Why Taper?
Some people can just quit drinking alcohol cold turkey without having significant withdrawal symptoms. Other people, however, may suffer significant withdrawal symptoms when they suddenly stop drinking. Alcohol withdrawal is potentially fatal, so if you find yourself starting to experience significant alcohol withdrawal symptoms when you stop drinking then it is important to gradually detoxify from alcohol rather than quitting all at once “cold turkey”. You can gradually detoxify from alcohol by tapering off. You can taper off either by using alcohol itself or by using medications.
Some people may also find it easier to just taper off their alcohol use rather than jumping immediately into an abstinence day even if they do not have significant withdrawal symptoms.
Who is likely to have significant alcohol withdrawal symptoms?
- People who have stayed drunk several days in a row
- People who have gotten drunk every night for a month or more
- People who have drank small amounts throughout the day for a month or more
- People with a history of alcohol withdrawal symptoms
What Are Withdrawal Symptoms?
Doctors classify withdrawal symptoms into three categories: mild, moderate, and severe.
- Mild or minor alcohol withdrawal usually occurs within 24 hours of the last drink and is characterized by tremulousness (shakes), insomnia, anxiety, panic, twitching, sweating, raised blood pressure and pulse, and stomach upset.
- Moderate or intermediate alcohol withdrawal usually occurs 24-36 hours after the cessation of alcohol intake. Its manifestations include intense anxiety, tremors, insomnia, seizures, hallucinations, high blood pressure, racing pulse.
- Severe or major alcohol withdrawal aka Delirium Tremens (D.T.s). This usually occurs more than 48 hours after a cessation or decrease in alcohol consumption. It is characterized by disorientation, agitation, hallucinations, tremulousness, racing heart, rapid breathing, fever, irregular heartbeat, blood pressure spikes, and intense sweating. When untreated about one person in five will die of D.T.s. Some people refer to shakes as D.T.s but this is inaccurate.
Even mild or moderate withdrawal can be dangerous for people with high blood pressure or bad hearts. Because withdrawal raises blood pressure there can be a danger of heart attack or stroke.
The longer and harder a person has drunk alcohol--the more severe the withdrawal will be.
Can people successfully use alcohol to taper off?
An unqualified YES. People have been using alcohol to taper off from alcohol since the dawn of history. Withdrawal medications are a recent invention. The idea that tapering cannot be done is a myth created by the alcohol treatment industry.
How do I know if I need to taper off?
If when you stop drinking your hands are visibly shaky, you begin to sweat a lot, you have a rapid or irregular pulse, or your blood pressure is very high then it is advisable to taper off alcohol and not quit cold turkey. You can taper off by using alcohol or by getting prescription meds from your doctor. A pulse of over 100 beats per minute is a definite danger sign.
How do I use alcohol to taper off?
Beer is the best form of alcohol to use when tapering off. If you attempt to taper off using wine or hard liquor you might just wind up getting drunk again because these have higher alcohol content than beer. Try to limit yourself to drinking no more alcohol than necessary when you start tapering. Drink just enough to keep the sweats and shakes at bay. Gradually reduce the consumption of beer as you continue to taper. If the withdrawal is not too extreme you should be tapered off in a day or so. Some people may, however take longer--three days or even a week. If you start to feel withdrawal that is a sign that your taper is not done yet.
It is also very important when tapering off to fight dehydration and to replenish lost vitamins. If you go through a medical detox the people they may rehydrate you with an IV and may also give you vitamin shots. If you are doing a self detox be sure to drink lots and lots of fluids and to take vitamin pills. We recommend Gatorade because it has balanced electrolytes. If you choose to drink water make sure that you get enough salt for electrolyte balance so that you avoid water intoxication.
How much alcohol should I drink when tapering off?
The average person takes around an hour and a half to metabolize a single standard drink--for example one 12 oz beer. People who have a very high tolerance to alcohol can metabolize up to two standard drinks (28 g of alcohol) per hour. People who have a very low tolerance to alcohol might require two or three hours to metabolize a standard drink. Males metabolize alcohol faster than females. The more you weigh the higher your tolerance. Heavy drinkers who have increased tolerance also metabolize alcohol more rapidly than average. On the other hand people who have liver damage and reverse tolerance metabolize alcohol more slowly than others.
Our general rule of thumb is for people to taper off by drinking one beer per hour. However, you may have to adjust this number up if your tolerance is very high, or you may have to adjust this number down to one beer per two or three hours if your tolerance is low. If you start with one beer an hour we recommend that you gradually cut this down to half a beer an hour over the course of the taper.
