Clinical Institute Withdrawal Assessment For Alcohol-Revised Scores Research Articles

Risk Factors for Alcohol Withdrawal-related Hospital Transfer in a Correctional Setting.

A major health concern among individuals with alcohol use disorder is alcohol withdrawal syndrome (AWS), where individuals with physical dependence on alcohol may experience withdrawal signs and symptoms upon stopping or reducing alcohol use. AWS has a range of severity, with the most severe cases referred to as complicated AWS, presenting as seizure or signs and symptoms indicative of delirium or new onset of hallucinations. In the general community, risk factors or predictors of complicated AWS among hospitalized patients have been described, but there is no literature that examines such risk factors in a correctional population. The Los Angeles County Jail (LACJ) is the nation's largest jail system and manages 10-15 new patients per day for AWS. Here we aim to identify the risk factors associated with alcohol withdrawal-related hospital transfers among incarcerated patients being managed for AWS in the LACJ. From January 1, 2019 to December 31, 2020, data were gathered about LACJ patients who required transfer to an acute care facility for alcohol withdrawal-related concerns while on the Clinical Institute Withdrawal Assessment for Alcohol revised (CIWA-Ar) protocol. Log regression analysis was performed to generate an odds ratio for acute care facility transfer for the following variables: race, sex assigned at birth, age, CIWA-Ar scores, highest systolic blood pressure (SBP), and highest heart rate (HR). Out of 15,658 patients on CIWA-Ar protocol during this 2-year timeframe, a total of 269 (1.7%) were transferred to an acute care facility for alcohol withdrawal-related concerns. Of those 269 patients, significant risk factors associated with withdrawal-related hospital transfer included: Other race (OR 2.9, 95% CI 1.5-5.5), male sex assigned at birth (OR 1.6, 95% CI 1.0-2.5), age ≥ 55 years (OR 2.3, 95% CI 1.1-4.9), CIWA-Ar score 9-14 (OR 4.1, 95% CI 3.1-5.3), CIWA-Ar score ≥ 15 (OR 21.0, 95% CI 12.0-36.6), highest SBP ≥ 150 mmHg (OR 2.3, 95% CI 1.8-3.0), highest HR ≥ 110 bpm (OR 2.8, 95% CI 2.2-3.8). Among patients studied, the higher CIWA-Ar score was the most significant risk factor associated with alcohol withdrawal-related hospital transfer. Other significant risk factors identified are race other than Hispanic, white, and African American; male sex assigned at birth; age ≥ 55 years; highest SBP ≥ 150mmHg; and highest HR ≥ 110 bpm.

A Comparison of Injectable Diazepam and Lorazepam in the Goal-Directed Management of Severe Alcohol Withdrawal.

Benzodiazepines are the gold standard for treatment of alcohol withdrawal, yet the selection of a preferred benzodiazepine is limited due to a lack of comparative studies. The primary objective of this study was to compare the efficacy and safety of injectable lorazepam (LZP) and diazepam (DZP) in the treatment of severe alcohol withdrawal syndrome (AWS). Retrospective cohort study of adult patients admitted to an intensive care unit with a primary diagnosis of AWS. Subjects who received at least 12 LZP equivalent units (LEU) of injectable DZP or LZP within 24 hours of initiation of the severe AWS protocol were included. The primary outcome was time with Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) scores at goal over the first 24 hours of treatment. A total of 191 patients were included (DZP n = 89, LZP n = 102). Time with CIWA-Ar scores at goal during the first 24 hours was similar between groups (DZP 12 hours [interquartile range, IQR, = 9-15] vs LZP 14 hours [IQR = 10-17]), P = 0.06). At 24 hours, LEU requirement was similar (DZP 40 [IQR = 22-78] vs LZP 32 [IQR = 18-56], P = 0.05). Drug cost at 24 hours was higher in the DZP group ($204.6 [IQR = 112.53-398.97] vs $8 [IQR = 4.5-14], P < 0.01). DZP or LZP are equally efficacious for the treatment of severe AWS. LZP may be preferred due to cost but both medications can be used interchangeably based on availability.

