Why is alcohol withdrawal so dangerous? How long does alcohol detox take? What's involved in treatment for alcoholism? Listen in as host William C. Moyers asks addiction recovery expert Marvin D. Seppala, MD, about the symptoms and complications of alcohol withdrawal, the process for safely detoxing from alcohol and the most effective ways to treat mild, moderate or severe alcohol use disorder.
0:00:15 William Moyers
Hello! And welcome to Let's Talk, a series of podcasts produced by the Hazelden Betty Ford Foundation on the issues that matter to us and the issues that we know matter to you, too. Prevention, research, addiction, treatment and recovery support. I'm your host, William Moyers, and joining us today is Dr. Marvin Seppala, the Chief Medical Officer of the Hazelden Betty Ford Foundation. Welcome, Marv.
0:00:40 Dr. Marv Seppala
0:00:42 William Moyers
Good to have you with us again today. Because today we're talking about a doctor's [sic] discusses alcohol withdrawal, detox and treatment. And I know you know a lot about this experience. Tell us, alcoholism—we've sort of lost touch with that word as it relates to the opioid epidemic and the debate about legalization of marijuana and the return of methamphetamine. Alcoholism it still is a big issue.
0:01:03 Dr. Marv Seppala
It is. It remains the biggest issue in the addiction field. You know, in our settings, over 60—about 60 percent of our patients—
0:01:10 William Moyers
0:01:11 Dr. Marv Seppala
—Have alcohol use disorder. If you look at the data associated with you know finances, you know the money spent on addiction, and its problems again alcoholism is way above everything else. The death rate from alcoholism is way above everything else, way above the opioid crisis. So, it's just in the opioid crisis sudden death most—a lot of young people, really obvious. Alcoholism usually after a long, long periods of drinking where people are kinda isolated because of the psychosocial issues associated with this disease.
0:01:48 William Moyers
A lot of people think that you have to be using alcohol for long periods of time before you develop a problem with it. That's not true, is it?
0:01:56 Dr. Marv Seppala
No, it isn't necessarily true. On average, so an average is you know or a balance basically, but, ten years of drinking before you really become a alcoholic that's certainly not true for everyone. You know people that are really committed and disciplined about their alcohol use can get [chuckles] become alcohol—alcoholic very quickly actually.
0:02:18 William Moyers
What are the signs and symptoms that somebody's use of alcohol is progressing into full-blown addiction to alcohol?
0:02:27 Dr. Marv Seppala
You know, if they start really using a lot of alcohol and not showing much effect of it. It's their tolerance is developing pretty dramatically, that's a symptom you can readily notice if you're a family member or close to them. Withdrawal symptoms, you know, they're shaky in the morning, they're starting to drink early in the day maybe even in the morning to prevent withdrawal. Usually you know we notice the shakiness but they might have nausea and vomiting, they might be really sweaty. Unable to really think clearly. And then all of a sudden, they have some alcohol and they look great! You know, that's pretty diagnostic [chuckles] of—
0:03:04 William Moyers
0:03:05 Dr. Marv Seppala
Of a withdrawal syndrome. Maybe not alcoholism, but probably. Consequences start to show up in their families and their social life, that sort of thing, and they don't pay attention to 'em. They just keep drinking instead. Their lives start to narrow. Where they had all kinds of other interests, hobbies, things they used to really enjoy doing—
0:03:27 William Moyers
0:03:27 Dr. Marv Seppala
And all of a—over time, that stuff all diminishes and everything they do sort of surrounded by the alcohol. Their—their life perspective becomes kinda ways of using alcohol as much as possible, really, instead of attending to the things they used to like.
0:03:46 William Moyers
And what about withdrawal? How does somebody know they're going into withdrawal and what effect does the lack of alcohol and the alcoholic system cause in terms of its impact on the body?
0:03:58 Dr. Marv Seppala
So, when people are going—the—the shakiness, the tremor, that's gonna be the first sort of thing that shows up.
0:04:04 William Moyers
0:04:05 Dr. Marv Seppala
Not necessarily DT's. So let's say it starts mildly.
0:04:08 William Moyers
0:04:08 Dr. Marv Seppala
So they get kinda shaky, feel this tremulousness even in their tongue. It—it can be in any muscle. Sweaty. Just not feeling right. Nausea, maybe vomiting. And their blood pressure can go up, their pulse can go up, respiratory rate can go up. Their body temperature can go up. So a lot of things are going on. And for most people that drink regularly they kinda know. You wake up in the morning and it's been several hours since that last drink. If they're drinking on a daily basis at fairly high levels, their withdrawal's gonna be fairly significant in the morning. Even sleep is disrupted. You know most people with an alcohol use disorder at least a moderate to severe one, they're gonna try and drink enough to get some sleep at night—
0:04:55 William Moyers
0:04:57 Dr. Marv Seppala
But the trouble is they start going into withdrawal within a few hours and that'll wake 'em right up because of all this kind of stimulatory nature of alcohol withdrawal.
