Chronic Drinkers and Harms Associated with Alcohol
I was recently prompted to write this article after receiving a call from a chronic drinker, “Sean” (not his real name). Sean was scheduled for admission for his addiction to alcohol. Sean was getting bad advice from his parents. Eager to see him in recovery, they asked him to stop drinking before he started treatment. That way, they explained to him, he wouldn’t be spending as much time going through alcohol withdrawal in our medical unit.
Instead, he would be able to participate in group activities and start receiving counselling sooner rather than later. The problem with going “cold turkey,” or abruptly abstaining from alcohol, is that it can be lethal for chronic drinkers like Sean. Fortunately, Sean continued to sip small amounts of alcohol (“maintenance drinking”) while travelling to our facility until our nurses were able to provide the medical support he needed to safely go through withdrawal. After a week in the medical unit, Sean was ready to join the rest of the peer group.
Acute Alcohol Withdrawal is Different From Alcohol Poisoning
The problem of acute alcohol withdrawal doesn’t get the attention that it deserves, likely because acute alcohol withdrawal is often confused with “hangovers” and alcohol poisoning. Many might minimize the risk of acute alcohol withdrawal since they confuse it with the upset stomach, fatigue, headache, thirst, and nausea that the average person experiences when he or she has had one too many on an evening out. Acute alcohol withdrawal is different.
Acute alcohol withdrawal is also confused with alcohol poisoning, which involves drinking large amounts of alcohol in a short period of time. Think of the college student who binge drinks on beer as a dare. As the Mayo Clinic points out, severe complications can coincide with alcohol poisoning (aka acute alcohol intoxication). For example, you can choke on your vomit because excessive alcohol depresses your gag reflex. People who are unconscious (passed out) are particularly at risk of choking on their vomit. Again, acute alcohol withdrawal is different.
Alcohol is a Dangerous Drug
Before I talk about acute alcohol withdrawal, let’s address another common misperception. Alcohol maybe a legalized drug but it is still dangerous. Lost in the ongoing opioid overdose public health emergency is our ongoing struggle with alcohol. A shortlist of problems associated with alcohol includes illness, unemployment, absenteeism, crime, assault, workplace incidents, motor vehicle collisions, family disruption, violence, abuse, and lost income.
A 2020 report by Canadian Substance Use Costs and Harms concluded that in 2017 the economic costs associated with substance use in Canada (primarily healthcare, lost productivity, and criminal justice) totaled $46.0 billion. Of this total, alcohol accounted for $16.6 billion (36.2%) followed by tobacco ($12.3 billion, 26.7%). The economic costs of other drugs combined pale in comparison to alcohol: e.g., opioids and other depressants ($5.9 billion, 12.9%), and cocaine and other stimulants ($3.7 billion, 8.1%). A separate 2017 study by the Canadian Institute of Health Information found that hospitalizations entirely caused by alcohol (77,000) exceeded hospitalizations for heart attacks (75,000) in 2015-2016.
Although 77,000 hospitalizations entirely caused by alcohol is a huge number, it would be far higher if it included hospitalizations partially attributable to alcohol such as cancer, strokes, motor vehicle traffic injuries, and heart disease. Alcohol accounted for more hospital stays than all other substances combined. Finally, a 2016 report by Canadian Centre for Substance Use and Addiction (CCSA) identified alcohol as the most common substance used by Canadians attending publicly-funded addiction treatment centres. This is certainly true of the clients’ drug of choice at our private centre, Sunshine Coast. Our own statistics show about 7 out of 10 of our clients are there because of alcohol, although many also struggle with other drugs (“polydrug use”).
Acute Alcohol Withdrawal is a Problem For Chronic Drinkers
An important difference between acute (or severe) alcohol withdrawal and “hangovers” and alcohol poisoning is how it is mostly a problem for chronic drinkers. In 2017, actor Nelsan Ellis died from alcohol withdrawal complications. A journalist working for the The Hollywood Reporter explained:
Nelsan’s father has bravely agreed for me to share the circumstances of Nelsan’s heart failure. Nelsan has suffered with drug and alcohol abuse for years. After many stints in rehab, Nelsan attempted to withdraw from alcohol on his own. According to his father, during his withdrawal from alcohol he had a blood infection, his kidneys shut down, his liver was swollen, his blood pressure plummeted, and his dear sweet heart raced out of control.
According to family members, Nelsan kept his problem drinking a secret because of stigma: “Nelsan was ashamed of his addiction and thus was reluctant to talk about it during his life. His family, however, believes that in death he would want his life to serve as a cautionary tale in an attempt to help others.” Perhaps that is another reason why we don’t talk about the dangers of acute alcohol withdrawal. As Nelsan’s story demonstrates, many people would rather suffer in private than reveal a shameful drinking problem.
