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Alcohol Withdrawal Syndrome (AWS)

Alcohol withdrawal syndrome (AWS) is the medical term for the symptoms that occur when a heavy drinker stops drinking.

Withdrawal symptoms develop when alcohol intake is suddenly stopped or reduced. Symptoms are both physical and emotional and can be severe.

This phase of recovery is one of the most difficult, with a high chance of relapse and other health concerns. People with alcohol use disorder (AUD) are at high risk for AWS. In some cases, it can be life-threatening.

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What Causes Alcohol Withdrawal Syndrome (AWS)?

When you drink alcohol, it depresses your central nervous system (CNS).

The CNS consists of your brain and spinal cord. It regulates your body temperature, physical coordination and reflexes, and cognition.

When you drink heavily, your CNS becomes physically dependent on alcohol.

This is why withdrawal symptoms can include things like sweating, shaking, and confusion. Your CNS expects alcohol and has trouble functioning without it.

Another symptom of AWS is agitation. Your body works hard to keep your brain in a more awake state and your nerves talking to one another. When the alcohol level drops suddenly, your brain stays in this keyed-up state.

Symptoms of Alcohol Withdrawal Syndrome (AWS)

Heavy drinkers who suddenly stop or reduce alcohol intake are likely to experience mild symptoms of AWS within 6 hours of their last drink. Symptoms can continue for up to 7 days.

Symptoms can be severe in the first few hours of withdrawal. They gradually become milder in the days and weeks that follow.

Symptoms might include any combination of the following:

  • Tremors
  • Anxiety
  • Nausea and vomiting
  • Headache
  • Elevated heart rate and/or blood pressure
  • Sweating
  • Irritability and confusion
  • Insomnia and nightmares
  • Hallucinations that can be tactile, auditory, or visual

Delirium tremens (DT) might be a symptom in severe cases. DTs usually start 48 to 72 hours after a person’s last drink.

Symptoms include:

  • Extreme confusion or agitation
  • Fever
  • Seizures
  • Hallucinations, including tactile, auditory, or visual
  • Racing heart
  • High blood pressure
  • Heavy sweating

If you or a loved one experiences any of these symptoms, it's necessary to seek medical attention immediately.

Alcohol Withdrawal Timeline

Symptoms of alcohol withdrawal tend to peak about 24 to 72 hours after a person’s last drink. Typically, symptoms fade and are gone within a week.

Alcohol withdrawal occurs in three phases:

Alcohol Withdrawal Timeline

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What are Alcohol Withdrawal Seizures? 

Abruptly reducing or stopping alcohol intake after extended heavy drinking might trigger alcohol seizures.

Generalized tonic-clonic (formerly known as Grand Mal) seizures are the most dangerous component of alcohol withdrawal syndrome.

Tonic-clonic seizures include both tonic and clonic activity:

  • Tonic activity includes loss of consciousness, strong muscle spasms, the potential for impaired breathing, gasping and gurgling sounds, and saliva or foam from the mouth.
  • Clonic activity includes intense and rapid jerking movements of the face, arms, and legs that eventually relax as seizure activity concludes.

People often remain unconscious for several minutes following the seizure as the brain recovers.

Neuronal networks in the brainstem trigger tonic-clonic withdrawal seizures. Long-term heavy drinkers experience more intense withdrawal symptoms, and over time, multiple detoxification episodes increase their risk for seizures.

Researchers theorize that alcohol withdrawal permanently alters the brain in a way that heightens seizure risk.

Treatment for Alcohol Withdrawal 

Those who suffer from alcohol dependence should seek medical attention. The first step is a physical exam by a health professional.

The professional may also perform a series of imaging tests. By showing alcohol-related organ damage, these tests provide evidence of alcohol use disorder.

The tests are also used to get an accurate diagnosis for AWS and allow a rehab center to develop a comprehensive treatment plan.

After this, addiction treatment can be pursued. 

Treatment begins with detoxification (or ‘detox’ for short). Severe symptoms should be treated at an inpatient clinic, where the person's symptoms can be monitored and treated.

