Drug and Alcohol Withdrawal Rehab Guide

When a person develops a dependence to a particular substance, such as drugs or alcohol, they will experience symptom of withdrawal should they reduce or stop using alcohol or drugs.¹ The symptoms and their severity depend on the type of substance used and can vary widely, from a mild headache to fatal seizures. Great care should be taken with withdrawal because, based on the drug, it may be dangerous—but you will get through it and begin your journey toward recovery.¹

What Is Withdrawal?

Withdrawal is characterized by  various physiological symptoms following discontinuation or reduction of  extended use of alcohol or drugs.² The time to symptom onset, duration, and intensity of withdrawal symptoms are highly variable and depend on many factors: the substances used, and the frequency, amount and duration of use.^2,3

Withdrawal symptoms are typically uncomfortable and some may be quite distressing, and in cases of severe dependency to alcohol or benzodiazepines, for example, severe withdrawal symptoms like seizures may even be life-threatening.  In some cases, medication can help to make withdrawal more comfortable and safer.¹ The avoidance of even mild to moderate withdrawal symptoms often motivate a person to return to using drugs or alcohol.

Substance Withdrawal Symptoms

Drug or alcohol withdrawal symptoms are highly variable, and in general, the symptoms of withdrawal are usually opposite of the substance’s pharmacological effects. In general, the symptoms that characterize withdrawal are similar in each given class—for example, as opioids, withdrawal symptoms experienced when discontinuing hydrocodone and oxycodone will be similar but will likely differ substantially to withdrawal symptoms experienced after prolonged use of a stimulant like cocaine. For any withdrawal syndrome, however, the duration, intensity and time to onset will vary depending on the particular drug, duration used and the degree to which the body and brain has adapted to the substance.¹⁷

Alcohol Withdrawal: Signs & Symptoms

Alcohol withdrawal symptoms range from mild and uncomfortable to severe and potentially lethal. Symptoms may start as soon as 6 hours to as late as 24 hours after the last drink and typically last 4 to 5 days. Withdrawal symptoms may come and go during this time and may vary in intensity.^9,10

The risk of experiencing severe symptoms such as life-threatening seizures is higher for individuals who have previously experienced moderate to severe alcohol withdrawal symptoms.⁹

Mild to moderate symptoms of acute alcohol withdrawal may include:^9-12

• Anxiety.
• Irritability.
• Restlessness.
• Appetite loss.
• Trouble sleeping.
• Cognitive impairment (i.e., not thinking clearly, problems remembering things).

Complicated or severe alcohol withdrawal symptoms need prompt medical attention as they can lead to fatal consequences. These include:

• Rapid heart rate (pulse above 100) and elevated blood pressure.
• Sweating or clammy skin.
• Fever.
• Tremors in your hands or arms.
• Nausea and vomiting.
• Seeing and/or hearing things not present (i.e., hallucinations).
• Marked agitation.
• Severe confusion.
• Seizures, which generally occur within the first 48 hours of withdrawal.

Individuals experiencing more severe symptoms or who have previously experienced complicated alcohol withdrawal usually will undergo alcohol detox in a supervised medical setting. When the risks of withdrawal complications are significantly high—such as with someone  who experienced seizures during a previous alcohol withdrawal experience inpatient medical withdrawal management is necessary.⁹

Benzodiazepine Withdrawal: Signs & Symptoms

Withdrawal symptoms from benzodiazepines and other sedative-hypnotic drugs resemble those of alcohol withdrawal. Like alcohol withdrawal, symptoms may vary considerably in time of onset or intensity as withdrawal progresses.¹⁸

Withdrawal from short-acting benzodiazepines (e.g., Ativan, Xanax, Restoril) typically begin within 6-8 hours after the last dose and peak around the second day and then begin to improve on the fourth or fifth day. Withdrawal effects as a result of taking long-acting benzodiazepines (e.g., Valium, Librium) may not develop for more than a week. They tend to peak during the second week, and improve during the fourth or fifth week.¹⁴

In general, withdrawal symptoms may include:^3,13

• Increased tension, anxiety, and panic attacks.
• Irritability.
• Sleep disturbances.
• Sweating.
• Nausea.
• Muscle aches and pains.
• Headache.
• Difficulty concentrating.
• Heart palpitations.
• Hand tremors.
• Seizures.

Although not likely to be as life-threatening as those associated with alcohol withdrawal, medical complications such as seizures and delirium are possible with severe benzodiazepine withdrawal. Medical supervision during detox can help to keep people safe and comfortable, and inpatient management may be required for extreme cases of benzodiazepine withdrawal.⁹

Opioid Withdrawal: Signs & Symptoms

Acute opioid withdrawal may result in some intensely uncomfortable symptoms when attempts are made to quit or cut back on continued opioid use.⁹ People at risk of severe symptoms may benefit from a supervised medical detox, performed with the guidance and support of a medical professional.

The timeline of opioid withdrawal may vary depending on the individual and the types of drugs taken.^9,14,15

• Heroin and other relatively short-acting opioids (e.g., immediate-release morphine, hydromorphone, oxycodone, hydrocodone, oxymorphone, codeine, fentanyl): Withdrawal symptoms may occur within 6-12 hours following use cessation. Severe symptoms generally peak at 24-72 hours and usually resolve within a week, though in some cases symptoms may last months.
• Longer-acting opioids (e.g. methadone): The occurrence of withdrawal may be slightly delayed, taking roughly 12-48 hours after cessation to experience the first symptoms, and as long as 10-20 days for symptoms to largely subside.

