Chapter 8 - Alcohol Withdrawal

Authors | Paul Haber & Nicholas Lintzeris

This chapter describes alcohol withdrawal and its clinical management, often occuring in people with longstanding high risk drinking who either stop or substantially decrease alcohol consumption.

Cite the Chapter: Haber PS, Lintzeris N (2021). Alcohol Withdrawal. In Haber PS, Riordan BC (Eds.). Guidelines for the Treatment of Alcohol Problems (4th edition). Sydney: Specialty of Addiction Medicine, Faculty of Medicine and Health, The University of Sydney

Alcohol withdrawal is a syndrome occurring in people with longstanding high risk drinking who either stop or substantially decrease alcohol consumption. The symptoms include adrenergic overactivity, CNS excitation and gastrointestinal disturbance. The risk of withdrawal is greater with higher levels of alcohol use, previous episodes of withdrawal and concurrent health problems including cessation of other drugs. Withdrawal ranges in severity from trivial to life-threatening, tending to greater severity with successive episodes.

Chronic alcohol consumption is associated with neuroadaptive changes that tends to restore equilibrium inducing tolerance to alcohol. There is downregulation of GABA receptors and increased expression of NMDA receptors with production of more glutamate to maintain central nervous system (CNS) transmitter homeostasis. Cessation of alcohol use leads to a state of disequilibrium with disinhibition of several neurotransmitter systems. There is increased activity of the adrenergic system as well as glutamate and GABA and these changes account for the clinical features of alcohol withdrawal. 

The signs and symptoms of alcohol withdrawal may be grouped into three major classes – autonomic hyperactivity, gastrointestinal, and cognitive and perceptual changes – and may feature uncomplicated or complicated withdrawal (see Table 8.1).

TABLE 8.1: Symptoms of alcohol withdrawal

  Autonomic hyperactivity Gastrointestinal features Cognitive and perceptual changes
Uncomplicated withdrawal features Sweating, Tachycardia, Hypertension, Tremor, Fever (generally <38°C) Anorexia, Nausea, Vomiting, Dyspepsia, Diarrhoea Poor concentration, Anxiety, Psychomotor agitation, Disturbed sleep, vivid dreams
Severe withdrawal complications Dehydration and electrolyte disturbances   Seizures, Hallucinations or perceptual disturbances (visual, tactile, auditory) Delirium