With a complex and potentially life-threatening process like alcohol or drug withdrawal, what you don’t know could hurt you. Here are six expert insights into withdrawal from triple board certified physician Michael Baron, MD:
- Alcohol withdrawal requires supervised medical detox, but usually only if you’re a severe alcoholic.
Many people know that alcohol withdrawal can be fatal. But this doesn’t mean every alcoholic requires medical detox. “Only about 10% to 20% of alcoholics have alcohol withdrawal that’s severe enough to require monitoring and medication,” explains Dr. Baron. “Most have morning shakes or sweats but don’t need medication to get through it.”
The trouble is it’s difficult to know if you’re in that 10% to 20% without medical input. Even if it’s not a medical necessity, many people still choose medical alcohol detox to ensure their comfort, safety and progress to the next stage of treatment. In addition, it’s important to seek medical help even for mild symptoms because alcohol withdrawal symptoms can get worse quickly. Others who shouldn’t stop drinking abruptly without supervision include people with other health conditions or who have gone through alcohol withdrawal before.
Making a guess at whether or not you need medical detox can be risky. Acute alcohol withdrawal typically lasts three to five days and can be life-threatening. Some of the more manageable symptoms include mild anxiety, shakiness, insomnia, nausea and abdominal pain. Those who have severe and potentially fatal withdrawal symptoms, such as seizures, hallucinations and delirium tremens (also known as DTs, which typically involves fever, racing heartbeat and confusion), must be treated and carefully monitored.
So if your fear of alcohol detox is keeping you from getting help, ask questions. You may not require medical detox, and if you do, there are many ways to make your symptoms more manageable.
- “DTs” is much more than the shakes.
It’s become trendy to use the term “DTs” to cover anything that resembles “the shakes.” In reality, delirium tremens is a life-threatening condition that involves sudden and severe mental or nervous system changes. “While DTs can include shakiness, it’s really a significant and serious constellation of symptoms that can include delirium, hallucinations, seizures, confusion, agitation and rapid mood changes,” says Dr. Baron. “Given the high mortality rate associated with DTs, it’s a dangerous term to toss around lightly.”
Delirium tremens can develop after a period of heavy drinking, particularly among those who drink heavily every day for several months. DTs can also be caused by illness in someone with a history of alcohol abuse, and is more common in people with a history of alcohol withdrawal or a long history (10-plus years) of drinking alcohol. The condition usually develops within 48 to 96 hours after the last drink, but it’s possible to experience DTs up to 10 days after drinking.
Delirium tremens is a medical emergency that needs to be treated in a hospital intensive care unit, where medical staff can track vital signs and other critical functions, treat symptoms, and administer medication to keep the person calm until they stabilize. In addition, the person may have other alcohol-related illnesses that require treatment, such as alcoholic liver disease or alcoholic cardiomyopathy.
“When someone drinks a lot but doesn’t eat much, they take in a lot of calories but little nutrition and their B vitamin levels get depleted quickly,” says Dr. Baron. “The brain doesn’t work well when vitamin B1 is depleted, and can lead to a number of life-threatening issues.” For example, a small subset of people may develop Wernicke-Korsakoff syndrome, which can progress to a type of psychosis.
- The symptoms of benzodiazepine withdrawal can be similar to alcohol, and may require medical detox.
Benzodiazepines (Xanax, Ativan, Valium) are typically used to treat anxiety and insomnia. Some of the most common symptoms of benzodiazepine withdrawal mirror the issues the person was trying to address with the medication, such as insomnia and panic attacks. Other symptoms include sweating, nausea, dizziness, rapid heart rate, headaches and irritability. But it can get worse, especially for those who take high doses or take the drug for a long period of time. Seizures and hallucinations can occur, in some cases reaching levels of severity most commonly associated with drugs like alcohol.
Although it’s not officially “on the books,” Dr. Baron has seen a number of patients develop delirium tremens symptoms during Xanax withdrawal. “They aren’t alcoholic, but they develop many of the same symptoms as alcoholics in withdrawal,” he says. “In essence, alprazolam is freeze-dried alcohol; to the brain it looks the same.” People coming off of Xanax have reported confusion, elevated temperature, distressing sensations like insects on the skin and hallucinations (often snakes or spiders), which are very similar to symptoms of alcohol DTs. Because benzo withdrawal can be lethal, people who are dependent on these drugs may require supervised medical detox.
- Different substances have different detox protocols.
Not all detoxes are the same. There are different best practices for different substances, which is another reason it’s safest to consult a medical professional before detoxing on your own. For example, a classic tool for alcohol detox is the Clinical Institute Withdrawal Assessment for Alcohol, or CIWA. This 10-item scale is used by medical professionals to gauge the severity of alcohol withdrawal. It also helps guide the process for managing symptoms, including whether to prescribe benzodiazepines. These objective, validated tools have been studied and proven to reduce treatment duration and minimize the risk of over- or under-treatment.
- Withdrawal doesn’t necessarily mean you’re addicted.
Not everyone who experiences withdrawal symptoms is addicted. People who take prescription medication in accordance with their doctor’s orders, following surgery or to treat chronic pain, for example, may become physically dependent on the drug. This means their brain has grown accustomed to it. They may experience withdrawal symptoms if they abruptly stop using it. But this doesn’t mean they’re addicted. Certain blood pressure medications, antidepressants and other non-addictive medications can also lead to withdrawal if suddenly stopped. Conversely, some highly addictive drugs like crack cocaine don’t cause withdrawal symptoms.
So how do you know if legitimate medication use has turned into addiction? Ask yourself a few key questions:
- Are you using the medication in accordance with your doctor’s orders?
- Do you crave the medication when you aren’t using it?
- Do you continue to use the medication in spite of negative consequences?
Talk with an addiction specialist if you feel yourself losing control or others have begun to express concerns about your medication use.
- Withdrawal symptoms can last for years.
People typically think of withdrawal as a three- to five-day process. And it is. But that’s the first stage of a two-part process. After “acute withdrawal,” there’s a second phase of withdrawal called post-acute withdrawal syndrome (PAWS), which can last a year or more. During this time, people often feel tired and irritable and unable to sleep or think properly. It’s a phase marked by intense emotional ups and downs as the brain chemistry gradually returns to normal.
“PAWS is less feared and less understood than acute withdrawal, but it’s far more likely to cause relapse,” says Dr. Baron. “By week 3 into recovery, most people start to feel a little better, their energy starts to improve. By the third or fourth month, they’re 80% of the way there. But it’s a slow go so it’s important to have realistic expectations.”
Recovery is different depending on the drug used. “The drugs that do the least harm while you’re using them — for example, benzodiazepines — tend to be the slowest healing,” says Dr. Baron. “Compare that to alcohol, which does the most harm when you’re actively addicted, but you can recover fairly quickly.” Dr. Baron describes one client who was using massive doses of Ativan. Once sober, she couldn’t sleep more than two hours at a time. “The drug completely altered her sleep architecture,” he recalls. “It wasn’t until year 2 that she finally started sleeping normally again.”
Although it can be a long, discouraging process, PAWS does not last forever. Those who know what to expect and stick to a recovery program can reap the rewards of allowing their brains time to heal.
There is a great deal of fear around drug detox and alcohol withdrawal. While the fear is understandable — withdrawal can be painful and lead to quick relapse if it isn’t handled properly — knowing what to expect can mean the difference between letting fear keep you stuck in addiction and taking the first bold step toward recovery.
By Meghan Vivo