How to Cope with Alcohol Withdrawal
Alcohol withdrawal is the only common drug withdrawal that can kill you outright. Opioid withdrawal feels worse on day three. Alcohol withdrawal can put you in the ICU. If you have been drinking heavily every day for months and you are thinking about stopping, do not just stop. Read this, then talk to a clinician.
Get emergency help now if: You feel confused, see or hear things that are not there, have a seizure, or have a heart rate over 120 with sweating and shaking. Severe alcohol withdrawal is a medical emergency. Call 911 or go to the nearest emergency department.
The four stages of alcohol withdrawal
Withdrawal does not present all at once. It moves through phases, and the dangerous symptoms appear later than people expect.
| Stage | Onset after last drink | Symptoms |
|---|---|---|
| Stage 1: Minor | 6-12 hours | Anxiety, tremor, sweating, insomnia, headache, nausea |
| Stage 2: Moderate | 12-24 hours | Increased heart rate, increased blood pressure, mild fever, more pronounced tremor |
| Stage 3: Severe (alcoholic hallucinosis) | 12-48 hours | Visual or tactile hallucinations with intact orientation, often disturbing but not life threatening |
| Stage 4: Delirium tremens (DTs) | 48-96 hours | Severe confusion, disorientation, hallucinations, fever, tachycardia, autonomic instability. Mortality 1-5% with treatment, up to 20% without. |
Seizures most often happen between 6 and 48 hours after the last drink. They can happen in patients who never had a seizure before. They tend to be generalized, brief, and self limiting, but they signal that delirium tremens may follow.
Who is at risk for severe withdrawal
Not everyone who drinks heavily develops dangerous withdrawal. Risk goes up with:
- Daily drinking for more than a few months at heavy levels (more than 8 drinks/day for men, more than 6/day for women)
- History of previous withdrawal seizures or DTs (the strongest predictor)
- Older age
- Concurrent medical illness, especially liver disease or pneumonia
- Concurrent benzodiazepine or sedative use
- Poor nutritional status, especially low thiamine
- Electrolyte disturbances
The single best predictor is whether the patient has had withdrawal before. If your last quit attempt landed you in the hospital, your next attempt without medical supervision will likely go the same way or worse.
The CIWA-Ar scale
Hospitals use the Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) to score severity. It has 10 items including nausea, tremor, sweating, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache, and orientation. Each item scores 0 to 7. Maximum total is 67.
- Score 0-9: Minimal withdrawal. Outpatient observation may be appropriate.
- Score 10-19: Mild to moderate withdrawal. Symptom triggered medication is usually started.
- Score 20+: Severe withdrawal. Aggressive medication management. Consider ICU.
Outpatient detox can be safe for low risk patients who score under 10 with no history of seizures or DTs. Anything above that needs supervision in a medical setting, even if you feel like you can tough it out.
How medical detox actually works
Medical alcohol detox is built around three goals: prevent seizures, prevent DTs, and replenish thiamine and electrolytes.
- Benzodiazepines are the first line. Long acting agents like chlordiazepoxide or diazepam taper smoothly. Lorazepam is preferred in liver disease because it does not require liver metabolism. Symptom triggered dosing using CIWA-Ar scores typically uses less total medication than fixed schedules and shortens length of stay.
- Thiamine is given before any glucose because giving glucose to a thiamine deficient patient can precipitate Wernicke encephalopathy. The default order in any alcohol detox is thiamine 100 mg IV, then glucose if needed.
- Magnesium and electrolytes are checked and replaced. Hypomagnesemia and hypokalemia are common in heavy drinkers.
- Phenobarbital is used in some protocols, particularly for patients who are not responding to benzodiazepines or who have a history of complicated withdrawal.
- Adjuncts like gabapentin, clonidine, and beta blockers can manage residual symptoms but are not first line for severe withdrawal.
What you can do if withdrawal is mild
For patients with no risk factors, no history of severe withdrawal, low CIWA-Ar scores, and reliable supervision at home, outpatient detox is reasonable. The elements:
- A clinician who has assessed you in person or by telehealth
- Daily check ins for the first week
- Hydration with electrolyte replacement (oral rehydration solutions, not just water)
- Thiamine 100 mg orally daily for at least 5 days, ideally as B complex
- A reliable adult who can stay with you and recognize warning signs
- A plan to escalate to emergency care if symptoms worsen
Some outpatient programs prescribe a short benzodiazepine taper for low risk patients. Others use gabapentin. Both work for genuinely mild cases. Neither is safe for moderate or severe withdrawal at home.
Beyond detox
Detox is the easy part. It treats the immediate physical syndrome. It does not treat the underlying alcohol use disorder, and patients who detox without a follow up plan return to use at high rates. The medications that work for longer term alcohol use disorder are:
- Naltrexone. Oral or monthly injectable. Reduces craving and the rewarding effects of alcohol. First line for most patients.
- Acamprosate. Oral, three times daily. Helps maintain abstinence after detox. Useful when naltrexone is contraindicated.
- Disulfiram. Causes a very unpleasant reaction if alcohol is consumed. Works only for highly motivated patients with structured supervision.
Behavioral treatment, peer support like AA or SMART Recovery, and in some cases contingency management improve outcomes. The medications work better when combined with behavioral support, but the medications work even when patients do not engage with behavioral support.