Alcohol withdrawal is the changes the body goes through when a person suddenly stops drinking after prolonged and heavy alcohol use. Symptoms include trembling (shakes), insomnia, anxiety, and other physical and mental symptoms.
Alcohol has a slowing effect (also called a sedating effect or depressant effect) on the brain. In a heavy, long-term drinker, the brain is almost continually exposed to the depressant effect of alcohol. Over time, the brain adjusts its own chemistry to compensate for the effect of the alcohol. It does this by producing naturally stimulating chemicals (such as serotonin or norepinephrine, which is a relative of adrenaline) in larger quantities than normal. If the alcohol is withdrawn suddenly, the brain is like an accelerated vehicle that has lost its brakes. Not surprisingly, most symptoms of withdrawal are symptoms that occur when the brain is overstimulated.
The most dangerous form of alcohol withdrawal occurs in about 1 out of every 20 people who have withdrawal symptoms. This condition is called delirium tremens (also called DTs). In delirium tremens, the brain is not able to smoothly readjust its chemistry after alcohol is stopped. This creates a state of temporary confusion and leads to dangerous changes in the way your brain regulates your circulation and breathing. The body’s vital signs such as your heart rate or blood pressure can change dramatically or unpredictably, creating a risk of heart attack, stroke or death.
If your brain has adjusted to your heavy drinking habits, it takes time for your brain to adjust back. Alcohol withdrawal symptoms occur in a predictable pattern after your last alcohol drink. Not all symptoms develop in all patients:
Tremors (shakes) — These usually begin within 5 to 10 hours after the last alcohol drink and typically peak at 24 to 48 hours. Along with tremors (trembling), you can have a rapid pulse, an increase in blood pressure, rapid breathing, sweating, nausea and vomiting, anxiety or a hyper-alert state, irritability, nightmares or vivid dreams, and insomnia.
Alcohol hallucinosis — This symptom usually begins within 12 to 24 hours after your last drink, and may last as long as 2 days once it begins. If this happens, you hallucinate (see or feel things that are not real). It is common for people who are withdrawing from alcohol to see multiple small, similar, moving objects. Sometimes the vision is perceived to be crawling insects or falling coins. It is possible for an alcohol withdrawal hallucination to be a very detailed and imaginative vision.
Alcohol withdrawal seizures — Seizures may occur 6 to 48 hours after the last drink, and it is common for several seizures to occur over several hours. The risk peaks at 24 hours.
Delirium tremens — Delirium tremens commonly begins two to three days after the last alcohol drink, but it may be delayed more than a week. Its peak intensity is usually four to five days after the last drink. This condition causes dangerous shifts in your breathing, your circulation and your temperature control. It can cause your heart to race dangerously or can cause your blood pressure to increase dramatically, and it can cause dangerous dehydration. Delirium tremens also can temporarily reduce the amount of blood flow to your brain. Symptoms can include confusion, disorientation, stupor or loss of consciousness, nervous or angry behavior, irrational beliefs, soaking sweats, sleep disturbances and hallucinations.
Alcohol withdrawal is easy to diagnose if you have typical symptoms that occur after you stop heavy, habitual drinking. If you have a past experience of withdrawal symptoms, you are likely to have them return if you start and stop heavy drinking again. There are no specific tests that can be used to diagnose alcohol withdrawal.
If you have withdrawal symptoms from drinking, then you have consumed enough alcohol to damage other organs. It is a good idea for your doctor to examine you carefully and do blood tests, checking for alcohol-related damage to your liver, heart, the nerves in your feet, blood cell counts, and gastrointestinal tract. Your doctor will evaluate your usual diet and check for vitamin deficiencies because poor nutrition is common when someone is dependent on alcohol.
It is usually difficult for people who drink to be completely honest about how much they’ve been drinking. You should report your drinking history straightforwardly to your doctor so you can be treated safely for withdrawal symptoms.
Symptoms of alcohol withdrawal typically improve within five days, though a small number of patients may have prolonged symptoms, lasting weeks.
Alcoholism is caused by many factors. If you have a sibling or parent with alcoholism, then you are three or four times more likely than average to develop alcoholism. Some people with family histories of alcoholism choose to abstain from drinking since this is a guaranteed way to avoid developing alcohol dependence. Many people without a family history also develop alcoholism. If you are concerned about your drinking, speak with your doctor.
If you have severe vomiting, seizures or delirium tremens, the safest place for you to be treated is in a hospital. For delirium tremens, treatment in an intensive care unit (ICU) is often required. In an ICU, your heart rate, blood pressure, and breathing can be monitored closely in case emergency life-support (such as artificial breathing by a machine) is needed.
