Alcohol Withdrawal

Alcohol withdrawal is characterized by a latent state of hyperexcitability, representing a “rebound” phenomenon from the previously chronically depressed central nervous system caused by alcohol. In humans, alcohol withdrawal after ingesting 10–15 drinks per day for 10 days leads to time-dependent effects that begin within a few hours of abstinence, depending on the blood alcohol levels obtained (Table 6.6). Early stages of withdrawal, up to 36 h, are characterized by tremor and elevated sympathetic nervous system responses, including increased heart rate, blood pressure, and body temperature. Such physical signs are accompanied by insomnia, anxiety, anorexia, and dysphoria. Later stages of withdrawal, if left untreated (which is rare today), can include more severe tremor, sympathetic responses, anxiety, and delirium tremens. Delirium tremens is characterized by vivid hallucinations and psychotic behavior. High fever can also occur and be life-threatening, but, again, this is rare in modern medicine because of the availability of benzodiazepines for treatment.

BOX 6.5

I am David. I am an alcoholic. I have always been an alcoholic. I will always be an alcoholic. I cannot touch alcohol. It will destroy me. It is like an allergy – not a real allergy – but like an allergy.

I had my first drink at sixteen. I got drunk. For several years I drank every week or so with the boys. I didn’t always get drunk, but I know now that alcohol affected me differently than other people. I looked forward to the times I knew I could drink. I drank for the glow, the feeling of confidence it gave me. But maybe that’s why my friends drank too. They didn’t become alcoholics. Alcohol seemed to satisfy some specific need I had, which I can’t describe. True, it made me feel good, helped me forget my troubles, but that wasn’t it. What was it? I don’t know, but I know I liked it, and after a time, I more than liked it, I needed it. Of course, I didn’t realize it. It was maybe ten or fifteen years before I realized it, let myself realize it. My need was easy to hide from myself and others (maybe I’m kidding myself about the others). I only associated with people who drank. I married a woman who drank. There were always reasons to drink. I was low, tense, tired, mad, happy. I probably drank as often because I was happy as for any other reason. And occasions for drinking – when drinking was appropriate, expected – were endless. Football games, fishing trips, parties, holidays, birthdays, Christmas, or merely Saturday night. Drinking became interwoven with everything pleasurable – food, sex, social life. When I stopped drinking, these things, for a time, lost all interest for me, they were so tied to drinking. I don’t think I will ever enjoy them as much as I did when drinking. But if I had kept drinking, I wouldn’t be here to enjoy them. I would be dead.

So, drinking came to dominate my life. By the time I was 25 I was drinking every day, usually before dinner, but sometimes after dinner (if there was a “reason”), and more on weekends, starting in the afternoon. By 30, I drank all weekend, starting with a beer or Bloody Mary in the morning, and drinking off and on, throughout the day, beer or wine or vodka, indiscriminately. The goal, always, was to maintain a glow, not enough, I hoped, that people would notice, but a glow. When five o’clock came. I thought, well, now it’s cocktail hour and I would have my two of three scotches or martinis before dinner as I did on non-weekend nights. After dinner I might nap, but just as often felt a kind of wakeful calm and power and happiness that I’ve never experienced any other time. These were the dangerous moments. I called friends, boring them with drunken talk; arranged parties; decided impulsively to drive to a bar. In one year, at the age of 33. I had three accidents, all on Saturday night, and was charged with drunken driving once (I kept my licence, but barely). My friends became fewer, reduced to other heavy drinkers and barflies. I fought with my wife, blaming her for her drinking, and once or twice hit her (or so she said – like many things I did while drinking, there was no memory afterward). And by now I was drinking at noontime, with the lunch hour stretching longer and longer. I began taking off whole afternoons, going home potted. I missed mornings at work because of drinking the night before, particularly Monday mornings. And I began drinking weekday mornings to get going. Vodka and orange juice. I thought vodka wouldn’t smell (it did). It usually lasted until an early martini luncheon, and I then suffered through until cocktail hour, which came earlier and earlier. By now I was hooked and knew it, but desperately did not want others to know it. I had been sneaking drinks for years – slipping out to the kitchen during parties and such – but now I began hiding alcohol, in my desk, bedroom, car glove compartment, so it would never be far away, ever. I grew panicky even thinking I might not have alcohol when I needed it, which was just about always.

For years, I drank and had very little hangover, but now the hangovers were gruesome. I felt physically bad – headachy, nauseous, weak – but the mental part was the hardest. I loathed myself. I was waking early and thinking what a mess I was, how I had hurt so many others and myself. The words “guilty” and “depression” sound superficial in trying to describe how I felt. The loathing was almost physical – a dead weight that could be lifted in only one way, and that was by having a drink, so I drank, morning after morning. After two or three, my hands were steady, I could hold some breakfast down, and the guilt was gone, or almost. Despite everything, others knew. There was the odor, the rheumy eyes, and flushed face. There was missing work and not working well when there. Fights with wife, increasingly physical. She kept threatening to leave and finally did. My boss gave me a leave of absence after an embarrassed remark about my “personal problems.” At some point I was without wife, home, or job. I had nothing to do but drink. The drinking was now steady, days on end. I lost appetite and missed meals (besides, money was short). I awoke at night, sweating and shaking, and had a drink. I awoke in the morning vomiting and had a drink. It couldn’t last. My ex-wife found me in my apartment shaking and seeing things, and got me in the hospital. I dried out, left, and went back to drinking. I was hospitalized again, and this time stayed dry for six months. I was nervous and couldn’t sleep, but got some of my confidence back and found a part-time job. Then my ex-boss offered my job back and I celebrated by having a drink. The next night I had two drinks. In a month I was drinking as much as ever and again unemployed. That was three years ago. I’ve had two big drunks since then but don’t drink other times. I think about alcohol and miss it. Life is gray and monotonous. The joy and gaiety are gone. But drinking will kill me. I know this and have stopped – for now.

From: anonymous

Such a description is reasonably accurate with regard to the physical signs of alcohol withdrawal, but it does not address the motivational effects of alcohol withdrawal. Individuals with alcoholism also show dramatic evidence of dysphoric states during acute withdrawal that persist into protracted abstinence, including symptoms of anxiety, dysphoria, and depression. In a number of inpatient studies, acute withdrawal (i.e., the first week post-alcohol) is characterized by Beck Depression Inventory scores and Hamilton Depression Scores in the range of moderate depression. In these inpatient studies, depression scores decline during subsequent weeks of treatment but remain at an intermediate elevated level for up to 4 weeks after withdrawal. Similar results were found for anxiety measures, even in subjects without comorbid anxiety or depression. Independent of comorbidity status, individuals who relapsed had higher trait anxiety scores than those who abstained. Although individuals with alcoholism show significant decreases in measures of depression and anxiety during withdrawal, there is a measurable level of depression/anxiety symptoms that persist long after acute withdrawal into protracted abstinence that may be relevant for the treatment of alcoholism.

TABLE 6.5

Progressively Worsening Alcoholic Employee Behavior Patterns

Source: Cline S. Alcohol and Drugs at Work. Drug Abuse Council, Washington DC, 1975.

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