Commonly experienced opioid withdrawal symptoms may include:^16,17

• Feeling anxious and restless.
• Nausea.
• Vomiting.
• Sweating.
• Runny nose.
• Abdominal cramping.
• Diarrhea.
• Goose bumps.
• Sweating.
• Yawning.
• Insomnia.
• Fever.

Stimulant Withdrawal: Signs & Symptoms

Stimulant withdrawal involves withdrawing from drugs including amphetamines, cocaine, methamphetamines, or medications including such as methylphenidate or Ritalin. While stimulant withdrawal may be unpleasant, it is not usually life-threatening.

Symptoms may begin as soon as drug usage has stopped, and some symptoms may last up to 2 weeks.¹⁸

Symptoms of stimulant withdrawal may include:¹⁸

• Anxiety.
• Agitation.
• Exhaustion.
• Sadness.
• Difficulty concentrating.
• Insomnia.
• Depression.
• Increased drug craving

Those going through stimulant withdrawal typically do not experience life-threatening symptoms, and medication management of the withdrawal is usually not necessary. Still, there is a possibility of an increased emotional risk for those going through withdrawal. One possibly symptom of stimulant withdrawal is intense depression, so this symptom should be monitored in order to avoid risks concerning suicidal thoughts or attempts.¹⁸

Withdrawal Factors

In addition to the symptoms associated with stopping use of a specific drug or of alcohol, other important factors that may influence the seriousness, onset, and length of the withdrawal syndrome include:^5,8

• How long the individual took the drug and how much they regularly used. Those who used drugs for longer periods or took them in larger doses could experience more extreme and longer withdrawal symptoms.
• The way the drug was used. Smoking, snorting, or injecting the drug may bring about more critical and difficult withdrawal syndromes vs. those from oral intake of liquids or pills.
• The use of additional drugs. Combining drugs with alcohol or with other drugs may lead to additional symptoms or more extreme and difficult withdrawal symptoms.
• Differences in metabolism and psychological makeup based on the individual. People may experience detoxification at different rates and may be more or less sensitive to the numerous physiological effects of withdrawal.

When is Medical Detox Necessary?

Medically supervised detox may be a good first step for a person looking to free themselves from a drug or alcohol addiction. Medical supervision and support can help provide a sense of safety and comfort, and also may also help prevent relapse.

In certain cases, medical detox is highly encouraged in an effort to minimize the risk of potentially life-threatening severe withdrawal symptoms like seizures, marked agitation, and delirium, such as that which may occur during withdrawal from alcohol and benzodiazepines.⁹ Potentially severe, relapse-prompting withdrawal is also a significant risk for people with pronounced opioid dependence.⁹

Medically managed detox is likely to be strongly encouraged for people who have a history of severe or complicated withdrawal, have had multiple withdrawal experiences, or are at risk of severe alcohol, sedative-hypnotic, and/or opioid withdrawal.⁹ 

Sources

1. National Institute on Drug Abuse. (2020). Frequently Asked Questions.
2. Gupta, M., Gokarakonda, S.B., Attia, F.N. (Updated 2020 Jul 2). Withdrawal Syndromes. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.
3. National Institute on Drug Abuse. (2017). Tolerance, Dependence, Addiction: What’s the Difference?
4. Doweiko, H. (2011). Concepts of chemical dependency. Stanford, CT: Nelson Education.
5. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
6. Heit, H. A. (2003). Addiction, physical dependence, and tolerance: Precise definitions to help clinicians evaluate and treat chronic pain patients. Journal of Pain & Palliative Care Pharmacotherapy 17(1), 15-29.
7. Ries, R. K., Fiellin, D. A., Miller, S. C., & Saitz, R. (2014). The ASAM principles of addiction medicine. New York: Lippincott Williams & Wilkins.
8. Center for Substance Abuse Treatment. (2006). Detoxification and Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series, No. 45. HHS Publication No. (SMA) 15-4131.
9. U.S. National Library of Medicine. (2019). MedlinePlus: Alcohol withdrawal.
10. Rogawski M. A. (2005). Update on the neurobiology of alcohol withdrawal seizures. Epilepsy Currents, 5(6), 225–230.
11. National Institute on Alcohol Abuse and Alcoholism. (2001). Alcohol alert: Cognitive impairment and recovery from alcoholism.
12. Petursson, H. (1994). The benzodiazepine withdrawal syndrome. Addiction, 89(11), 1455-1459.
13. Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). (2013). Washington D.C.: American Psychiatric Association.
14. Substance Abuse and Mental Health Treatment Services Administration. (2020). TIP 63: Medications for Opioid Use Disorder.
15. U.S. Food and Drug Administration. (2019). FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering.
16. U.S. National Library of Medicine. (2020). MedlinePlus: Opiate and opioid withdrawal.
17. Miller, S. C., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2019). The ASAM Principles of Addiction Medicine, Sixth Edition. Philadelphia: Wolters Kluwer.
18. Center for Substance Abuse Treatment. (1999). Treatment for Stimulant Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 33: Chapter 5—Medical Aspects of Stimulant Use Disorders.