The Alcohol Withdrawal Timeline
The alcohol withdrawal timeline is the sequence of symptoms that follows the last drink, starting 6 to 24 hours after drinking stops and carrying its highest seizure and delirium risk across the first five days.
This page maps each window hour by hour, explains delirium tremens, and covers the weeks that follow. The page also shows why past withdrawals, other illness and older age move the clock.
Read this first
Alcohol withdrawal triggers seizures and delirium tremens in some people, and both can be fatal. Anyone who drinks heavily every day should not stop suddenly without medical advice. If someone in withdrawal has a seizure, becomes confused, or develops a high fever, call 911.
Key Takeaways
- Alcohol withdrawal usually begins 6 to 24 hours after the last drink, according to the 2020 ASAM Clinical Practice Guideline on Alcohol Withdrawal Management.
- Jesse and colleagues (2017) report that more than 90% of alcohol withdrawal seizures happen within 48 hours of stopping.
- Delirium tremens can begin anywhere from the second to the fifth day after the last drink.
- Schwebach and Vempati (2023) report a death rate of about 1% to 4% once alcohol withdrawal progresses to delirium tremens.
- The ASAM guideline states that alcohol withdrawal stages do not always arrive in order, and a withdrawal seizure can be the first clear sign.
- The ASAM guideline defines kindling as repeated alcohol withdrawals becoming progressively more severe.
If you need help now
For a medical emergency, including a suspected overdose or a withdrawal seizure, call 911.
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Substance use disorders are treatable conditions. Most people who receive treatment improve, and returning to use after a period of abstinence is a common part of the course of the illness rather than a sign that treatment has failed.
What is the alcohol withdrawal timeline?
The alcohol withdrawal timeline is the order in which withdrawal symptoms appear after the last drink. Symptoms usually begin 6 to 24 hours after drinking stops. Seizures cluster in the first 48 hours. Delirium tremens can start as late as day five.
The American Society of Addiction Medicine (ASAM) sets out this sequence in its 2020 Clinical Practice Guideline on Alcohol Withdrawal Management. ASAM also states that not every patient moves through the stages in order. The alcohol withdrawal timeline is therefore a map of risk rather than a fixed schedule.
The ASAM guideline starts the withdrawal clock at the last drink, and a sharp reduction in drinking starts the same clock as stopping. Long-term drinking pushes the brain's excitatory signals up and its calming signals (GABA) down. When drinking stops, the brain is left with more excitatory than calming signal. ASAM times every withdrawal stage from the last drink, which makes the withdrawal clock a different measure from how long alcohol stays in your system.
The ASAM guideline, Jesse and colleagues, and Schwebach and Vempati agree on the usual order of events and differ on the exact hours. The table sets the three sources side by side.
| Stage | ASAM guideline, 2020 | Jesse and colleagues, 2017 | Schwebach and Vempati, 2023 |
|---|---|---|---|
| Early withdrawal (shakes, sweating, anxiety) | 6 to 24 hours | From about 6 hours | Under 6 hours |
| Alcohol hallucinosis | 12 to 24 hours | Can last up to 6 days | 8 to 12 hours |
| Withdrawal seizures | 8 to 48 hours, peak near 24 hours | 6 to 48 hours, over 90% within 48 hours | 12 to 24 hours |
| Delirium tremens | 72 to 96 hours in one passage; typically 24 to 48 hours, up to 3 to 5 days, in another | 48 to 72 hours | 24 to 72 hours |
Read together, the three sources place the first danger within the first day. The same three sources keep the delirium tremens window open until at least day five.
Many people who stop drinking never go through the full sequence. Richard Saitz reported in a 1998 review in the NIAAA journal Alcohol Health and Research World that 13% to 71% of people in detox studies developed significant symptoms. For people who do develop symptoms, the ASAM guideline times each stage in hours after the last drink.
What happens hour by hour after the last drink?
Alcohol withdrawal moves through four windows after the last drink. Early symptoms start from about 6 hours. Hallucinations can appear by 12 to 24 hours. Seizures are most likely in the first 48 hours. Delirium tremens can begin anywhere from the second to the fifth day.