The use of chlordiazepoxide for outpatient gamma-butyrolactone (GBL) detoxification: An observational study

Background Various detoxification regimens are used for gamma-hydroxybutyrate (GHB) and gamma-butyrolactone (GBL), including diazepam, barbiturates, baclofen and GHB itself. However, these regimens are primarily derived from inpatient units, and literature on outpatient GBL detoxification is sparse with no previous reports on chlordiazepoxide. We describe the characteristics of outpatient GBL detoxification using chlordiazepoxide. Methods Observational study of all patients who attended a community outpatient addiction service in South London between August 2015 and November 2017 seeking detoxification from GBL. The outpatient caseload is predominantly patients with alcohol, opioid and stimulant dependence. Routine clinical data including patient demographics, GBL usage, daily chlordiazepoxide dose and Clinical Institute Withdrawal Assessment for Alcohol-revised (CIWA-Ar) score were recorded. Results In the study period there were 17 attendances for GBL detoxification, 14 of which were undertaken in the outpatient setting. Twelve (86%) patients who had an outpatient detoxification were male, all of whom were men who have sex with men. Of 14 outpatient GBL detoxifications managed with chlordiazepoxide, 10 were successfully completed. One of the four patients that did not complete detoxification required inpatient treatment in an acute hospital. The average successful detoxification took 10 ± 3.1 days. For patients who completed a detoxification, the median maximum CIWA-Ar score on day one of the detoxification was 11 (range 2–17), with the mean dose of chlordiazepoxide used on day one being 140 mg (range 80–225 mg). Conclusions Chlordiazepoxide can be used for outpatient GBL detoxification in combination with a provision for crisis admission to hospital. CIWA-Ar score can be applied to GBL withdrawal to measure severity and inform a reducing regimen of chlordiazepoxide.

Can the alcohol withdrawal scale be applied to post-operative patients?

Assessment scales are commonly used to diagnose and treat alcohol withdrawal syndrome (AWS) in acute hospitals, although they have only been validated for use in detoxification facilities. There is a significant overlap between the symptoms and signs of AWS and other clinical presentations, including systemic inflammatory response syndrome (SIRS) and the physiological response to surgery. This may lead to both over-diagnosis and inappropriate treatment of AWS. This study sought to determine the false-positive rate for the commonly used Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) among post-operative patients. This was a prospective study of patients undergoing major abdominal surgery at University Hospital Geelong. Patients were recruited who were NOT at risk of alcohol dependency (using the World Health Organisation Alcohol Use Disorders Identification Test). Patients were assessed for AWS using the CIWA-Ar day one post-operatively with a false positive measured as a CIWA-Ar > 7. A total of 67 patients were included in the study. There were 31 (46%) men and 36 women. Their median age was 52 years (range 27-85). Thirty-six (52%) of patients underwent elective procedures, and 32 were emergencies. Twelve of the 67 patients (18%) had CIWA-Ar scores >seven. In the early post-operative period, the CIWA-Ar tool over-diagnoses AWS in 18% of patients. These false-positives could lead to delayed treatment of serious underlying conditions. We call for caution in the use of alcohol withdrawal scales in the acute hospital setting.

Impact of alcohol withdrawal training program on knowledge, attitude, and perception among healthcare providers in a hospital setting

ABSTRACT Background Delirium tremens is a life-threatening complication of alcohol withdrawal, which is preventable by prompt recognition and management. This study aimed to evaluate the impact of an alcohol withdrawal training program on knowledge, attitude, and perception among healthcare providers in a hospital setting. Methods This was a quasi-experimental study with a pre and post-test design conducted at the Department of Psychological Medicine, University Malaya Medical Center, Malaysia. A total of 36 participants consisted of postgraduate psychiatry trainees who underwent a 60-min online training program whereby pre- and post-training evaluation was done using a locally validated 21-item knowledge, attitude, perception questionnaire on alcohol withdrawal and the Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA-Ar) scales. Results There was a significant difference between pre- and post-training scores in knowledge, attitude, and perception domains (p < .05). Furthermore, significant difference in pre- and post-training CIWA-Ar scores (p < .05) were detected. Post-training CIWA-Ar score approached the true value and with minimal variation of scores among the participants. Conclusion The alcohol withdrawal training program was clinically significant with an effect size of 0.75. It can be utilized to train healthcare providers from various departments treating alcohol withdrawal patients to ensure better standardization of care.

