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When a person comes to a doctor’s office, two things will point toward a diagnosis of alcohol withdrawal: the first is long-term alcohol use with sudden cessation, and the second being symptoms typical of withdrawal (these will be explained in the following paragraphs).

What doctors look for when determining severity of alcohol withdrawal (CIWA-Ar)

For the symptoms, physicians use a largely accepted algorithm known as the CIWA-Ar (Clinical Institute Withdrawal Assessment) protocol. This survey takes a snapshot of a patient to determine how severe their withdrawal is at a point in time during their visit.

The categories assessed by the patient include nausea and vomiting, tremor (often in the hands), auditory, tactile or visual hallucinations, sweats, anxiety, headache, agitation, and disorientation. Additionally, the doctor will measure heart rate, blood pressure, and do a physical exam. Each category is measured out of 7 points, with 7 being the worst (the exception to this is disorientation, which is measured out of 4 points). The maximum score in the assessment is a 67, with patients under 10 usually being safe without medication, and with any number over 20 being considered severe withdrawal. However, this scale is meant to determine the severity of withdrawal, and is not as helpful in laying out a timeline of when these symptoms will present. For that, it is more helpful to understand the body’s reaction to the cessation of alcohol use.

Alcohol Withdrawal Timeline

The body is always metabolizing toxic substances in the blood to excrete them as waste, and alcohol is included as one of these. The liver gets to work straight away at metabolizing alcohol when it enters the bloodstream, at a rate of about one standard drink per hour. Alcohol has an elimination rate known as “zero-order”, meaning that regardless of the amount consumed, it takes about one hour per drink to be metabolized out of the body.

Here is a timeline of what you can expect during alcohol withdrawal:

After 6 Hours of Alcohol Withdrawal

When a long-term history of alcohol use is suddenly stopped, it takes about 6 hours for the body to become aware of this fact and start to materialize symptoms and signs of withdrawal. Behaviorally, this can manifest as increased anxiety, sleeplessness, restlessness, and stomach pains. An individual experiencing these symptoms will likely look similar to someone who is agitated or “worked up”. Occasionally, there can be claims of hallucinations, or visions that are not real.

From a clinical standpoint, a doctor will measure blood pressure, heart rate, body temperature, and perform a physical exam to determine the cause of this state. Often, the doctor will find things such as elevated blood pressure, a heart rate over 100 beats per minute, sweating, a tremor of the upper extremities (especially the hand), dilated pupils, and hyper arousal to the environment. Patients can also claim upset stomach as a symptom. The most severe early symptom is seizures, of which the patient is at greatest risk during the first 6-12 hours.

After 24 Hours of Alcohol Withdrawal

At hour 24, signs of brain hyperactivity can become apparent. This includes hallucinations and illusions (hallucination is the perception of something which does not exist, whereas an illusion is a distortion or misrepresentation of a real object), which peak between days 1 and 3 and can continue into day 7. At this point, it is more rare to see elevated heart rates or blood pressures, as the majority of symptoms are psychological. Any sort of fever or blood pressure changes at this stage would prompt a physician to investigate other underlying conditions, such as a hidden infection or metabolic imbalance.

Between 48-72 Hours of Alcohol Withdrawal

48-72 hours after last drink is when the most severe complications, and the reasons that would warrant hospitalization (aside from seizures, which should also be considered as a reason for hospitalization), can occur. This aggregate of symptoms is known as delirium tremens (known also as DTs clinically). This syndrome is diagnosed by a doctor, and is typically viewed to be an exacerbation of withdrawal symptoms into increasing severity (CIWA-Ar score is typically over 20).

During this time, if a patient undergoes DTs, hallucinations will often get worse, and it is not uncommon for symptoms such as increased heart rate, sweating, dilated pupils, and increased blood pressure to return. Additionally, patients will also have a reversed sleep-wake cycle, and will have altered sensation of their environment, often characterized as “crawling skin”. This syndrome can last for up to 2 weeks, and is thought to happen more if patients have an underlying condition. Some of these would be liver disease, electrolyte imbalances, older age, or dehydration.

If this syndrome occurs or is at a high risk of occurring, the patient should be admitted to the hospital to have IV administration of withdrawal drugs (the most commonly used drugs are of the benzodiazepine class, of which alprazolam, or Xanax, is a member). Patients will also be given vitamins (vitamin B1 and magnesium) and be checked for electrolyte disturbances, dehydration, and any other underlying causes that may be making the process worse and could be corrected. If the symptoms continue to get worse after medication, anti-psychotics can be used second, with a last resort of putting a patient in an Intensive Care Unit and inducing a medical coma until symptoms resolve.

After 72 Hours of Alcohol Withdrawal

If a patient undergoes delirium tremens syndrome, their symptoms can persist for up to 2 weeks. For the rest of the individuals, in most cases there will be a gradual decline of symptoms until about day 7 after last drink. After this, it becomes very rare that any new symptoms will become apparent or worsen, and most symptoms will have resolved.

For those undergoing mild withdrawal this happens even sooner, around day 5. This is considered the endpoint for detoxification of alcohol in most clinical scenarios. After this, patients can be sent home or provided with follow-up supportive care and nutritional information, and improvements should be gradual and long-lasting on follow-up appointments from a physical standpoint.

If you or a loved one are suffering with alcohol withdrawal symptoms, Compass Detox, a Florida-based alcohol detox facility can help. Contact us today!

Sources:

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4085800/
  2. https://umem.org/files/uploads/1104212257_CIWA-Ar.pdf
Jesse Kelso
Jesse Kelso
Jesse is a third-year medical student at the University of Toledo. He is interested in pursuing Family Medicine after his final year of schooling. Jesse has peripheral interests in addiction treatment and the psychology of addiction, as well as human performance. Jesse is originally from Buffalo, NY, where he has a younger brother who is also in medical school at the University at Buffalo, and an older sister who practices law in Pittsburgh, Pennsylvania.