Alcohol withdrawal is the most medically dangerous detox we manage. Untreated, it can produce seizures, delirium tremens, and death. With physician supervision, evidence-based benzodiazepine tapering guided by the CIWA-Ar scale, and aggressive thiamine and electrolyte repletion, it becomes safe, tolerable, and the first real step out of alcohol use disorder.
Alcohol detox is inpatient medical management of the physiologic withdrawal syndrome that follows abrupt cessation of chronic heavy alcohol use. It uses long-acting benzodiazepines — most often chlordiazepoxide (Librium) or lorazepam — dosed against the CIWA-Ar withdrawal score to control autonomic hyperactivity, prevent seizures, and eliminate the risk of delirium tremens across the roughly five-day peak-withdrawal window.
Because alcohol withdrawal is one of very few withdrawal syndromes with real mortality risk. Roughly 3 to 5% of untreated severe withdrawals progress to delirium tremens, which carries a 5% mortality rate even with modern hospital care. Symptom-triggered benzodiazepine protocols have been demonstrated in randomized trials to reduce total benzodiazepine exposure, shorten length of stay, and dramatically reduce complication rates compared to unmedicated or fixed-schedule dosing.
By calming the glutamatergic hyperactivity that drives seizures and DTs, replenishing the thiamine and magnesium that alcohol depletes and that are required to prevent Wernicke encephalopathy and cardiac arrhythmias, and bridging the patient safely to the maintenance phase — most commonly naltrexone (oral or monthly Vivitrol injection), acamprosate, or disulfiram — that dramatically reduces relapse risk over the following year.
Every alcohol-detoxing admission begins with a focused clinical assessment: quantity and frequency of daily alcohol use (grams of ethanol per day, drinking days per week), duration of heavy drinking, prior detox attempts, prior withdrawal seizures or DTs, cardiac and hepatic status, prescription and over-the-counter medications (especially other CNS depressants), and psychiatric history including suicidal ideation. Physical exam focuses on cardiovascular status, hepatic signs (jaundice, ascites, encephalopathy), neurological findings (tremor, ataxia, nystagmus suggesting Wernicke), and hydration.
Baseline laboratory includes CMP, CBC, hepatic panel, magnesium, phosphate, GGT, INR, urinalysis with urine drug screen, urine pregnancy in women of childbearing age, and a 12-lead EKG in patients over 50 or with cardiac risk. A CIWA-Ar score is obtained on admission and repeated every 4 hours across the first 72 hours (extended if withdrawal is prolonged). The first dose of benzodiazepine is triggered when the CIWA-Ar score is 8 or higher.
Chlordiazepoxide (Librium) is our default agent because its long half-life produces a gentler, self-tapering course; lorazepam (Ativan) is used instead in patients with significant hepatic impairment because it does not require hepatic oxidation. Typical dosing is 25-50 mg chlordiazepoxide (or 1-2 mg lorazepam) for CIWA scores 8-15, and 100 mg chlordiazepoxide (or 2-4 mg lorazepam) for scores 15 or higher, repeated as often as every hour early on. Peak daily requirement is usually reached by day 2, and dosing tapers naturally as symptoms subside.
IV thiamine 500 mg is administered daily for the first 3 days — before any glucose-containing IV fluid is hung — to prevent Wernicke encephalopathy, followed by oral thiamine 100 mg three times daily, oral folate, and a multivitamin. Magnesium sulfate 2-4 g IV corrects the hypomagnesemia that is nearly universal in chronic drinkers and reduces cardiac arrhythmia and seizure risk. Phosphate is repleted if serum phosphate drops below 2.0 mg/dL. Adjunctive gabapentin (300-600 mg TID) is added for craving and sleep in the last phase of detox; clonidine or propranolol may be used for persistent autonomic hyperactivity.
You arrive and complete admission within 90 minutes. Baseline vitals, physical exam, labs, EKG, and CIWA-Ar score are documented. Withdrawal symptoms — tremor, sweating, anxiety, mild elevated heart rate — typically begin 6-8 hours after the last drink. The first benzodiazepine dose is administered when CIWA-Ar is 8 or higher; most patients receive at least one dose in the first 8 hours. IV thiamine is administered before any glucose infusion.
CIWA-Ar scoring intensifies to every 4 hours. Symptoms typically escalate through the first 24 hours: tremor becomes more pronounced, nausea and vomiting may emerge, heart rate and blood pressure rise, anxiety and insomnia worsen. Benzodiazepine dosing rises correspondingly. This is the highest-monitoring window.
Withdrawal severity typically peaks at 36-72 hours after last drink. Patients with the highest CIWA-Ar scores get the closest monitoring. This is also the window where delirium tremens can emerge — an emergency with altered sensorium, severe agitation, fever, and hemodynamic instability, requiring aggressive benzodiazepine loading and possible transfer to a higher-acuity setting. Prior seizures or DTs in your history mean we take extra precautions from the start.
By day 4 the tremor has usually resolved, sleep is beginning to return, appetite is coming back. Benzodiazepine doses decline as CIWA-Ar scores normalize. Gabapentin is often added at this stage for residual anxiety, insomnia, and craving. Group activities resume gently, and case management deepens the aftercare plan.
Before discharge, every patient meets with the psychiatric provider to discuss maintenance MAT. Naltrexone (oral 50 mg daily, or monthly Vivitrol injection which is preferred for compliance), acamprosate 666 mg three times daily, and disulfiram 250 mg daily are all discussed with pros and cons. The chosen medication is prescribed and, in the case of Vivitrol, administered before departure. The first post-discharge outpatient appointment is booked within 3 days.