0:05:03 William Moyers
Hmm. Hmm. [nodding]
0:05:07 Dr. Marv Seppala
With that, alcohol will relieve it. So, let's what you start watching for—are they really drinking early in the day, are they sneaking away for a drink in the morning, whatever. That—that eliminates all of this. Now, from a neurobiological perspective, what's goin' on is that alcohol affects the GABA receptors in our brains. And those are the primary inhibitory neurotransmitters which really are a calming neurotransmitter system. They kinda limit activity, help people calm down, help people sleep, relax, that sort of thing. And early you know a few—a drink or two, that's how people feel. They're relaxed, right?
0:05:48 William Moyers
0:05:48 Dr. Marv Seppala
They feel a little bit better that way. Over time, if you're drinking alcohol on a daily basis or in high amounts regularly, that GABA system it doesn't need to be that much you know calmer, right? So, in order—the brain starts to respond because it wants to keep the person up and walking and talking.
0:06:11 William Moyers
Right. Mmm-hmm. [nodding]
0:06:12 Dr. Marv Seppala
Instead of falling down and falling asleep and passing out. And so, the stimulatory neurotransmitters in particular glutamate which is the primary stimulatory neurotransmitter that does keep us moving and doing things, those start to get increased. So the GABA system's down-regulating this calming system because alcohol is taking care of that part of it. And in response to that, this stimulatory this glutamate system and other stimulatory neurotransmitters start getting exaggerated. And the more you drink, for the longer you drink, the more out of balance this gets. But it looks like it's kind of in balance 'cause you're able to drink and kinda function. Well if you suddenly stop drinking, that system is way out of balance. The ratio's way off and the stimulatory part of the system is really elevated and the calming part is really low. So one's up-regulated, one's down-regulated. And so, alcohol use you know looks like calming, can fall asleep, all these things associated with that you know calming system, the GABA system. Is the opposite of alcohol withdrawal. Where all of a sudden, you're completely anxious, tremulous, shakin', can't think straight, nausea, vomit—all these things are associated with that stimulatory system it's no longer balanced by the calming system, nor the alcohol. So it's driving everything. Even to the point that you could have seizures just kinda the most extreme of sort of electronic stimulatory activity in the brain. And—and even the DT's, the Delirium Tremens, when it just overcomes our ability to think and and function. To the point that we can die from 'em.
0:08:10 William Moyers
So what should somebody do who's going into withdrawal from alcohol—too much alcohol use. What should they do or what should a family member do?
0:08:19 Dr. Marv Seppala
You know it can kill people, it can be really unsafe, especially if it's high use for long periods of time. So they should get into a—a medical system.
0:08:31 William Moyers
Like an ER?
0:08:32 Dr. Marv Seppala
They could go to an ER. It wouldn't be ideal because you know you go to an ER and they send ya out. They might give you a little bit of medication to help with your withdrawal but if it isn't for a few days that could be dangerous. It could be that you go to an ER and they're gonna admit you to the hospital, which may be a good thing. You could call a treatment center like our own, we have residential treatment with medical services unit that provide for this type of alcohol withdrawal day in and day out it's just kind of bread and butter in those settings. So a good evaluation by a medical professional either an ER, or a clinic or somewhere. Or, go straight into a treatment center and get the medical care you need to—to transition into this alcohol-free state in a real smooth, safe manner.
0:09:20 William Moyers
As I mentioned at the beginning of our conversation, you know the opioid epidemic has certainly seized the—the national attention and gotten all the headlines. The legalization of marijuana is what it is. We have a podcast actually on the marijuana issue. But—but when the alcoholic out there reads or hears about these things, he or she may think they have a problem but they're not as bad say as those opioid or those heroin addicts and they're not as you know as willful as those marijuana addicts—can alcoholics be treated in the same environment as others who are struggling with a dependence on a substance?
0:10:01 Dr. Marv Seppala
It actually works really well. They have people in the same environment.
0:10:02 William Moyers
0:10:04 Dr. Marv Seppala
Yeah. Yeah. You know 'cause it although these addictions are different in a lot of ways, socially and they look different when we meet these people and—and there may be different age groups and different interests, there's always something that they can learn from each other.
0:10:21 William Moyers
0:10:22 Dr. Marv Seppala
And and it's in that identification in—in establishing you know the relationships, the fellowship found among people in Twelve Step programs and—and other group settings where people get into recovery—that's what can make the difference. That you know and it doesn't really matter what drug. You know they all have pretty specific aspects to them.
0:10:46 William Moyers
0:10:47 Dr. Marv Seppala
For people with an alcohol use disorder, they could look just awful on admission to our residential facility.
0:10:54 William Moyers
0:10:54 Dr. Marv Seppala
You know just—just terrible. 'Cause alcohol you know it just has such a huge role in undermining people physically and mentally. However, they get over it really quick. A couple weeks later they look great!