How do I taper off with other meds?
If you tell your doctor that you are having a problem with alcohol withdrawal s/he will help you taper off with a benzodiazepine such as Valium or Librium. In some states such as Minnesota the doctor is required by law to commit anyone suffering from alcohol withdrawal to an inpatient detox facility for at least 72 hours. In other states the patient may be allowed to attend and outpatient detox program or the patient may be given a prescription for a benzodiazepine for use for self detox. Typical detox regimens using these medications are as follows:
- Diazepam (Valium); 10 mg 3 or 4 times in first 24 hours, then 3 or 4 times daily as needed.
- Chlordiazepoxide (Librium); 50 mg every 6 hours for four doses, then 25 mg every 6 hours for eight doses.
If you do go to a doctor for alcohol withdrawal you may have a diagnosis of alcoholism on your medical records for the rest of your life. This can make it difficult to get medical insurance and sometimes even employment. If you want to avoid this you may choose to do the self-detox using beer as described above.
Does an instance of alcohol withdrawal mean that I can never safely drink again?
Not necessarily. Every individual must decide for him/herself whether their best option is to pursue a goal of alcohol abstinence, moderate drinking, or harm reduction. If you choose to drink again the best way to avoid another instance of withdrawal is to avoid drinking two days in a row. If you can’t do this then at least try to get in three abstinence days during the week. Try to avoid drinking day and night. The more abstinence time you have each week the lower the chance of having another instance of withdrawal. If it is just too damn much work to pursue a goal of harm reduction or moderation with too little payoff, then you may just decide that quitting is simplest. HAMS is wholeheartedly opposed to programs which try to use fear to motivate permanent abstinence from alcohol. We see these programs as usually backfiring and leading people to ever worse binges and ever worse withdrawals. We have found that people are most successful at quitting when they choose that goal for themselves.
What causes alcohol withdrawal?
Alcohol withdrawal is caused by neurotransmitter rebound. The main neurotransmitter system involved in alcohol withdrawal is the GABA (gamma-aminobutyric acid) system. Simply put, GABA receptors cause a person to feel calm, relaxed or sleepy. Alcohol enhances the functioning of these GABA receptors. This is why when people drink alcohol they will feel calm, relaxed, or sleepy. However, when the GABA receptors are exposed to alcohol over a long period of time they struggle to overcome the effect of the alcohol and to return to normal functioning. This is one reason why drinking alcohol has less and less of a payoff when consumed constantly over a long period of time. One is not nearly so relaxed by alcohol the third day into a bender as one was on the first day. After being exposed to alcohol over a long period of time the GABA receptors stop responding as efficiently to the presence of GABA. When the alcohol is suddenly no longer there, these GABA receptors now respond only very weakly to the presence of GABA. The result is anxiety, panic, and insomnia.
Another thing which happens when the function of the GABA receptor is enhanced by alcohol is that the brain tries to overcome this calming effect by producing more adrenaline and other similar neurotransmitters. When the alcohol is completely taken away then this adrenaline and its cousins are left to run rampant in the brain. This leads to raised blood pressure, raised pulse rate, rapid breathing, fever, hallucinations, seizures and D.T.s.
Alcohol also inhibits the glutamate receptor--which is the cause of staggering, slurring, and general interference with muscular coordination. Glutamate receptor rebound also appears to contribute to the withdrawal symptoms described above.
What is "kindling"?
Some people who have repeatedly gone through cold turkey withdrawal without tapering off become more and more likely to have bad withdrawals form even small amounts of alcohol. This phenomenon is referred to as “kindling”. People who have undergone kindling can suffer withdrawal seizures from drinking as little as a six pack of beer. Some decades ago some detox facilities forced clients to undergo cold turkey withdrawal to "teach them a lesson". Not only did this fail to stop people from drinking, it resulted in many people suffering from kindling. Fortunately this barbaric practice has been discontinued. The way to avoid kindling is to taper off.
REFERENCES
RICHARD D. BLONDELL, M.D., Ambulatory Detoxification of Patients with Alcohol Dependence. American Family Physician, Vol. 71/No. 3 (February 1, 2005)
http://www.aafp.org/afp/20050201/495.html
Ashok Jain, MD, Withdrawal Syndromes, eMedicine from WebMD, November 15, 2005
http://www.emedicine.com/EMERG/topic643.htm
MAX BAYARD, M.D, et. al. Alcohol Withdrawal Syndrome. American Family Physician, March 15 2004.
http://www.aafp.org/afp/20040315/1443.html
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