Withdrawal Stages

Although alcohol is a licit drug, socially acceptable and widely used, it is more physically destructive when abused than nearly any other popular drug. Not only is it physically destructive when abused, but withdrawing from its use can be life-threatening.

Physical dependence upon alcohol occurs gradually and progresses in severity over a period of time. The severity of the withdrawal symptoms depends largely on how much the individual has been consistently drinking, for how long a time, and his general condition. One study showed that 68% of the alcoholics who had abused alcohol for three to five years had mild withdrawal symptoms to include tremors and autonomic hyperactivity. Alcoholics who had abused alcohol for six or more years had more severe withdrawal symptoms, including seizures, while 80% of those who suffered severe withdrawal symptoms to include delirium tremens (DT's) were individuals who had abused alcohol 10 years or more.

Acute withdrawal--Acute withdrawal from alcohol is usually complete in five to seven days if there are no complications. If complications occur, the individual will need medical supervision for a longer period of time. It should be remembered that withdrawal from alcohol can be unpredictable and symptoms can overlap.

• Stage 1-A

Withdrawal symptoms usually begin six to 12 hours after the last drink and include coarse intention tremors, flushing, tachycardia of 90 to 100, mild agitation, diaphoresis limited to the axilla, anorexia, restlessness, insomnia, increased respiratory rate of about 20 to 22, hyperreflexia (increased intensity of deep tendon reflexes), hypertension with increased of 10 to 20mmHg. Mild sedation or a small amount of alcohol will usually alleviate these symptoms. Of the alcoholics who experience only these symptoms, 75-80% will have a cessation of symptoms within 24 hours with or without treatment.

• Stage 1-B

Symptoms become progressively more severe. The outstanding sign of this stage is the appearance of grand mal seizures which tend to occur in clusters and only rarely progress to status epilepticus. They may occur as early as six hours after withdrawal begins, or as late as 72 hours after withdrawal begins.

The following withdrawal symptoms begin 24 hours after the last drink and last another 48 hours. Tachycardia of 110 to 120, the systolic blood pressure increases 20 to 30mmHg, and the diastolic increases 10 to 15mmHg, the respiratory rate increases to about 25 to 28, diaphoresis increases and includes the axilla, forehead, and palms, intention tremors are more severe and also can be observed at rest, hyperreflexia increases, agitation increases. The patient may also complain of tinnitus, anorexia, nausea and vomiting. These symptoms, with treatment, may resolve and the withdrawal process is completed.

• Stage 2

This stage is also called delirium tremens (DT's). DT's may appear 2 to 4 days after the last drink. Symptoms worsen as follows: The heart rate increases to greater than 120, systolic blood pressure increases about 40mmHg, and diastolic increases about 30mmHg, respiratory rate increases to 28, hyperreflexia increases with clonus, severe perfuse diaphoresis, total body tremors, metabolic imbalances, frightening hallucinations and an inability to distinguish them from reality, and total disorientation.

During this time, all the experiences the person is exposed to as a result of the hallucinations are greatly exaggerated. He becomes completely disoriented and may hear and see large and threatening animals or hear threatening human voices. He cannot speak coherently, understand instructions, or appreciate any words of comfort. It is very difficult to help the patient return to reality.

It is unknown exactly what causes DT's to occur, but it has been suggested that the higher centers of the brain are overstimulated by alcohol, or that the centers in the brain that act as a governor over the activity become exhausted and can no longer function.

Seizure activity is absent during delirium tremens. Without treatment, the delirium will gradually worsen and then disappear in a week to ten days. Fluid loss and metabolic imbalances can result in cardiovascular failure and death.

Protracted Withdrawal--Some alcoholics will experience withdrawal symptoms that may last up to a year after cessation of drinking. They include autonomic nervous system irregularities, such as labile blood pressure and pulse, irregular breathing, tolerance to sedatives, a fine tremor of the hands, persistent anxiety and depression, insomnia, fatigue, inability to concentrate, and memory impairment; hallucinations (alcoholic hallucinosis) may develop during an episode of heavy drinking, begin during withdrawal, or have an onset several weeks after the last drink and continue for weeks to months after withdrawal.

Neonatal Withdrawal--For mild withdrawal, supportive care is preferred, and includes swaddling to decrease sensory stimulation, frequent small feedings of hypercaloric formula, caloric intake to provide 150 to 250 calories per kilogram every 24 hours. The high caloric diet is needed to replace calories lost through vomiting, diarrhea, drooling, and increased motor activity.

Monitor sleeping patterns, temperature, weight, electrolytes, symptoms of illness, and administer IV fluids and electrolytes if needed.

Sleeplessness, dehydration, fever, seizures, serious weight loss, indicate severe withdrawal and medications should be administered with doses adjusted to weight. Paregoric may be administered at feeding times with initial dose 0.2ml P.O. q3 to q4 hours, and increased by 0.05ml per dose until the symptoms are controlled or the dose is up to 0.75ml or seizures occur, in which case add phenobarbital at 5mg/kg/day in three divided doses. This regimen should be maintained for five to seven days and then decreased by 0.05ml per day.

A protracted withdrawal may last for six months with symptoms of irritability, tremors, and poor sleeping patterns, but medication should not be continued.

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