Poor Care, Not Poor Protocols, for Alcohol Withdrawal–1

Abstract

To the Editor: I applaud Hecksel et al1Hecksel KA Bostwick JM Jaeger TM Cha S Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital.Mayo Clin Proc. 2008; 83: 274-279Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar for their study that found that many general hospital patients were treated inappropriately for alcohol withdrawal syndrome (AWS). Some patients had no recent alcohol use, and others who could not communicate were treated with a strategy that requires communication. However, the authors concluded that symptom-triggered therapy (STT) may be inappropriate in medically or surgically unstable patients or those with a history of alcohol dependence. These conclusions (echoed in the article title) cannot be drawn from their study. Because AWS occurs only in people with alcohol dependence, surely that diagnosis cannot preclude the use of STT. Furthermore, although alcohol symptom scales and STT have been studied less in general hospital patients than in patients in more specialized settings, I agree with the editorialists who concluded that STT was not inappropriate (“we doubt that the protocol itself is at fault”), rather that care was being implemented inappropriately.2Berge KH Morse RM Protocol-driven treatment of alcohol withdrawal in a general hospital: when theory meets practice.Mayo Clin Proc. 2008; 83: 270-271Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar There are 2 ways to treat AWS: STT or medications administered on a fixed schedule (FS).3Mayo-Smith MF American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal Pharmacological management of alcohol withdrawal: a meta-analysis and evidence-based practice guideline.JAMA. 1997; 278: 144-151Crossref PubMed Google Scholar Administering medications on an FS risks overdosing and underdosing but is often used to ensure that patients receive at least some benzodiazepine, often in settings in which close monitoring is impossible. However, FS doses should be supplemented (or withheld) on the basis of clinical status (ie, symptoms). Doses of STT, which are delivered on the basis of symptoms, can be implemented after an initial dose for an asymptomatic patient at high risk of complications. These 2 treatments are the only ones recommended on the basis of randomized trial results; no alternatives exist. Given the reality that people with AWS should be treated no matter their location, including in general hospitals, treatment should be with STT or FS strategies. Both approaches have limitations in general hospital patients, but the need for patients to be “monitored more closely” or the requirement of “higher benzodiazepine doses” are both issues that arise regardless of strategy. Neither proven approach limits medication doses, and both should include frequent monitoring (similar to blood sugar management in general hospitals). The editorialists suggested that AWS should be treated by specialists, in part because protocols can fail in the hands of physicians from diverse specialties. I hope they are incorrect because, if they are correct, general hospital care would need to come to a screeching halt. About 13% of general medical inpatients have current alcohol dependence.4Saitz R Freedner N Palfai TP Horton NJ Samet JH The severity of unhealthy alcohol use in hospitalized medical patients: the spectrum is narrow.J Gen Intern Med. 2006; 21: 381-385Crossref PubMed Scopus (64) Google Scholar Specialty involvement in every case of AWS is not feasible and is counter to goals of care integration for these patients whose care is so often fragmented. Generalist physicians must implement high-quality care in hospitals for numerous common conditions, including AWS. Evidence shows that they can do this (eg, venous thrombosis prophylaxis).5Tooher R Middleton P Pham C et al.A systematic review of strategies to improve prophylaxis for venous thromboembolism in hospitals.Ann Surg. 2005; 241: 397-415Crossref PubMed Scopus (231) Google Scholar More importantly, they must. We should not conclude that generalist hospital physicians cannot appropriately implement AWS care, although I agree with the authors that it has not yet been proved possible. Evidence-based protocols, along with training and systems that support good-quality care, will likely be required to achieve optimal management of AWS. Although AWS protocols may benefit from improvement, our patients will gain more if we focus on better implementation of known effective care.