Medical warning
Alcohol withdrawal seizures and delirium tremens can kill. A person who drinks heavily every day should not stop suddenly without medical advice. Call 911 if someone in withdrawal has a seizure, becomes confused, sees or hears things that are not there, runs a high fever, or has a racing heart.
6 to 12 hours after the last drink: early withdrawal and the shakes
Early withdrawal is the first window of the alcohol withdrawal timeline. Jesse and colleagues, writing in Acta Neurologica Scandinavica in 2017, place the start at about 6 hours after drinking stops. The ASAM guideline gives a wider start of 6 to 24 hours.
11 early alcohol withdrawal signs listed in the ASAM guideline:
- Anxiety
- Poor sleep
- Loss of appetite
- Vivid dreams
- Headache
- Nausea
- A racing heart (tachycardia)
- Overactive reflexes
- Heavy sweating
- Raised blood pressure
- Raised body temperature
Saitz lists tremor (the shakes), craving for alcohol and insomnia among the most common early symptoms. Saitz also reports that most of these early symptoms settle within several hours to several days, even without treatment. Early symptoms settling on their own does not rule out a later seizure or delirium tremens.
12 to 24 hours after the last drink: alcohol hallucinosis
Alcohol hallucinosis, meaning hallucinations while the person stays awake and aware, is the typical event of this window. The ASAM guideline places the onset of alcohol hallucinosis at 12 to 24 hours. Schwebach and Vempati place the onset earlier, at 8 to 12 hours.
A person in alcohol hallucinosis sees, hears or feels things that are not there but still knows where they are, according to Saitz. ASAM reports that these hallucinations typically clear within 24 to 48 hours if no signs of delirium appear.
24 to 48 hours after the last drink: the withdrawal seizure window
Withdrawal seizures are the main danger of the first two days. The ASAM guideline states that withdrawal seizures can begin as early as 8 hours after the last drink, continue for up to 48 hours, and peak at around 24 hours. Jesse and colleagues found that more than 90% of these seizures happen within 48 hours of stopping.
A withdrawal seizure is usually one generalized convulsion, meaning shaking of the arms and legs with loss of consciousness, as Saitz describes it. Jesse and colleagues report that more than half of people with withdrawal seizures have repeated seizures. In up to 5% of these people, the seizures progress to status epilepticus, a continuous seizure that is a medical emergency. The ASAM guideline advises admission to a closely monitored setting after any withdrawal seizure.
48 hours to 5 days after the last drink: the delirium tremens window
Delirium tremens, the severe late stage of alcohol withdrawal, belongs to this window. The ASAM guideline places the onset of delirium tremens at 72 to 96 hours after the last drink. Jesse and colleagues give 48 to 72 hours.
A second passage of the ASAM guideline gives an earlier typical onset for withdrawal delirium, 24 to 48 hours after drinking stops. The same passage notes that withdrawal delirium can appear as late as 3 to 5 days after drinking stops. Day four is therefore not a safe finish line, even for a person who felt better on day three. Delirium tremens has its own set of warning signs, and those signs differ from the shakes.
What is delirium tremens and when does it start?
Delirium tremens (DTs) is a severe form of alcohol withdrawal in which confusion arrives together with a racing heart, high blood pressure and fever. Delirium tremens can start from the second to the fifth day after the last drink and usually lasts 2 to 3 days.
Saitz describes delirium tremens as disorientation joined by signs of the body's stress system firing, including severe agitation, a rapid heartbeat, high blood pressure and fever. The ASAM guideline classes withdrawal as complicated once a seizure, confusion or new hallucinations appear.
6 signs of delirium tremens that need a 911 call:
- Confusion about time, place or people
- Trouble following simple instructions
- New hallucinations
- Severe agitation
- A racing heart
- A high fever
Delirium tremens differs from alcohol hallucinosis in one way a family can see. A person in alcohol hallucinosis stays aware of their surroundings, while a person in delirium tremens loses track of where they are. Delirium on its own is confusion with many possible causes. The ASAM guideline tells clinicians to test for other causes of delirium, such as low blood sugar, when the drinking history or timing does not fit alcohol withdrawal.
