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Alcohol Withdrawal Management: How Clinical Guidelines Should Be Improved

a person talks to a therapist about alcohol withdrawal management

Alcohol withdrawal is a serious condition. Someone who abuses alcohol habitually can experience tremors, insomnia, and even seizures when attempting to taper off alcohol. Unlike other forms of drug withdrawal, it can be potentially deadly if not treated properly. The American Society of Addiction Medicine (ASAM) recently began working on improving alcohol withdrawal management guidelines.

Many doctors find the common protocols for treating patients to be inadequate. It is vital, therefore, that the current modes of diagnosis and treatment for alcohol withdrawal be looked at and improved upon. A reassessment of the clinical guidelines could help to reduce suffering from alcohol withdrawal symptoms and increase successful recovery rates.

How Is Alcohol Withdrawal Diagnosed?

Alcohol withdrawal can be identified according to several symptoms. These symptoms may appear following prolonged or heavy usage of alcohol. The symptoms are as follows:

Shaking or Tremors

Certain people will find that they can’t stop shaking during withdrawal. These shakes or tremors are one sign that the body craves a drink. Shaking may be accompanied by a severe withdrawal headache.

Nausea or Vomiting

If you are going through alcohol withdrawal, you may get extremely sick. Vomiting can last up to ten days after your last drink.


The inability to sleep is a common symptom. This may be due, in part, to extreme pain or an overactive nervous system.

Loss of Control over Bodily Functions

Someone experiencing withdrawal may experience abnormal hyperactivity. They may not be able to focus their eyes or maintain the stillness of their limbs. They might experience palpitations of the heart or stomach.


As with any drug addiction, those who attempt to stop using alcohol are likely to experience severe anxiety. This anxiety will taper off a few weeks after you stop drinking.


Alcohol dependency has a severe effect on the brain. The mind becomes accustomed to operating under the circumstances it creates. When attempting to withdraw, the lack of alcohol in the brain may make it difficult to think clearly. This should pass within the first few days.


Some people see and hear things during the withdrawal process. This can also include sensations like imaginary bugs crawling on the skin. These hallucinations usually only last for the first 48 hours after the last drink but are a sign that more severe symptoms may be present.


Seizures might occur during the first two days of detox. Some users might have clusters of minor seizures every few minutes, while others may experience prolonged seizures every few hours.

Withdrawal Timeline

There are four stages of alcohol withdrawal recognized by the ASAM. Every person withdrawing from alcohol will not necessarily experience all of them—only in some cases do people progress to the worst stages.

Autonomic Hyperactivity

This is the medical term for the stage in which you shake and feel anxiety. People will experience this stage in varying degrees of intensity. Some may simply feel slight tremors, while others vomit and vibrate uncontrollably. This stage usually peaks within two days of the last drink.


Once someone starts to hear or see things, they’ve entered the second stage of alcohol withdrawal. In its worst form, this stage will last up to one week. One significant sign of entering the hallucinatory stage is a slowly loosened grip on reality. This is a clear sign that the person should seek professional help.

Neuronal Excitation

Only around 10% of people get to this stage. At this point, seizures will start to occur. During these seizures, people often lose consciousness completely. They will experience extreme vomiting or diarrhea. It is vital that a person in this stage consults a doctor.

Delirium Tremens

The worst cases of alcohol withdrawal will produce delirium tremens, commonly known as DTs. The symptoms are uncontrollable tremors and confusion to the point of losing reality. While milder cases may have similar symptoms, the DTs produce much more intense versions. People who have this will need to be treated by an intensive care doctor.

Can You Die from Alcohol Withdrawal?

Improper detox can be deadly. Severe alcoholics can cause extreme damage to their bodies when using the cold-turkey method. People can go into shock during alcohol withdrawal because their body is dependent on the substance. This means that, without alcohol in their system, their organs don’t know how to function properly. Death can occur during the delirium tremens stage of alcohol withdrawal. Many factors can be responsible. Seizures, for example, can cause the brain to shut down. Gastric bleeding induced by vomiting can also play a major part.

