Alcohol Withdrawal Syndrome

Thursday, March 12, 2009
Pamela Kulbarsh, RN, BSW

Law enforcement officers will encounter alcoholics who have stopped drinking either because of lack of access to alcohol or illness. This sudden cessation may lead to a number of physical and mental symptoms that can range from mild to life threatening. Depending on when their alcohol supply has been cut off, the symptoms of withdrawal may not occur until after the individual has been arrested and placed in a squad car, holding cell, or taken to jail. Delirium tremens (DT) is the most acute manifestation of alcohol withdrawal. DT is a medical emergency that requires immediate treatment. It is essential that all patrol and corrections officers recognize the symptoms of acute alcohol withdrawal and intervene appropriately. Failure to do so could result in the death of a citizen or suspect, as well as the possibility of a lawsuit filed against you and/or your department.

Alcohol withdrawal syndrome can occur in any individual who is physically dependent on alcohol that stops or decreases their alcohol consumption. Alcohol dependence, also known as alcoholism, is a condition characterized by impaired control over drinking, compulsive drinking, a preoccupation with drinking, an increased tolerance to alcohol, and physical withdrawal symptoms. Approximately 15.2 million Americans are alcohol dependent. Individuals who experience acute alcohol withdrawal symptoms have typically abused alcohol on a daily basis for at least three months, or they have consumed large quantities for at least one week. Symptoms frequently worsen rapidly.

Alcohol has a sedating effect on the brain. When an individual's brain is continually exposed to the depressant effect of alcohol it begins to adjust its own chemistry. The brain starts producing serotonin and norepinephrine in larger than normal quantities. If alcohol is suddenly stopped the brain is not able to readjust its chemistry. The brain becomes over-stimulated and can create a state of temporary confusion, which may lead to dangerous changes in circulation, respiration, seizures, as well as numerous other psychiatric and physical symptoms.

The four categories of alcohol withdrawal syndrome

1. Minor withdrawal: The most common sign of alcohol withdrawal in chronic alcohol abusers is tremulousness, also referred to as the shakes or jitters, especially in the hands. These symptoms usually begin within the first five to ten hours after the individual's last drink, and peak between 24 and 48 hours. Additional symptoms of minor withdrawal may include anxiety, nausea, vomiting, rapid pulse, an increase in blood pressure, rapid breathing, irritability, nightmares or vivid dreams, insomnia, and a hypersensitivity to light, noise, and touch. In jail these symptoms are often seen the morning after arrest.
2. Major Withdrawal: The hallmark of major withdrawal is alcohol hallucinations, which occur ten to 72 hours after the last drink, and may last for two days. The symptoms can appear as frank psychosis. Up to 25% of alcohol-dependent individuals in withdrawal will have alcoholic hallucinations, which can be visual, tactile and/or auditory. They hear accusatory or threatening voices. They report seeing crawling insects, falling coins, or other moving objects. They feel things moving on or under their skin. Alcohol hallucinations are not necessarily followed by seizures or delirium tremens.
3. Withdrawal Seizures: Withdrawal seizures, also referred to as rum fits, occur within six to 48 hours after the last drink of alcohol. The risk peaks at 24 hours. 23-33% of individuals in acute alcohol withdrawal syndrome will have alcohol withdrawal seizures. The seizures are usually brief, generalized, tonic-clonic (grand mal), and without any aura. These seizures frequently occur in a cluster, and it is common for several seizures to occur over several hours. Most seizures generally terminate spontaneously, or are easily controlled with benzodiazepines (Librium, Valium, and Ativan) or other anti-seizure medications. About 30-50% of patients with alcohol withdrawal seizures progress to delirium tremens.
4. Delirium Tremens (DT): DT is the most severe manifestation of alcohol withdrawal; it is acute and may be fatal. Delirium tremens occurs in approximately 5% of people who experience alcohol withdrawal symptoms. Delirium tremens usually occurs 48 to 72 hours after the last drink, but onset may be as long as a week to ten days. Peak intensity is usually four to five days after the last alcoholic beverage. Delirium tremens is most frequently seen in individuals who are habitual chronic drinkers; but may occur after a single heavy bout of drinking. Historically, the mortality rate from delirium tremens has been as high as 35%. Early recognition and improved treatment has reduced this rate from approximately 1-5%. Delirium tremens causes dangerous shifts in breathing, circulation and temperature control. Physical manifestations include hypertension, increased respirations and heart rate, fever, and severe dehydration (from excessive sweating). DT can also restrict blood flow to the brain producing symptoms of loss of consciousness, global confusion, stupor, disorientation, anxiety, agitation, aggressive behavior, sleep disturbances, delusions and hallucinations.

