Alcohol withdrawal syndrome: symptoms, timeline and safe treatment

With regular heavy drinking the brain and body adjust to the constant presence of alcohol. When alcohol is suddenly reduced the nervous system is left overactive, producing the symptoms of withdrawal. The NHS describes this as a sign that the body is dependent on alcohol.

It is not only people who drink every day who are at risk. Anyone who has developed dependence, including those who binge or who drink steadily without obvious intoxication, may experience it. People who have had withdrawal seizures or delirium tremens before are considered at higher risk in future attempts, according to NICE.

The NHS lists anxiety, difficulty sleeping, feeling or being sick, a racing heartbeat, sweating, shaking (tremor), hallucinations, confusion and seizures. Milder symptoms that suggest medicine may be needed include anxiety after waking, sweating and mild tremor, and nausea, retching or vomiting in the morning.

The NHS says withdrawal symptoms usually start 6 to 12 hours after the last drink and last from 3 to 7 days, but some symptoms, may linger for a few months, particularly after long periods of heavy drinking.

The NHS says medicine to help you stop can often be taken at home or when attending a local service daily, but some people need a short stay in a medically supported unit, either an NHS inpatient unit or a residential service, depending on the assessed medical need.

NICE suggests considering inpatient or residential withdrawal when someone drinks more than 30 units a day, scores above 30 on the dependence questionnaire, has a history of epilepsy or withdrawal seizures or delirium tremens, needs to come off benzodiazepines at the same time, or drinks 15 to 30 units a day with significant psychiatric or physical illness, learning disability or cognitive impairment. The threshold is lower in vulnerable groups such as people who are homeless or older.

NICE says the preferred medication for assisted withdrawal is a benzodiazepine, either chlordiazepoxide or diazepam, and that one benzodiazepine rather than several is best. Regimens can be fixed-dose or symptom-triggered in inpatient or residential settings, and the dose is reduced over a short period, so this is never something to try with leftover or borrowed tablets.

To reduce the risk of Wernicke-Korsakoff syndrome, a brain condition linked with thiamine (vitamin B1) deficiency, NICE advises thiamine, given by injection then by mouth, for people entering planned assisted withdrawal in specialist inpatient services or prison settings who are malnourished or at risk of malnourishment, or who have decompensated liver disease.

Withdrawal is the first step, not the whole treatment. The NHS says most people need some kind of ongoing help to stay in control or alcohol-free, and relying only on family, friends or carers is often not enough. Options include talking therapies, relapse-prevention medicines such as acamprosate, naltrexone or disulfiram, and mutual-aid groups such as AA or SMART Recovery. NICE suggests acamprosate or naltrexone alongside psychological therapy after a successful withdrawal in moderate and severe dependence.

NHS and local authority alcohol services provide assessment and community or inpatient detoxification. Private detox and rehabilitation exist, and insurers sometimes fund them for a limited time. Whichever route is used, a clinician should assess physical risk before withdrawal begins, and a plan for aftercare should be agreed before leaving.