Evaluation of the course and treatment of Alcohol Withdrawal Syndrome with the Clinical Institute Withdrawal Assessment for Alcohol – Revised: A systematic review-based meta-analysis

BackgroundAlthough the Clinical Institute Withdrawal Assessment for Alcohol – Revised (CIWA-Ar) is a gold standard tool for the clinical evaluation of alcohol withdrawal syndrome (AWS), a systematic analysis using the total scores of the CIWA-Ar as a means of an objective follow-up of the course and treatment of AWS is missing. The aims of the present study were to systematically evaluate scientific data using the CIWA-Ar, to reveal whether the aggregated CIWA-Ar total scores follow the course of AWS and to compare benzodiazepine (BZD) and non-benzodiazepine (nBZD) therapies in AWS. Methods1054 findings were identified with the keyword “ciwa” from four databases (PubMed, ScienceDirect, Web of Science, Cochrane Registry). Articles using CIWA-Ar in patients treated with AWS were incorporated and two measurement intervals (cumulative mean data of day 1−3 and day 4−9) of the CIWA-Ar total scores were compared. Subgroup analysis based on pharmacotherapy regimen was conducted to compare the effectiveness of BZD and nBZD treatments. ResultsThe random effects analysis of 423 patients showed decreased CIWA-Ar scores between the two measurement intervals (BZD: d = –1.361; CI: –1.829 < δ < –0.893; nBZD: d = –0.858; CI: –1.073 < δ < –0.643). Sampling variances were calculated for the BZD (v1 = 0.215) and the nBZD (v2 = 0.106) groups, which indicated no significant group difference (z = −1.532). ConclusionsOur findings support that the CIWA-Ar follows the course of AWS. Furthermore, nBZD therapy has a similar effectiveness compared to BZD treatment based on the CIWA-Ar total scores.

Study of relationship between serum creatine phosphokinase levels with severity of alcohol withdrawal

Background: Alcohol withdrawal syndrome is a potentially life-threatening condition with severe complications such as withdrawal seizures and delirium tremens. A valid and reliable biomarker for predicting the severity of alcohol withdrawal can be instrumental in individualizing effective therapy at the earliest.Methodology: This was an observational study done on 120 patients to study the relationship between serum creatine phosphokinase (CPK) levels with severity of alcohol withdrawal. The assessment for the severity of alcohol withdrawal was done with Clinical Institute Withdrawal Assessment for Alcohol-revised (CIWA-Ar) scale and an association was studied between the serum CPK levels and the severity of alcohol withdrawal. The data was analyzed using Chi-square test and Kruskal–Wallis tests.Results: The severity of alcohol withdrawal as per the CIWA was 26.66% mild, 55% moderate, and 18.33% severe. The mean serum CPK level for mild withdrawal was 126.93 IU/L, moderate withdrawal was 303.66 IU/L, and for severe withdrawal was 780.81 IU/L. A statistically significant association was obtained indicating that patients with higher CIWA-Ar scores are likely to have a higher level of serum CPK levels.Conclusion: Serum CPK levels were significantly associated with severity of alcohol withdrawal and can possibly serve as a candidate biomarker.

Clinical Pharmacist’s Role in an Alcohol Detox Unit in a Correctional Setting

Introduction: Newly incarcerated inmates with chronic alcohol use are at high risk for alcohol withdrawal. This descriptive study aims to describe the role of a clinical pharmacist within an alcohol detoxification unit (ADU) in the Los Angeles County jail that serves nearly 18 000 inmates facility-wide daily. Methods: This descriptive analysis was conducted from August 2, 2018 through October 31, 2018 within the jail ADU. The pharmacist attended daily assessments on all alcohol detox patients; identified and assessed patients at high risk of severe withdrawal; and initiated, modified, and discontinued withdrawal medication for selected patients. Patients were determined to be high risk of severe withdrawal if they had history of severe withdrawal, any Clinical Institute Withdrawal Assessment for Alcohol-revised (CIWA-Ar) score ≥15, or polysubstance withdrawal. Results: A total of 1263 patients were admitted to the ADU during the study (average 97 per week). A total of 282 patients were assessed by the pharmacist. Patient assessments included substance use and medication history, CIWA-Ar score, response to pharmacotherapy, and referral to a substance use counselor. Medications were initiated, modified, or discontinued in 148 patients after discussion with a physician. Transfer to an acute care facility occurred in 48 patients. Zero alcohol detox patient deaths occurred during the study. Conclusion: This is a novel role of a pharmacist in a correctional setting. A pharmacist can aid in an ADU by identifying and assessing patients at high risk of severe withdrawal and managing pharmacotherapy. Future studies can examine pharmacist withdrawal management of additional substances.

