- Alcohol Withdrawal
- Alcohol Withdrawal Symptoms
- Delirium Tremens
- Alcohol Withdrawal Treatment
- Delirium Tremens (DTs)
- Dealing with the DTs
- Dying from Alcohol Withdrawal: What is Delirium Tremens?
- Alcohol DT Treatment: Professional Detox
- Alcohol Detox at Home: Can You Wean Yourself Off?
- Delirium Tremens: A Dangerous (but Preventable) Condition
- You’re Wrong About Alcohol Withdrawal
- Alcohol has a depressive effect on your nervous system, slowing down brain function and the way your nerves send messages back and forth throughout the body.
- What Is It?
Alcohol withdrawal symptoms usually begin 6 to 48 hours after the last drink.
Alcohol withdrawal — symptoms that develop when a person suddenly stops drinking alcohol after prolonged, heavy drinking — is a common feature of alcohol dependence, or alcoholism.
Alcohol is a central nervous system depressant. In response to alcohol, the brain tries to maintain balance by using several mechanisms to increase the excitability of neurons.
But when alcohol use abruptly stops, the brain temporarily remains in this state of excessive excitability, resulting in alcohol withdrawal symptoms.
Alcohol Withdrawal Symptoms
Withdrawal symptoms vary widely among people and typically begin 6 to 48 hours after the cessation of drinking, according to the National Institute of Alcohol Abuse and Alcoholism (NIAAA).
Common initial symptoms may include:
- Agitation or irritability
- Sleep disturbances
- Nausea and vomiting
- Heightened sensitivity to light and sound
- Difficulty concentrating or thinking clearly
- Loss of appetite
- Rapid heart rate
In serious cases of alcohol withdrawal, some people experience vivid hallucinations.
About 25 percent of all withdrawal episodes also involve withdrawal-associated seizures, which may happen once or several times over a short period.
These symptoms typically intensify and then resolve within about four days, but some people suffer from alcohol withdrawal for weeks, according to the U.S. National Institutes of Health.
Delirium tremens (DT) is the most serious syndrome (group of related symptoms) of alcohol withdrawal.
DT generally occurs in people who have been drinking excessively for years, and begins two to four days after the last drink. It’s estimated to affect about 5 percent of people who go through alcohol withdrawal, according to the NIAAA.
Symptoms of DT include:
- Severe agitation
- Delirium, a condition characterized by confusion with a fluctuating level of consciousness and inattention
- Persistent hallucinations
- Spikes in heart rate (arrhythmia), breathing rate, pulse, and blood pressure
- Profuse sweating
These symptoms may persist for up to a week, according to UpToDate.
Up to 5 percent of people with DT die while experiencing it, usually due to arrhythmia, pneumonia, or other complicating illnesses — or because of other (undetected) health issues that preceded the cessation of alcohol use, such as pancreatitis, hepatitis, an infection, or injury to the central nervous system.
Alcohol Withdrawal Treatment
The goals of alcohol withdrawal treatment are to reduce symptoms, prevent complications, and help maintain abstinence from alcohol.
Treatment typically begins with a physical examination to detect any coexisting conditions, such as arrhythmia, alcoholic hepatitis, infectious diseases, or pancreatic diseases (including alcoholic pancreatitis), among other conditions.
Supportive care — either in a hospital or clinic, or in an outpatient setting with a caregiver watching over you — is standard in alcohol withdrawal treatment after other conditions have been ruled out or adequately treated.
If you have only mild or moderate symptoms from alcohol withdrawal, you may be able to detoxify successfully in an outpatient setting with supportive friends and family to help you.
But you may require in-patient detoxification if you’re pregnant, or if you have:
- Severe symptoms
- Previous seizures or DT
- Certain medical conditions or severe psychiatric disorders
- Multiple past detoxifications
- No reliable support network
During outpatient supportive care, your caregiver will make sure you have a comfortable environment (quiet and with low lighting), limited interactions with people, proper nutrition and fluids, and copious reassurance and positive encouragement.
Your caregiver may also administer benzodiazepine sedative drugs, such as Valium (diazepam), Ativan (lorazepam), Librium (chlordiazepoxide), or Serax (oxazepam).
If you’re receiving in-patient care, your doctor will also continuously monitor various vital signs (blood pressure, temperature, pulse, and breathing rate) and blood chemistry levels (electrolytes and vitamins), keep an eye out for serious symptoms (such as DT), and possibly provide you with fluids with electrolytes and essential vitamins and minerals, and medications intravenously (by IV).
Your doctor may also prescribe drugs that target specific symptoms, such as anticonvulsants for seizures, and beta blockers or other medications for heart rate and blood pressure issues.