0:11:07 William Moyers
0:11:08 Dr. Marv Seppala
You know. [chuckles] And yet, somebody that has like methamphetamine, let's say they come in and—and their memory's shot.
0:11:18 William Moyers
0:11:19 Dr. Marv Seppala
Because it can affect parts of the brains and harm brain cells in their memory parts of the brains in such a way that they cannot learn new information. And alcoholics can look like that when they arrive but a month later, they look great. Or certainly much better. You know, alcohol among the substances of you know intoxication that we use, is one of the only ones that kills brain cells.
0:11:50 William Moyers
Oh interesting, I didn't realize that.
0:11:51 Dr. Marv Seppala
And any amount of alcohol kills brain cells. So, someone who drinks one beer will lose some brain cells.
0:11:59 William Moyers
0:12:00 Dr. Marv Seppala
Someone who drinks one shot will lose some brain cells. It—and we lose brain cells all the time for all kinds of reasons, so, in a way, it's not considered that big a deal but if you're drinking a lot and over time, the old terminology about wet brain—
0:12:14 William Moyers
0:12:14 Dr. Marv Seppala
In reference to alcoholics had to do with there were so much loss of brain cells that the brain itself shrunk inside the skull, allowing for fluid to cerebrospinal fluid to kind of fill that empty space—
0:12:28 William Moyers
0:12:29 Dr. Marv Seppala
And so if you took a brain scan you'd see all this fluid and called a wet brain 'cause it's all filled w—[skips or stumbles] filled with fluid now. All because of that death of brain cells. And you think of the opioids by comparison. They're killing at remarkable rates right now from overdose. The opioids don't harm our brain cells. We have an internal opioid system with receptors made for those substances. And it does—they don't harm us unless we take too much. I mean you could have a basically stop breathing from opioids and then be revived. And while you stop breathing have you know a lack of circulation, blood circulation, through your brain and kill off a whole bunch of brain cells and be left unable to move your whole left side or unable to think anymore and remember anything.
0:13:17 William Moyers
0:13:18 Dr. Marv Seppala
But it—it wasn't the opioid you know by itself harming those cells—
0:13:23 William Moyers
0:13:24 Dr. Marv Seppala
It was because you stopped breathing. [laughs]
0:13:26 William Moyers
Mmm-hmm. Mmm-hmm. [nods]
0:13:27 Dr. Marv Seppala
That remarkable different mechanism of action. And alcohol is a solvent. You know, you—if you put your hand in alcohol long enough it would absorb some. And that was why we couldn't study alcohol in the brain for so long 'cause it—there's not a distinct receptor for it; it goes all over.
0:13:45 William Moyers
0:13:45 Dr. Marv Seppala
And it was really hard to study initially. Now, we know a lot about it. And fortunately so because it's helped us develop medicines for alcohol use disorders and to figure out all this withdrawal stuff we've been talking about.
0:13:57 William Moyers
0:13:59 Dr. Marv Seppala
But it's when I was in college, I took a chemistry course. Of course, I mean preparing for medical school I gotta take chemistry. In the book I had there was a whole chapter on alcohols. And I mean there is [sic] hundreds of alcohols. I didn't know this before this course. And there's only one that humans can safely ingest. Ethyl alcohol. All the rest kill you. Almost immediately. All those other hundreds. And this one just slowly kills you by eating away at your brain and your liver and all these other parts of your body, right? [both chuckle] So it's—it's really, really, odd; they're all toxic it's just this one we tolerate somehow.
0:14:41 William Moyers
And yet despite the destructive nature of alcohol, it is possible to recover and—and to regain a healthy life, a productive life, an engaging life. Recovery from alcoholism is possible.
0:14:55 Dr. Marv Seppala
It sure is. And—and really good recovery rates. In our settings over 60 percent of people with an alcohol use disorder are sober at one year. Really remarkable. And doing really well. We look not just at are they sober but what's their quality of life.
0:15:14 William Moyers
0:15:14 Dr. Marv Seppala
And we have multiple measures used in the research literature about that. And their quality of life is dramatically better once sober. And we see real miracles. You know people getting their jobs back, re-establishing their families—
0:15:27 Dr. Marv Seppala
Going on to do remarkable things in their lives.
0:15:32 William Moyers
Look at us!
0:15:32 Dr. Marv Seppala
Like you and me!
[Both laugh heartily]
0:15:36 William Moyers
0:15:37 Dr. Marv Seppala
0:15:38 William Moyers
Well we'll end on that positive note. There's hope, just look at us! All right but Dr. Seppala, thank you very much for bringing your remarkable depth and breadth of professional experience and your personal passion to these subjects today. I know you've left our fans of the podcast I know you've left them with a lot of hope today. So, thanks a lot for joining us. [turns to camera] And thanks to all of you for joining us for another edition of Let's Talk, a series of podcasts on the issues that matter to Hazelden Betty Ford and we know matter to you, too. Again, I'm your host William Moyers, thanks for joining us and we'll see you again.