Clinical Institute Withdrawal Assessment For Alcohol-Revised Research Articles

Eliminating the benzos: A benzodiazepine-sparing approach to preventing and treating alcohol withdrawal syndrome.

Alcohol withdrawal syndrome (AWS) represents significant cost to the hospitalized trauma population from a clinical and financial perspective. Historically, AWS has been managed with benzodiazepines. Despite their efficacy, benzodiazepines carry a heavy adverse effect profile. Recently, benzodiazepine-sparing protocols for the prophylaxis and treatment of AWS have been used in medical patient populations. Most existing benzodiazepine-sparing protocols use phenobarbital, while ours primarily uses gabapentin and clonidine, and no such protocol has been developed and examined for safety and efficacy specifically within a trauma population. In December of 2019, we implemented our benzodiazepine-sparing protocol for trauma patients identified at risk for alcohol withdrawal on admission. Trauma patients at risk for AWS admitted to an academic Level 1 trauma center before (conventional) and after (benzodiazepine-sparing [BS]) protocol implementation were compared. Outcomes examined include morphine milligram equivalent dosing rates and lorazepam equivalent dosing rates as well as the Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scores, hospital length of stay, intensive care unit length of stay, and ventilator days. A total of 387 conventional and 134 benzodiazepine sparing patients were compared. Injury Severity Score (13 vs. 16, p = 0.10) and admission alcohol levels (99 vs. 149, p = 0.06) were similar. Patients in the BS pathway had a lower maximum daily CIWA-Ar (2.7 vs. 1.5, p = 0.04). While mean morphine milligram equivalent per day was not different between groups (31.5 vs. 33.6, p = 0.49), mean lorazepam equivalents per day was significantly lower in the BS group (1.1 vs. 0.2, p < 0.01). Length of stay and vent days were not different between the groups. Implementation of a benzodiazepine-sparing pathway that uses primarily clonidine and gabapentin to prevent and treat alcohol withdrawal syndrome in trauma patients is safe, reduces the daily maximum CIWA-Ar, and significantly decreases the need for benzodiazepines. Future studies will focus on outcomes affected by avoiding AWS and benzodiazepines in the trauma population. Therapeutic/Care Management; Level IV.

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.

Beyond benzodiazepines: a meta-analysis and narrative synthesis of the efficacy and safety of alternative options for alcohol withdrawal syndrome management.

To compare the efficacy and safety of non-benzodiazepines (non-BZDs) to benzodiazepines (BZDs) in the treatment of alcohol withdrawal syndrome (AWS). For relevant literature, Google Scholar, PubMed, Embase, OVID MEDLINE, EBSCO, Cochrane Central Registry of Controlled Trials, Web of Science, and Scopus were searched. Randomized control trials (RCTs) were included, omitted were nonblinded trials, blinded trials that were not randomized, and open-label studies. The Effective Public Health Practice Project Quality Assessment was used to assess the trial's quality. A meta-analysis and a narrative synthesis were carried out. Twenty non-BZDs and five BZDs were investigated in thirty RCTs. Meta-analysis favored gabapentin over chlordiazepoxide and lorazepam (d = 0.563, p < 0.001) and carbamazepine over oxazepam and lorazepam (d = 0.376, p = 0.029), for reducing Clinical Institute Withdrawal Assessmentfor Alcohol-Revised (CIWA-Ar)scale scores. Eleven non-BZDs fared better than BZDs for reducing CIWA-Ar, Total Severity Assessment, Selective Severity Assessment, Borg and Weinholdt, and Gross Rating Scale for Alcohol Withdrawal scores. Eight non-BZDs outmatched BZDs regarding autonomic, motor, awareness, and psychiatric symptoms. Sedation and fatigue were prevalent in BZDs, while seizures were prevalent in non-BZDs. For AWS treatments, non-BZDs are superior to or equally effective as BZDs. Non-BZD adverse events warrant further investigation. Agents that inhibit gated ion channels are promising candidates. PROSPERO CRD42022384875.

Demonstration of the Managing for Daily Improvement Quality Improvement Methodology in an Alcohol Withdrawal Protocol Audit.

The Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) is an assessment tool designed to standardize care and minimize the risk of complications in patients experiencing alcohol withdrawal. After discovering an increase in medication errors and late assessments under this protocol, pharmacists at a 218-bed community hospital performed an audit of protocol compliance using a performance improvement methodology known as Managing for Daily Improvement (MDI). A daily audit of CIWA-Ar protocol compliance was performed across all hospital units, followed by discussions with frontline nurses regarding barriers to compliance. The daily audit included assessments of appropriate monitoring frequency, medication administration, and medication coverage. Nurses caring for CIWA-Ar patients were interviewed to identify perceived barriers to protocol compliance. The MDI methodology provided a framework and tools to visualize audit results. The visual management tools used in the methodology include daily tracking of 1 or more discrete process measures, daily identification of barriers to perfect process performance at the patient and process level, and collaborative action plan tracking to resolve barriers. Forty-one audits were collected for 21 unique patients over 8 days. After conversations with multiple nurses across different units, the most commonly reported barrier to compliance was a lack of communication at shift handoff. The results of this audit were discussed with nurse educators, patient safety and quality leaders, and frontline nurses. Process improvement opportunities identified from this data included improved widespread nursing education, development of protocol auto-discontinuation criteria based on scores, and determination of downtime processes for the protocol. The MDI quality tool successfully assisted in identifying end-user barriers to and focused areas of improvement of compliance with a nurse-driven CIWA-Ar protocol. This tool is elegant in its simplicity and ease of use. It can be customized to cover any timeframe or monitoring frequency while providing visualization of progress over time.

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.

Decreasing Length of Stay in Opioid Withdrawal.

