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Alcohol Withdrawal
Signs | Symptoms | Treatments

Table of Contents

What is Alcohol Withdrawal

Alcohol withdrawal is the change the body goes through when a person suddenly stops drinking after prolonged and/or heavy alcohol use. Alcohol has a depressant effect on the brain. In a frequent, long-term, or heavy drinker the brain is almost constantly experiencing the depressant effect of alcohol. 

The brain adjusts to this exposure by producing more stimulating neurotransmitters (like serotonin or norepinephrine). If alcohol is removed abruptly, the brain is accelerated because of the chemicals it has been producing in excess to counteract the alcohol. The resulting imbalance causes many of the symptoms of withdrawal.

Prevalence Of Alcohol Abuse

Prevalence 1
24.5 percent of people ages 12 and older reported binge drinking in the past month
24.5%
51.7 percent of people ages 12 and older reported using alcohol in the past month
51.7%
86% of people ages 18 or older reported drinking alcohol at some point in their lifetime
86%

Causes of Alcohol Withdrawal

Acute alcohol withdrawal is the sudden loss of alcohol after long-term misuse 2; this sudden drop of intake is the cause of well-known symptoms that affect a person physically and psychologically. Both the mind and body form a dependence on alcohol after extended and everyday use. The influx of so much alcohol causes a depressant effect that slows the mind. The brain adjusts its chemistry to compensate for the increased levels of alcohol. Once the body is deprived of the constant drinking, it reacts, often negatively, as it adjusts to functioning without alcohol. A recorded estimate states that 14% of those living in a community-based area within the United States have an alcohol use disorder 3. It was reported that with hospitalized patients, alcoholism is as high as 40%, and at least half of these patients experience withdrawal symptoms

Alcohol Addiction

Alcohol addiction, or alcoholism, is described as a physical or mental dependency on alcohol. It changes the structure of the brain and creates uncontrollable cravings4. Dr. George Koob, director of NIH’s National Institute on Alcohol Abuse and Alcoholism, stated in an article published by News in Health, “The brain actually changes with addiction, and it takes a good deal of work to get it back to its normal state5. The more alcohol you’ve taken, the more disruptive it is to the brain.”

Large intake and continual use of alcohol will disrupt the brain’s natural circuits that release endorphins and other chemicals that reward the body for healthy behaviors. Substance abuse takes control of the brain’s circuitry that produces pleasure and joy, rewiring it to reward the body only when there is an intake of alcohol. Once tolerance is gained, a higher intake of alcohol is then required to sustain those feelings of pleasure.

Fear of withdrawal can lead to a continuing addiction problem, and withdrawal symptoms can cause relapse after abstinence. It is reported that those who do not receive professional treatment are likely to relapse within three years6.

Related Illnesses & Co-occurring Disorders

A co-occurring disorder is a product of having a mental disorder or physical illness as well as being addicted to alcohol. Alcoholism is often found in connection with psychological and physical health issues; it has been stated in the NIAA Strategic Plan 2017-2021 that “Alcohol misuse also contributes to more than 200 diseases and injury-related health conditions.”7  Among these is liver disease, abuse of alcohol has been responsible for nearly half of liver disease-related deaths. HIV is another disease listed that is negatively affected by alcohol. While not a direct cause of the illness, it adds to HIV transmission and reduces HIV screening. Alcohol can also cause difficulties in following HIV medications as well as worsen other maladies involved in people with HIV.

Risk Factors

There are significant risks involved with alcohol withdrawal. One of the most dangerous reactions to withdrawal is delirium tremens, which occurs in every one out of twenty people8.  The reaction occurs when the brain is unable to readjust back to its original chemistry before the abuse of alcohol. This confuses the brain and can affect the way it regulates breathing and blood circulation. It can cause dramatic changes in heart rate and blood pressure increases the chance of a heart attack, stroke, or possibly death. More common withdrawal risks are9:

Vomiting

Headaches

Increased Heart Rate

Seizures

Fever

Visual  and Auditory Hallucinations

Hospitalization may be required if symptoms become too severe.
Doctors will be able to supervise the patient and manage any complications that might occur.

