Alcohol Withdrawal Timeline

If you have alcohol use disorder (AUD), you likely have a clinical tolerance for alcohol and a physical dependence on it. These characteristics of AUD develop over time with chronic and increasing levels of alcohol use.1

If you have a physical dependence on alcohol, especially if you have developed a tolerance, you likely experience negative symptoms when you use less alcohol or try to stop using it.1 The acute onset of these symptoms when you become abstinent from alcohol is known as alcohol withdrawal syndrome.1 For many people, alcohol withdrawal syndrome is an uncomfortable but necessary first step in the recovery process.

In this article:

What Is Alcohol Withdrawal Syndrome?

In a clinical sense, a natural “high tolerance” does not exist. This concept of tolerance—generally thought of as how much alcohol a specific person can use before feeling the effects or before becoming highly intoxicated—really refers the differences in how bodies process alcohol. A person who is known to have a tolerance of this kind is more likely to exhibit age, height, metabolic, and body composition characteristics that result in their body processing alcohol efficiently, leading to the appearance of lower effects.

Clinical tolerance to alcohol refers to the decreased neurochemical activation that you experience when using alcohol chronically. As you use alcohol over a sustained period of time, your brain reacts less intensely to alcohol. This alteration in brain chemistry leads to a need to use more alcohol or to use alcohol more frequently to feel the same effects you previously felt.1

Physical dependence is more likely to occur as your tolerance for alcohol, and therefore the amount you use, increases. Dependence occurs when your brain and body begin to need a minimum level of alcohol to function normally.1 You may have trouble focusing, sleeping, regulating your emotions, and so on if you have a physical dependence on alcohol.

When you are physically dependent on alcohol, you will experience withdrawal symptoms if you use less alcohol, do not use alcohol over a longer period of time than you are used to, or attempt to stop using alcohol entirely. 1 You may use alcohol again to alleviate them. The longer you are in this cycle, the worse the withdrawal symptoms can become.1

Alcohol withdrawal syndrome refers to the set of symptoms that occur when you suddenly stop drinking. The symptoms can range from mild to severe, depending on how long and how much you have been drinking.2

Symptoms occur in three stages, with the first symptoms typically appearing within 8 to 10 hours after your last drink if you have severe AUD.

Who Is at Risk for Severe Withdrawal Symptoms?

Risk factors for experiencing severe symptoms of alcohol withdrawal include the following:3

  • A history of seizures or delirium tremens
  • Recent use of extremely large amounts of alcohol in the days or weeks before detox begins
  • Chronic alcohol misuse over a period of years or decades
  • Underlying mental or physical health issues
  • Previous head trauma
  • Mixing alcohol with other substances, including prescription and over-the-counter medications, that amplify withdrawal symptoms

What Are the Stages of Withdrawal?

How long alcohol withdrawal lasts can depend on a variety of factors. Your symptoms may simply be uncomfortable or can be medically significant and require care.

Do not hesitate to seek medical attention during any phase of alcohol withdrawal. A medical evaluation can determine if your symptoms need to be monitored. Even if your current symptoms are not dangerous, a care team may be able to provide measures, such as medication-assisted therapy, to reduce the severity of your symptoms.4 Your medical team can also issue referrals to alcohol rehab centers following detox.

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Below, the three stages are broken down into an alcohol withdrawal timeline.

Stage One of Alcohol Withdrawal

For most people, stage one symptoms appear within 8 to 10 hours. In the most severe cases, symptoms can appear as soon as six hours after your last drink.4

Mild symptoms may include:4

  • Difficulty concentrating
  • Shakiness
  • Anxiety
  • Depression
  • Mood swings
  • Nausea
  • Vomiting
  • Heart palpitations
  • Sleep disturbances

Moderate symptoms may include:4

  • Itchy, tingling feeling in legs and feet
  • Brain fog
  • More severe shaking
  • Increased heartrate
  • More severe nausea and vomiting

Severe symptoms may include:4

  • Inability to sleep
  • Dry heaves
  • Extreme shakiness
  • Profuse sweating
  • High anxiety
  • Hallucinations
  • Tunnel vision
  • Pins and needles in legs and feet
  • Diarrhea

Stage Two of Alcohol Withdrawal

Stage two starts after 24 hours have passed from the last time you took a drink of alcohol. It can last two to three days with varying levels of intensity. Below are examples of mild, moderate, and severe symptoms during stage two of withdrawal.

Mild symptoms of withdrawal:4,5

  • Headaches
  • Trouble sleeping
  • Anxiety
  • Sweating
  • Lightheadedness
  • Irritability
  • Obsessive thinking about using alcohol

Moderate symptoms of withdrawal:4,5

  • Heartburn and indigestion
  • Sweating
  • Shakiness
  • Trouble sleeping
  • Minor hallucinations
  • Headaches
  • Fever
  • Mood swings
  • Thoughts of wanting to drink again
  • Fatigue
  • High anxiety
  • Racing heartrate

Severe symptoms of withdrawal:4,5

  • Major sweating
  • More severe hallucinations involving multiple senses
  • Tremors
  • Seizures
  • Confusion
  • Dehydration
  • Panic attacks
  • Achy muscles and bones
  • Nightmares and vivid dreams
  • Strong urges to drink
  • Delirium tremens

Stage two can feel worse than stage one for many. Medical help is necessary for many people experiencing moderate or severe symptoms. 4 Doctors can provide medication to help you sleep, ease headaches, give you an IV for dehydration, and more. 5

Stage Three of Alcohol Withdrawal

For some, stage three means things are getting better. Your withdrawal symptoms are easing, your mind is less foggy, and you see the light at the end of the tunnel. For others, stage three can bring on symptoms that put your life at risk—for example, delirium tremens—that may not have appeared in previous stages.4,5

Delirium tremens (DTs) is a condition that combines tremors, hallucinations, disorientation, and anxiety sometimes referred to as “the shakes.” 4 DTs can present with numerous additional side effects. Examples include seizures, stomach pain, restlessness, anxiety, increased startle reflexes, delusions, and all the other symptoms you may have experienced in earlier stages.5

As the days progress, physical symptoms will subside. However, it can take longer for psychological symptoms to fade away. You may experience:5

  • Strong urges and cravings to drink alcohol
  • Obsessive thoughts about alcohol
  • Anxiety and depression
  • Fatigue
  • Irritability

What Are the Treatment Options During Withdrawal?

