Alcohol Withdrawal

Why withdrawal happens

Alcohol slows brain activity by boosting the calming neurotransmitter GABA and blocking the excitatory one, glutamate. With regular heavy drinking, the brain adapts by reducing GABA activity and increasing glutamate. When alcohol is suddenly removed, the brain is left over-excited. That over-activity causes tremor, anxiety, a racing heart and, at its worst, seizures and delirium. Each episode of withdrawal can make the next one more severe, a process called kindling.

Alcohol withdrawal timeline

Symptoms

Mild to moderate

• Shaking hands (tremor)
• Sweating and clammy skin
• Anxiety, irritability and restlessness
• Nausea, vomiting and loss of appetite
• Headache
• Insomnia and vivid dreams
• Fast heartbeat and raised blood pressure

Severe

• Withdrawal seizures: usually generalized tonic-clonic seizures, often single, between 12 and 48 hours.
• Alcoholic hallucinosis: hallucinations, often visual or tactile (insects crawling on the skin), with otherwise normal awareness.
• Delirium tremens: fluctuating confusion, disorientation, agitation, hallucinations, fever, profuse sweating and unstable heart rate and blood pressure. It occurs in about 3% to 5% of people hospitalized for withdrawal and is a medical emergency.

Who is at risk of severe withdrawal

• Daily heavy drinking for weeks to years
• Drinking first thing in the morning to stop shakes
• Previous withdrawal seizures or DTs
• Previous detoxes
• Older age
• Use of other sedatives such as benzodiazepines
• Liver disease, infection, injury or other acute illness
• Low potassium, magnesium or platelets on blood tests

Diagnosis and assessment

Doctors diagnose withdrawal from the drinking history and symptoms. They measure severity with a scale such as the CIWA-Ar, which scores tremor, sweating, anxiety, agitation, nausea, headache, hallucinations and orientation. Tests include blood alcohol level, liver function, electrolytes (sodium, potassium, magnesium, phosphate), blood sugar, a blood count and checks for infection, head injury or pancreatitis, which can mimic or worsen withdrawal.

Treatment

Where to detox

• Outpatient (home) detox with daily checks by a clinician can be suitable for people with mild expected withdrawal, no seizure or DT history, a supportive person at home and no serious medical or mental health problems.
• Inpatient detox in a hospital or specialist unit is advised for anyone at risk of severe withdrawal, who has had seizures or DTs, is pregnant, has significant medical or psychiatric conditions, or lacks support.

Do not stop suddenly on your own after long-term heavy drinking without medical advice.

Medicines

• Benzodiazepines are the main treatment. They calm the over-excited brain and prevent seizures and DTs. They are given on a fixed schedule or according to symptom scores, then tapered.
• Phenobarbital or gabapentin and carbamazepine are alternatives in some settings.
• Thiamine (vitamin B1), given before glucose, prevents Wernicke-Korsakoff syndrome, a serious brain disorder caused by thiamine deficiency.
• Fluids, electrolytes and nutrition, including magnesium and potassium replacement.
• Delirium tremens is treated in a monitored or intensive care setting.

After detox: treating alcohol use disorder

Detox treats the withdrawal, not the drinking. Without further support, most people return to drinking. Effective next steps include:

• Medicines that reduce cravings and relapse: naltrexone, acamprosate and disulfiram, prescribed by a doctor
• Counseling: cognitive behavioral therapy, motivational interviewing and family therapy
• Mutual support: Alcoholics Anonymous, SMART Recovery and similar groups
• Treating depression, anxiety and sleep problems

See alcohol use disorder for more. The SAMHSA National Helpline, 1-800-662-4357, offers free, confidential referrals 24 hours a day.

Complications

• Seizures and injuries from falls
• Delirium tremens, which can be fatal without treatment
• Wernicke encephalopathy
• Heart rhythm problems
• Dehydration and electrolyte imbalance
• Aspiration pneumonia
• Relapse to drinking

Frequently asked questions

How long does alcohol withdrawal last?

Symptoms usually start 6 to 24 hours after the last drink, peak at 24 to 72 hours and settle within 5 to 7 days in mild to moderate cases. Sleep problems, anxiety and cravings can continue for weeks or months. Delirium tremens, if it develops, usually starts 2 to 4 days after stopping.

Can alcohol withdrawal kill you?

Yes, in severe cases. Withdrawal seizures and delirium tremens can be fatal without treatment. With prompt medical care, the risk of death from DTs is low. This is why people who drink heavily every day should stop under medical supervision.

What are the first signs of alcohol withdrawal?

The earliest signs, 6 to 24 hours after the last drink, are shaky hands, sweating, anxiety, irritability, nausea, headache, a fast heartbeat and difficulty sleeping. Many people notice them in the morning and drink to relieve them, which is a sign of physical dependence.

Is it safe to detox from alcohol at home?

It can be for people with mild expected withdrawal, no history of seizures or DTs, no serious health problems and someone to stay with them, ideally with medical guidance. People who drink heavily every day or have had severe withdrawal before should detox under medical supervision.

What is delirium tremens?

Delirium tremens is the most severe form of alcohol withdrawal, usually starting 48 to 96 hours after the last drink. It causes confusion, agitation, hallucinations, fever, heavy sweating and a racing heart. It is a medical emergency treated in hospital, often in intensive care.