Treatment Of Alcohol Withdrawal Research Articles

Challenges in Prediction, Diagnosis, and Treatment of Alcohol Withdrawal in Medically Ill Hospitalized Patients

Challenges in Prediction, Diagnosis, and Treatment of Alcohol Withdrawal in Medically Ill Hospitalized Patients

USE OF BIOCHEMICAL MARKERS IN EARLY PREDICTION OF DELIRIUM TREMENS IN GERIATRIC PATIENTS WITH ALCOHOL USE DISORDERS

Introduction Delirium Tremens (DT) may be an underrecognized entity in the elderly, leading to both morbidity and mortality in patients with alcohol use disorders (AUDs). The clinical institute of withdrawal assessment for alcohol- revised (CIWA-Ar) protocol has been established and widely used in hospital systems for management and prevention of further complications in geriatric patients with AUDs. The CIWA- Ar score is also often used in disposition decision making with patients being discharged from the emergency room for outpatient detoxification if score is Methods The authors conducted a literature review regarding identification and management of delirium tremens in geriatric patients with a history of alcohol use disorder.We searched PubMed using keywords and phrases including: delirium tremens, alcohol withdrawal, chronic alcoholism, CIWA, alcohol effect on CNS, treatment of delirium tremens, treatment of alcohol withdrawal. Results If early identification of delirium tremens and appropriate disposition is the goal that small rural healthcare settings should aim for then it is critical that early predictors of alcohol withdrawal seizures and delirium tremens are clearly established. The overdependence on physical markers such as pulse and blood pressure may be counterproductive in psychiatric units, which lack adequate nursing staff to constantly monitor these vitals. The CIWA-Ar protocol, although validated and useful in many patients with alcohol withdrawal in the general hospital setting, does have drawbacks. Its efficacy and use has not been as successful in patients with complex medical illnesses as well as post-surgical patients. Conclusions Established laboratory tests such as γ-glutamyltransferase (GGT) activity, aspartate aminotransferase (AST) activity, high-density lipoprotein cholesterol (HDL-C) content of serum, and erythrocyte mean corpuscular volume (MCV) are established markers of alcohol intake and provide valuable measures of recent alcohol intake and abstinence. In the same light, homocysteine, potassium levels and platelet counts should be integral part of the assessment of persons with hazardous alcohol consumption. The employment of biochemical markers, electrolyte assessment and BP monitoring along with basic history taking and examination skills in decision making regarding disposition and treatment should form the basis of alcohol use disorder management protocols especially in low resource settings with limited nursing support. This research was funded by: No funding was received for this poster presentation

The alcohol detoxification protocol and creation of the e-consult at Central Texas Veterans health care system

Within the Central Texas Veterans Health Care System, the alcohol-related disorder readmission rate has been recognized as an area that needs improvement. The aim of this quality improvement initiative was to develop an alcohol detoxification protocol. This protocol assesses the need for inpatient vs outpatient management of alcohol withdrawal and provides guidance pertaining to medication options, with emphasis on prescribing gabapentin for treatment of alcohol withdrawal. The protocol also contains the alcohol detox e-consult, which prompts a physician to call the patient daily to assess alcohol withdrawal, ability to abstain from alcohol, medication compliance, interest in substance abuse treatment programs, and appropriate follow-up. After implementing the protocol and e-consult, we saw a reduction in the admission rate of alcohol-related disorders and patients found the consult helpful.

Patient-Centered Placement Matching of Alcohol-Dependent Patients Based on a Standardized Intake Assessment: Primary Outcomes of an Exploratory Randomized Controlled Trial