Delirium Tremens (DTs)
Michael James Burns, MD, FACEP, FACP, FIDSA Health Science Clinical Professor, Department of Emergency Medicine, Department of Internal Medicine, Division of Infectious Diseases, University of California Irvine School of Medicine
Michael James Burns, MD, FACEP, FACP, FIDSA is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American College of Physicians, American Geriatrics Society, American Society of Tropical Medicine and Hygiene, California Medical Association, Infectious Diseases Society of America, Phi Beta Kappa, Royal Society of Tropical Medicine and Hygiene, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Michael E Lekawa, MD, FACS Associate Clinical Professor of Surgery, University of California, Irvine School of Medicine; Chief, Department of Surgery, Division of Trauma and Critical Care, Director of Trauma Services, Director of Surgical Intensive Care Unit, Director of Student Critical Care Teaching Program, Medical Director of Surgery Clinics, University of California, Irvine Medical Center
Michael E Lekawa, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Society of Critical Care Medicine
Disclosure: Nothing to disclose.
James B Price, MD Attending Emergency Physician, Mission Hospital; Clinical Faculty, Department of Emergency Medicine, Harbor-UCLA Medical Center
James B Price, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians
Disclosure: Nothing to disclose.
Michael R Pinsky, MD, CM, Dr(HC), FCCP, FAPS, MCCM Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease, Clinical and Translational Science and Anesthesiology, Vice-Chair of Academic Affairs, Department of Critical Care Medicine, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine
Michael R Pinsky, MD, CM, Dr(HC), FCCP, FAPS, MCCM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Thoracic Society, European Society of Intensive Care Medicine, Society of Critical Care Medicine
Disclosure: Received income in an amount equal to or greater than $250 from: Masimo, Edwards Lifesciences, Cheetah Medical, Exostat<br/>Received honoraria from LiDCO Ltd for consulting; Received intellectual property rights from iNTELOMED for board membership; Received honoraria from Edwards Lifesciences for consulting; Received honoraria from Masimo, Inc for board membership.
Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
William K Chiang, MD Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center
William K Chiang, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
William G Gossman, MD Associate Clinical Professor of Emergency Medicine, Creighton University School of Medicine; Consulting Staff, Department of Emergency Medicine, Creighton University Medical Center
William G Gossman, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.
J Stephen Huff, MD Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Lisa Kirkland, MD, FACP, CNSP, MSHA Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; ANW Intensivists, Abbott Northwestern Hospital
Lisa Kirkland, MD, FACP, CNSP, MSHA is a member of the following medical societies: American College of Physicians, Society of Critical Care Medicine, and Society of Hospital Medicine
Disclosure: Nothing to disclose.
Harold L Manning, MD Professor, Departments of Medicine, Anesthesiology and Physiology, Section of Pulmonary and Critical Care Medicine, Dartmouth Medical School
Harold L Manning, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph’s Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.
Sage W Wiener, MD Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Assistant Director of Medical Toxicology, Department of Emergency Medicine, Kings County Hospital Center
Sage W Wiener, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Anne Yim, MD Resident Physician, Department of Emergency Medicine, Kings County Hospital and State University of New York Downstate Medical Center
Anne Yim, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.
Dealing with the DTs
Irritability. Tremors. Sweating and a rapid heart rate. Extreme confusion. Fever. Convulsions. These are all symptoms of acute alcohol withdrawal syndrome. A patient may develop acute alcohol withdrawal syndrome when chronic alcohol use is interrupted by hospital admission. Increasingly patients are being treated for alcohol withdrawal on general medical wards.
Acute withdrawal is most safely managed in an inpatient setting if the patient has been using high doses of sedatives, has a history of seizures or delirium tremens, or has co-morbid medical or psychiatric problems.1 The severity of the withdrawal syndrome is affected by concurrent medical illness. Up to 20% of patients develop delirium tremens if left untreated.2 Recognition and effective treatment of alcohol withdrawal are needed to prevent excess mortality or prolonged hospitalization due to complications. It is essential for hospitalists to recognize and effectively treat acute alcohol withdrawal to prevent adverse outcomes in hospitalized patients.
Acute withdrawal is most safely managed in an inpatient setting if the patient has been using high doses of sedatives, has a history of seizures or delirium tremens, or has comorbid medical or psychiatric problems.
Development of Withdrawal
Hospitalized patients may not be forthcoming about their alcohol consumption for numerous reasons. They may not consider it a problem; they may not recognize that acute withdrawal is a serious and even fatal complication; or they may wish to conceal their alcoholism from family and physicians due to concerns about stigmatization.