Symptoms of Alcohol Withdrawal

A person who drinks alcohol will inevitably experience symptoms of alcohol withdrawal. The mild, short term symptoms of withdrawal are commonly called a “Hangover.” When a person overindulges, even just for one evening, their bodies react to the metabolization of alcohol by producing feelings of general discomfort.

Most Common symptoms of a hangover include:

  • Nausea
  • Headaches
  • Fatigue
  • Dizziness
  • Irritabil

Hangovers are a small sample of the effects that alcohol withdrawal can produce in a person who has become physically dependent on alcohol. It is important to note how many systems within the body are affected by alcohol. This shortlist of mild symptoms include negative effects on a person’s mood, motor skills, cognitive abilities, and gastrointestinal system.

As the body adjusts to the chronic influx of alcohol, numerous internal systems must adapt to the presence of alcohol and the byproducts that are created once it is broken down by the liver. 

The symptoms of alcohol withdrawal are often categorized into three groups:

  • Autonomic Hyperactivity
  • Gastrointestinal
  • Cognitive and Perceptual 

The symptoms of alcohol withdrawal syndrome can be temporary and mostly benign in casual drinkers. But the more dependent a person is on alcohol, the more severe and dangerous their withdrawal can be. The severity of alcohol addiction can also affect when a person begins to experience withdrawal. In some heavy drinkers, the symptoms of withdrawal can begin before a person’s blood-alcohol level lowers to zero.

Timeline

Alcohol withdrawal side effects and symptoms are categorized into 3 stages:

Stage 1: Approximately 8 hours after the last drink. Common symptoms include: Anxiety, insomnia, nausea, and abdominal pain.

Stage 2: Approximately 24 to 48 hours after the last drink. Common symptoms include: High blood pressure, increased body temperature, unusual heart rate, and confusion.

Stage 3: Approximately 2 to 4 days after the last drink. Common symptoms include: Hallucinations, fever, seizures, and agitation.

*Symptoms typically decrease after 5 to 7 days.

Symptoms (Acute)

Autonomic Hyperactivity:

Sweating
As the liver processes excess alcohol it creates heat. The excess heat is then released through the skin. This creates a feeling of warmth in intoxicated individuals and can signal their body to cool itself through perspiration. Drinking alcohol causes the blood vessels in the skin to dilate and allows blood to flow more quickly. This can cause a person to sweat more than usual. If this moisture is not replaced with water, it can cause a person to become dehydrated. Dehydration can contribute to a variety of other symptoms of withdrawal.
Increased Heart Rate

Alcohol causes a person’s heart rate to increase by disrupting the electric signals that travel to the heart from the brain. After a prolonged period of alcohol abuse, this increased activity can lead to atrial fibrillation (AFib). AFib causes a person’s heart to be more erratically which makes a person more prone to Blood Clots, Strokes, and Heart Failure. 

High Blood Pressure

According to The National Child Traumatic Stress Network, an estimated 45 to 66 percent of young people had a substance abuse disorder before they experienced some kind of trauma, such as sexual or physical abuse. Unfortunately, a person with a substance abuse disorder typically has an even harder time coping with their recovery. Some experts say this is because people who abuse substances may have a hard time coping with stress and trauma.

Irregular Heart Rate

Chronic Alcoholism often leads to dehydration. Dehydration leads to a drop in Electrolytes which regulate a person’s heart rate. Alcohol abuse can also cause a person to have artery spasms that cause blood vessels to narrow suddenly. This can cause heart and chest, neck and arm pain during the alcohol withdrawal process.

Fever

Fevers are typically a symptom of a viral infection. When fighting off the virus, a person’s body raises its core temperature to stop the spread of the infection. Alcohol withdrawal causes the immune system to react in a similar way. The process triggers the production of cytokines. These small proteins help cells within the immune system communicate with one another, but also cause inflammation which can result in fever, fatigue, muscle aches, nausea, and headaches.

