Alcohol Withdrawal Syndrome: A Deadly Consequence of Drinking

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Alcohol Use Disorder (AUD) is a term used by mental health and other medical professionals to diagnose individuals with significant alcohol problems. Withdrawal symptoms are considered to be a physical component of AUD and are the result of changes in brain chemistry that occur after prolonged periods of heavy alcohol use. Approximately 50% of individuals with AUD experience withdrawal symptoms or alcohol withdrawal syndrome (AWS).⁶

AWS occurs in individuals who are particularly sensitive to the neurochemical imbalances that result from prolonged, heavy drinking. Although a significant percentage of individuals with AUD experience AWS, only a small number of people will experience severe AWS,⁶ which considered a life-threatening, medical emergency.

What is Alcohol Withdrawal Syndrome (AWS)?

Alcohol Withdrawal Syndrome is a collection of withdrawal symptoms experienced in approximately 50% of individuals with alcohol use disorder (AUD).⁶ AUD is diagnosed in individuals who drink excessively and whose functioning (social, psychological, physical) is at least moderately impacted by their drinking.

The types of symptoms experienced in AWS are broken down into three components: autonomic, motor, and psychiatric.

Autonomic symptoms are responses of the nervous system and include:³

• Rapid heart rate
• Rapid breathing
• Dilated or larger than normal pupils
• Elevated blood pressure
• Elevated body temperature
• Diarrhea
• Nausea/vomiting

Motor symptoms are responses of the body’s nervous and muscular systems and include:

• Hand and body tremors
• Ataxia (impaired speech, balance, or coordination when not intoxicated)
• Changes in a person’s gait
• Hyper responsive reflexes
• Seizures

Psychological symptoms are changes to a person’s mood and perceptual experiences. These symptoms include:

• Paranoia
• Delusions (a fixed, false belief)
• Hallucinations (seeing, hearing, or feeling things that aren’t there)
• Mood instability
• Combativeness
• Agitation
• Disorientation
• Delirium
• Insomnia

Severity of AWS

AWS can be diagnosed as mild, moderate, or severe depending on the type and severity of withdrawal symptoms experienced. There are different schools of thought on what determines severity, but, generally, mild AWS include symptoms like tremors, anxiety, depression, and nausea.

Severe AWS is characterized by seizures, hallucinations, delirium, and coma. The most severe form of AWS is commonly referred to as delirium tremens, which occurs in approximately 5% of patients with AWS.

Disorientation is an important factor that separates moderate symptoms of AWS from a severe presentation like delirium tremens. Severe AWS is considered a medical emergency that should be addressed immediately.¹¹

Rates of death from delirium tremens are similar to that of other deadly illnesses. However, with early detection and treatment, rates of death drop below 1%.³

Alcohol Withdrawal Timeline

• 6-12 hours: Tremors, rapid breathing, rapid heart rate, elevated blood pressure, and nausea/vomiting.
• 12-24 hours: Visual, auditory, and tactile, hallucinations (seeing, hearing, and feeling things that are not there–the patient is aware these are not real)
• 24-48 hours: Seizures
• 48-72 hours: Delirium, psychosis (hallucinations patient believes are real), dangerously high blood pressure. 

The timeline for experiencing AWS is sometimes unpredictable. The onset and duration of symptoms can depend on a variety of variables. Most importantly are the individual and their drinking–both how much and how long.

The first symptoms to present, usually 6-12 hours after a person’s last drink, are tremors and autonomic symptoms. Autonomic symptoms include:

• Sweating
• Rapid breathing
• Rapid heart rate
• Elevated blood pressure
• Nausea/vomiting

12-24 hours after last drink is when more moderate to serious symptoms begin to present. These include sensory disturbances like auditory and visual hallucinations (seeing and hearing things that are not there). It is important to note that at this earlier stage, the patient is aware that these disturbances are not real.

