Alcohol Withdrawal Symptoms and Treatment

Alcohol Withdrawal Mechanism (Pathophysiology)

Alcohol inhibits the stimulating effects of signaling molecules (neurotransmitters) in the brain. In a chronic alcoholic, the brain–in the attempt to maintain its normal functions–adapts by “upregulating” itself and thus counteracting the inhibitory effect of alcohol. During alcohol withdrawal, the inhibitory effect of alcohol ceases within hours of stopping drinking, but the upregulation of the brain persists for several days, which results in hypersensitivity to internal and external stimuli in this period ^[1].

Acute Alcohol Withdrawal Syndrome Symptoms and Signs

A person who drinks large amounts of alcohol on a daily basis for several months and then suddenly stops to drink or markedly reduces the alcohol intake may develop some of the following symptoms ^[1,2,3,4,5]:

1. Mild withdrawal symptoms, which may appear within 6-24 hours (rarely, earlier) after stopping drinking and may last for 5 days or more, may include:

• Anxiety, depression, panic attacks, restlessness, irritability
• Shakiness (jitters)
• Insomnia, nightmares
• Anorexia, nausea, vomiting
• Alcohol craving, sugar craving
• Increased sensitivity to sound, light and thermal pain
• Headache, dizziness, fatigue
• Low-grade fever, excessive sweating, dry mouth, thirst, chills
• Rapid breathing, racing heart, pounding heart (palpitations) or irregular heartbeat (arrhythmia)
• Exhaustion, after the above symptoms cease.

2. Transient hallucinations may appear within 10-72 hours after stopping drinking and usually resolve within 48 hours after the onset. A person with transient hallucinations remains fully oriented, unlike a hallucinating person during delirium tremens (see below). Hallucinations may include:

• Hearing (auditory) hallucinations, such as commanding voices
• Visual hallucinations, such as insects crawling the walls
• Tactile hallucinations, such as tingling and numbness or “electric fleas.”

3. Seizures in the form of generalized muscle cramps (convulsions) may appear 6-48 hours after stopping drinking or, rarely, sooner or later than that. Sometimes, seizures are the first and only symptom of alcohol withdrawal. Withdrawal seizures in the non-epileptic individuals usually appear as brief generalized muscle cramps ^[2]. Multiple seizures may occur, but the duration between the first and last seizure is rarely more than 6 hours ^[2]. The risk of seizures increases with recurrent withdrawals and taking drugs, such as tramadol ^[6,7]. Withdrawal seizures may be prevented and treated with benzodiazepines, such as diazepam or lorazepam ^[8,9,10]. Alcohol withdrawal seizures are often followed by delirium tremens ^[11].

4. Delirium tremens (DTs) [from Latin; wild excitement with trembling] may develop 48-72 hours or, sometimes, up to 10 days after stopping drinking in about 5% of those with withdrawal symptoms and may last for five days or more. Symptoms and signs of DTs may include:

• Wild excitement (agitation), confusion, disorientation
• Mood changes, strong fear
• Persistent hearing and visual hallucinations
• Hyperthermia (body temperature higher than 101.3 °F or 38.5 °C) and excessive sweating
• Dilated pupils
• Increased blood pressure (hypertension)
• Diarrhea
• Coma

Risk factors for DTs include older age, high amount of alcohol consumed, previous detoxifications, severity of the withdrawal symptoms, strong craving for alcohol, illness, liver cirrhosis and head injury ^[4]. Death occur in up to 15% untreated individuals with DTs; risk factors for death include high fever, dehydration, infection, trauma, hepatitis and pancreatitis.

Complications of Alcohol Withdrawal

Alcohol withdrawal increases secretion of cortisol, which kills neurons and increases the risk of infections ^[12].

Wernicke encephalopathy, a transient brain damage caused by thiamin (vitamin B1) deficiency with apathy, confusion, double vision and wide-based gait, may occur during alcohol withdrawal ^[1].

Rarely, severe pain behind the breastbone (chest pain) eventually spreading to the neck and left arm, usually occurring at rest in the second half of the night after drinking alcohol the day before, and lasting for 5-30 minutes, is due to spasm of the coronary heart arteries ^[13]. The condition is called Prinzmetal or “variant” angina and may occur during alcohol withdrawal in individuals with either healthy or narrowed coronary arteries ^[23]. Chest pain may be relieved by nitroglycerin ^[23].

Rarely, severe pain and weakness in one or more limbs, often in calves, may develop within hours to few days after stopping drinking due to muscle disintegration (rhabdomyolysis) caused by a pressure of the body upon the limb when lying during a severe alcohol poisoning ^[24]. Rhabdomyolysis is a medical emergency. Symptoms may persist for weeks.

Only about 50% alcohol-dependent drinkers develop withdrawal symptoms that would require medical attention ^[14]. The risk of withdrawal symptoms increases with the severity, duration and regularity of drinking (daily drinking) ^[4]. The likelihood of severe withdrawal symptoms increases with the severity of symptoms during previous withdrawals, head injury, advanced liver disease, malnutrition, infection, anxiety, depression, psychiatric illness or abuse of illegal drugs ^[15]. The severity of withdrawal symptoms usually increases with repeated withdrawals ^[15]. This may be due to long-term changes in the nervous system that make it increasingly excitable; this is known as kindling hypothesis ^[15,16]. The fear of withdrawal symptoms may be a strong reason for chronic alcoholics to continue to drink.

Acute Alcohol Withdrawal Treatment

A person with withdrawal symptoms should contact his or her personal doctor or a detoxification center. Severe withdrawal symptoms require hospital treatment, which usually lasts for about a week. Treatment may include intravenous fluids, dietary supplements, such as thiamin, folate, magnesium, potassium and glucose, benzodiazepines (diazepam), antipsychotics (in hallucinations), sedatives, or other drugs as prescribed ^[17,18,19]. Gradual withdrawal by decreasing amounts of alcohol is not recommended ^[9].

Conditions that may mimic alcohol withdrawal syndrome:

• Parkinson’s disease and other neurological diseases with tremor
• Opiate (morphine, codeine, heroin) or cocaine withdrawal

Post Acute Withdrawal Syndrome (PAWS)

Racing thoughts, rigid thinking, difficulty concentrating and learning new things, emotional numbness or hyper-reactivity, impaired short-term memory, feeling of guilt or anger, insomnia, hopelessness, are symptoms of post acute withdrawal syndrome (PAWS) that may persist for 6-18 months after stopping drinking. Symptoms may be aggravated by stress and usually improve with time ^[20]. What may help in PAWS: sufficient sleep, regular meals, physical activity, meditation, avoiding unnecessary stress and caffeine ^[20].

Some other sources mention protracted withdrawal syndrome with tremor, anxiety, depression, emotional numbness, inability to experience pleasure (anhedonia), alcohol craving, fatigue, confusion, increased body temperature, heartbeat and blood pressure persisting for a year or longer ^[1,21].  Some people reported sugar craving for weeks after stopping drinking.

In Alcohol Anonymous (AA) groups the term “dry drunk syndrome” is used to describe the absence of favorable personal changes after stopping drinking, and the related symptoms ^[22]:

• Mood swings, intolerance, overreacting, impatience, impulsiveness
• Complaining, judgmental attitude
• Grandiosity (“big me” or “poor me”)
• Lack of spontaneous expression of feelings
• Detachment from reality
• Low attention span
• Irresponsibility, childish behavior
• Nostalgia, daydreaming