Shakes
In an effort to balance out the depressive effects of alcohol, the body produces excitatory neurotransmitters. This heightens nerve activity to keep a person awake and alert. People who have become physically dependent on alcohol have trained their brains to produce large quantities of these chemicals. When an alcoholic stops drinking, these neurotransmitters are still produced although they are no longer needed. This excess energy is burned off through involuntary shaking, tremors, and hyperactivity. 10
Hand Tremors
Excessive drinking can cause a person to experience tremors for another reason. Long term alcohol abuse can damage the cerebellum and cause intention tremors. These tremors are more pronounced when a person reaches for an object or makes a similar purposeful movement. Dysfunctions in the cerebellum caused by alcoholism can also cause clumsiness, slurred speech, and poor coordination. 11

Gastrointestinal:

Diarrhea

Alcohol that is not absorbed by the intestines is excreted from the body through feces and urine. Alcohol increases the speed that the colon muscles contract. This forces water to be processed faster, which reduces the amount of water that can be absorbed. This causes feces to be more watery than normal, resulting in diarrhea. Alcohol also irritates the digestive tract, making diarrhea worse. This process can cause a person to become dehydrated, which can cause or contribute to other withdrawal symptoms.

Vomiting

The gastrointestinal system breaks alcohol down into acetaldehyde. In normal circumstances, the liver neutralizes acetaldehyde with an antioxidant called glutathione. When a person becomes physically dependent on alcohol, their liver is not able to produce enough glutathione to balance out the other chemical. This excess of acetaldehyde causes irritation to mucous membranes in the stomach. In these cases, the liver will signal the body to expel the acetaldehyde through vomiting.

Acetaldehyde

Acetaldehyde is a carcinogenic chemical that can be found in ripe fruits, vegetables, cigarette smoke, and gasoline. Exposure to acetaldehyde vapors often results in irritation of the eyes, skin, and lungs. Large doses may cause death from respiratory paralysis.

Nausea

Large quantities of alcohol and the alcohol by-product, acetaldehyde, are irritants that aggravate the stomach lining. An excess of these substances causes a person to feel nauseated. Over time, this stomach irritation can cause alcohol gastritis an erosion of the stomach lining. This condition can lead to chronic nausea, heartburn, acid reflux, and ulcers.

Loss of Appetite
Alcoholic beverages contain sugars and carbohydrates that, when metabolized, can fool the body into thinking that it has eaten. Alcohol abuse can also cause an acid buildup in the stomach that causes irritation. This produces feelings of nausea that can suppress a person’s natural appetite. Alcohol also diminishes the body’s ability to absorb nutrients, vitamins, and minerals. So even when a person does eat, they do not receive the food’s full nutritional benefits. 12

Cognitive Perpetual:

Insomnia
Alcohol acts as a mild anesthetic and makes it easier to fall asleep. Without alcohol, a person with Alcohol Use Disorder can have trouble falling asleep and sleeping through the night. An alcoholic who stops drinking will have to restructure their circadian rhythms and develop healthy sleep habits without alcohol. It can take months for this process to complete. Drinking also interferes with a person’s ability to enter into deeper stages of sleep. This makes it more difficult for a drinker to get restful and rejuvenating REM sleep and paralytic sleep. 13
Anxiety
Alcohol use alters the levels of serotonin and other brain chemicals (or neurotransmitters) in the brain. When a person withdrawals from alcohol, these chemical imbalances can exacerbate existing anxiety. Because alcohol acts as a sedative and depressant, some people rely on it to help them regulate stress. Approximately 20% of people with a social anxiety disorder have a co-occurring issue with alcohol dependence. By relying on alcohol instead of developing coping skills, these people are often unable to tolerate stress in a healthy way. 14
Agitation & Irritability
There are many contributing factors to the development of agitation and irritability during alcohol withdrawal. A bad mood can be the result of malnutrition and lack of sleep. Or it can be the result of environmental factors like stress and difficulty in adapting to change. Another reason for irritability during alcohol withdrawal is a lack of serotonin in the brain. During intoxication, alcohol consumption spikes serotonin production in the brain. However, longterm drinking stunts serotonin production. Without alcohol to trigger this release, a person will not be satisfied by their base level of depleted serotonin. Because serotonin causes a person to feel joy and euphoria, a deficit in the chemical can cause them to feel irritated and agitated. 15
Serotonin

Serotonin has an impact on almost every part of the body. It affects everything from digestion to emotions and motor skills. Serotonin is a natural mood stabilizer. It helps a person sleep, eat, and heal. 