Approximately 10% of patients with AWS experience seizures, which occur approximately 24-48 hours after a person’s last drink. Seizures can occur in the absence of any other withdrawal symptoms. More than half of individuals who experience seizures have more than one seizure.

48-72 hours after a person’s last drink is when the most severe symptoms typically present. These symptoms include delirium, psychosis (where the person believes their visual and auditory disturbances are real), and dangerously high blood pressure. Severe AWS, or delirium tremens, can persist as long as two weeks.³

The majority of alcohol withdrawals are self-managed and occur largely without medical complication.⁹ However, even mild withdrawals can become intolerable to the point of causing relapse.¹ Indeed, many people with AUD relapse to relieve withdrawal symptoms or put off quitting in an attempt to avoid withdrawal symptoms.

When severe AWS sets in, it may be too late or difficult to treat if the person is not under medical supervision. Some risk factors for severe AWS have been identified, but predicting outcomes is difficult.

Because individuals may not yet know if they will experience AWS or, if they do present, how severe symptoms will be, medical supervision may benefit any individual with AUD (regardless of the severity). Medical supervision can help prevent dangerous medical complications of AWS or simply reduce the risk of relapse.

Who Is At Risk of Alcohol Withdrawal Syndrome?

At risk for AWS are, first and foremost, those who consume alcohol excessively over a prolonged period of time. Recommendations for alcohol use usually stipulate no more than 2 “standard drinks” per day for men and 1 standard drink per day for women.¹²

A “standard drink” is considered either:

• 12 oz of beer, 5% alcohol by volume
• 8-9 fl oz of malt liquor
• 5 oz of wine, 12% alcohol by volume
• 5 oz of spirits, 40% alcohol by volume

Excessive drinking can be difficult to evaluate, especially when considering society’s widespread use and acceptance of alcohol. On the lower end of severity is alcohol misuse. Alcohol misuse is an occasional pattern of heavier drinking (or “binge drinking”)–defined as 5 or more drinks on one occasion for men, 4 or more for women.¹⁰

Alcohol use disorder (AUD) is a term used by mental health professionals to diagnose individuals with more severe alcohol problems. Although alcohol misuse may result in intoxication and some social or health problems, AUD indicates more severe functional impairments that result from excessive drinking.

If you have alcohol use disorder, you are more at risk for AWS. Severe AWS or delirium tremens is a medical emergency, and while predicting who will experience severe AWS isn’t an exact science, some risk factors have been identified.

The most significant risk factor is a previous episode of alcohol withdrawal. Other risk factors include:³

• Using other illicit substances with alcohol, especially other central nervous system depressants like benzodiazepines (e.g., Xanax, Ativan, or Klonopin) or barbiturates (e.g., Propofol, Phenobarbital)
• High blood alcohol level
• High blood pressure
• Older age
• Moderate to severe alcohol use disorder (AUD)
• Medical or surgical illness (e.g. head trauma, liver disease, and electrolytes like sodium or potassium in the blood)

Treatment for Alcohol Withdrawal Syndrome

Since it’s difficult to know whether you will have AWS or how severe it may be, medically supervised detox is recommended as it can reduce the risk of complications from severe AWS or reduce the risk of relapse.

If you have a history of withdrawals, particularly severe withdrawals like seizures, delirium, visual disturbances, or severe mood symptoms, it’s especially important to seek medical care when quitting alcohol.

Medications

In severe cases of AWS or delirium tremens, barbiturates are sometimes prescribed in addition to benzodiazepines. Barbiturates are stronger than Benzodiazepines and carry significant risks of extreme sedation, they are normally delivered in intensive care units with close medical monitoring.