Even when patients acknowledge their drinking, they often underestimate the amount, which may be because a patient is minimizing or because alcohol is an amnestic agent, causing drinkers to lose count of how much they have had to drink. It is simplest to ask—in a nonjudgmental manner—all patients admitted to the hospital about drinking and to be alert for signs of acute alcohol withdrawal in all patients.
Not all patients who drink alcohol will develop an acute withdrawal syndrome. Those who drink less frequently—only on weekends with no drinking at all on weekdays, for example—are at lower risk of acute withdrawal. Those who drink on most days of the week are more likely—due to tolerance—to develop withdrawal. Even a habit of two or three drinks each day is enough to set up a person for withdrawal. Not all daily drinkers are guaranteed to develop withdrawal, and it is difficult to predict who will and who will not. The best predictor of whether a patient will develop acute withdrawal while hospitalized is a past history of acute alcohol withdrawal.
The alcohol withdrawal syndrome has two phases: early withdrawal and late withdrawal. (See Table 1, below.) The signs and symptoms of early withdrawal usually occur within 48 hours of the last drink. The initial indication is an elevation of vital signs: heart rate, blood pressure, and temperature. Tremors develop next—first a fine tremor of the hands and fasciculation of the tongue, then gross tremors of the extremities. As the syndrome progresses, disorientation and mild hallucinations (often auditory but occasionally visual) develop, accompanied by diaphoresis. Seizures are an early sign of alcohol withdrawal and may even be the presenting symptom.
Late alcohol withdrawal is also known as delirium tremens—the DTs—and consists of the worsening autonomic dysregulation that is responsible for the morbidity and mortality attributed to alcohol withdrawal. It begins after early withdrawal—usually 72 hours or more after the last drink. Some patients do not progress from early to late withdrawal, and their symptoms simply subside after a few days, with or without treatment. But it is impossible to predict which patients will progress and which will not. The signs of late withdrawal consist of worsening diaphoresis, nausea, and vomiting (which may result in aspiration pneumonia), delirium with frank hallucinations, and rapid, severe fluctuation in vital signs. Sudden changes in blood pressure and heart rate may result in complications such as myocardial infarction or a cerebrovascular event. Untreated late withdrawal results in significant morbidity and even death.3 Adequate treatment of early withdrawal prevents progression to late withdrawal.
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When you or a colleague suspect that a hospitalized patient may develop alcohol withdrawal, regularly assess the patient for signs of early withdrawal. Use a validated assessment scale to quantify the severity of the withdrawal syndrome, and initiate treatment decisions such as the dose of medication. If no withdrawal signs manifest after 48 hours, then it is usually safe to discontinue monitoring for withdrawal. Monitor patients for whom alcohol withdrawal is not considered but who then develop withdrawal signs using an assessment scale.
The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is commonly used to assess severity of withdrawal.4 Competent nurses can give it in less than five minutes. A CIWA-Ar score less than 5 indicates minimal withdrawal with no need for pharmacotherapy, whereas a score that falls in the range of 6-19 indicates mild withdrawal that may benefit from medical treatment. A score greater than 30 indicates severe withdrawal that requires close monitoring due to the risk for complications such as seizures and autonomic instability.5
The CIWA-Ar is just as useful for evaluating and treating withdrawal in hospitalized patients on general medical wards as it is for use in chemical dependency units. It can also be used to determine an appropriate pharmacotherapy dose for patients in withdrawal who also have other medical illnesses.6
Monitor patients every few hours, with the frequency of evaluation varying by severity of withdrawal signs. Every four hours is sufficient for most patients, but those who have developed late withdrawal or those with CIWA-Ar scores greater than 30 should be monitored hourly to prevent complications. Continue regular assessment until the withdrawal syndrome has been under control (CIWA-Ar score less than 6) for at least 24 hours.
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Medications: Pharmacotherapy is indicated for the management of moderate to severe withdrawal. Any cross-tolerant medication may be used; benzodiazepines or barbiturates are most commonly prescribed. It is inappropriate to use beverage alcohol to prevent or treat alcohol withdrawal. Use of intravenous alcohol infusion is reserved for poisoning with methanol, isopropanol, or ethylene glycol. It should not be given for treatment of acute alcohol withdrawal due to potential complications such as intoxication with delirium and development of gastritis.
Both benzodiazepines and barbiturates, which are different classes of sedative-hypnotic medications, are cross-tolerant with alcohol and effectively treat alcohol withdrawal.7 Acute alcohol withdrawal in the United States is most often managed with benzodiazepines.8 There are a variety of benzodiazepines available, from ultra-short-acting to long-acting, as well as parenteral and oral forms. Diazepam has been used extensively due to rapid onset of action when given intravenously and long duration of action when given orally.