Delirium tremens carries a real risk of death. Schwebach and Vempati report death rates of about 1% to 4% once alcohol withdrawal progresses to delirium tremens. Saitz's 1998 NIAAA review put the figure at about 5%, with deaths from heart and metabolic complications, injury or infection.
The ASAM guideline states that delirium tremens can last only a few hours but usually lasts 2 to 3 days. Jesse and colleagues report that severe late withdrawal can last up to 2 weeks. Saitz adds that people often call the shakes "the DTs", and the two are not the same condition.
After the acute phase, a longer stage called protracted abstinence begins.
What happens after the first week without alcohol?
After the first week, most physical withdrawal symptoms have settled, but poor sleep, anxiety, low mood and craving can continue for months. Researchers call this stage protracted abstinence, and Heilig and colleagues describe it as lasting beyond 3 months in humans.
Heilig, Egli, Crabbe and Becker reviewed this stage in Addiction Biology in 2010. Their review reports that sleep problems common in early withdrawal often extend into protracted abstinence. The Heilig review also names the lasting shift in mood as a major factor behind craving and relapse.
By 15 days or 3 weeks without alcohol, most people are past the seizure and delirium windows. Poor sleep, low mood and craving often remain at that point.
The ASAM guideline gives firmer rules for the first days than for these later weeks. Its evidence review looked at the first 5 days of withdrawal and did not include protracted withdrawal. The length of each earlier stage also varies from person to person.
Why does the withdrawal timeline differ from person to person?
The withdrawal timeline shifts with a person's drinking pattern, past withdrawals, past seizures or delirium tremens, other medical illness and older age. The ASAM guideline finds strong support for a past withdrawal seizure or delirium as a predictor of another severe withdrawal.
Saitz traces the differences between people to their pattern of alcohol use, their other illnesses and their genetics. How much and how long someone has been drinking forms part of that drinking pattern.
6 risk factors for severe withdrawal named in the ASAM guideline:
- A past episode of delirium tremens
- A past withdrawal seizure
- A past episode of severe withdrawal
- A low platelet count on blood tests
- A raised level of the liver enzyme ALT
- A serious medical illness
ALT is a liver enzyme, and a raised ALT level is a sign of liver strain. The ASAM guideline warns that long-acting benzodiazepines build up in people with poor liver function and in older adults. The ASAM liver warning covers people whose liver function is impaired by liver disease caused by alcohol.
Kindling is the model for why repeated withdrawals can grow worse over time. Ballenger and Post proposed the kindling model in 1978, and the ASAM guideline defines kindling as repeated withdrawals becoming progressively more severe.
Howard Becker's 1998 NIAAA review reports a 1988 study by Brown and colleagues on people treated in hospital for detox. In that study, 48% of people who had a seizure during detox had been through 5 or more earlier withdrawals. Only 12% of people without a seizure had that history.
Clinicians estimate the risk of complicated withdrawal before symptoms start with the Prediction of Alcohol Withdrawal Severity Scale (PAWSS). Maldonado and colleagues found that a PAWSS score of 4 or more identified complicated withdrawal with 93.1% sensitivity and 99.5% specificity in medically ill hospital patients. In plain terms, the PAWSS caught about 93 of every 100 people who went on to develop complicated withdrawal. The PAWSS wrongly flagged about 1 in every 200 people who did not.
The ASAM guideline adds that older adults may follow a different timeline. Using other sedatives alongside alcohol also changes how withdrawal shows itself, according to ASAM.
Common misconception
Withdrawal always follows the stages in order, so a person without bad shakes is past the danger of a seizure.
What the evidence shows. The ASAM guideline states that not all patients move through the stages in order, and that a seizure can occur without other clear withdrawal signs. Jesse and colleagues report the same pattern (ASAM, 2020; Jesse et al., Acta Neurologica Scandinavica, 2017).
Because the withdrawal clock varies this much, clinicians score withdrawal as it happens with a severity scale rather than relying on the hour alone.
How do clinicians track and treat withdrawal as it unfolds?
Clinicians track alcohol withdrawal with the CIWA-Ar, a 10-item withdrawal checklist scored again as symptoms change. The ASAM guideline classes a CIWA-Ar score under 10 as mild, 10 to 18 as moderate and 19 or more as severe. ASAM names benzodiazepines as first-line treatment.