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.

Comparative efficacy of baclofen and lorazepam in the treatment of alcohol withdrawal syndrome.

Background:Benzodiazepines (BDZs) have been the treatment of choice for alcohol withdrawal syndrome (AWS); however, they are associated with several side effects and also have abuse potential. In some studies, the use of baclofen has been effective in reducing symptoms of alcohol withdrawal symptoms.Aim:The objective of this study was to compare the efficacy of baclofen and benzodiazepine (lorazepam) in reducing symptoms of AWS.Materials and Methods:It was a single-center, randomized, open-label study. Patients with alcohol dependence syndrome were enrolled in the study and randomized into two groups using computer-generated random table number. Baclofen (experimental group, 10 mg three times a day) and BZDs (control group, lorazepam, 8–12 mg/day in divided doses) were orally administered for reducing symptoms of alcohol withdrawal. Both groups received Vitamin B1 (100 mg/day through intramuscular route) and psychotherapeutic interventions. The severity of alcohol dependence was assessed by using the Severity of Alcohol Dependence Questionnaire, and alcohol withdrawal was assessed with the Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar).Results:Sixty-six patients were randomized (baclofen n = 34, benzodiazepine (BZD) group n = 32). Two patients (one patient in each group) had complicated withdrawal symptoms and were dropped from the final analysis. There was a significant reduction in alcohol withdrawal symptoms in both groups. There were no significant differences in CIWA-Ar scores between the two groups. Both the drugs were well-tolerated.Conclusion:Baclofen and lorazepam are comparable in efficacy and tolerability in reducing symptoms of AWS.

Occurrence, Predictors, and Prognosis of Alcohol Withdrawal Syndrome and Delirium Tremens Following Traumatic Injury.

We sought to determine occurrence, predictors, and prognosis of alcohol withdrawal syndrome and delirium tremens in patients with traumatic injury. Retrospective multicenter cohort study. Three U.S. trauma centers. Twenty-eight thousand one hundred one trauma patients admitted from 2010-2014. None. Measures included occurrence of alcohol withdrawal syndrome and delirium tremens, injury characteristics, risk factors for alcohol withdrawal syndrome, clinical outcomes, pharmacologic treatment for alcohol withdrawal syndrome, and Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) scores. Alcohol withdrawal syndrome severity was defined by CIWA-Ar score as minimal (< 10), moderate (10-20), and severe (> 20). Alcohol withdrawal syndrome developed in 0.88% (n = 246), including 12% minimal, 36% moderate, and 53% severe. Alcohol withdrawal syndrome progressed to delirium tremens in 11%. Before adjustment, alcohol withdrawal syndrome severity was associated with injury severity, hypokalemia, baseline CIWA-Ar score, and established alcohol withdrawal syndrome risk factors. Logistic regression identified the following predictors of delirium tremens: baseline CIWA-Ar score greater than or equal to 10 (odds ratio, 6.05; p = 0.02) and age greater than or equal to 55 (odds ratio, 3.24; p = 0.03). In patients with severe alcohol withdrawal syndrome, severe head injury also predicted progression to delirium tremens (odds ratio, 6.08; p = 0.01), and hypokalemia was borderline significant (odds ratio, 3.23; p = 0.07). Clinical outcomes of hospital length of stay, ICU length of stay, and alcohol withdrawal syndrome complications differed significantly by alcohol withdrawal syndrome severity and were worse with more severe manifestations of alcohol withdrawal syndrome. Mortality also significantly differed by alcohol withdrawal syndrome severity but was only greater in patients who progressed to delirium tremens (11.1%; p = 0.02); otherwise, there were no differences in mortality by severity (4%, 4%, and 0% by minimal, moderate, and severe alcohol withdrawal syndrome). Trauma patients with alcohol withdrawal syndrome experience a high occurrence of delirium tremens that is associated with significant mortality. These data demonstrate the predictive ability of baseline CIWA-Ar score, age, and severe head injury for developing delirium tremens.