For similar reasons, chlordiazepoxide is also used widely. Lorazepam, an intermediate-acting benzodiazepine that can be given orally or parenterally, has been used extensively for treatment of acute alcohol withdrawal, especially in hospitalized patients, because it has fewer active metabolites than other benzodiazepines. This makes it safer to use in treating patients with severe liver disease, which is important when treating chronic alcoholics. Benzodiazepines have a relatively high therapeutic index when used to treat patients with illnesses in addition to acute withdrawal. This makes benzodiazepines an excellent choice for the treatment of acute withdrawal in patients on general medical wards.
Barbiturates have been used successfully to treat acute alcohol withdrawal syndrome in general medical inpatients, with phenobarbital the most common choice.9,10 Phenobarbital may be preferable to other sedative-hypnotics; with its longer half-life, patients rarely achieve a “high” as they do with other sedatives, and it is available in multiple dosage forms.11
A number of alternative non-sedative-hypnotic medications exist to treat acute alcohol withdrawal. Beta-adrenergic blockers (atenolol, propranolol), clonidine, and anticonvulsant agents (carbamazepine, valproate) decrease alcohol withdrawal symptoms and have been used successfully in the treatment of mild withdrawal. They are not cross-tolerant with alcohol, however, and may result in progression of the withdrawal syndrome. These alternative medications are not appropriate to use as single agents in the treatment of withdrawal in a general medical setting.
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Dosing regimens: There are no standard protocols for withdrawal management in widespread use.12 A fixed dosing schedule is commonly used for treatment of acute withdrawal, but either fixed-schedule or symptom-triggered dosing—medication given as needed for withdrawal signs—is efficacious in the treatment of withdrawal, even in patients with medical comorbidity.6
Fixed-schedule dosing is a one-size-fits-all approach for treating alcohol withdrawal. It uses the same dose of cross-tolerant medication on a fixed schedule for all patients for 24-48 hours; the dose is then tapered if the patient is stable. (See Table 2, left.) Reducing the dose by 10%-20% of the initial dose each day over five to 10 days provides a comfortable taper—especially in patients who initially required higher doses of medication to control the withdrawal. Fixed-schedule dosing offers less flexibility for individual patients, but it is a simple approach that can be applied in many settings.
Symptom-triggered therapy occurs when cross-tolerant medication is given only for symptoms of withdrawal rather than on a schedule. (See Table 3, p. 25.) Patients are monitored closely and assessed regularly using a tool such as the CIWA-Ar. The dose of cross-tolerant medication prescribed is based on the severity of withdrawal symptoms as measured by the CIWA-Ar score. This approach is similar to the sliding scale of insulin dosing used to treat hyperglycemia. Symptom-triggered therapy provides individualized treatment for withdrawal without overmedicating or underdosing, but it is a complex system to carry out on a general medical unit.
Severe withdrawal: Treat severe DTs manifested by abnormal and fluctuating vital signs and/or delirium aggressively in an ICU environment with sufficiently large doses of medication to suppress the withdrawal.11 Use IV medications with a rapid onset of action for immediate effect. Lorazepam and diazepam have a rapid onset of action when given intravenously, although the duration of action is shorter than when given orally.
For example, give lorazepam in a dose of one to four mg every 10-30 minutes until the patient is calm but awake and the heart rate is below 120 beats per minute. A continuous intravenous infusion may be warranted to control withdrawal symptoms, and the rate can be titrated to the desired level of consciousness. After stabilization, the patient can be changed to an equivalent dose of a long-acting sedative-hypnotic and tapered as above.
Assessing and medicating acute withdrawal remain necessary first steps in the treatment of the disease of alcohol dependence. After acute detoxification has begun, long-term treatment of alcoholism is necessary to prevent readmission for continuing medical problems due to alcohol consumption. Refer patients who have been treated for alcohol withdrawal for long-term treatment of alcoholism. This may include Alcoholics Anonymous, outpatient counseling, and other treatment modalities.
Ask all patients admitted to the hospital about drinking alcohol and be alert for signs of acute alcohol withdrawal in any patient. The best predictor of whether a patient will develop acute withdrawal is a past history of withdrawal. Signs of withdrawal usually occur within 48 hours of the last drink. Untreated withdrawal may result in significant morbidity and mortality.
