What is Alcohol Withdrawal Syndrome (Alcohol Withdrawal)?
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has identified alcohol as the most widely used substance in the United States. Over 75% of people aged 12 and older have at some point consumed alcohol. The consumption of alcohol falls on a scale going from low risk to severe alcohol use disorder (AUD). Consistent heavy drinking or having AUD raises the chances of experiencing alcohol withdrawal syndrome. This syndrome is a significant health concern because of the number of people it affects in the US.
Although most instances of alcohol withdrawal syndrome are mild and don’t require medical help, there can be severe cases. These severe cases can lead to dangerous complications and need immediate medical intervention in different healthcare settings. These settings include the emergency room, outpatient clinic, intensive care unit, or detox facility. Based on a patient’s symptoms, healthcare teams must decide the best place for treatment.
When a person stops drinking alcohol, alcohol withdrawal syndrome typically shows minor symptoms like mild anxiety, headaches, stomach discomfort, and trouble sleeping. More severe symptoms can develop, such as delirium from alcohol withdrawal, which can be challenging to diagnose and treat. Mild symptoms can progress to alcohol hallucinosis, where a person experiences visual or auditory hallucinations that typically go away within 48 hours of stopping alcohol. In some cases, people can have seizures within just a few hours of stopping alcohol.
The most severe symptom of alcohol withdrawal syndrome, called delirium previously known as delirium tremens, reveals itself through fever, rapid heart rate, agitation, profuse sweating, hallucinations, disorientation, and high blood pressure. This can occur anywhere between 3 to 8 days after a person stops drinking alcohol. Although only about 3% to 5% of people with alcohol withdrawal syndrome will reach this stage, it can be fatal. It’s essential to identify which patients are at risk of developing delirium from alcohol withdrawal using a validated tool and taking into account the patient’s history of complicated withdrawal. This is a critical part of managing the syndrome.
What Causes Alcohol Withdrawal Syndrome (Alcohol Withdrawal)?
Alcohol is a substance that can slow down the brain’s functioning. It does this by increasing the activity of GABA, a chemical in the brain that calms everything down. When someone drinks too much alcohol in a short amount of time, they produce a lot of GABA, which is why they might feel sedated or drowsy.
If someone drinks alcohol regularly, it changes the balance between calming (GABA) and stimulating (glutamate) chemicals in the brain. The body works to balance out the extra calming effect from the alcohol by producing more glutamate, an excitatory signal.
So, if a person who is used to drinking regularly suddenly stops or cuts down on their alcohol intake, their brain has less GABA activity. This means glutamate dominates, making the brain overly excited, and causing what’s known as alcohol withdrawal syndrome. It’s basically the body’s reaction to the sudden lack of alcohol, leading it to go into an overly active state.
Risk Factors and Frequency for Alcohol Withdrawal Syndrome (Alcohol Withdrawal)
The use of alcohol has been on the rise nationally, particularly during the COVID-19 pandemic. This increase has also brought about a rise in alcohol withdrawal syndrome and associated complications. People showing unhealthy alcohol use, including risky drinking and Alcohol Use Disorder (AUD), risk developing alcohol withdrawal syndrome when they reduce their usual drinking amount. Roughly half of those who stop or reduce their drinking abruptly will experience alcohol withdrawal syndrome, but how severe it is can vary.
Alcohol withdrawal syndrome is a common reason for people needing to go to the hospital, and it’s frequently treated in patients already in the hospital for other reasons. For instance, a 2013 snapshot of over 450,000 admissions to veterans’ hospitals found that 1 in 17 admitted patients were treated for alcohol withdrawal syndrome.
Signs and Symptoms of Alcohol Withdrawal Syndrome (Alcohol Withdrawal)
Alcohol withdrawal syndrome is a medical condition that can be determined through a person’s medical history and physical signs. This condition usually shows up a few hours after a person stops drinking alcohol and typically peaks around 72 hours. The symptoms of this syndrome are a result of increased brain activity when the calming effect of alcohol is gone. They may include:
- Shakiness
- Insomnia (difficulty in sleeping)
- Agitation (restlessness)
- Excessive sweating
- High blood pressure
- Rapid heart rate
- Seizures
If someone sees, hears, or feels things that aren’t really there during alcohol withdrawal, they may be experiencing alcohol hallucinosis, which impacts about 2% of people going through withdrawal. If the person’s mind seems altered or confused and they’re seeing or hearing things that aren’t there, it might be alcohol withdrawal delirium. When a doctor is taking a patient’s history, they’ll ask about past instances of severe withdrawal symptoms, defined as withdrawal that involves either seizures or delirium. If someone has had severe withdrawal before, they’re more likely to experience it again, and they should be watched closely in a clinical setting during withdrawal.
Testing for Alcohol Withdrawal Syndrome (Alcohol Withdrawal)
If your doctor suspects you have alcohol withdrawal syndrome, they might use a trusted tool called the CIWA-Ar to measure the intensity of your symptoms. This includes shaking, feeling things that aren’t there, and feeling restless. A CIWA-Ar score of 8 or less is considered mild alcohol withdrawal, while a score between 8 and 15 signifies moderate withdrawal. If your score is more than 15, it means you are experiencing severe withdrawal.
People with mild withdrawal symptoms but no other risk factors for severe withdrawal may be treated at home. Home treatment requires the help of a person who can carefully observe the patient’s symptoms, manage their medicines, and keep in touch with the medical team.
However, if you are found to have moderate to severe alcohol withdrawal syndrome from the start, you will need to be treated in a hospital. Frequent checks to monitor your condition will be carried out to avoid the development of serious issues like delirium and seizures. Each check-up includes a CIWA-Ar assessment and vital sign check. However, it’s important to note that the CIWA-Ar can only be used if you are awake and alert. If you can’t take the CIWA-Ar assessment, a different scale called the MINDS score is used instead.