450

Introduction: Benzodiazepines (BZD) are standard of care for management of alcohol withdrawal syndrome (AWS). Valproic acid (VPA) avoids many of the undesirable effects of BZD; several studies have demonstrated efficacy of VPA for AWS however they contained methodological flaws and small patient populations. This study assessed if VPA combined with BZD improved outcomes related to management of AWS compared to BZD alone. Methods: This was a retrospective cohort analysis. All adult patients from a mixed intensive care unit population who had a Clinical Institute Withdrawal Assessment for Alcohol Revised (CIWA-Ar) assessment performed and received either BZD or VPA were retrospectively identified. Patients were stratified into two groups: BZD alone and BZD combined with VPA. The primary endpoint was amount of BZD in lorazepam equivalents. Secondary endpoints included: total mortality, hospital and ICU lengths of stay (LOS), treatment duration, mean CIWA-Ar score, and percentage of CIWA-Ar <8. Results: A total of 127 patients met inclusion criteria; 90 (70.9%) received BZD alone while 37 (29.1%) received combination therapy. Median total BZD use was 12.8 mg compared to 17 mg with combined therapy (p=0.81). No difference was found in mortality (p=1). Both hospital and ICU LOS were significantly lower with standard therapy (p<0.01,0.00). Treatment duration was similar between groups (p=0.95). The mean percentage of CIWA-Ar<8 was 65.7% and 55% (p=0.04) for BZD alone and combined therapy patients; median average CIWA-Ar scores were 6 and 8.5 (p=0.01) respectively. Conclusions: No benefit was seen for addition of VPA to BZD however it was not found to worsen outcomes. VPA may lower CIWA-Ar scores however optimal dosing strategies will require further study.

874

Introduction: Alcohol withdrawal is associated with increased morbidity and mortality, potential for intubation and mechanical ventilation requiring admission to the intensive care unit (ICU) and prolonged hospital length of stay (LOS). Benzodiazepines are the mainstay of therapy; however several case reports have demonstrated dexmedetomidine can be used as an adjunctive agent for treatment of alcohol withdrawal. Methods: A retrospective review was performed evaluating subjects that received continuous infusion benzodiazepines in addition to dexmedetomidine. The total benzodiazepine dose 24 hours before dexmedetomidine initiation and 2, 12 and 24 hours following was assessed. Additionally, ICU LOS, duration of mechanical ventilation, Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) scale, and heart rate and blood pressure were collected. Results: Thirty-seven subjects, 92% male, received dexmedetomidine and continuous infusion benzodiazepines. The mean CIWA-Ar score prior to dexmedetomidine was 10.54 and 24 hours post dexmedetomidine initiation and reduced to 7.4 ± 5. Mean heart rate 24 hours after dexmedetomidine was 80 bpm and mean systolic blood pressure (SBP) was 130 mmHg. The average ICU LOS was 10.7 days and 62.2% of subjects were mechanically ventilated for 7.18 ± 4.3 days. There was a statistically significant increase in ICU LOS in those that were mechanically ventilated and received dexmedetomidine (p= 0.017). Although there was a reduction in the benzodiazepine requirement at 2, 12 and 24 hours (3, 2.45, 1.9 mg/hr, respectively) the difference was not statistically significant (p= 0.23). There was a reduction in mean CIWA-Ar scores at 2, 12 and 24 hours (9.71, 8.41, 8.53, respectively); however the reduction was not statistically significant (p= 0.7). Conclusions: Perhaps due to a small sample size, these data do not demonstrate the anticipated decrease in duration of mechanical ventilation or reduction in ICU LOS in subjects that received dexmedetomidine in addition to benzodiazepines.