Patients in withdrawal should be monitored closely and given appropriate doses of benzodiazepines or barbiturates to treat withdrawal signs. Cross-tolerant medication may be given on a fixed schedule or as symptom-triggered therapy. Severe withdrawal may require a continuous intravenous infusion in an ICU. Recognition and effective treatment of alcohol withdrawal can prevent significant complications in hospitalized patients. TH
Dr. Weaver is associate professor of internal medicine and psychiatry at Virginia Commonwealth University, Richmond.
As there is no ‘one-size-fits-all’ approach to treating alcohol abuse, recovery programs usually consist of:
Inpatient rehab facilities offer a safe, supervised environment for patients struggling with alcohol addiction. With 24-hour care, this is the most intensive form of treatment and typically entails 30, 60 or 90-day programs.
Outpatient rehab allows patients to attend to their daily responsibilities while in recovery. This option is best suited for those with less severe forms of alcohol abuse since individuals will be around drinking triggers and other influences.
To help relieve uncomfortable withdrawal symptoms, many treatment programs offer medication-assisted therapy. Certain prescribed medications can treat alcohol withdrawal, allowing patients to focus on other aspects of recovery.
Alcohol rehab counselors provide support during the highs and lows of alcohol withdrawal. Counselors also look to see if there are underlying factors that may have influenced an alcohol addiction and coach patients on how to work through various matters.
Recovery continues long after rehab. Support groups, like Alcoholics Anonymous and Al-Anon, offer an outlet to discuss treatment goals and challenges with other people who are in alcohol recovery. This will provide you with motivation to maintain your sobriety.
After the alcohol withdrawal stage, you will transition into other treatment therapies, activities and programs. These will provide you with the tools and resources to prevent triggers, continue on-going recovery and live a well-balanced life after rehab.
Alcohol withdrawal syndrome affects nearly two million Americans each year.
Symptoms of alcohol withdrawal syndrome can surface as early as two hours after a person’s last drink.
Alcohol addiction rehabs offer a safe, secure and comfortable environment during the withdrawal phase.
Don’t Let Fear Keep You from Getting Help
Although alcohol withdrawal can be a dangerous and painful process, it is a necessary step on the road to recovery. When conducted under the supervision of medical professionals, alcohol withdrawal is a much safer and easier process. Contact a treatment expert today to find out what options are available to you.
Dying from Alcohol Withdrawal: What is Delirium Tremens?
Randomized trials showed that benzodiazepines were more effective to prevent DTs than neuroleptics. The right electrolyte support, monitoring of vital signs, and support of the respiratory system reduces the mortality rate to 3% due to DT. In the medical industry, it’s been proven through studies that if a person is trying to stop drinking, they do need support. They need a reassuring environment that doesn’t cause them to become too anxious or excited. They also need to be constantly monitored for any early signs of DT.
Alcohol DT Treatment: Professional Detox
The best treatment for Delirium Tremens is found in a professional detox facility. These centers are staffed with medical professionals who understand alcohol withdrawal. They can work with you to assess your situation and ensure that the detox process goes as smoothly as possible.
Remember, you can die from alcohol withdrawal. So, it’s not smart to go through the process alone. Medical professionals can help to prevent the risk of DT’s when you detox under their supervision. The understand all possible Delirium Tremens treatments and will choose the one that works best for you.
There is a 35% fatality rate among those who experience the DT’s but fail to seek treatment. Conversely, the fatality rate among those who seek professional treatment is as little as 1%. It is possible to die from alcohol detox, so make sure you get the help you need.
Medical Alcohol Detoxification is The Best Treatment for Delirium Tremens
There are numerous benefits to professional detox. Particularly if you have a severe alcohol habit, it’s important to seek expert treatment.
Some of the biggest benefits include:
Medical expertise: Obviously, this is the #1 benefit of checking in to a professional alcohol detoxification facility before you go through withdrawals. The doctors on-staff will be able to assess your situation. They’ll determine whether you can quit cold turkey or you must wean yourself off. They’ll also prescribe medications for alcohol withdrawal symptoms if necessary.
No triggers: If you’ve gotten to the point that you’re experiencing Delirium Tremens, you most likely suffer from alcohol addiction. Therefore, you will feel strong cravings when you go through withdrawal. The great thing about detox is that there is no alcohol available in the facility. When you’re at home, you’ll still have the opportunity to relapse. But, in a detox center, those opportunities are taken away. Essentially, this helps to prevent you from relapsing before you even get sober.
Peace and quiet: The DT’s are quite uncomfortable. Even in less severe cases, they’re accompanied by headaches, stomach pains, and anxiety. Noise and stress will exacerbate all of these symptoms. In a detox center, you’ll have the peace and quiet you need to get well. You’ll have the chance to rest and to focus on getting sober without having to deal with stress. Therefore, this is a great resource for heavy and mild alcoholic alike.
