Alcohol withdrawal: the timeline and the danger signs

Alcohol withdrawal usually starts 6 to 24 hours after the last drink, or after a big cut in drinking, according to ASAM’s 2020 guideline. Seizures can come as early as hour 8. Delirium, the most dangerous stage, typically begins 72 to 96 hours in. So the risk doesn’t peak on day one, and feeling a bit better on day two doesn’t mean it’s over.

It can also start before you’re sober. SAMHSA’s TIP 45 notes that acute withdrawal may begin while blood alcohol is still high.

Call 911 if

• They have a seizure, even a short one.
• They’re confused or don’t know where they are.
• They’re seeing or hearing things and also seem disoriented.
• They faint.
• They’re so drowsy you can’t wake them properly.
• They may have hit their head.
• They talk about hurting themselves or someone else.

If it’s milder but getting worse (vomiting that won’t stop, heavy shaking, real agitation), get medical care today. ASAM lists those as reasons to move someone to a more intensive level of care.

The timeline, hour by hour

These windows come from ASAM’s 2020 guideline. ASAM adds that not everyone moves through the stages in order, and that older adults may follow a different timeline.

Time since last drink	What can happen
6 to 24 hours	First symptoms: anxiety, poor sleep, vivid dreams, no appetite, headache, nausea, fast heartbeat, sweating, raised blood pressure, raised temperature, jumpy reflexes
From 8 hours	Seizures become possible
12 to 24 hours	Hallucinations (alcoholic hallucinosis) may begin
Around 24 hours	Seizure risk is at its peak
24 to 48 hours	Hallucinosis usually clears in this window if delirium doesn’t develop
Up to 48 hours	Seizures can still occur until about here
72 to 96 hours	Alcohol withdrawal delirium (delirium tremens, DTs) can begin
After DTs start	Usually lasts 2 to 3 days, sometimes only a few hours

An older review in American Family Physician (2004) put DT onset earlier, at 48 to 72 hours. Treat these as typical ranges, not deadlines.

Seizures

Almost 10% of people who show withdrawal symptoms go on to have a withdrawal seizure, per a 2015 review in Drugs. Two things make them hard to plan around. A seizure can happen with no other obvious withdrawal signs, ASAM says. And TIP 45 says predicting who will have one “cannot be accomplished with any great certainty.”

A seizure also raises the odds of progressing to DTs. That’s why a seizure during withdrawal is a 911 call, not a wait-and-see.

Hallucinosis is not the same as DTs

Some people see, hear or feel things that aren’t there in the first day or two. That’s alcoholic hallucinosis. It often fades within 24 to 48 hours. The difference from delirium is orientation: a person with hallucinosis usually still knows where they are. A person in delirium doesn’t. If hallucinations come with confusion, treat it as delirium and call 911.

Delirium tremens

ASAM now calls it alcohol withdrawal delirium. It happens in about 5% of people in alcohol withdrawal, per the 2015 Drugs review. In a study of medically ill hospital patients with alcohol use disorder, complicated withdrawal (seizures or delirium) occurred in up to 20%.

Even with medical care, 1 to 5 percent of DT episodes end in death, according to both the 2015 Drugs review (Mirijello) and the 2004 American Family Physician review. TIP 45 adds that once full DTs have developed, they “tend to run their course despite medication.” The aim of good care is to stop it from getting there.

Who is at high risk

ASAM lists these as raising the risk of complicated withdrawal:

• A past withdrawal seizure or past DTs
• Many withdrawal episodes over your lifetime (TIP 45 flags more than three past detoxes)
• A seizure during this withdrawal
• Being over 65
• Many years of heavy, regular drinking
• Another serious medical or surgical illness, especially a brain injury
• A racing pulse, high blood pressure or heavy sweating at the start
• Physical dependence on benzodiazepines or barbiturates

Other drug use, withdrawal signs while alcohol is still in the blood, and an active psychiatric condition may add risk too. Risk factors stack: two is worse than one.

Each withdrawal tends to be worse than the last. ASAM calls this kindling. If last time was rough, plan for this time to be rougher.

Clinicians use scales to put numbers on this. The PAWSS (Prediction of Alcohol Withdrawal Severity Scale) is one ASAM names. In its validation study of 403 medically ill inpatients, a score of 4 or more was a strong predictor of complicated withdrawal (93.1% sensitivity, 99.5% specificity). The CIWA-Ar scores current symptoms; ASAM treats a score of 10 or more on arrival as a sign that severe or complicated withdrawal may follow. ASAM also says these scales shouldn’t be used alone to choose the level of care.

What treatment looks like

Benzodiazepines are first-line, ASAM says, because they reduce symptoms and the chance of seizures and delirium. The Drugs review credits them with an 84% reduction in seizures.

Phenobarbital is an alternative for clinicians experienced with it, in supervised settings. When benzodiazepines aren’t an option and withdrawal is mild or moderate, ASAM names carbamazepine and gabapentin.

Thiamine (vitamin B1) is given to prevent Wernicke encephalopathy, which ASAM notes can progress to chronic Korsakoff syndrome if it isn’t treated. A clinician sets the dose and how it’s given. Suspected Wernicke means inpatient care and thiamine by injection right away.

Treatment shouldn’t wait on lab results or a bed opening up. Both ASAM and TIP 45 say so.

Where this happens depends on risk. People with few risk factors can often be managed as outpatients, with a clinician checking in daily for up to five days. Complicated withdrawal belongs in an inpatient setting. A clinician makes that call. See detox at home: what the guidelines allow and levels of withdrawal care.

Getting through withdrawal is only the first step. Withdrawal management “alone is not an effective treatment for alcohol use disorder,” ASAM says. What comes after detox covers the next steps.

If you’re worried about today

If any 911 sign is present, call 911. If not, get a clinician to assess you today: your primary care office, an urgent care, or a detox program. Enter your ZIP in the finder to see withdrawal management programs near you. SAMHSA’s National Helpline, 1-800-662-4357 (free, 24/7), refers callers to local treatment.

Sources

• ASAM, The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management, J Addict Med, 2020 (adopted Jan 23, 2020)
• SAMHSA, Quick Guide for Clinicians Based on TIP 45: Detoxification and Substance Abuse Treatment, based on TIP 45 (2006)
• Mirijello A, et al. Identification and management of alcohol withdrawal syndrome, Drugs, 2015
• Bayard M, et al. Alcohol Withdrawal Syndrome, Am Fam Physician, Mar 15, 2004
• Maldonado JR, et al. Prospective Validation Study of the PAWSS in Medically Ill Inpatients, Alcohol and Alcoholism, Sep 2015
• SAMHSA National Helpline, last updated Jun 9, 2023