Minor withdrawal (tremor, anxiety, insomnia) is the most common. Withdrawal seizures — usually generalized tonic-clonic — occur in 5-15% of untreated severe withdrawals, typically within the first 48 hours. Alcoholic hallucinosis (auditory or visual hallucinations without confusion) can emerge at 12-48 hours. Delirium tremens (altered sensorium, severe autonomic instability, fever, agitation) develops in about 3-5% of untreated severe withdrawal at 48-96 hours, with 5% mortality even in modern care. All of these are dramatically reduced with our CIWA-Ar-driven protocol.
Alcohol detox at RECO Island is appropriate for medically stable adults. Patients requiring ICU-level care for hepatic decompensation (grade 3-4 encephalopathy, active variceal bleeding), unstable cardiac status, severe pancreatitis, or acute psychosis are stabilized in a higher-acuity setting first. Pregnant patients are accepted only with OB coordination and specific gentler-taper protocols.
Even with optimal management, expect some sleep disruption, mild anxiety, and appetite fluctuation. Benzodiazepines cause drowsiness and mild ataxia. Nausea and diarrhea are common in early withdrawal. We use ondansetron for nausea, hydroxyzine for insomnia, and gentle mobility to reduce ataxia risk. The goal is safe and tolerable, not pain-free.
Chronic alcohol use depletes thiamine (vitamin B1) and impairs its absorption. Untreated thiamine deficiency in the acute detox window can precipitate Wernicke encephalopathy — confusion, ataxia, ophthalmoplegia — that, if not treated within hours, progresses to permanent Korsakoff amnestic syndrome. That is why every alcohol detox at RECO Island starts with IV thiamine 500 mg daily for 3 days, before any glucose-containing fluid, before any glucose challenge, no exceptions.
Alcohol detox at RECO Island is covered by every major commercial insurance plan and most managed Medicaid plans at the ASAM Level 3.7-WM inpatient per-diem rate. Common carriers include Aetna, BlueCross BlueShield, Cigna, Optum/United, Humana, Magellan, and ComPsych. Prior authorization is typically obtained within an hour of the benefits check. Initial authorization is usually 3 to 5 days with extension based on documented clinical need.
Our admissions team completes benefits verification within 60 minutes of your call and tells you exactly what will be covered and what — if anything — you will owe out-of-pocket. If your plan denies medical necessity on initial review, our clinical team peer-reviews with the plan medical director and appeals. Financing options are available for any residual cost.
Very. Untreated severe alcohol withdrawal — the kind that follows daily heavy drinking sustained over weeks or months — carries real seizure and delirium tremens risk. Roughly 3 to 5% of untreated severe withdrawals progress to DTs, which even in modern hospital care carries about 5% mortality. Withdrawal seizures occur in 5 to 15% of severe cases. Trying to stop heavy drinking without medical supervision is one of the higher-risk decisions a person with alcohol use disorder can make; medical detox reduces those risks to near zero.
Most patients complete acute medical detox in 5 to 7 days at RECO Island. The most intense withdrawal window is 24 to 72 hours after the last drink; by day 4 the tremor has usually resolved and sleep is beginning to return. Length of stay is driven by CIWA-Ar scoring, vital-sign stability, and readiness for the next level of care — not by a fixed calendar.
Chlordiazepoxide (Librium) is our default benzodiazepine because its long half-life produces a gentler self-tapering course. Lorazepam (Ativan) is used in patients with significant hepatic impairment because it does not require hepatic oxidation. IV thiamine 500 mg daily is administered for the first 3 days to prevent Wernicke encephalopathy. Magnesium is repleted; phosphate corrected if low. Gabapentin is added in later detox for craving and sleep. Adjunctive clonidine or propranolol may be used for persistent autonomic symptoms.
Every patient who completes alcohol detox at RECO Island discusses maintenance MAT with the medical director before discharge. Naltrexone (oral 50 mg daily, or monthly Vivitrol injection) is our most-used option; acamprosate and disulfiram are alternatives. If you choose Vivitrol, it is administered before you leave. If you choose oral naltrexone or acamprosate, the prescription is written and dispensed as a bridge until your first outpatient appointment (typically within 3 days).
Only for very mild cases — someone drinking a few drinks daily with no prior withdrawal complications and no medical comorbidities. For anyone drinking heavily (more than about 6 standard drinks per day sustained over weeks), with prior withdrawal seizures or DTs, with significant medical comorbidities, or with concurrent benzodiazepine or opioid use, home detox is medically unsafe. Symptom-triggered inpatient benzodiazepine tapering has demonstrably lower mortality, complication, and readmission rates than outpatient detox in this population.
Prior alcohol withdrawal seizures are a strong risk factor for further seizures — the risk increases with each detox episode (kindling). We take that history very seriously: higher starting benzodiazepine doses, more frequent monitoring, continuous seizure precautions for the first 72 hours, and consideration of adjunctive anticonvulsants. Our medical team is trained in acute seizure response, and every room has emergency equipment. Prior DTs mandate a low threshold for higher-acuity transfer if clinical status deteriorates.
Detox is the beginning of recovery, not the end. Every patient discharges with a coordinated plan: MAT continuation, a booked appointment with an outpatient prescriber within 3 days, a referral to residential or IOP care when clinically indicated, and access to our alumni line for the first 90 days. Detox alone, without continuation into structured treatment and long-term MAT, has among the highest relapse rates in medicine.
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