Gabapentin Versus Chlordiazepoxide for Outpatient Alcohol Detoxification Treatment

Benzodiazepines are used to treat alcohol withdrawal (AW) but cause cognitive impairment, sedation, and ataxia, and interact with alcohol. Nonbenzodiazepine anticonvulsants are promising and possibly safer alternatives for the treatment of AW. To compare follow-up measures of Epworth Sleepiness Scale (ESS), Penn Alcohol Craving Scale (PACS), ataxia rating, and Clinical Institute Withdrawal Assessment for Alcohol revised (CIWA-Ar) symptoms between alcohol-dependent individuals randomized to treatment with gabapentin or chlordiazepoxide. A randomized, double-blind study was conducted in US veterans with alcohol withdrawal (DSM-IV criteria). Subjects requiring hospitalization or taking benzodiazepines or nonbenzodiazepine anticonvulsants were excluded. Twenty-six participants were randomized: 17 received gabapentin and 9 received chlordiazepoxide. Gabapentin doses were 1200 mg orally for 3 days, followed by 900 mg, 600 mg, and 300 mg for 1 day each. Chlordiazepoxide doses were 100 mg orally for 3 days, followed by 75 mg, 50 mg, and 25 mg for 1 day each. CIWA-Ar, ESS, PACS scales and evaluation for ataxia were administered daily. Follow-up mean ESS and PACS scores did not differ significantly between treatment groups in the early treatment period (days 1-4) but were lower (mean difference -3.70; 95% CI -7.21 to -0.19; p = 0.04) and (mean difference -6.05; 95% CI -12.82 to 0.72; p = 0.08), respectively, at the end of the treatment period (days 5-7) in gabapentin-treated subjects. CIWA-Ar scores were reduced similarly in both groups. Ataxia was not observed. No significant adverse events were noted. Limitations include our small sample size and 35% loss to follow-up at the end of the treatment period. In ambulatory veterans with symptoms of alcohol withdrawal, gabapentin treatment resulted in significantly greater reduction in sedation (ESS) and a trend to reduced alcohol craving (PACS) by the end of treatment compared to chlordiazepoxide treatment. Although limited by the small sample size, the suggestion of reduction in sleepiness and less craving warrants replication of the study with a larger sample.

Successful Use of Oxazepam in the Treatment of Delirium Tremens

To the Editor: Delirium tremens is a manifestation of alcohol withdrawal syndrome that occurs in about 5% of patients and has a high mortality rate.1 The withdrawal state involves reduced brain γ-aminobutyric acid (GABA) levels and GABA receptor sensitivity and activation of glutamate systems, which leads to neuronal overactivity in the absence of alcohol.2,3 Longer-acting benzodiazepines such as diazepam with active metabolites are preferred over shorter-acting ones for detoxification because they are associated with a lesser chance of recurrent withdrawal.4 Benzodiazepines with a short half-life (eg, oxazepam and lorazepam) have potential benefit for patients with liver disease, which is a common comorbid medical condition in alcohol-dependent individuals. The efficacy and safety of the short-acting benzodiazepine oxazepam in alcohol withdrawal–related delirium are not clear. To our knowledge, this is the only case reported in the literature of the use of oxazepam in the treatment of delirium tremens. Case report. Mr A, a 42-year-old man, presented to the psychiatric emergency services with a 15-year history of alcohol use. He met DSM-IV-TR criteria for alcohol dependence with a history suggestive of craving, tolerance, salience, loss of control, and withdrawal symptoms for the past 5 years. After being abstinent from alcohol for 4 days, he had developed symptoms characterized by disorientation to time, place, and person; tactile hallucinations; severe tremulousness; and autonomic instability signs. On the day of admission in July 2010, the patient’s Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar)5 score was 42, corresponding to severe withdrawal. Mr A did not have a history of seizures, loss of consciousness, or significant head injury. Neurologic examination revealed no focal deficits, and there were no signs or symptoms suggestive of neuroinfection. Computed tomographic scanning of the brain was normal except for mild cerebral atrophy. Biochemical investigations revealed abnormal liver function values, while the results of other tests including sugar levels, renal function parameters, and electrolyte levels were within normal range. In view of the patient’s liver function values, we started treatment with the shorter-acting benzodiazepine oxazepam 90 mg/d in 3 divided doses of 30 mg each, with the dose tapered every 3 days. With tapering doses of oxazepam, Mr A showed improvement, with reduction of CIWA-Ar score to less than 10 by the fifth day. In this case, oxazepam, which is a shorter-acting benzodiazepine, was used to treat delirium tremens. Most benzodiazepines have active metabolites, and hence their duration of action seems to exceed their plasma half-life.4 Oxazepam has no cytochrome P450 interactions and no active metabolites. It does not have initial euphoric effects because of its slow resorption, and therefore there is less risk of misuse. The half-life of oxazepam is 4–10 hours, and it has a better therapeutic window compared to other short-acting agents. Oxazepam has been used in the treatment of uncomplicated alcohol withdrawal syndrome.6 Safety data on the use of oxazepam in medical emergencies such as delirium tremens would be of benefit in cases with associated impaired liver functioning. The outcome of this case, as well as the pharmacokinetics of oxazepam, suggests that it may be a good alternative to lorazepam for patients with significant comorbid hepatic illnesses.