Medicines called benzodiazepines can lessen alcohol withdrawal symptoms. Commonly used medicines in this group include chlordiazepoxide (Librium) and lorazepam (Ativan).
Most alcohol abusers who are having withdrawal symptoms have a shortage of several vitamins and minerals and can benefit from nutritional supplements. In particular, alcohol abuse can create a shortage of folate, thiamine, magnesium, zinc and phosphate. It also can cause low blood sugar.
When To Call a Professional
Get help if you or someone you love has an alcohol-related problem. Alcoholism is an illness that can be treated.
If you have an alcohol dependency problem and have decided to stop drinking, call your doctor for help. Your doctor can advise you and can prescribe medicines to make withdrawal symptoms more tolerable if they occur. Your doctor can also put you in touch with local resources that will help you to stay alcohol free.
Alcohol withdrawal is common, but delirium tremens only occurs in 5% of people who have alcohol withdrawal. Delirium tremens is dangerous, killing as many as 1 out of every 20 people who develop its symptoms.
After withdrawal is complete, it is essential that you not begin drinking again. Alcohol treatment programs are important because they improve your chances of successfully staying off of alcohol. Only about 20 percent of alcoholics are able to abstain from alcohol permanently without the help of formal treatment or self-help programs such as Alcoholics Anonymous (AA). Of people who attend AA, 44 percent of those who remain free of alcohol for 1 year probably will remain abstinent for another year. This figure increases to 91% for those who have remained abstinent and have attended AA for 5 years or more.
On average, an alcoholic who doesn’t stop drinking can expect to decrease his or her life expectancy by at least 15 years.
The benefits of psychiatric drugs have been exaggerated and the harms underplayed due to poor trial designs, argues one expert in The BMJ. But another expert and a patient contend that the evidence supports the use of these drugs.
More than half a million people aged above 65 years die from the use of psychiatric drugs every year in the Western world and the benefits would need to be “colossal” to justify these “immensely harmful” treatments, argues Peter Gøtzsche, professor and director of the Nordic Cochrane Centre, Denmark.
But benefits are “minimal,” he explains, adding that these treatments should “almost exclusively be used in acute situations.” New guidelines should support this change as well as widespread withdrawal clinics to help many patients gradually come off these medications.
Benefits have been overemphasised and harms understated, he says, because randomised controlled trials have been biased, not blinded appropriately, have not fully evaluated the effects of these drugs and deaths have gone under reported.
For example, the majority of studies have included patients already using a psychiatric drug and such patients may undergo abstinence and suffer from withdrawal symptoms. As a result, this study design exaggerates the benefits of treatment and increases the harms in the placebo group.
Industry funded trials have under reported deaths, he adds, estimating that there have probably been 15 times more suicides among people taking antidepressants than reported by the US Food and Drug Administration (FDA).
He calculates that deaths from three classes of drugs — antipsychotics, benzodiazepines and similar drugs, and antidepressants — were responsible for 3693 deaths every year in Denmark. This number corresponds to 539,000 deaths in the United States and European Union combined.
The beneficial effects of psychiatric drugs are so small, he says, that it would be possible to stop current use almost completely without causing harm. He recommends stopping the use of all antidepressant, ADHD and dementia drugs, and prescribing only a small fraction of currently used antipsychotics and benzodiazepines.
But Allan H Young, a professor of mood disorders at King’s College London, and John Crace, a psychiatric patient, argue that research supports the use of psychiatric drugs which are just as beneficial and efficacious as treatments for other common, complex conditions.
These drugs are needed, they insist, to reduce the long term harms of psychiatric conditions, which are the fifth leading cause of disability worldwide. Most patients suffer from co-existing health conditions, they add, a primary cause of death among this group.
They explain that psychiatric drugs are rigorously examined for efficacy and safety and while the evidence base is “imperfect,” research shows that psychiatric drugs are more beneficial than harmful.
Careful evaluation of these drugs is undertaken before and after regulatory approval, they explain, and that post surveillance after a drug is licensed can include safety of a medication in the general population, which unlike study populations, includes people with varied medical conditions.
Yet concerns persist and many are “overinflated,” they add, and list recent studies supporting the use of lithium, once labelled a “toxic placebo,” and antipsychotics, and treatments for mood disorders.
But as with any drug treatment, the harms and benefits need to be evaluated from group data in trials, and be applied to individual patients whose subjective experiences are important to consider, they argue.