Background: Placement matching guidelines are promising means to optimize patient-centered care and to match patients’ treatment needs. Despite considerable research regarding placement matching approaches to optimize alcohol abuse treatment, findings are inconclusive. Objectives: To investigate whether the use of patient-centered placement matching (PCPM) guidelines is more effective in reducing heavy drinking and costs 6 months after discharge from an inpatient alcohol withdrawal treatment compared to usual referral to aftercare. Secondary aims were to investigate whether age, gender, trial site or level of care (LOC) are moderators of efficacy and whether patients who were actually referred to the recommended LOC had better treatment outcomes compared to patients who were treated under- or overmatched. Methods: Design. Exploratory randomized controlled trial with measurements during withdrawal treatment and 6 months after initial assessment. Setting. Four German psychiatric clinics offering a 7–21 day inpatient qualified withdrawal program for patients suffering from alcohol dependence. Participants. From 1,927 patients who had a primary diagnosis of alcohol dependence and did not have organized aftercare when entering withdrawal treatment, 299 were invited to participate. Of those, 250 were randomized to the intervention group (IG, n = 123) or the control group (CG, n = 127). Intervention. The PCPM were applied to patients of the IG by feeding back a recommendation to a LOC for aftercare that was calculated from the Measurements in the Addictions for Triage and Evaluation (MATE) and discussed with the staff of the treatment unit. Patients of the CG received a general feedback regarding their MATE interview on request. Measurements. The MATE, the Client Socio-Demographic and Service Receipt Inventory-­European Version and the MATE-Outcomes were administered. Data were analyzed using generalized linear models. Results: In the intention-to-treat analysis, there were no significant differences between IG and CG regarding days of heavy drinking (incident risk ratio [IRR] 1.09; p = 0.640), direct (IRR 1.06; p = 0.779), indirect (IRR 0.77; p = 0.392) and total costs (IRR 0.89; p = 0.496). Furthermore, none of the investigated moderator variables affected statistically significant drinking or cost-related primary outcomes. Regardless of group allocation, patients who received matched aftercare reported significantly fewer days of heavy drinking than undermatched patients (IRR 2.09; p = 0.004). For patients who were overmatched, direct costs were significantly higher (IRR 1.79; p = 0.024), but with no additional effects on alcohol consumption compared to matched patients. Conclusions: While the use of PCPM failed to affect the actual referral to aftercare, our findings suggest that treating patients on the recommended LOC may have the potential to reduce days of heavy drinking compared to undertreatment and costs compared to overtreatment.

Actigraphy assessment of motor activity and sleep in patients with alcohol withdrawal syndrome and the effects of intranasal oxytocin.

The alcohol withdrawal syndrome increases autonomic activation and stress in patients during detoxification, leading to alterations in motor activity and sleep irregularities. Intranasal oxytocin has been proposed as a possible treatment of acute alcohol withdrawal. The aim of the present study was to explore whether actigraphy could be used as a tool to register symptoms during alcohol detoxification, whether oxytocin affected actigraphy variables related to motor activity and sleep compared to placebo during detoxification, and whether actigraphy-recorded motor function during detoxification was different from that in healthy controls. This study was a part of a randomized, double blind, placebo-controlled trial in which 40 patients with alcohol use disorder admitted for acute detoxification were included. Of these, 20 received insufflations with intranasal oxytocin and 20 received placebo. Outcomes were actigraphy-recorded motor activity during 5-hour sequences following the insufflations and a full 24-hour period, as well as actigraphy-recorded sleep. Results were related to clinical variables of alcohol intake and withdrawal, including self-reported sleep. Finally, the actigraphy results were compared to those in a group of 34 healthy individuals. There were no significant differences between the oxytocin group and the placebo group for any of actigraphy variables registered. Neither were there any correlations between actigraphy-recorded motor function and clinical symptoms of alcohol withdrawal, but there was a significant association between self-reported and actigraphy-recorded sleep. Compared to healthy controls, motor activity during alcohol withdrawal was lower in the evenings and showed increased variability. Intranasal oxytocin did not affect actigraphy-recorded motor activity nor sleep in patients with acute alcohol withdrawal. There were no findings indicating that actigraphy can be used to evaluate the degree of withdrawal symptoms during detoxification. However, patients undergoing acute alcohol withdrawal had a motor activity pattern different from than in healthy controls.