Drugs can be provided that will reduce symptoms. These include:

  • Naltrexone
  • Disulfiram
  • Topiramate
  • Baclofen

Benzodiazepines can also be used to treat severe AWS symptoms. These include:

  • Ativan
  • Klonopin
  • Xanax
  • Valium

Symptoms that are more mild be able to be treated at home.

If other drugs besides alcohol are being abused are involved that will complicate treatment. Drugs and alcohol interact with each other in ways that make the effects stronger and reinforce dependence.

This is known as polysubstance abuse disorder and it requires around the clock monitoring at an inpatient clinic.

Oftentimes, addiction is accompanied by mental illness. In this case dual diagnosis treatment may be necessary. After treatment the person can proceed to counseling and therapy.

Alcohol withdrawal syndrome and the associated symptoms are avoidable if you don't drink. If you’ve already developed a dependence on alcohol, seek ongoing counseling and medical care to manage your addiction and avoid relapse. Avoiding alcohol, either immediately or through a gradual reduction in consumption, is the only way to avoid alcohol withdrawal symptoms.

Treatment Options for Alcohol Abuse & Addiction

Here are some of the best treatments for AUD:

Inpatient Programs

Inpatient treatment is the most intensive and effective option for alcohol addiction treatment.

These programs usually last 30, 60, or 90 days. They may be longer in some instances.

Throughout an inpatient program, you'll live on-site in a safe, substance-free environment.

You'll go through medically supervised detoxification first, then behavioral therapy. Other services may be added to your regimen.

Many of these treatment programs will assist you with an aftercare program afterward.

Partial Hospitalization Programs (PHPs)

PHPs are the second most intensive alcohol addiction programs. They are sometimes referred to as intensive outpatient programs (IOPs). Partial hospitalization programs provide comparable services to inpatient programs.

These may include:

  • Detoxification
  • Medical services
  • Behavioral therapy
  • Support groups
  • Other holistic or custom treatments

The main difference between PHPs and inpatient programs is that you return home and sleep at your house during a partial hospitalization program.

Some PHPs provide food and transportation. This varies by program.

PHPs are ideal for new patients and those who have completed an inpatient program and still require intensive treatment.

Outpatient Programs

Outpatient programs are less intensive than inpatient programs and PHPs. They are best for people who are highly motivated to achieve sobriety. They usually have responsibilities at work, home, or school.

These programs customize your treatment sessions around your schedule.

Outpatient programs can help people achieve success. They may also be a part of aftercare programs once a patient completes an inpatient program or PHP.

Medication-Assisted Therapy (MAT)

Certain people qualify for medication-assisted therapy. Some medications can assist you throughout detoxification and withdrawal. Others can reduce cravings and normalize your bodily functions.

The most common medications used to treat AUD are:

  • Disulfiram (Antabuse)
  • Acamprosate (Campral)
  • Naltrexone (Revia and Vivitrol)

MAT can help prevent relapse and increase your chance of recovery if combined with other therapies.

Support Groups

Support groups are peer-led organizations made of people dedicated to helping each other stay sober. They can be the first step towards sobriety or a component of an aftercare plan.

Many of these programs follow the 12-step approach.

Resources

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  1. Rogawski, Michael A. “Update on the Neurobiology of Alcohol Withdrawal Seizures.” Epilepsy Currents, vol. 5, no. 6, Nov. 2005, pp. 225–230.
  2. Tonic-Clonic (Grand Mal) Seizures.” Johns Hopkins Medicine, 2020.
  3. Centers for Disease Control and Prevention. “Alcohol Use and Your Health.www.cdc.gov, 2021.
  4. Mason, Barbara J and Heyser, Charles J. “Alcohol Use Disorder: The Role of Medication in Recovery.Alcohol Research: Current Reviews, vol. 41, no. 1, 2021. arcr.niaaa.nih.gov.
  5. National Institute on Alcohol Abuse and Alcoholism. “Alcoholism and Psychiatric Disorders.pubs.niaaa.nih.gov.
  6. Quello, Susan B., et al. “Mood Disorders and Substance Use Disorder: A Complex Comorbidity.Science & practice perspectives, vol. 3, no. 1, 2005, pp. 13-21. www.ncbi.nlm.nih.gov.

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