Alcohol Withdrawal

The symptoms you experience when you stop drinking may vary based on the amount of alcohol you consume, whether you’ve experienced withdrawal symptoms previously, and how long it’s been since your last drink. Symptoms are sometimes categorized into the following stages: 

• First stage: This stage characterizes mild symptoms, which may begin within six hours of alcohol reduction and last for approximately one week. 
• Second stage: This stage characterizes serious symptoms, such as withdrawal seizures, which may occur within 48 hours, and generally peak within 72 hours.
• Third stage: For people who experience withdrawal seizures, it’s estimated that 50% may progress to delirium tremens or third-stage alcohol withdrawal syndrome (AWS). Typically, these symptoms occur around 48 hours after your last drink and last for two to three days. 

The following are mild symptoms of alcohol withdrawal that characterize first-stage AWS: 

• Tremors or shaking
• Insomnia or nightmares
• Anxiety
• Irritability
• Gastrointestinal issues, such as nausea or vomiting
• Dilated pupils 
• Sweating
• Headache
• Fatigue
• Difficulty concentrating and brain fog
• Increased heart rate and high blood pressure

Delirium tremens (DT) is a severe form of withdrawal that occurs in approximately 3% to 5% of AWS cases, typically within 48 hours. DT has a mortality rate of up to 37% if treatment³ is not received. Recognizing the following symptoms early can significantly reduce the risk of mortality: 

• Fever
• Extreme confusion or agitation
• Visual, auditory, or tactile hallucinations
• Irregular heartbeat or other changes in vital signs
• Loss of consciousness

GABA (gamma-aminobutyric acid) is a depressant neurotransmitter that makes you feel calm and happy. When you drink an alcoholic beverage, the ethanol present in the drink binds to GABA, which causes symptoms of intoxication like relaxation, loss of inhibition, euphoria, slurred speech, difficulty concentrating, and lack of coordination. 

If you drink regularly, your brain may begin balancing the effects of alcohol by reducing the production of GABA. These changes can make the brain dependent on alcohol. When you suddenly reduce or eliminate your consumption of alcohol, your brain experiences an excitatory imbalance that results in alcohol withdrawal symptoms. 

Risk factors of severe withdrawal from alcohol

Not everyone with alcohol use disorder may experience withdrawal symptoms, but mild symptoms are common. Though uncommon, severe symptoms can be fatal if left untreated. Risk factors for severe alcohol withdrawal include:

• Chronic heavy alcohol use
• Comorbid health conditions 
• History of severe withdrawal symptoms

To experience withdrawal, your brain must have adapted to chronic alcohol use. Often, the greater your dependence on alcohol, the greater your likelihood of experiencing withdrawal symptoms when you cut back on alcohol or quit drinking altogether.

Alcohol withdrawal is often addressed with supportive care, depressant medications, anticonvulsants, and vitamins to prevent, relieve, and treat serious symptoms. Talk therapy and self-care strategies are often recommended once alcohol detoxification resolves to reduce the risk of relapse and address underlying mental health challenges.

Medication

Consult a medical doctor before starting, changing, or stopping a medication for any condition. The information in this article is not a replacement for medical advice. Below are a few medication options people with alcohol withdrawal may consider:

• Benzodiazepines are anxiolytic medications that can be prescribed to reduce the risk of anxiety, seizures, and DT. Benzodiazepines may be given as a fixed daily dose, a loading dose, or a symptom-triggered treatment. For individuals without a history of serious withdrawals, symptom-focused treatment may reduce the duration of detoxification.
• Physicians may prescribe anticonvulsants as an alternative or complement to benzodiazepine treatment. Though anticonvulsants have a lower risk of dependence and may cause less sedation than benzodiazepines, they may not be as effective at preventing DT.  
• Naltrexone is approved by the Food and Drug Administration (FDA) to treat AUD alongside therapy after withdrawal symptoms have dissipated. It blocks ethanol from binding to GABA receptors, reducing the risk of relapse.

