to 12 days.
• The danger of withdrawal seizures starts about 24–48 hours after the last drink.
• Seizures can occur within two hours and up to 20 days after the last drink.

The time of onset, duration and severity of withdrawal symptoms depend on several different factors, including:

• Whether or not the withdrawal is being medically assisted
• The health of the liver (which is responsible for metabolizing alcohol and detoxing the body)
• The age and gender of the individual
• The general health of the individual
• The number of previous episodes of AWS (due to the kindling effect)
• The genetic and biological makeup of the individual

Treatment for Alcohol Withdrawal

The main goals of treatment of alcohol withdrawal are:

• Safety
• Relapse prevention during detox
• Seizure prevention
• Proper hydration and nutrition
• Medical management of complications, such as DTs or seizures
• Symptom relief (especially nausea, insomnia, hallucinations, anxiety, etc.)

Treatment for alcohol withdrawal also includes administration of vitamin B1, also known as thiamine, either through an intravenous or oral route. This therapy treats any undetected Wernicke-Korsakoff syndrome (sometimes referred to as “wet brain”) effects that may have developed in the individuals.

Medical Detox

Medical detox is the safest and most comfortable way to withdraw and detoxify from alcohol use. Medical detox usually happens in a rehab setting that provides a safe place to get through the withdrawal process without any distractions or temptations from the outside world and with constant supervision from medical professionals in case of any complications.

Medical detox provides the medications and support needed to prevent seizures and other potential complications and treat uncomfortable symptoms. For people vomiting, intravenous fluids and medications can be provided, which can result in a remarkable improvement in symptoms and complications.

Medical detox also allows for recovery planning, as medically detoxing from alcohol use does not constitute treatment for AUD.

Related Topic: Alcohol Detox

Medication-Assisted Treatment

Medication-assisted treatment consists of medications used to help people through medical detox or improve their chances of successful recovery after medical detox by reducing cravings and helping prevent relapse.

Several medications are useful in helping some people withdraw from alcohol use:

• Benzodiazepines for seizure prevention, sedation and reducing agitation and anxiety
• Heart and blood pressure medications (such as beta-blockers or clonidine)
• Anti-seizure medications
• Muscle relaxants
• Thiamine and magnesium to treat nutritional deficiencies associated with alcohol use that can have serious medical consequences

Other medications are sometimes used, starting during or shortly after detox, but are meant to help with relapse prevention and not with withdrawal or detox specifically:

• Acamprosate
• Disulfiram
• Naltrexone (oral or injectable extended-release drug)

Related topic: Ativan for Alcohol Withdrawal

Detoxing at Home

Detoxing from alcohol at home is generally not safe. No test or formula can predict the severity of withdrawal (although attempts are being made to do so), so detox is unpredictable.

However, if people are considering self-detoxing, they should consider doing so only if certain conditions are in place:

• They consult their physician first
• Their alcohol use was not heavy or prolonged
• They do not live alone, and there are people there who know they are detoxing
• They have a safe and alcohol-free home
• There is help available if they develop serious complications, such as DTs or seizures, and can’t help themselves

One of the hallmark psychological characteristics of alcohol use disorder is that people maintain a persistent need for control and remain convinced that they can handle their addiction on their own, even after multiple failures to do so. As such, people with AUD may be wise to consult their physician and loved ones when they decide to self-detox.

People who develop seizures or DTs can’t help themselves, so having capable and informed help nearby is essential.

Related Topic: Vitamins for Alcohol Detox

Finding a Detox Center

It is important to find a medical detox center with the expertise and experience to assess and treat withdrawal from alcohol use and address any co-occurring substance use or mental health disorders. It is also wise to consider a facility with multiple treatment programs so individuals can transition smoothly into treatment for their AUD following a successful medical detox.

To find a detox center, you can:

• Use the Substance Abuse and Mental Health Services Administration’s treatment locator tool
• Call The Recovery Village at Baptist Health, which offers comprehensive medical detox and rehab programs
• Search for recovery resources in the state of Florida