Alcohol Withdrawal

Clinical picture

• Autonomic hyperactivity begins 6 to 24 hours after the last drink: tremor, diaphoresis, tachycardia, hypertension, nausea, anxiety, and insomnia.
• Withdrawal seizures are generalized tonic-clonic, usually single or in a brief cluster, and peak between 12 and 48 hours after cessation.
• Alcoholic hallucinosis appears at 12 to 24 hours with vivid visual or tactile hallucinations, a clear sensorium, and preserved orientation.
• Delirium tremens emerges at 48 to 96 hours with clouded consciousness, disorientation, severe agitation, fever, and full autonomic storm.
• Severity worsens with each prior detoxification through kindling, so a history of past withdrawals predicts course better than reported intake.
• Occult trauma, infection, pancreatitis, GI bleeding, and hepatic encephalopathy frequently coexist and can mimic or amplify withdrawal.

Criteria snapshot

• Requires cessation or reduction of heavy, prolonged alcohol use followed by at least 2 of 8 characteristic signs within hours to a few days.
• The eight signs are autonomic hyperactivity, hand tremor, insomnia, nausea or vomiting, transient hallucinations or illusions, psychomotor agitation, anxiety, and seizures.
• Symptoms must cause significant distress or impairment and must not be attributable to another medical condition or to another substance.
• The specifier with perceptual disturbances applies when hallucinations or illusions occur with intact reality testing and a clear sensorium.
• Delirium tremens is coded separately as alcohol withdrawal delirium, which additionally requires disturbed attention and awareness.

Neurobiology

• Chronic alcohol downregulates GABA-A receptors and upregulates NMDA receptors; abrupt cessation leaves unopposed glutamatergic excitation.
• Sympathetic outflow surges as alpha-2 autoreceptor inhibition is lost, producing tachycardia, hypertension, tremor, and diaphoresis.
• Kindling from repeated withdrawal episodes progressively lowers seizure threshold through limbic sensitization, so each detox is more dangerous.
• Hypomagnesemia, hypokalemia, hypophosphatemia, and hypoglycemia are near-universal and independently lower the seizure threshold further.
• Thiamine stores deplete within 2 to 3 weeks of poor intake, and a glucose load given without thiamine can precipitate Wernicke encephalopathy.
• The Wernicke triad of confusion, ophthalmoplegia, and ataxia is complete in fewer than 20% of cases, so treat empirically on suspicion alone.

Psychology

• Fear of withdrawal itself is a major driver of continued drinking and of premature self-discharge from medical detoxification.
• Anxiety, insomnia, and dysphoria persist for weeks as protracted withdrawal and strongly predict early relapse if left unaddressed.
• Conditioned withdrawal responses can be triggered by drinking cues alone, producing craving that convincingly mimics physiologic symptoms.
• Detoxification is not treatment; without immediate linkage to ongoing care, relapse after medical withdrawal alone exceeds 70%.
• Shame and prior negative experiences in emergency settings reduce honest disclosure of intake, so corroborate the history when possible.

Differential & comorbidity

• Score severity with the 10-item CIWA-Ar (maximum 67): under 8 is mild, 8 to 15 moderate, and above 15 severe with high complication risk.
• Exclude sepsis, meningitis, subdural hematoma, thyrotoxicosis, hepatic encephalopathy, anticholinergic toxicity, and sedative-hypnotic withdrawal.
• CIWA-Ar is invalid in intubated, delirious, or non-communicating patients; use RASS with objective vital signs in those settings instead.
• Predict risk prospectively with the PAWSS: a score of 4 or more identifies patients who need prophylactic medication for complicated withdrawal.
• Delirium tremens risk factors: prior DTs or withdrawal seizure, CIWA-Ar above 15, systolic BP above 150, concurrent infection, and heavy daily intake.

Pharmacologic treatment

• Benzodiazepines are the only class proven to reduce withdrawal seizures and delirium; every other agent is adjunctive, never a substitute.
• Symptom-triggered dosing when CIWA-Ar exceeds 8 to 10 lowers total benzodiazepine exposure and shortens treatment versus fixed schedules.
• Fixed-schedule chlordiazepoxide 50-100 mg every 6 hours tapered over 3 to 5 days suits unmonitored settings and prior complicated withdrawal.
• Front-loading diazepam 10-20 mg every 1 to 2 hours to light sedation exploits active metabolites to produce a self-tapering course.
• Give thiamine 100-500 mg IV before any dextrose, and use lorazepam 1-4 mg in cirrhosis, advanced age, or respiratory compromise.

Psychotherapy

• Withdrawal management alone does not treat alcohol use disorder; begin motivational interviewing during the medicated phase itself.
• CBT with relapse prevention started on the inpatient unit and continued in outpatient care improves 12-month abstinence rates.
• Brief interventions of 1 to 4 sessions during the hospital stay increase treatment entry and reduce subsequent drinking quantity.
• A warm handoff to a scheduled outpatient appointment within 72 hours of discharge outperforms a referral slip by a very wide margin.
• Twelve-step facilitation begun during the admission raises mutual-help attendance after discharge and supports early abstinence.

Adjunct options

• Phenobarbital 10-15 mg/kg loading is used for benzodiazepine-refractory withdrawal and increasingly as monotherapy in emergency settings.
• Refractory delirium tremens needs ICU care with dexmedetomidine or propofol infusion alongside continued benzodiazepines and airway control.
• Beta blockers and clonidine blunt autonomic signs but mask CIWA-Ar scores and do not prevent seizures or delirium on their own.
• Admit for prior DTs or withdrawal seizure, PAWSS of 4 or more, unstable medical or psychiatric comorbidity, pregnancy, or no sober support.
• Correct magnesium, potassium, phosphate, and folate; check glucose, LFTs, lipase, CBC, and head CT when trauma or focal signs are present.

Clinical pearls

• Thiamine before glucose, always: dextrose first can precipitate Wernicke encephalopathy.
• Kindling means each prior detox raises seizure and DT risk; count past withdrawals.
• Untreated delirium tremens kills 15-20%; treated, under 5%. It is an emergency.