Alcohol Detox at Home: Can You Wean Yourself Off?
Depending on the nature of your habit, it may be safe to wean yourself off of alcohol. This means that you’ll be able to detox at home. If you are a mild alcoholic (i.e you’re accustomed to taking breaks or you only drink at night), it may be safe to detox on your own.
If you are a full-time alcoholic and you’re accustomed to having booze in your body at all times, however, it is not safe for you to quit by yourself. You’ll need to enlist the help of medical professionals to detox safely. Otherwise, you’ll put yourself at risk of a nasty case of DT’s.
Either way, we recommend that you reach out to a doctor before you try to quit. They’ll take a look at your specific habit and determine the safest route for you to take.
Furthermore, professional detox is always the best option if you have a drinking problem. Between 40% and 60% of folks who attempt an at-home detox end up relapsing. Even if you’re not at risk of dying from Delirium Tremens, a professional detox program could help you get clean and stay that way.
Delirium Tremens: A Dangerous (but Preventable) Condition
Unfortunately, the DTs are a potential reality for some drinkers. After all, alcohol is a powerful drug. No one plans to become addicted to alcohol, but many of us find ourselves slowly slipping into a battle with addiction. Before you know it, you’re unable to withdraw from alcohol without experiencing these life-threatening symptoms.
Luckily, however, Delirium Tremens is both curable and preventable. All you need is the right type of support.
If you’re worried that you’re unfit to go through alcohol withdrawal alone or that doing so will put your life at risk, please call us. We can assess your habit and help you to determine the best course of action. We’ll make sure that you get on the safest and smoothest path to recovery.
You’re Wrong About Alcohol Withdrawal
I had a lot to learn when I began practicing medicine in county jails. One of the most important of those lessons was how to properly assess and manage alcohol withdrawal. In my previous life as an ER physician, I had seen a few alcohol withdrawal patients and even one or two cases of DTs. I thought I knew what I was doing. Wrong-o! I was first unprepared for the sheer number of alcohol withdrawal patients I would see as a correctional physician. Alcohol withdrawal in jails is simply very common.
But I was also unprepared because much of what I had been taught about alcohol withdrawal was inaccurate or misleading. Nothing teaches like experience! After many years of treating a lot of alcohol withdrawal, I have gained some insight.
Onset of delirium tremens doesn’t always fit textbook timelines. Emergency Medicine: A Comprehensive Study Guide, for example, says that DTs occur 3-5 days after the last drink. While this may be true in the majority of cases, it is not at all uncommon for my patients to manifest severe alcohol withdrawal much sooner than this and also much later.
My record for the earliest manifestation of alcoholic delirium was a patient who manifested true DTs within 12 hours after his last drink. This particular patient became a frequent flyer, and would reliably become delirious within 12 hours of arrest — until we learned to treat him early and aggressively. On the other end of the spectrum, I had a patient who developed DTs at day 8 after admission to the jail. It was so late, that I almost missed the diagnosis.
Alcoholic hallucinosis has been rare in my patients. As taught in the textbooks, alcoholic hallucinosis is a syndrome that begins around 12-24 hours after the last drink and can last for 1 or 2 days. These patients typically see bugs or animals in the room (“pink elephants”). Patients with alcoholic hallucinosis are reportedly not disoriented and have normal vital signs.
I have only seen one patient with alcoholic hallucinosis that I know of over my entire correctional career. It has been exceedingly uncommon. I believe that there are two reasons for this. First, alcoholic hallucinosis is thought to be related to thiamine deficiency and my patients are relatively well nourished as a group. Second, like most jails, my alcohol withdrawal patients are given lots of thiamine as soon as they are identified — and for several days afterward.
Hallucinations of delirium tremens are unique “immersion” hallucinations. The hallucinations of the typical DT patient are different from those of alcoholic hallucinosis and, indeed, from any other kind of hallucinations. They are unique. The hallucinations of the DT patient are like this: the patient thinks he is in some other physical location and he is interacting with that location. For example, a DT patient could be fiddling with the wall at the back of his cell and when you ask what he is doing, he will say, “I’m just trying to get this microwave to work.” In his mind, he is at home in his kitchen. Or he might be continuously trying to open the door of his cell, but in his delirium, he is at the store and just trying to get the door of the store open. DT patients are immersed in another time and place and are interacting with that environment.