Treatment Options for Alcohol Withdrawal Syndrome (Alcohol Withdrawal)
People with mild symptoms of alcohol withdrawal can usually be treated in an outpatient setting. This treatment can involve the gradual reduction of medication such as benzodiazepines or gabapentin, given with the assistance of a supportive individual. Sometimes, additional doses might be needed if symptoms persist. If symptoms become worse, patients should go to the emergency room for further examination and treatment.
In a hospital setting, the treatment typically involves benzodiazepines and/or phenobarbital. Benzodiazepines can be given in fixed-doses with additional doses for severe symptoms. Unless there is a considerable concern regarding liver problems, diazepam is usually the first choice due to its fast-acting and longer-lasting effects. If diazepam isn’t an option, another drug known as lorazepam can be used. In more severe cases of alcohol withdrawal, a large initial dose of benzodiazepine or phenobarbital might be necessary.
People dealing with alcohol withdrawal often lack necessary nutrients, so they should also receive supplements like thiamine and folate. To treat a condition known as Wernicke’s syndrome and to prevent further brain complications, high-dose thiamine can be given intravenously or by injection. Since thiamine consumed orally isn’t absorbed well, injections are preferred. Levels of electrolytes, such as magnesium and phosphorus, should also be checked and increased if necessary, as low phosphorus levels could lead to a dangerous condition called refeeding syndrome.
It’s also common to find signs of metabolic acidosis (a chemical imbalance) in patients with alcohol withdrawal. In such cases, treatment should include fluids containing glucose, such as a saline solution with 5% dextrose.
Lastly, it is very important to diagnose and treat any existing alcohol use disorder (AUD). This often involves starting medication and ensuring proper follow-up care after leaving the hospital. The FDA has approved three medications for AUD: naltrexone, acamprosate, and disulfiram. These medications can often be safely started before the patient leaves the hospital and they have been shown to reduce the chance of needing to be readmitted within 30 days.
What else can Alcohol Withdrawal Syndrome (Alcohol Withdrawal) be?
When doctors are trying to diagnose alcohol withdrawal syndrome, they also need to think about whether the patient might be withdrawing from other drugs, like sedative or calming medications called benzodiazepines or barbiturates. If the patient is also having seizures or experiencing delirium, the doctor should think about other medical or neurological causes besides alcohol withdrawal.
When they’re running tests and trying to make a diagnosis, doctors should also keep in mind that there are quite a few medical conditions that can look a lot like alcohol withdrawal syndrome. These include:
- Thyrotoxicosis (a high level of thyroid hormones in the body)
- Low blood sugar (hypoglycemia)
- Diabetic ketoacidosis (a serious diabetes complication)
- Use of drugs that stimulate the central nervous system
- Status epilepticus (a dangerous type of seizure)
- CNS infection (an infection in the brain or spinal cord)
- Withdrawal from sedative drugs
- Essential tremors (a nervous system disorder that causes shaking)
- Hepatic encephalopathy (a decline in brain function due to severe liver disease)
- Brain bleeding (intracranial hemorrhage)
- Stroke (cerebrovascular accident)
- Psychosis (a severe mental disorder where thought and emotions are so impaired that contact is lost with external reality).
What to expect with Alcohol Withdrawal Syndrome (Alcohol Withdrawal)
The outcome of alcohol withdrawal syndrome, or the symptoms that occur when an individual abruptly stops drinking alcohol, can depend on how severe the syndrome is when it first presents itself and how quickly treatment is started. Using benzodiazepines, a type of medication, can help reduce the risk of the syndrome worsening. However, for patients who have a seizure because of alcohol withdrawal, there’s a risk of having more seizures in the future and of developing alcohol withdrawal delirium, a serious and rapid onset of confusion.
Historically, the possibility of dying from alcohol withdrawal delirium was as high as 20%, but with improvements in specialized medical care, as well as quick diagnosis and treatment, that rate has now decreased to about 1%.
Possible Complications When Diagnosed with Alcohol Withdrawal Syndrome (Alcohol Withdrawal)
Stopping or drastically reducing alcohol can cause multiple complications, such as:
- Wernicke encephalopathy: This is a severe brain disorder caused by a lack of thiamine (Vitamin B1), which can be fatal. It can cause changes in eye movements, mental confusion, and difficulties with coordination.
- Withdrawal seizure: People can experience seizures 8 to 48 hours after stopping drinking alcohol. After a seizure, the person should get medicine to calm their brain and be closely watched for about 24 hours. These seizures can happen even without other withdrawal symptoms present.
- Alcohol hallucinosis: This is a type of disorder where the person hears things that aren’t there and may become extremely suspicious or fearful. This usually clears up within 72 hours of stopping alcohol.
- Alcohol withdrawal delirium: Also known as delirium tremens, this can happen up to 3 to 5 days after a person stops drinking alcohol and can require hospital treatment. It is especially likely to happen if the person has been getting high doses of calming medications like benzodiazepines or phenobarbital.
Preventing Alcohol Withdrawal Syndrome (Alcohol Withdrawal)
Alcohol withdrawal syndrome varies in intensity from being mild to potentially life-threatening, signaling how crucial it is for people to seek professional medical help for an evaluation of their symptoms. If someone has had challenging withdrawals before, they should never try to cut back on their alcohol usage without discussing it first with their healthcare team. If they start to show signs of severe withdrawal, such as seizures, confusion, or restlessness, they should find emergency help right away. After overcoming alcohol withdrawal syndrome, it’s wise to get checked for Alcohol Use Disorder (AUD) and, if needed, receive suitable treatment. This treatment can include medication and behavior therapy.