Protocols for Treatment

The severity of a patient’s symptoms will determine treatment. In certain cases, people can recover from withdrawal at home. In most instances, however, a doctor will need to treat the patient in the hospital. The current protocol for alcohol withdrawal management is called the Clinical Institute Withdrawal Assessment for Alcohol (CIWA). Using CIWA, doctors will use a predetermined rubric to decide which type of treatment the patient needs. Medications are prescribed in fixed doses, except during intensive care treatments. It is common for doctors to prescribe benzodiazepines (benzos) to treat alcohol withdrawal. These medications include:

  • Chlordiazepoxide
  • Diazepam
  • Lorazepam

CIWA Protocol

When using CIWA, doctors are supposed to diagnose alcohol withdrawal under two circumstances. First, the patient must have a history of recent alcohol use. Additionally, patients must be able to communicate. If they cannot speak, sign, or explain their symptoms in any way, they cannot be diagnosed as withdrawing from alcohol. If they meet both criteria, patients are then judged on their symptoms and treated accordingly.

Recent Studies on the Downside of CIWA

According to recent studies, the CIWA protocol is often misused. The study shows the CIWA rubric to be faulty, which can result in disastrous effects among patients. It suggested that 48% of patients undergoing CIWA didn’t meet both criteria. In fact, 31% met neither criterion. 14% of those diagnosed were drinkers but could not talk. This is part of a larger subsection of people tested but did not use alcohol. Even more, 55% were capable of communicating but did not drink. These people, however, were still diagnosed with alcohol withdrawal. This resulted in a large percentage of unnecessary treatment.

What’s Wrong with CIWA?

Misdiagnosis is a dangerous thing. Those who receive an improper diagnosis are in danger of receiving the wrong treatment. When dealing with people struggling with addiction, it is necessary to avoid medications that may lead to further addiction. CIWA’s tendency to prescribe benzos for alcohol withdrawal is a major flaw in the protocol. Replacing alcohol with other addictive substances can lead to relapses. Those with a history of addiction should avoid taking benzos and seek other means of treatment if possible.

Dietary Treatment

It is important to make dietary changes to stay sober from alcohol after detox. This is one of the aspects of recovery that the ASAM does not emphasize enough. Making changes in diet can help addicts to prepare for withdrawal. Eating a combination of the right foods can ease symptoms and decrease the possibility of relapsing.

Alcohol Detox Diet

Most Americans have poor diets in general. People struggling with alcohol, on the other hand, show signs of being more nutritionally deficient than most people. Because alcohol is comprised of empty calories that cause feelings of fullness, they often fail to eat the amount of food they need. In turn, a person struggling with alcohol addiction lacks the vitamins and minerals necessary for a healthy body. When detoxing from alcohol, it is vital to get the proper dietary intake.

Eating the right foods will help provide the vitamins and minerals people in recovery need. These foods include:

  • Fruits and vegetables – Fruits and veggies are high in fiber and low in calories. For this reason, they’re helpful to the digestive system. When withdrawing from alcohol, you want to start moving toxins out of your body. Maintaining a healthy gut will help you to do so.
  • Protein – Although you should avoid fatty foods, you’ll need protein to keep you strong. Poultry, like chicken and turkey, is a good source of protein. Beans, peas, nuts, and seeds are also great, especially if you don’t eat meat.
  • Plenty of water – Water is the key to flushing toxins out of your system. After years of alcohol abuse, your body is flooded with them. Drinking water is critical, as it will help to cleanse your bloodstream. It will also help you absorb all the nutrients in your healthy meals.
  • Whole foods – Don’t eat processed foods while withdrawing or recovering. Foods with too much unnatural sugar can increase cravings and strain the digestive system. If fresh foods are out of your budget, canned fruits and vegetables will work fine.

A Future of Better Alcohol Withdrawal Management

As the ASAM conducts research into alcohol withdrawal, experts hope that they work toward a better understanding of the condition. The current modes of treatment save many people each year. However, more comprehensive diagnoses and treatment methods will be good for everybody. Those who struggle with alcohol and drug addiction, in particular, will benefit from an improvement in the ASAM’s clinical guidelines.

By working toward alternative treatments that don’t require drug usage, the organization can help prevent future deaths and relapses. By making progress in the ways experts manage withdrawal, the ASAM can help people in recovery and their families.