HAMS: Harm Reduction for Alcohol

What Is Alcohol Withdrawal?



Alcohol withdrawal is different from withdrawal from most other drugs because alcohol withdrawal can be deadly. The only drugs as likely to cause death from withdrawal as alcohol are the benzodiazepines. Heroin withdrawal rarely if ever kills anyone. But untreated major alcohol withdrawal can kill one person in three. Fortunately these fatalities are almost completely preventable if people are properly tapered off from their alcohol use. See our web page How To Taper Off Alcohol for information about tapering off. To learn about how to avoid alcohol withdrawal please visit our web page How To Prevent Alcohol Withdrawal.

The Levels of Alcohol Withdrawal

Doctors generally recognize three levels of alcohol withdrawal:

Level 1) Minor Withdrawal: Shaky hands. Sweating. Mild anxiety. Insomnia. Nausea. Headache. These symptoms may appear within 6 to 12 hours after quitting drinking.

Level 2) Mid-level Withdrawal: Minor withdrawal symptoms at a more intense level plus visual, auditory or tactile hallucinations. The patient generally is aware that the hallucinations are not real. Possible seizures. Racing pulse. Irregular heartbeat. These symptoms may appear within 12 to 48 hours after quitting drinking.

Level 3) Major Withdrawal: Delirium. Alcohol-induced hallucinations. Patient generally cannot distinguish hallucination from reality. Profuse sweating. Seizures. Severe blood pressure spikes. Sever tremor. Racing and irregular heartbeat. Fever. Possible death. These symptoms may appear within 48 to 72 hours after quitting drinking and peak in five days.

If you want to see if you are likely to have alcohol withdrawal if you quit drinking, please see our web page The Odds Of Going Through Alcohol Withdrawal. Mild or mid-level alcohol withdrawal are rarely if ever fatal unless you have a very weak heart. Major withdrawal is the dangerous one.

Popular slang in the United States refers to the shakiness which comes with mild alcohol withdrawal as "D.T.s". This is a rather confusing use of terminology since properly speaking "D.T.s" refers to delirium tremens which is associated with major withdrawal.. Real delirium tremens is life-threatening and can kill one in three untreated patients. The shakiness associated with minor withdrawal is not life-threatening.

Perhaps the best and most accurate description of D.T.s in literature is Mark Twain's description of Pap Finn's attempt to kill his son in the book Huckleberry Finn. To read this description please click on Pap Finn Has the Delirium Tremens.

What Causes Alcohol Withdrawal?

Alcohol withdrawal is caused by neurotransmitter rebound. When alcohol suppresses the action of a neurotransmitter system over a long period of time the neurotransmitter system adapts by working harder and harder to overcome the effect of the alcohol and to try and function at normal levels in spite of the presence of the alcohol. When the alcohol is suddenly removed from the body the neurotransmitter system still continues to function far in excess of normal levels. Since the alcohol is no longer present to suppress the effects of this hyperactivity, what we now see are effects which are precisely the opposite of those caused by alcohol. It is much like two people playing tug-of-war who are equally balanced--if one person suddenly lets go of the rope the other goes flying in the opposite direction. When alcohol is suddenly removed from a neurotransmitter system which has been fighting to overcome its effects --the neurotransmitter system goes flying off in the opposite direction.

The main neurotransmitter system involved in alcohol withdrawal is the GABA system. Alcohol's effect on the GABA system leads to relaxation, sleep, calm, and the soothing of panic. When alcohol is suddenly removed from the brain then the neurotransmitter rebound in the GABA system leads to insomnia, nightmares, hallucinations, anxiety, panic, muscle cramps, and seizures. Benzodiazepines affect the GABA system in much the same way as alcohol does and this is why benzodiazepine withdrawal is also life-threatening.

Some web sites try to use scare tactics and tell you that very tiny amounts of alcohol will cause withdrawal, that it is impossible to taper off alcohol, or that no one can quit drinking on their own. These things are no more true than the scare tactics of Reefer Madness were true. You do not need a Higher Power to take charge of your drinking.Even people who have had alcohol withdrawal in the past do not need to repeat the experience. It is up to you as an individual to decide if your best bet is safer drinking, reduced drinking, or quitting altogether.


RICHARD D. BLONDELL, M.D., Ambulatory Detoxification of Patients with Alcohol Dependence. American Family Physician, Vol. 71/No. 3 (February 1, 2005)


MAX BAYARD, M.D, et. al. Alcohol Withdrawal Syndrome. American Family Physician, March 15 2004.


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