The potential effects of an extended alcohol withdrawal treatment programme on morbidity and mortality among inpatients in the German city of Bremen: a simulation study

BackgroundAccording to the German guidelines, people with severe alcohol use disorders (AUDs) should receive withdrawal treatment. Compared to somatic withdrawal treatment (SWT), extended duration and psychosocial elements of so-called “qualified withdrawal treatment” (QWT) aim to reduce relapse rates. Despite promising results of prospective studies on QWT, only few German inpatients seeking withdrawal treatment receive QWT. We estimated the potential effects on mortality and morbidity for higher proportions of treatment-seeking patients receiving QWT rather than SWT in the German city of Bremen.MethodsIn 2016 and 2017, 2051 inpatients were admitted to two specialised hospitals for withdrawal treatment. The potential beneficial effects of QWT over SWT were estimated by simulating treatment outcomes taken from two prospective studies. Outcomes comprised number and length of all-cause hospitalisations within 5 years, as well as abstinence and all-cause mortality rates within 28 months. Outcomes were estimated for actual and increased rates of QWT (25, 50%) among inpatients seeking alcohol treatment.ResultsIn the selected hospitals, 170 patients (8%) received QWT. If 25% of AUD inpatients were to receive QWT, benefits in abstinence rates (+ 18%), the total number of hospitalisations (− 9%) and hospital days (− 10%) could be expected. If 50% of AUD inpatients were to receive QWT, benefits in abstinence rates (+ 45%), the total number of hospitalisations (− 23%) and hospital days (− 26%) were more pronounced, in addition to reductions in mortality (− 20%).ConclusionIncreasing the proportion of people with severe AUD enrolled in extended withdrawal treatment programs (such as QWT) may contribute to reduce overall alcohol-attributable burden of disease. Randomised controlled trials or other prospective studies controlling for confounding factors are needed to determine the potential at the population level.

Cannabidiol (CBD) for the Treatment of Alcohol Withdrawal

Cannabidiol (CBD) for the Treatment of Alcohol Withdrawal

Benzodiazepine resistant alcohol withdrawal: What is the clinician's preferred definition?

Although alcohol withdrawal is common, the recognition of benzodiazepine-resistant alcohol withdrawal is a relatively new concept. To provide a framework for both literature review and future research, we assessed clinicians' personal definition of resistant alcohol withdrawal. We developed a cross-sectional web-based survey. Administrators from collaborating toxicology and emergency medicine associations deployed the survey directly to their respective memberships. Only physicians, pharmacists, and other clinicians routinely treating alcohol withdrawal were eligible to participate. Respondents selected their preferred definition among the three most common author sources - JB Hack, NJ Benedict, D Hughes - or provided their own. Additional criteria to define resistant alcohol withdrawal were explored. 384 individuals answered the survey. Respondents were mostly attending physicians (79%), in full-time practice (90%), in emergency medicine (70%), and from North America (90%). The majority (64%) described resistant alcohol withdrawal as a high benzodiazepine dosage. Seizures (26%) and persistent tachycardia (16%) were also main characteristics. The median dose to describe high benzodiazepine dose (n = 146) was 40 mg per hour of diazepam equivalents (IQR 20-50). Available definitions were ranked equally as the preferred one: Hack (27%); Benedict (28%); Hughes (28%). Our results did not identify one single preferred definition for resistant alcohol withdrawal even though a high total dose of benzodiazepine is a major component. Hourly requirements of 40 mg of diazepam equivalents or more emerged as a possible threshold. These findings serve as a base to explore consensus guidelines or future research.

DNA-methylation of the dopamin receptor 2 gene is altered during alcohol withdrawal

The dopaminergic neurotransmission is known to be of crucial importance in addictive behavior. Epigenetic regulation like methylation of DNA influences the function of dopaminergic transmission. The present study investigated alterations of DNA methylation in the dopamine D2 receptor (DRD2)-gene in patients suffering from alcohol dependence. The study sample consists of 99 alcohol dependent males admitted for alcohol withdrawal treatment and a control group of 33 healthy participants. Blood samples underwent bisulfite sequencing to determine levels of DNA-methylation of the promoter region of the DRD2 gene. Mixed linear modeling was used to test differences between patients and controls, course of methylation during detoxification. While DRD2-gene methylation did not differ significantly between patients and controls, we found a significant increase of DRD2-gene methylation during alcohol withdrawal/early abstinence. Craving, measured with the Obsessive Compulsive Drinking Scale (OCDS), was significantly associated with DRD2-gene methylation. Furthermore, smoking significantly influenced DRD2-gene methylation in both, patients and controls. As in other types of addictive disorders, DRD2-gene methylation is altered during alcohol withdrawal/early abstinence. The findings regarding an association with alcohol craving and tobacco consumption point towards a crucial role of DRD2-gene methylation in the neurobiology of addictive behavior.

