Alcohol dependence:
withdrawal, relapse prevention and ways out of addiction

1. What is alcohol dependence?

Alcohol dependence is a chronic illness — not a weakness of character and not a lack of willpower. According to the ICD-10, it is present when at least three of these six criteria have been met within one year:^¹

• Craving: a strong desire or compulsion to drink alcohol.
• Loss of control: when drinking starts, how much is drunk and when it stops can no longer be controlled.
• Withdrawal symptoms: shaking, sweating, restlessness as the alcohol level falls — or drinking to avoid them.
• Tolerance: more and more is needed for the same effect.
• Narrowing: other interests fall away in favour of drinking and recovering from it.
• Continuing to drink despite harm: even though physical, psychological or social consequences are noticeable.

According to current knowledge, there is no completely risk-free amount of alcohol — for your health, the rule is: the less, the better.^² Anyone who is not dependent but regularly drinks a lot still has a health problem. And: dependence is very treatable — the earlier, the better.

2. From risky drinking to dependence

The transitions are fluid. Specialists distinguish three stages, each of which calls for a different kind of help:^¹,³

The guideline is clear: in dependence, abstinence is the primary treatment goal. If it cannot be achieved at the moment, the aim should be to reduce the amount and frequency — every step down reduces the harm.^¹

3. Signs and consequences

How you might notice it

• Drinking in order to function — in the morning against shaking, sweating or inner restlessness, in the evening to switch off or to be able to sleep.
• Secrecy — hidden bottles, drinking before going out, playing down the amounts.
• Memory gaps — “blackouts” after drinking.
• Resolutions fail — despite a firm intention, it ends up being more than planned.
• Conflicts — with your partner, at work, on the road.

What alcohol does to the body

In the long term, alcohol damages almost every organ: the liver, from fatty liver to cirrhosis; the pancreas and stomach; the heart, with high blood pressure and rhythm disturbances such as atrial fibrillation; the nerves, with polyneuropathy; and the brain, with memory problems. The risk of several types of cancer rises, including cancer of the mouth, throat, oesophagus, liver, bowel and breast. Psychologically, alcohol problems often go hand in hand with depression, anxiety and sleep problems — cause and effect reinforce each other.^⁴

4. Causes and risk factors

Dependence arises from the interplay of several factors — nobody “decides” to become dependent:^¹

• Predisposition — dependence runs in families; genes influence how strongly alcohol acts and how quickly tolerance develops.
• Adaptation in the brain — alcohol intervenes in the reward system. Over time the brain adapts, and without alcohol a state of deficiency arises.
• Mental health — stress, loneliness, anxiety, depression or trauma: alcohol as “self-medication” brings relief in the short term and makes things worse in the long term.
• Environment — constant availability, a drinking culture among friends or at work, starting early in adolescence.

5. Diagnosis: taking an honest look

Your GP practice is a good first port of call — it is bound by medical confidentiality. The diagnosis is based mainly on conversation.^¹

• Questionnaire: the guideline recommends the AUDIT or its short form, the AUDIT-C — ten or three questions respectively about the amount, frequency and consequences of drinking.
• Conversation: the six criteria of dependence, drinking patterns, previous withdrawals, seizures or episodes of delirium — important for planning a safe withdrawal.
• Physical examination: liver, blood pressure, nerves, signs of withdrawal.
• Blood tests: liver values such as gamma-GT, the volume of the red blood cells (MCV) or CDT can point to chronic drinking. They cannot prove it, and normal values do not rule out a problem — see Understanding blood values.
• Co-occurring conditions: depression, anxiety, sleep disorders and other addictions are recorded and treated as well.
• Medication list: complete, including sleeping tablets and painkillers — it helps determine which withdrawal and relapse prevention medicines are safe.

6. Withdrawal: why not on your own

Anyone who has drunk heavily over a long period should not simply stop abruptly — and certainly not alone. Just a few hours after the last drink, shaking, sweating, restlessness, nausea, sleeplessness, a racing heart and rising blood pressure can set in. The most feared complications are seizures and delirium tremens, with confusion and hallucinations, which is life-threatening if untreated.^¹,⁴

According to the guideline, baclofen and GHB are not recommended for withdrawal — and neither is alcohol itself as a “medicine”. Which medicines are used and at what dose is decided by the treating team on the basis of how severe the withdrawal is.^¹

7. Relapse prevention: therapy and medication

Withdrawal is the beginning, not the treatment. The guideline calls for seamless follow-on treatment lasting at least one year.^¹

• Addiction rehabilitation — outpatient, full-day outpatient or inpatient, usually funded by the German statutory pension insurance. The addiction counselling service helps with the application.
• Psychotherapy — cognitive behavioural therapy and motivational interviewing are well supported by evidence: recognising triggers, riding out cravings, building alternatives.
• Self-help — such as Alcoholics Anonymous or the German self-help associations Blaues Kreuz, Kreuzbund and Guttempler. For many people a mainstay over years.

Put honestly: the medicines lower the risk of relapse measurably, but moderately — according to the guideline they work as part of an overall treatment plan, not as a substitute for one. Whether a medicine is suitable, and which one, is decided by the treating practice.^¹

8. Alcohol and medicines

As long as drinking continues, interactions are a real risk — and a damaged liver breaks down many medicines differently. The most important combinations:^⁴

The detailed overview, including everyday questions such as a glass of wine with an antibiotic, is in the guide Medications and alcohol; how liver damage affects dosing is covered under Medications in kidney and liver disease.

9. Relapse: not a failure

For many people, relapses are part of the course of an addiction. They do not mean that everything was in vain — what matters is how quickly you get back out.^¹

• Talk straight away: to your therapist, addiction counselling service or self-help group — the sooner, the shorter the relapse.
• Do not stop your medication on your own: acamprosate and naltrexone do not trigger an intolerance reaction with alcohol. Clarify with the practice how to proceed.
• Tolerance has dropped: after a long period of abstinence, previous amounts have a much stronger effect — risk of poisoning.
• Withdrawal again: if heavy drinking has resumed over several days, withdrawal symptoms can return — then stop with medical support.
• Review rather than condemn: what was the trigger, what would have helped? This feeds into the emergency plan.

10. Everyday life, family and help

• Use addiction counselling — free of charge, anonymous if you wish, and also for family members. The Sucht & Drogen Hotline (German addiction and drugs helpline) can be reached round the clock on 01806 313031 (charged at 20 cents per call).^³
• Plan for triggers — celebrations, stress, loneliness: if you know beforehand what you will drink and when you will leave, you are better protected.
• Learn to sleep without alcohol again — in the first weeks many people sleep badly. This usually improves; help without a risk of addiction under Sleep disorders.
• Make naltrexone visible in an emergency — a note in your wallet ensures that the emergency services and the hospital adjust pain treatment; see Medical emergency card.
• Family and friends: help rather than control — searching for bottles and covering with excuses is exhausting. Talk about your worries openly, set boundaries and get support for yourself, for example in groups for relatives.

The way out of dependence is rarely a straight line. But it is very much possible — with medical support, people who walk alongside you and a plan for the difficult moments.

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