Delirium tremens is most common in people who:

• Have a previous history of alcohol withdrawal symptoms, especially seizures
• Drink the equivalent of one pint of liquor per day for several months
• Have had a history of habitual alcohol use or dependence for ten years or more
• Have other risk factors, including older age, abnormal liver function, head injury, infection, other acute medical illness

Treatment

The goals of treatment are to prevent death, relieve symptoms, and reduce complications of acute withdrawal syndrome. Most individuals experiencing alcohol withdrawal can be treated safely and effectively as outpatients. Intensive care hospitalization is usually indicated if there are significant changes in vital signs, vomiting, seizures, or delirium tremens. A subdued environment is ideal; with access to respiratory and cardiac emergency treatments readily available. Benzodiazepines, the medications of choice (Valium, Librium, and Ativan), are central nervous system depressants that can prevent the more severe manifestations of acute alcohol withdrawal syndrome: seizures and delirium tremens. Additional drugs that may be given include; Phenobarbital or Phenytoin (for seizures), Haldol (for hallucinations), and Clonidine or Atenolol (for arrhythmias and hypertension). Appropriate nutrition and B vitamin supplementation is also initiated. Treatment of alcohol withdrawal should be followed by treatment for alcohol dependence.

Law Enforcement Liability

The State of Alaska paid $573,000 to settle a federal civil rights lawsuit involving the death of Troy Wallace, who was 31 years old. Wallace suffered seizures and DT before collapsing in his Ketchikan jail cell. The lawsuit alleged that jail employees, including corrections officers, were negligent and deliberately indifferent to Wallace's medical needs. (2006)

If you are an arresting or detention officer and you believe that a subject is in acute alcohol withdrawal, seek emergency medical treatment immediately.

Incarceration results in an immediate cessation of alcohol, to which an inmate may have become physically addicted. If you believe that a subject may go into seizures or delirium tremens, inform the jail's medical staff. The consequences of acute alcohol withdrawal can be fatal, even during hospitalization. Departments and facilities have a duty to educate staff about DT. Failure by a law enforcement officer to act immediately and appropriately to any medical emergency can be considered as negligence or deliberate indifference in a court of law.

Acute withdrawal is just one of many calls law enforcement officers regularly deal with related to individuals who are dependent on alcohol. Alcohol dependence is frequently a factor in assaults, domestic violence, welfare checks, traffic collisions, ad infinitum.

Arresting and re-arresting the same usual suspects for public intoxication is most often merely an exercise in futility. Even if an alcohol-dependent individual is booked into jail, it is often for a misdemeanor. He/she is released as soon as they can walk and talk again, and is back on your beat drinking and creating more hate and discontent. This cycle is time consuming and expensive. The criminal justice system incurs the ever increasing high costs of handling the chronically alcohol-dependent. Many departments have initiated serial inebriate programs. Frequent flyers with chronic arrests for being drunk in public are incarcerated for increasing sentences after each offense. These programs allow an individual more sober time while in custody while providing substance abuse counseling.

You may encounter someone who truly wants to recover from alcohol dependence. Refer these individuals to resources in your community that can help with detoxification, rehabilitation, and individual or community support.