Evaluation of the Brief Alcohol Withdrawal Scale Protocol at an Academic Medical Center.

The standard of care for treatment of alcohol withdrawal is symptom-triggered dosing of benzodiazepines using a withdrawal scale. Abbreviated scales are desired for clinician efficiency. The objective of this study was to evaluate the use of the 5-item Brief Alcohol Withdrawal Scale (BAWS) protocol. This single-center, retrospective, observational, cohort study assessed patients ordered the BAWS protocol between August 1, 2016 and July 31, 2017. Data were collected on benzodiazepine exposure, duration of treatment, withdrawal severity, agitation, over-sedation, and delirium while being treated for alcohol withdrawal. Comparisons were made to analyze predetermined patient subgroups. Seven hundred ninety-nine patients were initiated on the BAWS protocol. Patients received a median (IQR) of 0 (0-4) lorazepam equivalents (LEs) and were on the BAWS protocol for a median (IQR) of 44.9 (22.4-77.2) hours. Of the patients that received benzodiazepines while on the BAWS protocol, a median (IQR) of 4 (2-11) LEs were given. Seventeen (2.1%) patients had severe withdrawal. Days of agitation, over-sedation, and delirium were minimal, with the median (IQR) of 0 (0-0). Few patients received adjunctive medications for symptom management. Intensive care unit (ICU) patients had more severe withdrawal than non-ICU patients, but received the same cumulative benzodiazepine dose. Most patients on the BAWS protocol received little-to-no benzodiazepines; severe withdrawal, agitation, delirium, or over-sedation were uncommon. This is the first evaluation of the BAWS protocol on a diverse population of hospitalized patients.

Dexmedetomidine infusions and phenobarbital in the treatment of an unusual presentation of benzodiazepine-resistant alcohol withdrawal

Background: Alcohol withdrawal is a life-threatening condition characterized by a myriad of physiologic changes including tachycardia, hypertension, lowered seizure threshold, hallucinations, and potential for delirium tremens. Benzodiazepines remain the gold standard for treatment of alcohol withdrawal, although few studies have compared barbiturates to benzodiazepines as first-line treatment. Methods: This study is a single patient chart review. Results: Over the course of his hospital stay, in addition to receiving a continuous infusion of dexmedetomidine, the patient received a total of 389 mg lorazepam, 650 mg phenobarbital, 40 mg haloperidol, 25 mg quetiapine, 5 mg midazolam, and 75 mg diphenhydramine. Conclusion: Phenobarbital is an effective first line agent for management of alcohol withdrawal and may be a safer and more effective treatment with lower rates of intubation and shorter hospital stays than benzodiazepines. It is particularly successful in patients who require high doses of benzodiazepines or ICU admission. Furthermore, the role of dexmedetomidine infusions in alcohol withdrawal remains unclear but may play a critical role in mitigating tachycardia and hypertension though it poses a risk of bradycardia and hypotension. Keywords: Alcohol withdrawal, Dexmedetomidine, Precedex, Phenobarbital, Ativan, Lorazepam, CIWA, GABA channel.

Treatment of Unhealthy Alcohol Use

Unhealthy alcohol use represents the fifth leading cause of morbidity and mortality globally, and the first leading cause among persons 18 to 45 years of age. Despite the global impact of unhealthy alcohol use, the adoption of evidence-based treatments has been sluggish. Behavioral strategies for lower level drinking include the brief motivational interview, designed to be within the scope of any healthcare provider, and more specialist-driven approaches for those with alcohol use disorder (AUD) such as cognitive behavioral therapy and motivational enhancement therapy. Benzodiazepines remain the mainstay treatment for inpatient alcohol withdrawal treatment, whereas other medications have similar efficacy in managing patients in the outpatient setting with milder forms of withdrawal. For maintenance treatment of AUD, four FDA-approved medications exist, with efficacy in treating AUD, as well as several non–FDA-approved medications that have been found to be effective in promoting abstinence and reducing drinking. The use of medication to treat many patients with AUD falls within the scope of primary care providers. This review contains 6 tables and 54 references. Key Words: addiction, alcohol, counseling, drinking, pharmacotherapy, primary care, psychotherapy, relapse, treatment