Alcohol withdrawal has a stage not mentioned in textbooks. Medical reference books, like Emergency Medicine: A Comprehensive Study Guide and UpToDate, typically divide alcohol withdrawal into two basic stages: mild alcohol withdrawal and severe alcohol withdrawal (or DTs). However, in my experience, a recognizable syndrome of intermediate symptoms almost always precedes DTs: not eating, not sleeping, not stopping (relentless pacing), and tachycardia. This also means that once a patient has progressed to the stage of DTs, he usually is significantly dehydrated — because he has not been eating. More importantly, if we can catch patients in this stage of withdrawal and recognize it as “the Pre-DT syndrome,” we can treat the patient more aggressively and perhaps avert delirium.
It takes exponentially more Valium to treat withdrawal the further it progresses. I should say here that I use Valium (diazepam) in my jails to treat alcohol withdrawal. You may use Librium (chlordiazepoxide) or Ativan (lorazepam), and that is just fine. They all work.
Many patients can be successfully treated with a single 10-mg dose of diazepam if given early on. If treatment is delayed until the patient has progressed and is sicker, it will take quite a bit more diazepam to reverse his progression. But by the time a patient progresses to the stage of delirium tremens, he will need literally hundreds of milligrams of diazepam — which is one reason why most cases of DTs should be treated in a hospital setting. Because of this, it makes sense to be liberal with diazepam. One 10-mg diazepam given early in the course of withdrawal can prevent the need for much, much more later on.
Seizures due to alcohol withdrawal are a “wild card.” They can happen to anyone, at any stage. In my patients, it is not true that those with more severe symptoms of alcohol withdrawal are at higher risk of seizures. Patients with mild symptoms are just as likely to have seizures as those with more severe symptoms, in my experience. Instead of the severity of withdrawal, the two factors that do seem to correlate to the risk of alcohol withdrawal seizures are:
- Patients who have had alcohol withdrawal seizures in the past are much more likely to have them again
- Patients who have been given a dose of diazepam as treatment for alcohol withdrawal, even a single dose, are less likely to have a seizure
In my cohort of patients, most of the patients who had alcohol withdrawal seizures had not yet received a dose of diazepam. In my mind, this underscores the importance of treating alcohol withdrawal early. More on that next.
CIWA-Ar has a couple of serious shortcomings (and many lesser ones). CIWA-Ar is, of course, the standard, accepted way of assessing alcohol withdrawal used almost universally. CIWA-Ar scores the severity of the withdrawal state by assessing several withdrawal symptoms. CIWA-Ar also recommends treatment based on the patient’s score on the symptom rating scale. CIWA-Ar has been around since the mid-1990s and works OK-ish.
However, in my opinion, CIWA-Ar is a flawed instrument. CIWA-Ar has at least two major problems and several minor ones. The first major problem with CIWA-Ar is that it does not incorporate the single best objective measure of the severity of alcohol withdrawal — the heart rate. In my experience, the heart rate corresponds very well to the progression of alcohol withdrawal. Patients with minor withdrawal tend to have normal heart rates — less than 100. As the severity of withdrawal symptoms worsen, so does the heart rate — predictably. DT patients have markedly elevated heart rates — usually well over 150. I would be very concerned by a patient whose heart rate went up from, say, 80 to 110 even if her other subjective symptoms did not change. Heart rate is also an objective measure — as opposed to the CIWA-Ar scoring measures, which are all subjective.
The second major problem with CIWA-Ar is that it does not treat all cases of alcohol withdrawal. If a patient’s symptoms are judged by CIWA-Ar to be too mild, CIWA-r says not to treat, despite the fact that the patient is, indeed, suffering from alcohol withdrawal. I have a serious objection to this. If we diagnose alcohol withdrawal, even in its earliest stages, we should treat it! Without treatment, most of these patients are going to progress. With even a single dose of diazepam, many will not. And what is the downside? There are times to be stingy with benzodiazepines — but this is not one of them.
Jeffrey E. Keller, MD, FACEP, is a board-certified emergency physician with 25 years of experience before moving full time into his “true calling” of correctional medicine. He now works exclusively in jails and prisons, and blogs about correctional medicine at JailMedicine.com.
Last Updated April 18, 2019 Comment
Alcohol has a depressive effect on your nervous system, slowing down brain function and the way your nerves send messages back and forth throughout the body.
When you consume large amounts of alcohol for an extended time period, the body starts to adapt to this depressive state by working harder to keep your nerves properly communicating with each other. If you suddenly stop drinking, the brain needs time to adjust to its normal functioning. This period of recalibrating your nervous system is what causes the physical and emotional symptoms of alcohol withdrawal.
Risk Factors for Delirium Tremens
Despite being legal and widely available, alcohol is actually one of the most dangerous drugs to withdraw from. Delirium tremens (DTs) is a term used to refer to the most serious form of alcohol withdrawal. DTs is sometimes called alcohol withdrawal delirium.
