The experience of alcohol detox will vary based on the severity of the dependence on alcohol and various individual factors.
Since some symptoms of alcohol withdrawal can be life-threatening, medical detox with continual supervision is recommended.
Physical Dependence on Alcohol
The diagnostic criteria for alcohol withdrawal as defined in the the Diagnostic and Statistical Manual of Mental Disorders (DSM–5), and stated here, indicate that withdrawal signs typically occur after one stops drinking alcohol when their alcohol use has been heavy and/or chronic. Withdrawal symptoms can occur within several hours to a few days after the person stops drinking or cuts down significantly on their alcohol use.
More severe withdrawal symptoms are associated with higher levels of alcohol use. People who are diagnosed with moderate to severe alcohol use disorders are more likely to have more severe and complicated withdrawal symptoms.
The difference between a mild alcohol use disorder compared to a moderate or severe alcohol use disorder depends on the number of diagnostic criteria the person meets. People satisfying more of the diagnostic symptoms listed by APA have more severe manifestations of alcohol use disorders.
Why Detox Is Important
The symptoms of alcohol withdrawal can be mild to severe, and they can be dangerous even in individuals with mild alcohol use disorders. The potential for individuals to develop seizures associated with withdrawal from alcohol is significant enough that anyone diagnosed with alcohol use disorder should only stop drinking while under the care of a physician.
Those who have chronic alcohol use disorders and experience a drop in their blood alcohol level as a result of abstinence may develop delirium tremens, a severe syndrome that consists of confusion, disorientation, psychosis, periods of hyperactivity or hypoactivity, and potential seizures. Delirium tremens occurs most often in those who chronically abuse alcohol.
Seizures without associated delirium tremens could potentially occur in anyone diagnosed with an alcohol use disorder who suddenly stops drinking, but they are more likely to occur in individuals diagnosed with moderate to severe alcohol use disorders.
Emotional distress and confusion without delirium tremens or seizures can also occur during alcohol withdrawal.
Seizures can produce significant brain damage and be potentially fatal. People experiencing psychosis, emotional distress, or confusion are potential dangers to themselves as a result of accidents or poor decisions.
What to Expect Based On Severity
Individuals diagnosed with mild alcohol use disorders can typically expect:
- Mild withdrawal symptoms that begin within three to 24 hours after they stop using alcohol.
- A short duration of withdrawal that ranges from 28 to 48 hours. Symptoms reach their peak within 12 to 24 hours after they begin.
- Symptoms that do not involve significant confusion, seizures, or psychosis, though this is not always the case.
- Mild to moderate discomfort that is not necessarily dangerous, although individuals who vomit repeatedly may suffer from dehydration.
Those with more moderate to severe alcohol withdrawal symptoms can usually expect:
- Very rapid onset of symptoms, even within a couple of hours after discontinuing alcohol.
- A duration of symptoms that lasts from one day to several weeks.
- An increased potential to experience complicated withdrawal symptoms that can include hallucinations, delusions, and/or seizures. These will most often occur within 12 to 18 hours of discontinuation, but they can happen at any time.
- Significant waxing and waning of their symptoms over several weeks. Symptoms may include the potential for hallucinations, delusions, confusion, and seizures.
The Necessity of Supervision
The American Society for Addiction Medicine (ASAM) outlines the protocols and procedures used in the treatment of substance use disorders, including the treatment of alcohol withdrawal. Individuals who meet the diagnostic criteria for mild alcohol use disorder would most likely be initially followed by a physician on an outpatient basis unless they begin to develop significant distress associated with their withdrawal symptoms. They can expect to receive some medications to deal with nausea, headache, sluggishness, and sleepiness. A physician needs to make the initial assessment regarding the best course of treatment.
Those who are at risk to develop complicated withdrawal symptoms from alcohol should receive more intense supervision. This includes people who have very chronic and moderate to severe alcohol use disorders, a history of complicated withdrawal, and a history of relapses.
The overall recommendation is to place someone in an inpatient medical detox program where they can be observed and treated around the clock. Depending on the severity of the withdrawal symptoms, this can last for several days to several weeks.
The protocols used to address alcohol withdrawal symptoms are extremely effective. Individuals can typically get through the withdrawal process with minimal discomfort.
Medical Detox Protocol
ASAM and other organizations recommend the use of benzodiazepines to assist with withdrawal associated with moderate to severe alcohol use disorders. The most common benzodiazepines used for this process are long-acting benzodiazepines, such as Valium (diazepam) or Librium (chlordiazepoxide). Benzodiazepines are very effective at controlling alcohol withdrawal symptoms, potential issues with seizures, and even psychosis during the withdrawal process.
Other benzodiazepines can be used in some instances, and have been proven effective in controlling seizures during alcohol withdrawal over numerous studies.
The general program consists of:
- Establishing an initial dose of the benzodiazepine that controls the withdrawal symptoms
- Making small reductions in the dosage over time, to wean the person off the drug and account for the diminishing intensity of withdrawal
- Eventually discontinuing use of the benzodiazepine
- Administering other medications if needed and using behavioral therapies
Use Of FDA-Approved Medications
Although benzodiazepines are often the drug of choice for alcohol withdrawal, physicians certainly use other medications. Anticonvulsant medications will control any potential seizures, and antipsychotics can manage any issues with psychosis.
In addition, there are three medications that are approved by the U.S. Food and Drug Administration (FDA) to treat alcohol abuse, and these may be used during the withdrawal process.
Antabuse (disulfiram) is used to keep individuals from drinking alcohol due to its ability to produce a nauseous state when individuals take the medication and then drink alcohol. This medication would likely not be used during the detox process, but it could be used for someone who has had numerous relapses.
Campral (acamprosate) is approved to reduce cravings in individuals with alcohol use disorders. It appears to be more effective in limiting the amount of alcohol a person uses as opposed to stopping a person from drinking. It may be part of a detox medication regime.
ReVia (naltrexone) is an opioid antagonist drug that has been shown to reduce cravings for alcohol in individuals recovering from alcohol use disorders, but it does not address alcohol withdrawal.
Off-Label Use
Although not formally approved by the FDA, several other medications are commonly used during the withdrawal process because they have some research evidence that supports their use.
Potentially Helpful Withdrawal Medications
- Catapres (clonidine) may be used to reduce cravings and potential seizures.
- Anticonvulsant drugs, such as Neurontin (gabapentin) and Topamax (topiramate), may be used. In addition to preventing seizures, some studies suggest they may control cravings and other withdrawal symptoms.
- The muscle relaxant Lioresal (baclofen) may address cravings for alcohol and control other withdrawal symptoms in some individuals.
The Difference Between Rehab and Detox
Although individuals who are in medically assisted detox can expect to receive some interventions like group participation or therapy, the detox process focuses on addressing withdrawal symptoms from alcohol safely and avoiding relapse during withdrawal.
Detox is not enough. If it is not followed by rehab, where an individual participates in more intensive therapy, acquires new skills, and learns relapse prevention, relapse is likely.
Rehab is designed to teach a person to live without drinking alcohol. Detox is designed to get the person through withdrawal. Going through detox without aftercare or rehab will not result in a successful recovery.