Sullivan and colleagues published the revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) in the British Journal of Addiction in 1989. Because the CIWA-Ar score is repeated over time, the score shows whether withdrawal is climbing or settling.
4 CIWA-Ar severity bands in the ASAM guideline:
- Mild withdrawal: CIWA-Ar under 10, with anxiety, sweating and poor sleep but no tremor
- Moderate withdrawal: CIWA-Ar 10 to 18, with mild tremor
- Severe withdrawal: CIWA-Ar 19 or more, with moderate to severe tremor but no confusion
- Complicated withdrawal: CIWA-Ar 19 or more with a seizure, confusion or new hallucinations
The ASAM guideline states that withdrawal can typically be managed safely outside hospital for people with few risk factors. For that group, ASAM advises a daily check-in with a nurse or other qualified provider for up to five days after stopping.
Benzodiazepines are the first-line medicines for alcohol withdrawal in the ASAM guideline. Benzodiazepines ease withdrawal by making up for the shortfall in the brain's calming GABA signals, according to the ASAM guideline.
Three other medicines sit outside first-line care. The ASAM guideline limits phenobarbital, an older sedative, to inpatient care with clinicians experienced in its use, because its safe dose range is narrow. ASAM lists ketamine as an add-on that still needs well-controlled trials, and finds insufficient evidence to support baclofen for withdrawal.
ASAM's evidence review measured linkage to long-term treatment for alcohol addiction, which clinicians diagnose as alcohol use disorder (AUD), as one outcome of withdrawal care.
Medical Detox in Montana
New Frontier Recovery Center provides medically supervised detox at ASAM Level 3.7 and residential treatment at ASAM Level 3.5 for adults with alcohol use disorder in Huntley, Montana. Read about our medical detox program in Huntley.
About this page
New Frontier Recovery Center publishes this material for general education. It does not replace assessment by a licensed clinician.
Frequently asked questions
How long does alcohol withdrawal last?
What is the hardest day when you quit drinking?
What happens on day 4 without alcohol?
What are the signs of alcohol withdrawal that can be serious?
How long does delirium tremens last?
What happens when you are 15 days sober from alcohol?
Is there a way to quickly detox from alcohol?
Sources
- American Society of Addiction Medicine (2020). The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management, Journal of Addiction Medicine, 14(3S Suppl 1), 1-72. Onset, seizure, hallucination and delirium timing, non-sequential stages, risk factors, CIWA-Ar severity bands, setting and medication status.
- Jesse, S. et al. (2017). Alcohol withdrawal syndrome: mechanisms, manifestations, and management, Acta Neurologica Scandinavica, 135(1), 4-16. Early withdrawal from 6 hours, over 90% of seizures within 48 hours, status epilepticus, delirium tremens onset and duration.
- Schwebach, C. and Vempati, A. (2023). Alcohol Withdrawal with Delirium Tremens, Journal of Education & Teaching in Emergency Medicine, 8(3), S1-S33. Stage timing and delirium tremens mortality of about 1% to 4%.
- Saitz, R. (1998). Introduction to alcohol withdrawal, Alcohol Health and Research World, 22(1), 5-12. Variability of symptoms, early symptoms, hallucinosis, delirium tremens signs and historical mortality.
- Becker, H. C. (1998). Kindling in alcohol withdrawal, Alcohol Health and Research World, 22(1), 25-33. The Ballenger and Post kindling model and prior-withdrawal seizure data.
- Sullivan, J. T. et al. (1989). Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar), British Journal of Addiction, 84(11), 1353-1357. The 10-item CIWA-Ar instrument.
- Maldonado, J. R. et al. (2015). Prospective Validation Study of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) in Medically Ill Inpatients, Alcohol and Alcoholism, 50(5), 509-518. PAWSS cutoff of 4, sensitivity and specificity.
- Heilig, M. et al. (2010). Acute withdrawal, protracted abstinence and negative affect in alcoholism: are they linked?, Addiction Biology, 15(2), 169-184. Protracted abstinence beyond 3 months, sleep disturbance, craving and relapse.