Baclofin and Gamma‐hydroxybutyric acid (GHB) and Sodium oxylate (SMO) are also sometimes administered during detoxification from alcohol.^4,6

Medications like Dexmedetomidine may be used only in addition to other medications to reduce symptoms like severe agitation, anxiety, and dangerously high blood pressure.⁴

When you have completed medically-supervised detox, other medications may be introduced to reduce cravings for alcohol and prevent relapse. The two most effective and commonly prescribed medications are:

• Acamprosate
• Naltrexone: has the unique benefit of reducing the euphoric feelings that accompany alcohol when consumed. It does this by blocking opioid receptors in the brain which contribute to alcohol’s pleasure-causing effects.⁸

Other medications that are sometimes used to treat alcoholism are:

• Disulfiram: Antabuse medication that has been approved to treat alcoholism since 1949.⁵ It blocks the enzyme responsible for metabolizing a toxic component of alcohol. The result is a cluster of undesirable effects (e.g. nausea, vomiting, flushing) that occur when alcohol is consumed.
• Gabapentin and Topiramate: Anti-seizure medications that are prescribed off-label for alcoholism. Both medications are thought to reduce cravings.⁸

Behavioral Therapy

Medications for treating alcoholism are not considered stand-alone treatments. Behavioral therapy is also encouraged during the treatment of AUD. Results show that therapy and medication in combination have the lowest rates of relapse.⁷

Therapy for alcohol addiction varies but the most studied and effective is cognitive behavioral therapy, or CBT.⁷ CBT examines and works to modify thoughts, emotions, and behaviors associated with alcohol use.

References

1. Blaine, S. K., & Sinha, R. (2017). Alcohol, stress, and glucocorticoids: from risk to dependence and relapse in alcohol use disorders. Neuropharmacology, 122, 136-147.
2. Hermann, D., Hirth, N., Reimold, M. et al. Low μ-Opioid Receptor Status in Alcohol Dependence Identified by Combined Positron Emission Tomography and Post-Mortem Brain Analysis. Neuropsychopharmacol 42, 606–614 (2017).
3. Jesse, S., & Ludolph, A. (2019). Alcohol Withdrawal Syndrome: Clinical Picture and Therapeutic Options. In Neuroscience of Alcohol(pp. 671-680). Academic Press.
4. Jesse, S., Bråthen, G., Ferrara, M., Keindl, M., Ben-Menachem, E., Tanasescu, R., Brodtkorb, E., Hillbom, M., Leone, M. A., & Ludolph, A. C. (2017). Alcohol withdrawal syndrome: mechanisms, manifestations, and management. Acta neurologica Scandinavica, 135(1), 4–16.
5. Kranzler, H. R., & Soyka, M. (2018). Diagnosis and pharmacotherapy of alcohol use disorder: a review. Jama, 320(8), 815-824.
6. Mirijello, A., D’Angelo, C., Ferrulli, A., Vassallo, G., Antonelli, M., Caputo, F., … & Addolorato, G. (2015). Identification and management of alcohol withdrawal syndrome. Drugs, 75(4), 353-365
7. Ray, L. A., Meredith, L. R., Kiluk, B. D., Walthers, J., Carroll, K. M., & Magill, M. (2020). Combined pharmacotherapy and cognitive behavioral therapy for adults with alcohol or substance use disorders: a systematic review and meta-analysis. JAMA network open, 3(6), e208279-e208279.
8. Reus, V. I., Fochtmann, L. J., Bukstein, O., Eyler, A. E., Hilty, D. M., Horvitz-Lennon, M., … & McIntyre, J. (2018). The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. American Journal of Psychiatry, 175(1), 86-90.
9. Tucker, J. A., Chandler, S. D., & Witkiewitz, K. (2020). Epidemiology of Recovery From Alcohol Use Disorder. Alcohol research : current reviews, 40(3), 02.
10. S. Centers for Disease Control and Prevention. (2018, February 1). Alcohol & Substance Misuse. Retrieved December 7, 2020.
11. S. National Library of Medicine. (2019, January 10). Alcohol withdrawal: MedlinePlus Medical Encyclopedia. Retrieved December 7, 2020.