Depression
Alcohol use is closely tied to depression. The depression that people experience during withdrawal is characterized by feelings of emptiness, joylessness, and hopelessness. Some people turn to alcohol as a temporary solution to these feelings. When an alcoholic stops drinking they lose their most reliable source of dopamine, a brain chemical that can temporarily improve their mood. Extended alcohol abuse can dramatically impact a person’s brain chemistry. Alcohol suppresses the excitatory neurotransmitter glutamate which decreases energy levels and brain activity16. At the same time, alcohol increases the inhibitory neurotransmitter GABA which generally calms a person down. During the withdrawal process, an alcoholic is often left with depleted amounts of dopamine and GABA, leaving them especially susceptible to depression. 17
Gamma-aminobutyric Acid (GABA)

GABA is a naturally-occurring amino acid that functions as an “inhibitory” neurotransmitter. It suppresses brain signals and decreases activity in the nervous system. When GABA attaches to the GABA receptors in the brain, it produces a calming effect. Increasing the production of GABA in the brain helps to soothe anxiety, stress, and fear. Some people take GABA supplements to counteract seizures, Parkinson’s disease, Panic Disorder, and ADHD.

Seizures
Alcohol is a depressant that affects the central nervous system. In small doses, it produces euphoria and behavioral excitation by interacting with receptors in the brain. In the long term, it can change the way that these receptors behave. When alcohol is no longer a constant presence the sudden change shocks these systems. The resulting disruption can put a person in alcohol withdrawal at risk of having a seizure. The most dangerous time for seizures is between 6 and 48 hours after the last drink. In order to minimize the risk of seizures, a medical doctor will often prescribe benzodiazepines or other antiepileptic medications during this time period. 18

Symptoms (Post-Acute)

Post-Acute Withdrawal Symptoms:

Froggy Thinking / Trouble Remembering 

Urges and Cravings

Irritability or Hostility

Sleep Disturbances – Insomnia or Vivid Dreams

Fatigue

Issues with Fine Motor Coordination

Anxiety or Panic

Stress Sensitivity 

Depression

Lack of Initiative

Impaired Ability to Focus

Mood Swings

Alcohol Withdrawal Treatments

Detox

Detoxification from alcohol is the process of removing alcohol from ones body. There are various means to detox safely often times a medical or clinical detoxification is recommended.

Clinical detox includes a combination of medication followed by various behavioral therapies and continuing care to alleviate distressing mental, emotional, and physical symptoms.

Detoxing from alcohol includes acute withdrawal symptoms, lasting days or weeks, depending on:

  • How much of the alcohol was used
  • How frequently they used alcohol
About one-third of those who attend a clinical detox facility complete treatment, and around one-fifth of those people remain abstinent after five years. 19

Those who find themselves physically dependent on alcohol are often best suited for attending a clinical detoxification program. Detox usually begins with an initial evaluation by psychiatric and medical professionals, followed by a stabilization period.

Medications

A vital component of the medical detox process is the use of medications to alleviate withdrawal and reduce risk of major complications.  

Naltrexone

Naltrexone is a drug that is approved to treat alcohol use disorder and works by blocking the opioid receptors in an alcoholic’s brain. There is convincing data that naltrexone can significantly reduce alcoholic relapses and studies suggest it can help someone control the number of alcoholic drinks they ingest, and even the severity of their cravings. 20
Another perk of naltrexone is that it isn’t addictive and has no have adverse effects with alcohol.

Other medications might be used temporarily in a detox process to prevent life-threatening symptoms, such as seizures. This is up to the provider’s discretion and dependent upon the patient’s choice.

