Acute alcohol withdrawal symptoms

Symptoms may vary depending on the individual. There may be mild or severe symptoms, and some may need close inpatient, or medical supervision.

Serious withdrawal symptoms include:

• Delirium tremens
• The Wernicke-Korsakoff syndrome
• Seizures
• Depression
• Electrolyte disturbances
• Complications due to associated liver disease

Withdrawal symptoms:

• Symptoms typically present about 8 hours after a significant fall in blood alcohol levels. They peak on day 2 and, by day 4 or 5, the symptoms have usually improved significantly.
• Minor withdrawal symptoms (can appear 6-12 hours after alcohol stopped):
• Insomnia and fatigue
• Tremor
• Mild anxiety/feeling nervous
• Mild restlessness/agitation
• Nausea and vomiting
• Headache
• Excessive sweating
• Palpitations
• Anorexia
• Depression
• Craving for alcohol

Other complications during withdrawal:

• Alcoholic hallucinations (can appear 12 to 24 hours after alcohol stopped);  Includes visual, auditory, or tactile hallucinations
• Withdrawal seizures (can appear 24 to 48 hours after alcohol stopped); These are generalized tonic-clonic seizures
• Alcohol withdrawal delirium or ‘delirium tremens’ (can appear 48 to 72 hours after alcohol stopped).

To properly assess the severity of the problem, and  properly manage withdrawal symptoms, it is important to take into consideration a person’s history of drinking:

• Quantity of alcoholic intake and duration of alcohol use
• Time since last drink
• Whether previous alcohol withdrawals have been attempted
• Medical history including psychiatric history.
• Drug history (including prescribed drugs and drugs of abuse and any drug allergies).
• Support network

Most people with alcohol dependence can undergo withdrawal safely at home. It is always best to see a physician who can complete a risk assessment, and offer advice, suggest medication, and educate about possible withdrawal symptoms.

Features indicating a high risk of complicated withdrawal include:

• Severe dependence;
• Previous delirium tremens;
• Previous alcohol withdrawal seizures;
• Previous failed detoxification(s) in the community;
• Poor support at home;
• Cognitive impairment

Severe withdrawal requires medical attention. The aim of medically assisted withdrawal is to prevent complications including seizures and delirium tremens, as well as making withdrawal more comfortable for the person, and providing an environment offering interventions that can help maintain abstinence. Inpatient detoxification allows for further assessment and takes into consideration the following:

• Acute or chronic physical illness (e.g. infection and diseases of the liver, cardiovascular system, or respiratory system)
• Acute or chronic mental health problems (e.g. suicidal ideation, depression, anxiety, psychosis, or acute distress)
• Malnutrition
• Self-neglect
• Older age
• Poly-substance use: benzodiazepines or active misuse of other drugs

What can help with the withdrawal symptoms?

• Understanding the symptoms
• Knowing  how to cope with symptoms
• Understand the risk situations that require urgent medical attention, including: delirium, confusion, seizures, falls, severe    nausea or vomiting, and high levels of distress
• Having a friend/relative to act as support, round-the-clock if possible.
• Having activities planned: going to a meeting, a support group, counseling, walk, swimming
• Having time off work; having childcare if needed
• Having an emergency contact phone number
• Taking appropriate medication as prescribed by a physician; Benzodiazepines are the recommended medication for alcohol withdrawal

Thiamine:

Thiamine deficiency is common in people who are alcohol-dependent due to their poor diet, the presence of gastritis which can affect its absorption and also the fact that it is a coenzyme in alcohol metabolism. This deficiency can cause Wernicke’s encephalopathy, which if left untreated can lead to Korsakoff’s syndrome. Oral thiamine is poorly absorbed in dependent drinkers. For this reason, all those undergoing detoxification in the community are best treated with parenteral high potency B complex vitamins. However, because of the risk of anaphylaxis, resuscitation facilities need to be available at the time of administration. The risk of anaphylaxis is lower if the drug is given intramuscularly.

Delirium tremens:

Delirium tremens is a medical emergency. A hyper adrenergic state is present. Clinical features: Delirium tremens usually begins 24-72 hours after alcohol consumption has been reduced or stopped. The symptoms/signs differ from usual withdrawal symptoms in that there are signs of altered mental status. These can include:

• Hallucinations (auditory, visual, or olfactory)
• Confusion
• Delusions
• Severe agitation
• Seizures can also occur.

Examination may reveal signs of chronic alcohol abuse/stigmata of chronic liver disease. There may also be:

• Tachycardia
• Hyperthermia and excessive sweating
• Hypertension
• Tachypnea
• Tremor
• Mydriasis
• Ataxia
• Altered mental status
• Cardiovascular collapse

Risk factors:

• Previous history of delirium tremens
• Previous history of alcohol withdrawal seizures
• Coexisting infection or medical problems including pancreatitis or hepatitis
• Recent higher than normal levels of alcohol intake
• Older age
• Abnormal liver function
• More severe withdrawal symptoms on presentation

Blood tests can help to assess other medical problems. Dehydration and electrolyte disturbance may be present. Tests can include:

• Full blood count
• Liver function tests
• Clotting
• Arterial blood gases (to look for metabolic acidosis)
• Glucose
• Blood alcohol levels
• Urea, electrolytes and creatinine
• Amylase
• Creatine phosphokinase (especially if patient was unconscious for a long time due to risk of rhabdomyolysis)
• Blood cultures (if there are concerns about infection)
• Chest X-ray should be considered if there are signs of respiratory distress. Coexisting pneumonia is common. There is also the possibility of aspiration, especially if reduced consciousness or seizures have occurred.
• CT head may be needed if there are seizures or evidence of a recent head injury.
• ECG may show an arrhythmia.

Management

• This should be in a hospital setting. Intensive care may be needed for very unwell patients.
• It should first include assessment and management of Airway, Breathing and Circulation.
• Any hypoglycaemia should be treated.
• Sedation with benzodiazepines is suggested. Diazepam has a rapid onset of action.
• Addition of barbiturates may also be necessary in those refractory to benzodiazepine treatment and may reduce the need for mechanical ventilation in very unwell patients in the intensive care unit.
• People with delirium tremens may also have Wernicke’s encephalopathy and should be treated for both conditions
• Magnesium may also protect against seizures and arrhythmias.

Follow-up after detoxification and acute alcohol withdrawal

• Close follow-up is needed.
• Counseling, self-help and groups including Alcoholics Anonymous may be helpful.
• In those discharged from secondary care, involvement of the patient’s GP (with their permission) should be encouraged.
• Drugs can be used in abstinence to help prevention of relapse. These are discussed in the separate article Alcoholism and Alcohol Abuse – Management.
• Any co-existing medical and psychological problems should also be addressed.

Acute alcohol withdrawal symptoms could be life threatening and should not be ignored. It may be beneficial to discuss acute withdrawal symptoms with a physician prior to making changes in alcohol consumption.