What is Acute Alcohol Withdrawal?
Alcohol is a depressant which slows down the central nervous system. The central nervous systems of chronic drinkers respond to the constant presence of high quantities of alcohol by producing extra amounts of excitatory brain chemicals that offset its depressant effect. When alcohol is suddenly discontinued the body does not have sufficient time to adjust brain chemistry, leading to overstimulation. Symptoms of overstimulation in chronic drinkers resulting from sudden alcohol withdrawal are presented in the next section.
Stages of Acute Alcohol Withdrawal
A little known fact is that withdrawing from alcohol is far more dangerous and more likely to cause death than withdrawal from opioid drugs. Acute alcohol withdrawal typically follows four stages (Hart et al., 2016) with a predictable timeline (Long et al., 2017):
Stage 1 (begins 6-8 hours after last drink): tremors, rapid heartbeat, hypertension, profuse sweating, loss of appetite, and trouble sleeping.
Stage 2 (12-24 hours after last drink): hallucinations–typically auditory, visual, and tactile (touch).
Stage 3 (3 days after appearance of withdrawal symptoms, last 1 to 8 days): delusions, disorientation, and delirium (delirium tremens [DTs])..
Stage 4 (12-48 hours after last drink): seizure activity.
About 5 percent of people experiencing alcohol withdrawal also experience DTs or seizures (Schuckit, 1995). These relatively low numbers may be due to people receiving medical care before progressing to stages 3 and 4. Interventions involving a sedative drug (benzodiazepines, particularly diazepam) administered at stages 1 or 2 drastically reduce the likelihood that alcohol withdrawal reaches stage 3 or 4.
Another problem for the chronic drinker is the cumulative effects of acute alcohol withdrawal. Each episode of acute alcohol withdrawal brings with it increased withdrawal severity, cognitive impairment, and additional health complications (cited in Lingford-Hughes et al., 2004). This is another feature of acute alcohol withdrawal that should dissuade us from seeking a cold turkey approach.
Chronic Drinkers Have to Worry About Other Diseases, Too
Although I have focused on the problem of acute alcohol withdrawal here, chronic drinkers can also experience brain damage, liver disease, heart disease, and cancer. Chronic alcohol abusers can lose brain tissue over time due to alcohol toxicity, leading to a loss of brain function. Brain damage can also occur in chronic drinkers because of a deficiency of thiamine (vitamin B1), resulting in Wernicke-Korsakoff syndrome.
Chronic drinkers can also develop a condition referred to as fatty liver (or alcoholic fatty liver disease) in which the cell membrane of liver cells burst and die. Left untreated, fatty liver can develop into alcoholic hepatitis in which the liver becomes inflamed. Alcohol hepatitis can, in turn, develop into hepatic encephalopathy or cirrhosis. Cirrhosis is the loss of liver function resulting from severe scarring of the liver.
Much heart disease associated with chronic alcohol consumption is due to damage to the heart muscle. Heavy drinkers are also more susceptible to heart attacks, high blood pressure, and strokes. Finally, chronic drinking has also been associated with a range of cancers affecting the mouth, tongue, pharynx, larynx, esophagus, stomach, liver, lung, pancreas, colon, and rectum. According to a study by Hayashida (1998), chronic drinkers who have any of these conditions (in addition to acute alcohol withdrawal) should only receive treatment at a residential or inpatient treatment centre that is adequately staffed with medical professionals.
The tragedy of acute alcohol withdrawal is its entirely preventable nature. With proper medical care, alcohol withdrawal need not progress to delirium tremens or seizures. In the larger scheme of things, a few more days of drinking for a chronic drinker is not going to have much, if any, impact on his or her prospects for a successful recovery. Maintenance drinking in the days leading up to residential addiction treatment is key to minimizing injury or death due to acute alcohol withdrawal.
References
Hart, C. L., Ksir, C., Hebb, A. L., & Gilbert, R. W. (2016). Drugs, behaviour, and society (2nd Canadian ed.). Toronto, ON: McGraw Hill Education.
Hayashida, M. (1998). An overview of outpatient and inpatient detoxification. Alcohol Health & Research World, 22(1), 44-46.
Lingford-Hughes, A. R., Welch, S., & Nutt, D. J. (2004). Evidence-based guidelines for the pharmacological management of substance misuse, addiction and comorbidity: Recommendations for the British Association for Psychopharmacology. Journal of Psychopharmacology, 18(3), 293-335.
Long, D., Long, B., & Koyfman, Al. (2017). The emergency medicine management of severe alcohol withdrawal. American Journal of Emergency Medicine, 35, 1005-1011.
Schuckit, M. A. (1995). Drug and alcohol abuse: A clinical guide to diagnosis and treatment (4th ed.). New York, NY: Plenum Medical Book Company.