A Retrospective Chart Review Comparing Tiagabine and Benzodiazepines for the Treatment of Alcohol Withdrawal

Although benzodiazepines are the standard of care in the treatment of alcohol withdrawal, several studies have suggested that anticonvulsants may be equally effective at alleviating alcohol withdrawal symptoms and may pose less of a risk of causing rebound of symptoms which could contribute to relapse. This report compares treatment outcomes for patients (N = 13) treated for alcohol withdrawal with either the anticonvulsant tiagabine or the benzodiazepines oxazepam and lorazepam. The Clinical Institute Withdrawal Assessment for Alcohol-revised (CIWA-Ar) was utilized to gauge alcohol withdrawal symptoms over the course of the study. When possible, follow-up data was obtained on alcohol use post-treatment. Both benzodiazepines and tiagabine appeared to reduce CIWA-Ar scores at about the same magnitude. There was a trend for tiagabine patients to have less postdetoxification drinking (Fisher exact test, p = 0.12). The reduction in alcohol withdrawal symptoms and decreased tendency to relapse observed in patients treated with the anticonvulsant tiagabine suggests that a double-blind, placebo controlled trial may be warranted.

Multiple previous detoxifications are associated with less responsive treatment and heavier drinking during an index outpatient detoxification

Investigators have found a relationship between the number of previous alcohol withdrawals (AWs) and severity of withdrawal. We evaluated patients with multiple previous AWs, as compared to those with 0–1 previous withdrawals, in an outpatient detoxification trial comparing lorazepam (LZ) to carbamazepine (CBZ). A mixed model analysis of covariance was used to analyze Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) scores as a function of detoxification history (0–1 vs. 2 or more), drug group (CBZ vs. LZ), assessment day, and hours since last drink. The mixed model analysis of covariance (ANCOVA) indicated a significant detoxification history by assessment day interaction ( P≤.03). Least square means associated with this interaction suggested that the CIWA-Ar scores for the multiple detox patients declined more slowly than those with 0–1 previous detoxifications. Patients with multiple detoxes were 150% more likely to experience a heavy drinking day during treatment ( P≤.03). The multiple detox group drank more each drinking day ( P=.001) and a greater proportion of this group had early heavy drinking ( P=.0002). In the present study, intensity of AW symptoms and early heavy drinking were independent of treatment medications and were more common in patients who had previously undergone multiple treatments for AW.

Divalproex in the Treatment of Alcohol Withdrawal

The present study represents an open-label clinical trial comparing treatment with a benzodiazepine (lorazepam) to divalproex in 11 inpatients with uncomplicated alcohol withdrawal syndrome. The trial used the Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA-Ar) scale. There were no significant differences in demographics or substance use parameters between the divalproex group (n = 6) or the lorazepam group (n = 5). A significant Group × CIWA-Ar score interaction [F(8,72) = 2.57, p ≤. 01] was confirmed and further substantiated by a quadratic trend component for the interaction [F(1,9) = 24.9, p ≤. 001]. This preliminary study supports further investigation of divalproex in the treatment of alcohol withdrawal.