Inpatient

Commonly referred to as residential treatment, inpatient rehabilitation provides structure to recovering addicts that are seeking to extend their treatment after any acute withdrawal symptoms subside.

In doing so, they can form new lifestyle habits free from alcohol under the direct care of addiction and mental health professionals. Inpatient rehabs utilize therapies such as cognitive behavioral therapy, dialectical behavioral therapy, medications, and group therapy to encourage synergistic healing through 24/7 care.

Around two-thirds of people tend to complete their stay at a residential facility after detoxification.  

Outpatient

Outpatient treatment happens after residential treatment. In this setting patients attend groups during the day usually 3-6 hours per day.

Outpatient care tends to be longer than inpatient care. Once an alcoholic is physically, mentally, and emotionally stable, they may transition to an outpatient care center where they can continue to work, go to school, and socialize outside of the treatment program.

Aftercare

Aftercare planning consists of the organization of living arrangements, doctor scheduling, and other planning for success after one leaves treatment.

Resources are available for those who leave treatment, including AA meetings, SMART recovery meetings, sober living homes, psychiatric or therapist referrals, and more.

Non-Clinical Treatments

Holistic Home Remedies

Some people decide they would rather detox from their own home than in an accredited facility. There are many reasons for this, including that going through such a process in one’s home can allow them to feel more secure and in control of their recovery, or relieve any financial burdens.

Medical professionals generally do not recommend detoxing from home due to the steep health risks of acute withdrawal. Not only this but due to the frequent uncomfortably of withdrawal symptoms, many people can acquire multiple failed attempts at quitting their drug.

Despite the health and relapse risks, if someone chooses to detox from home, there are a few options available.

Detox kits, for example, can aid in the expulsion of toxins from one’s body. However, these kits aren’t synonymous with medical care from a health professional. Due to the fact that they are unregulated, detox kits bought in stores or online claiming to eradicate any trace of alcohol.

Some researchers believe the following vitamins, herbs, and supplements may also support the successful aridification of a drug from one’s body:

  • Vitamin B
  • Milk Thistle
  • Vitamin C
  • Cranberry extract
  • Garlic
  • Apple Cider Vinegar
Many of these supplements sport antioxidant properties that can aid in the restoration of the brain, liver, and other vital organs. Those detoxing should always: 24
  • Maintain a balanced diet
  • Prioritize hydration and
  • drink plenty of fluids
  • Remain in contact with a physician in case any medical emergency should arise

Sources

  1. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-facts-and-statistics
  2. https://pubs.niaaa.nih.gov/publications/arh22-1/61-66.pdf
  3. https://www.uptodate.com/contents/alcohol-withdrawal-epidemiology-clinical-manifestations-course-assessment-and-diagnosis
  4. https://www.goodrx.com/alcohol-addiction
  5. https://newsinhealth.nih.gov/2015/10/biology-addiction
  6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860472/
  7. https://www.niaaa.nih.gov/strategic-plan/introduction
  8. https://www.health.harvard.edu/a_to_z/alcohol-withdrawal-a-to-z
  9. https://www.healthline.com/health/alcoholism/withdrawal#treatment
  10. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Tremor-Fact-Sheet
  11. https://practicalneurology.com/articles/2013-mar-apr/overview-of-adult-onset-cerebellar-ataxia
  12. https://pubs.niaaa.nih.gov/publications/arh27-3/220-231.html
  13. Substance Abuse and Mental Health Services Administration (SAMHSA) 
  14. https://www.adaa.org/understanding-anxiety/social-anxiety-disorder/social-anxiety-and-alcohol-abuse
  15. https://pubs.niaaa.nih.gov/publications/arh21-2/144.pdf
  16. https://www.sciencedaily.com/releases/2008/07/080708104521.htm
  17. https://www.nature.com/articles/npp200890
  18. https://www.ncbi.nlm.nih.gov/pubmed/14594442
  19. https://www.addictioncenter.com/treatment/drug-and-alcohol-detox/
  20. https://www.samhsa.gov/sites/default/files/programs_campaigns/medication_assisted/efficacy-naltrexone-treatment-alcohol-dependence.pdf
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