Treatment of Unhealthy Alcohol Use

Unhealthy alcohol use represents the fifth leading cause of morbidity and mortality globally, and the first leading cause among persons 18 to 45 years of age. Despite the global impact of unhealthy alcohol use, the adoption of evidence-based treatments has been sluggish. Behavioral strategies for lower level drinking include the brief motivational interview, designed to be within the scope of any healthcare provider, and more specialist-driven approaches for those with alcohol use disorder (AUD) such as cognitive behavioral therapy and motivational enhancement therapy. Benzodiazepines remain the mainstay treatment for inpatient alcohol withdrawal treatment, whereas other medications have similar efficacy in managing patients in the outpatient setting with milder forms of withdrawal. For maintenance treatment of AUD, four FDA-approved medications exist, with efficacy in treating AUD, as well as several non–FDA-approved medications that have been found to be effective in promoting abstinence and reducing drinking. The use of medication to treat many patients with AUD falls within the scope of primary care providers. This review contains 6 tables and 54 references. Key Words: addiction, alcohol, counseling, drinking, pharmacotherapy, primary care, psychotherapy, relapse, treatment

Treatment of Unhealthy Alcohol Use

Unhealthy alcohol use represents the fifth leading cause of morbidity and mortality globally, and the first leading cause among persons 18 to 45 years of age. Despite the global impact of unhealthy alcohol use, the adoption of evidence-based treatments has been sluggish. Behavioral strategies for lower level drinking include the brief motivational interview, designed to be within the scope of any healthcare provider, and more specialist-driven approaches for those with alcohol use disorder (AUD) such as cognitive behavioral therapy and motivational enhancement therapy. Benzodiazepines remain the mainstay treatment for inpatient alcohol withdrawal treatment, whereas other medications have similar efficacy in managing patients in the outpatient setting with milder forms of withdrawal. For maintenance treatment of AUD, four FDA-approved medications exist, with efficacy in treating AUD, as well as several non–FDA-approved medications that have been found to be effective in promoting abstinence and reducing drinking. The use of medication to treat many patients with AUD falls within the scope of primary care providers. This review contains 6 tables and 54 references. Key Words: addiction, alcohol, counseling, drinking, pharmacotherapy, primary care, psychotherapy, relapse, treatment

Symptom-Triggered Therapy for Alcohol Withdrawal Syndrome: a Systematic Review and Meta-analysis of Randomized Controlled Trials.

Benzodiazepines are the standard medication class for treating alcohol withdrawal. Guidelines recommend dosing based on objectively measured symptoms (symptom-triggered therapy) rather than fixed dose regimens. However, the superiority of symptom-triggered therapy has been questioned, and concerns have been raised about its inappropriate use and safety. We aimed to assess whether symptom-triggered therapy is superior to fixed dose schedules in terms of mortality, delirium, seizures, total benzodiazepine dose, and duration of therapy. A systematic literature search using Medline, Embase, and the Cochrane Registry through February 2018 was conducted for randomized controlled trials of patients with alcohol withdrawal syndrome comparing fixed dose benzodiazepine schedules to symptom-triggered therapy. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Outcomes were pooled using random effects meta-analysis. Heterogeneity was estimated using the I2 statistic. Strength of evidence was assessed using methods outlined by the Agency for Healthcare Research and Quality. Six studies involving 664 patients were included. There were no deaths and only one seizure in each group. Four studies reported delirium, which occurred in 4 out of 164 patients randomized to symptom-triggered therapy compared to 6 out of 164 randomized to fixed dose therapy (odds ratio, 0.64 [95% CI, 0.17-2.47]). Three studies reported duration of therapy, which was 60.4h less with symptom-triggered therapy (95% CI, 39.7-81.1h; p < 0.001). Six studies reported total benzodiazepine dosage, which was 10.5mg in lorazepam-equivalent dosing less with symptom-triggered therapy (95% CI, 7.1-13.9mg; p = 0.011). Moderate strength evidence suggests that symptom-triggered therapy improved duration of therapy and total benzodiazepine dose in specialized detoxification settings of low-risk patients but the applicability of this evidence in general hospital settings is low. There was insufficient evidence for any conclusions about symptom-triggered therapy for the major outcomes of mortality, seizure, and delirium in any setting. CRD42017073426.

