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Heavy drinking is bad for health. However, suddenly stopping alcohol consumption can also be dangerous for heavy drinkers.
Alcohol withdrawal syndrome is a collection of physical and mental symptoms experienced by regular, heavy drinkers who suddenly stop drinking.
These withdrawal symptoms can range from mild to severe. Among the severe symptoms are seizures and delirium tremens (DTs).
Alcohol is a depressant. The substance has a calming effect on the central nervous system. It does this by influencing certain brain chemicals called neurotransmitters.
Alcohol affects two neurotransmitters:1
In everyday situations, glutamate and GABA are in balance. This is necessary to keep the brain functioning optimally.
When a person drinks, alcohol triggers GABA activity. This action reduces nerve excitation, causing relaxation.
If people drink regularly, they eventually become dependent on alcohol. They drink more to get the same relaxing effect they felt when they first started drinking alcohol.
Over time, the body becomes used to alcohol. It works hard to counter alcohol’s suppressive effect to keep the brain and nerves awake.
When a person suddenly stops drinking, GABA drops to below normal levels.
The excitation of nerves caused by glutamate will be left unopposed. This causes the brain to go into hyperactive mode, leading to alcohol withdrawal (symptoms like tremors, seizures, and delirium).1, 2
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Alcohol withdrawal syndrome is made up of four stages based on severity:3, 4
The following mild symptoms may develop within 6 to 12 hours after the last drink:
Hallucinations may happen 12 to 24 hours after the last drink.
The minor symptoms from stage 1 can also become severe and life-threatening if not treated.
The onset of seizures or “rum fits” happens during this stage.
Seizures happen in about 10% of patients undergoing alcohol withdrawal. They typically start 24 to 48 hours after a person’s last drink.4
Alcohol itself rarely causes seizures. But during withdrawal, alcohol’s relaxing effect is removed. As a result, the brain becomes hyperactive and more prone to seizures.
Alcohol withdrawal seizures are of the tonic-clonic type. They involve muscle stiffening (tonic phase) and twitching or jerking (clonic phase).
Delirium tremens (DTs) usually happen 48 to 72 hours after the last drink. Symptoms include:1, 5
Reports say that patients with delirium tremens have a mortality rate of 1 to 15%.6, 7
The Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) is a tool used to identify withdrawal symptoms.
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), an alcohol withdrawal syndrome diagnosis is made by observing the person. There must be at least two symptoms present:8
Each item is scored depending on the severity of symptoms. Items 1 to 9 are assigned 0 to 7 points. Item 10 is assigned 0 to 4 points. The highest score a patient can get is 67 points.9
The total score is computed and used to classify the patient’s alcohol withdrawal condition:2, 4
Here are some risk factors for severe alcohol withdrawal:4
While alcohol withdrawal can lead to seizures, not everyone experiencing withdrawal will have them. The above risk factors do not automatically apply to seizures.
Here are the risk factors that studies have linked to withdrawal seizures:2, 10, 11
Previous withdrawal episodes appear to be the most reliable predictor of who is at risk for future withdrawal, with or without seizures.
Treatment of alcohol withdrawal is usually based on the severity of withdrawal.
For mild and moderate symptoms, a person may go to an outpatient setting. This option is safe, effective, and relatively cheap. It also doesn’t disrupt their personal life.
Hospital treatment is needed for more serious withdrawal cases. Intravenous fluids (to prevent dehydration) and medications (to ease symptoms) are often used. Doctors can also monitor and manage any complications.
Those with these conditions are top candidates for inpatient treatment:3, 5, 12
Those with severe withdrawal symptoms may need interventions that involve medications. However, not all drugs for alcohol withdrawal will be effective for seizures.
Benzodiazepines are the top choice for treating and preventing alcohol withdrawal in the U.S.
They are sedatives that help reduce seizures and prevent symptoms from becoming severe.3, 5, 12, 13, 14
The commonly prescribed benzodiazepines are chlordiazepoxide, lorazepam, and alprazolam.
Benzodiazepine can be combined with haloperidol, beta-blockers, clonidine, and phenytoin to treat withdrawal complications.15
Benzodiazepines carry an FDA warning because of their addictive properties. You should discuss this risk with your doctor and follow instructions carefully.
Carbamazepine is an anticonvulsant. It’s an alternative to benzodiazepines in the outpatient treatment of mild-to-moderate symptoms.15 It’s commonly prescribed in Europe.13
Chlormethiazole (also called clomethiazole or heminevrin) enhances GABA activity. It can protect against withdrawal seizures. Like carbamazepine, it’s commonly prescribed in Europe.13
Valproate (also known as valproic acid) reduces the incidence of seizures. It also prevents the progression of withdrawal symptoms.4 Like chlormethiazole and carbamazepine, it is commonly prescribed in Europe.13
Neuroleptic agents (like haloperidol and phenothiazines) may reduce the severity of withdrawal symptoms. They may work with patients with uncontrolled agitation. However, they are not as effective as benzodiazepines in treating seizures and delirium.3
The combination of benzodiazepines and certain barbiturates can increase the efficacy of benzodiazepines’ action.4
One of propofol’s effects is to stimulate GABA. This makes the drug useful for patients with severe delirium tremens who respond poorly to benzodiazepines.4
Sodium oxybate is structurally similar to GABA. It is approved in some European countries for alcohol withdrawal treatment. However, it’s not approved in other countries because of its addictive properties.4
Gabapentin is another drug that’s structurally similar to GABA. It can be combined with other medications to treat partial seizures.3, 4
Baclofen can reduce alcohol withdrawal symptoms by activating GABA receptors.3, 4
Vitamins and minerals are given to replace essential nutrients that alcohol use has depleted. In particular, thiamine and folic acid are given to prevent a neurological disease called Wernicke’s encephalopathy.4
Additional supplements may be given to address nutritional deficiencies once the withdrawal is gone.5
Treatment is not the best way to fix alcohol withdrawal. The best way to prevent seizures and other withdrawal symptoms is to avoid regular and heavy alcohol use.
Detoxification is another approach. It can minimize withdrawal symptoms, prevent complications, and speed up the process of abstinence.2 It can be done by:
If you or someone you know has alcohol use disorder, know that help is available. Speak with an addiction specialist today.
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