In-Custody Acute Alcohol Withdrawal

July 10, 2013
If you are an arresting or a detentions officer, and you believe that a subject is in or at risk for acute alcohol withdrawal, seek emergency medical treatment immediately. The consequences of acute alcohol withdrawal can be fatal, even during hospitalization.

In March, 2012 Kendall Lyons filed a lawsuit in the U.S. District Court in Eugene, Oregon.  Lyons suffered a seizure and struck his head on a cement bed while withdrawing from alcohol. He claims that his injuries could have been prevented had sheriff’s officials been more responsive to his medical condition. The lawsuit seeks $352,000 in noneconomic damages and $31,496 in medical expenses.

In May, 2011 New York City agreed to pay $2 million to settle a civil rights action lawsuit alleging that a postal worker died in jail because his severe alcohol withdrawal went untreated due to deliberate indifference by medical personnel and correction officers.

In June, 2006 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.

The Problem

Approximately 18 million Americans are alcohol dependent.  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.  Alcoholics invariably have an increased rate of contact with law enforcement and subsequent incarceration. It is estimated that 12% of all the inmates in the country’s jails are alcohol dependent. It is essential that all patrol and corrections officers recognize the symptoms of acute alcohol withdrawal and intervene quickly and appropriately. Failure to do so could result in the injury or death of a detainee or inmate, as well as the possibility of a lawsuit filed against you and/or your department. 

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 jail. 

Acute alcohol withdrawal symptoms can occur in any individual who is physically dependent on alcohol that stops or decreases their alcohol consumption.  Inmates are not always honest about their alcohol and drug habits on intake. Some over-report hoping for special treatment and medications.  Others under-report, fearing criminal charges. Without honest information the intake nurse may not identify a need for withdrawal monitoring. Officers need to be aware of symptoms of withdrawal that indicate a need for medical intervention.  The three primary signs of early alcohol withdrawal are pacing, sleeplessness, and elevated heart rate (140+). Additionally, individuals withdrawing from alcohol typically do not have an appetite/frequently refuse food, tremble, and perspire profusely. 

What Happens When an Alcoholic is Deprived of Alcohol?

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. Individuals who experience acute alcohol withdrawal symptoms typically have abused alcohol on a daily basis for at least three months, or they have consumed large quantities for at least one week.   Delirium tremens (DT) is the most acute manifestation of alcohol withdrawal.  Delirium refers to a syndrome of disorientation, confusion and often hallucinations caused by a specific disease process. DT is a medical emergency that requires immediate treatment.

The Four Categories of Alcohol Withdrawal Syndrome:  Minor to Fatal

  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 5-10 hours after the individual’s last drink, and peak between 24-48 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 occurs 10-72 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/rats/dogs, 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, were previously referred to as “rum fits”, and occur within 6-48 hours after the last drink of alcohol (the risk peaks at 24 hours). Between 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. They frequently occur in a cluster, but it is also common for several seizures to occur over several hours.  Most seizures generally terminate spontaneously, or are easily controlled with benzodiazepines or other anti-seizure medications.  About 30-50% of patients with alcohol withdrawal seizures progress to DTs.
  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 48-72 hours after the last drink, but onset may be as long as a week to 10 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.  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. The mortality of untreated DTs as high as 30%. However, early recognition and improved treatment has reduced this rate to less than 5%. 

Delirium Tremens is Most Common in People Who:

  • Have a previous history of alcohol withdrawal symptoms, especially seizures
  • Drink the equivalent of 1 pint of liquor per day for several months
  • Have had a history of habitual alcohol use or dependence for 10 years or more
  • Other risk factors:  older age, abnormal liver function, head injury, infection, other acute medical illness


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

After reviewing the three opening cases, take this one crucial point with you.  If you are an arresting or a detentions officer, and you believe that a subject is in or at risk for acute alcohol withdrawal, seek emergency medical treatment immediately.  The consequences of acute alcohol withdrawal can be fatal, even during hospitalization.   Incarceration results in an immediate cessation of alcohol, which any inmate may have become physically addicted to.  If you believe that a subject may go into seizures or delirium tremens, inform the jail’s medical staff right away.  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.

Additional Safety Concerns

There are additional safety concerns related to inmates who are withdrawing from alcohol.  Seizures and disorientation increase the inmate’s risk for falls.  Alcohol dependent individuals are at a greater risk for suicide than the general population.  This is especially true for inmates who are withdrawing from alcohol. Pay special attention to a possible increased suicide potential in these individuals. 

Ideally, any individual at risk for acute alcohol withdrawal should be placed in the infirmary or another special observation unit where ongoing assessment can be performed and staff backup is at the ready. 

About the Author

Pamela Kulbarsh

Pamela Kulbarsh, RN, BSW has been a psychiatric nurse for over 25 years. She has worked with law enforcement in crisis intervention for the past ten years. She has worked in patrol with officers and deputies as a member of San Diego's Psychiatric Emergency Response Team (PERT) and at the Pima County Detention Center in Tucson. Pam has been a frequent guest speaker related to psychiatric emergencies and has published articles in both law enforcement and nursing magazines.

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