Medically supervised detoxification is the best way to withdraw from alcohol safely. You receive care from doctors, nurses, and therapists 24/7. Each of your symptoms can be treated. For example, if you can’t sleep, you can receive medicine to help you sleep. If you have anxiety, you can receive anti-anxiety medication. If you have cravings for alcohol, there are medicines to ease those urges.6

Commonly used medications at a medically supervised detox program include the following:

  • Benzodiazepines are sedatives used to treat anxiety and some seizures. Librium and Valium are common benzodiazepines used for treating alcohol withdrawal. Because benzodiazepines have a high risk of misuse, they will likely only be used temporarily.7
  • Anti-seizure medications may be prescribed for both anxiety disorders and for preventing seizures. They have less potential for misuse and can be used instead of benzodiazepines.7
  • Disulfiram (Antabuse®) creates negative symptoms when someone drinks alcohol. As soon as 10 minutes after drinking alcohol, a person taking disulfiram can become nauseous, vomit, have headaches, sweat, and have blurred vision. The medicine acts as a deterrent for people who do not want to experience those symptoms.8
  • Naltrexone (Vivitrol® or Revia®) is a medication that reduces a person’s desire to drink. Vivitrol® is often given as a shot by a physician once a month. Revia® comes in pill form and can be taken daily. Neither are meant for long-term use.8

It is essential to transition to an inpatient rehab after detox for ongoing medication management and learn recovery skills.9

What Are the Treatment Options After Withdrawal?

Many individuals experience better recovery outcomes when they continue to “step down” in care after detox.

Inpatient Rehab

Inpatient rehab—or residential treatment—for AUD offers continued medical supervision and care, as well as individual and group counseling and education classes.9

Working with licensed mental health and addiction treatment specialists, you can learn early recovery skills, relapse prevention skills, self-care, relationship skills, and life skills. You get to put more time between yourself and alcohol. You also get to work on mental health issues that may have become more noticeable once you stopped drinking.9

Sober Living

A sober living facility allows you more freedom than an inpatient rehab facility, but provides a more recovery-focused environment than you would have if you lived at home. In sober living, you get to practice the skills you learned while in inpatient rehab. You live with peers who also have drug or alcohol use disorders. You can work, attend meetings, and continue practicing recovery skills.9

Intensive Outpatient Programs

Intensive outpatient programs (IOP) provide 10 or more hours a week of individual and group counseling. 9 You will continue learning early recovery and relapse prevention skills. If needed, you can continue medication management to help with alcohol withdrawal symptoms. You can attend work, school, and family functions when you are not attending IOP sessions.9

Continued Support

Continued support—which may consist of a formal aftercare plan created by your inpatient or IOP care team—involves individual counseling, social support groups, 12-step groups, and recovery activities. These can continue for as long as you feel you need extra support.9

If you want to stop using alcohol but are not sure where to start, call us at 800-839-1686Who Answers?. Our treatment specialists can walk you through the various programs and help you decide which is best. If you have stopped using alcohol and are experiencing withdrawal symptoms, we can help you get the right treatment to ease your symptoms so you can stay on your path to sobriety.

Resources

  1. National Institute on Drug Abuse. (2017). Tolerance, Dependence, Addiction: What’s the Difference?
  2. 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.
  3. Wood, E., Albarqouni, L., Tkachuk, S., Green, C. J., Ahamad, K., Nolan, S., McLean, M., & Klimas, J. (2018). Will this hospitalized patient develop severe alcohol withdrawal syndrome?: the rational clinical examination systematic review. JAMA, 320(8), 825–833.
  4. Mirijello, A., D’Angelo, C., Ferrulli, A., Vassallo, G., Antonelli, M., Caputo, F., Leggio, L., Gasbarrini, A., & Addolorato, G. (2015). Identification and management of alcohol withdrawal syndrome. Drugs, 75(4), 353–365.
  5. Heilig, M., Egli, M., Crabbe, J. C., & Becker, H. C. (2010). Acute withdrawal, protracted abstinence and negative affect in alcoholism: are they linked? Addiction Biology, 15(2), 169–184.
  6. Center for Substance Abuse Treatment. (2006). Detoxification and Substance Abuse Treatment – 1 Overview, Essential Concepts, and Definitions in Detoxification. Rockville (MD): Substance Abuse and Mental Health Services Administration (US). Treatment Improvement Protocol (TIP) Series, No. 45.
  7. Sachdeva, A., Choudhary, M., & Chandra, M. (2015). Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond. Journal of Clinical and Diagnostic Research: JCDR, 9(9), VE01–VE07.
  8. Crowley P. (2015). Long-term drug treatment of patients with alcohol dependence. Australian Prescriber, 38(2), 41–43.
  9. Substance Abuse and Mental Health Services Administration. (2014). What is Substance Abuse Treatment? A Booklet for Families.

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