Other treatment options

Below are a few alternative treatment options for alcohol withdrawal: 

• Supportive Care: Healthcare providers often provide supportive care during alcohol withdrawal by providing counseling, patient education, hydration support, and symptom monitoring. Supportive care may include vitamin supplementation, as alcohol can interfere with the body’s ability to absorb nutrients. 
• Brief Intervention: Brief interventions are short in duration and may not require follow-up appointments. They are typically led by a licensed therapist and aim to minimize alcohol use.
• Support Groups: Groups like Alcoholics Anonymous can be effective at reducing the risk of relapse for individuals with alcohol use disorder.

Self-care

Below are a couple of self-care exercises you might try: 

• Keep a journal: Some people find it helpful to use a journal to track their symptoms, cravings, and drinking habits. 
• Exercise: Exercise can reduce alcohol cravings, boost mood, and improve sleep quality.     

The best treatment is the one that works for you. Various treatment methods are often combined to reduce symptoms of alcohol withdrawal and alcohol use disorder.

Psychotherapy (talk therapy) is often recommended to address substance use disorders. Cognitive-behavioral therapy (CBT) is a subset of talk therapy that emphasizes the relationship between thoughts, emotions, and behaviors. Cognitive-behavioral therapists help their clients develop coping skills, reframe unhealthy automatic thoughts, and identify the causes of wanting to drink. When used in combination with medications, cognitive-behavioral therapy can effectively address AUD symptoms. 

Some clients may face barriers when seeking in-person therapy. Online therapy platforms like BetterHelp offer online CBT, which may provide a significant sense of safety for people who experience shame surrounding their alcohol use. Research shows that online CBT can reduce alcohol use and the risk of relapse. 

Aside from personalized therapy sessions, there are other resources available to address alcohol use, including the following:

• Support Groups: Popular nationwide support groups include Alcoholics Anonymous, SMART Recovery, and Recovery Dharma. Many of these support groups are available for free, and they often include options for in-person or online attendance.
• Educational Materials: The National Institute on Alcohol Abuse and Alcoholism (NIAAA) provides detailed education on evidence-based treatment for alcohol use. While the NIAAA references alcohol abuse and alcoholism, those terms are no longer used and have been replaced by alcohol use disorder, the clinical term for this condition.

For help with substance use, contact SAMHSA’s National Helpline at 1-800-662-HELP (4357).

Alcohol withdrawal syndrome commonly occurs in hospital settings, affecting approximately 8% to 40% of patients who are admitted into surgical intensive care units. While treatment for AWS has historically been initiated after individuals begin showing symptoms, recent guidelines support screening patients and giving prophylactic treatment to patients at risk of severe AWS, whether they’re exhibiting severe symptoms or not. The proactive use of benzodiazepines may reduce the risk of serious symptoms. 

However, while benzodiazepines can effectively reduce AWS symptoms, they are associated with some serious adverse effects, such as sedation, dependency risk, aspiration, falls, and delirium. The authors of a 2022 study published in JAMA Open Network found that approaches to minimize benzodiazepine use and dosage can improve health outcomes, significantly reducing the length of hospital stays and use of intensive care units. Medical professionals can take an individualized approach to evaluate the treatment option that is most appropriate for you.

Less than 20% of people experiencing withdrawal require hospitalization

Alcohol withdrawal is often treatable or manageable at home, and under 20% of people experiencing alcohol withdrawal disorder require hospitalization or extensive care.¹

¹Journal of Clinical & Diagnostic Research

Below are more key statistics on alcohol withdrawal: 

• According to the 2021 National Survey on Drug Use and Health, 11.3% of US adults had alcohol use disorder within the past year. 
• The likelihood of experiencing alcohol withdrawal increases when you drink more. One survey found that increasing consumption by ten drinks per week doubled the possibility of withdrawal symptoms. 
• Over 90% of withdrawal seizures occur within the first 48 hours of alcohol reduction or cessation.