Investigação de desvios de qualidade em comprimidos de tiamina (vitamina B1) devido à suspeita de ineficácia terapêutica no tratamento de condições neuropsiquiátricas

Introduction: Thiamine supplementation for alcohol-dependent patients is one of the most important strategies for treating alcohol withdrawal syndrome and preventing and treating more serious neurological related complications. Also, it is used as adjuvant treatment for neurological conditions in geriatric patients. A municipal sanitary surveillance service from Sao Paulo requested the analysis of batches of thiamine hydrochloride tablets after complaints of therapeutic inefficacy during treatment of distinct neuropsychiatric conditions. Objective: To check if the thiamine therapeutic inefficacy complaints were associated to the medications’ quality. Method: Fiscal analyses were performed including aspect, weight variation, identification and potency of thiamine hydrochloride, uniformity of unitary doses and dissolution. Results: There was no quality deviation in the medications, as all performed assays presented satisfactory results. Conclusions: The administration of quality medications is essential for obtaining expected clinical effects. Other factors not associated to the medication quality such as patients’ adherence to the treatment and poor oral absorption might be associated to the complaints.

Effect of intranasal oxytocin on alcohol withdrawal syndrome: A randomized placebo-controlled double-blind clinical trial

BackgroundIn a pilot study, intranasal oxytocin was demonstrated to reduce the benzodiazepine dose needed to relieve withdrawal symptoms during alcohol detoxification. The aim of the present study was to compare the effect of oxytocin and placebo during a three-day period of alcohol detoxification at an addiction treatment center in Norway. MethodsRandomized, double-blind, placebo-controlled trial with 40 patients fulfilling criteria for ICD-10 diagnosis of alcohol dependence (F10.2), admitted for alcohol detoxification and withdrawal treatment. The benzodiazepine oxazepam was given as symptom-triggered treatment based on the scores of the Clinical Institute Withdrawal Assessment for Alcohol revised (CIWA-Ar) scale. Participants were randomized to receive either intranasal oxytocin (24 IU twice daily) or placebo. Primary outcome: Oxazepam dose required to complete a three-day course of detoxification. Secondary outcomes: Scores of the CIWA-Ar, the 10-item Hopkins Symptom Check List (HSCL-10), and self-reported total number of hours of sleep. ResultsThe mean total oxazepam dose (± standard deviation) was 56.8 ± 72.8 mg in the oxytocin group and 79.0 ± 122.9 in the placebo group (p = 0.490; difference -22.3 mg; 95% confidence interval (CI) -86.9 to +42.4 mg). The findings were inconclusive as to whether a difference in the CIWA-Ar score (5.94 ± 3.86 vs. 6.48 ± 3.92; p = 0.665) or in any of the other secondary outcomes was present. No serious adverse events were reported. ConclusionCompared to placebo, intranasal oxytocin did not significantly reduce the oxazepam dose needed to complete a 3-day course of alcohol detoxification and withdrawal treatment.

Benzodiazepines vs barbiturates for alcohol withdrawal: Analysis of 3 different treatment protocols