Not everyone who experiences alcohol withdrawal will develop DTs. The lifetime risk for developing DTs is estimated to be between 5% and 10% for people who suffer from chronic alcoholism. Risk factors for this type of withdrawal include:
- Heavy alcohol consumption, defined as 4 to 5 pints of wine, 1 pint of hard alcohol, or 7 to 8 pints of beer daily
- Extended history of regular heavy drinking, typically for 10 years or more
- Concurrent medical conditions or poor overall health
- Older age
- Presence of structural brain lesions
- Experience of intense alcohol cravings
- A prior withdrawal experience that included DTs
There is no significant difference in the risk for DTs between genders when alcohol consumption is the same. However, white patients have twice the risk of severe alcohol withdrawal when compared to non-white patients. This is thought to be due to genetic variations in how the body processes alcohol.
Symptoms of DTs
Symptoms of DTs typically begin 2 or 3 days after an alcoholic’s last drink, but can take as long as 7 to 10 days to appear. Most cases last just 24 hours, but severe cases can last for up to 5 days.
Every case is different, but symptoms of DTs may include:
- High blood pressure
- Heavy sweating
- Rapid heartbeat
- Chest pain
- Nausea or vomiting
- Severe anxiety, similar to a panic attack
- Visual, auditory, and/or tactile hallucinations
- Uncontrollable tremors
DTs can be fatal without treatment, due to the increased risk of developing respiratory arrest, aspiration pneumonitis, or cardiac arrhythmias. Without treatment, mortality rates are between 15% and 40%.
Although DTs are most strongly associated with alcohol, certain other drugs can create similar risks. Someone who tries to quit barbiturate or benzodiazepine tranquilizers abruptly after extended use is at risk of experiencing DTs.
DTs are different from alcoholic hallucinosis, which is a relatively rare alcohol-induced psychotic disorder developed as a complication of withdrawal. Both conditions are most common in long term alcohol abusers, but alcoholic hallucinosis is a less serious diagnosis than DTs and is not potentially fatal.
Someone who is at risk for developing DTs needs to be closely monitored for their own comfort and safety. It can be extremely dangerous for a high-risk alcoholic to attempt withdrawal at home.
Treatment for DTs typically includes:
- Sedation to suppress the excitability of the nervous system, thus reducing the severity of symptoms
- Thiamine and other vitamins to promote proper nutrition
- IV fluids to prevent dehydration
- Dextrose to prevent hypoglycemia
- Monitoring and replacement of electrolytes as necessary, since people suffering from alcoholism often have low calcium, magnesium, phosphorous, or potassium levels
- Treatment of any co-occurring health conditions, such as alcoholic neuropathy, alcoholic cardiomyopathy, Wernicke-Korsakoff syndrome, or alcoholic liver disease
Providing a calm, quiet environment with supportive assurance from medical staff helps keep the patient comfortable throughout the withdrawal process. The physical symptoms of DTs can be very frightening, so addressing a patient’s emotional needs is just as valuable as providing medical care.
Once the withdrawal process is complete, the patient can begin receiving therapy to help maintain sobriety. This can include group, individual, and family counseling as well as participation in alternative therapies such as art therapy, equine therapy, and yoga to promote positive coping skills for a sober lifestyle.
Although being at risk for developing DTs can be scary, it’s important to consider that not seeking treatment for chronic alcoholism is a risky endeavor in itself. Long term alcohol abuse can cause problems with your career, family, and personal relationships as well as an increased risk of cancer, mental illness, cardiovascular disease, liver disease, and cognitive deficits. The sooner you seek help, the sooner you’ll be on your way to a brighter future.
For more information about our treatment programs at Waypoint Recovery Center, please contact us anytime at (888) 978-5188.
Delirium tremens. MedlinePlus
Delirium Tremens (DTs). Medscape.
Delirium Tremens. The New York Times.
Alcohol Withdrawal Delirium. Healthline.
What Is It?
Published: April, 2019
Alcohol withdrawal is the changes the body goes through when a person suddenly stops drinking after prolonged and heavy alcohol use. Symptoms include trembling (shakes), insomnia, anxiety, and other physical and mental symptoms.
Alcohol has a slowing effect (also called a sedating effect or depressant effect) on the brain. In a heavy, long-term drinker, the brain is almost continually exposed to the depressant effect of alcohol. Over time, the brain adjusts its own chemistry to compensate for the effect of the alcohol. It does this by producing naturally stimulating chemicals (such as serotonin or norepinephrine, which is a relative of adrenaline) in larger quantities than normal.
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