IntroductionAlcohol withdrawal treatment varies widely. Benzodiazepines are the standard of care, with rapid onset and long durations of action. Recent drug shortages involving IV benzodiazepines have required incorporation of alternative agents into treatment protocols. Phenobarbital has similar pharmacokinetics to select benzodiazepines frequently used for alcohol withdrawal. The objective of this study is to describe the effectiveness and safety of our institutional protocols during three time periods utilizing benzodiazepines and barbiturates for the acute treatment of alcohol withdrawal in the emergency department. MethodsAdult patients presenting to the ED for acute alcohol withdrawal from April 1st, 2016 to January 31st, 2018 were reviewed. Patients who received at least one dose of treatment were included. Treatments were based on availability of medication and given protocol at time of presentation. The primary outcome was the rate of ICU admission. Results300 patient encounters were included. Overall baseline characteristics were equal across groups, except for age. There was no difference in rate of ICU admission from the ED between groups (D:8, L&P:11, P:13 patients, p = 0.99). Rate of mechanical ventilation was no different across all groups (D:1, L&P:3, P:3 patients, p = 0.55). ConclusionDuring benzodiazepine shortages, phenobarbital is a safe and effective treatment alternative for alcohol withdrawal. Incorporating phenobarbital into a benzodiazepine based protocol or as sole agent led to similar rates of ICU admission, length of stay, and need for mechanical ventilation in patients treated for alcohol withdrawal in the emergency department.

Treatment of Alcohol Withdrawal Syndrome: Phenobarbital vs CIWA-Ar Protocol.

Benzodiazepine-based therapy for alcohol withdrawal is associated with agitation and respiratory depression. Treatment can be complicated by a need for adjunctive therapy to control these symptoms and in patients requiring mechanical ventilation. Strong evidence for the effectiveness of alternative treatment modalities is lacking, despite the availability of promising pharmacological agents such as phenobarbital. To compare the standard of care for the treatment of alcohol withdrawal-a symptom-triggered benzodiazepine protocol used in conjunction with the revised Clinical Institute Withdrawal Assessment of Alcohol (CIWA-Ar) scale-with a phenobarbital protocol. Retrospective cohort study conducted from January 2016 through June 2017 at a 42-bed medical intensive care unit in a private teaching hospital in Nashville, Tennessee. The primary outcome was intensive care unit length of stay. Secondary outcomes included hospital length of stay, incidence of invasive mechanical ventilation, and use of adjunctive pharmacotherapy. Patients who received phenobarbital had significantly shorter stays in the intensive care unit than did those who received therapy based on the CIWA-Ar scale (mean [SD], 2.4 [1.5] vs 4.4 [3.9] days; P < .001). Those who received phenobarbital also had significantly shorter hospital stays (4.3 [3.4] vs 6.9 [6.6] days; P = .004). The incidence of invasive mechanical ventilation was lower in the phenobarbital group (1 [2%] vs 14 [23%] patients; P < .001), as was use of adjunctive agents for symptom control, including dexmedetomidine (4 [7%] vs 17 [28%] patients; P = .002). A phenobarbital protocol for the treatment of alcohol withdrawal is an effective alternative to the standard-of-care protocol of symptom-triggered benzodiazepine therapy.

Who Leaves Early? Factors Associated With Against Medical Advice Discharge During Alcohol Withdrawal Treatment.

To determine if certain patient, clinical, and disease factors are associated with against medical advice (AMA) discharge among patients admitted for treatment of alcohol withdrawal. Data from admissions to a dedicated unit for treatment of substance withdrawal were collected over a 6-month period. Patients with AMA and planned discharge were compared with regard to demographics, clinical data, and substance use disorder disease characteristics. A stepwise logistic regression was used to find the best model. The study population included 655 patient encounters. A total of 93 (14%) discharges were AMA. Bivariate analysis showed patients with AMA discharge were younger (mean age 43 vs 46 years; P < 0.05), more likely to leave on a Tuesday to Thursday, and to have an initial withdrawal score at or above the median (AMA 69% vs planned 56%; P = 0.02). Emergency department (ED) admissions had an AMA discharge rate of 21% compared with 10% of community admissions (P < 0.05). Regression analysis found AMA discharge was significantly associated with admission from the ED (odds ratio [OR] 2.03, confidence interval [CI] 1.27-3.25) and younger age (OR 0.97, CI 0.95-0.99). There was no significant difference in discharge disposition among patients with concurrent opioid use disorder who were on opioid agonist therapy. AMA discharges occurred in 1 of every 7 admissions. Being admitted from the ED and younger age was associated with AMA discharge. No other patient or clinical factors were found to be associated with AMA discharge.