In 2017, more than 1,200 opioid-related deaths were reported in Virginia, with slightly fewer in 2018, at 1,193 deaths. The current opioid crisis has placed a strain on an already limited number of mental health (MH) inpatient beds. The industry standard for assessment and treatment of opioid withdrawal symptoms, in the inpatient setting, is the Clinical Opiate Withdrawal Scale (COWS), and yet some units continue to utilize the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) for this population. The purpose of this nurse-led performance improvement project was to implement COWS in the inpatient MH setting and improve length of stay (LOS) by 1 day. In 2018, in a large federal teaching facility in the mid-Atlantic region, the COWS was implemented to replace the CIWA-Ar for opioid withdrawal, with the focus on decreasing LOS. Prior to implementation of COWS, LOS on the inpatient MH unit for opioid withdrawal was 8.6 days, which was higher than the ~6- to 7-day LOS for surrounding private sector hospitals. Individual electronic medical records were reviewed for LOS and completion of COWS and pertinent details were discussed daily with nursing staff and monthly with the interdisciplinary team. Baseline data were collected from April 2017 to March 2018, with data collection continuing through the project implementation, April to September 2018. Completion of COWS on 100% of patients admitted with opioid withdrawal and a decrease in LOS from 8.6 to 4.7 days was found, a 45% reduction. The nurse-driven performance improvement project affected business acumen, through decreased LOS, as well as quality of care, through better symptom management.

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.

Pattern of alcohol withdrawal syndrome and its clinical correlates

Introduction and Aim: Management strategies of Alcohol Withdrawal Syndrome could be optimized if patients with greater risk are identified early and treated aggressively. Studying the pattern and predictors of alcohol withdrawal syndrome was the main objective of our study.&#x0D; &#x0D; Materials and Methods: A total of 100 consenting male patients in the age group of 18-60 years diagnosed with alcohol dependence and uncomplicated alcohol withdrawal undergoing in-patient detoxification in tertiary care center in north India were included in the study. A semi structured proforma was used to collect socio-demographic data, Alcohol Use Disorders Identification Test (AUDIT) was used as screening tool and Clinical Institute Withdrawal Assessmentfor Alcohol-revised (CIWA- Ar) was used to assess severity of withdrawal.&#x0D; &#x0D; Results: Symptoms like difficulty in orientation, seizures and hallucinations were relatively specific for severe AWS, while tremors and anxiety were common to all the patients and were non-specific for predicting severity of AWS. The severity of AWS symptoms correlated significantly with increasing age, duration of alcohol use and AUDIT score.&#x0D; &#x0D; Conclusion:We concluded that increasing age, longer duration of alcohol use, higher AUDIT score and symptoms related to hallucinations, orientation and seizure are linked to severe alcohol withdrawal. Prior knowledge of these predictors will help to identify the patients at risk of severe alcohol withdrawal so that individual care can be enhanced.

The effectiveness and tolerability of anti‐seizure medication in alcohol withdrawal syndrome: a systematic review, meta‐analysis and GRADE of the evidence

AbstractBackground and AimsAnti‐seizure medications (ASMs) have been used historically as treatment options in alcohol withdrawal syndrome (AWS). In the past 10 years, there have been no large‐scale meta‐analyses comparing ASMs with placebo or the current AWS treatment standard, benzodiazepines. We aimed to evaluate the efficacy and tolerability of ASMs in AWS.MethodsSystematic review and meta‐analysis of randomised controlled trials (RCTs) via searching Medline, Embase and PsychINFO from database inception to March 2020 involving adults age &gt;18 years with AWS. We included 24 RCTs reporting on a total of 2223 participants. Efficacy outcomes included the number of participants experiencing AWS related seizures or delirium, Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA‐Ar) score reduction and rescue medication requirements. Tolerability outcomes included adverse event rate and dropout because of adverse events, alongside severe and life‐threatening adverse event rates. Quality was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE).ResultsThere was no evidence of significant improvements in any efficacy outcomes when comparing ASMs with placebo or benzodiazepines. When compared with benzodiazepines, ASMs demonstrated significantly increased odds of requiring rescue medications (OR = 3.50, 95% CI = 1.32, 9.28; P = 0.012). When comparing ASMs with placebo, there were significantly more dropouts because of adverse events (OR = 1.86, 95% CI = 1.05, 3.28; P = 0.034). Most results were of very low quality with the majority of included studies conducted before 2000.ConclusionsThis systematic review and meta‐analysis found no evidence to support general first line clinical use of anti‐seizure medications in alcohol withdrawal syndrome treatment.

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.

P.3.012 - Baclofen in managing acute alcohol withdrawal: preliminary findings from a randomised controlled trial

Introduction Alcohol-use disorders (AUD) have a high global prevalence and about half of the patients suffering from AUD will develop withdrawal symptoms upon cessation of alcohol intake. Therefore, management of alcohol withdrawal has a significant place in medical care. The current gold standard for the prevention and treatment of the alcohol withdrawal syndrome is the GABA-A agonist diazepam [1]. Because of side-effects like high sedation, risk of respiratory depression, its addictive properties and possible liver impairment, alternative pharmacological treatment options are desirable. Baclofen, a GABA-B agonist prescribed for the treatment of spasticity, seems like a promising agent to act as such an alternative. More recently, its off-label use has found its place in the management of alcohol-use disorder because of its anti-craving properties [2]. Given its effects on the GABA system and it lacking the negative aspects of diazepam, baclofen could be a viable treatment alternative in managing alcohol withdrawal. Promising results from studies by Addolorato and Lyon, included in a recent Cochrane review, substantiate the above claim [3]. Moreover, as baclofen treatment can be continued to counter craving, it can offer a simplification of the pharmacological treatment of alcohol-use disorder as a whole. Goal The current study investigates the use of baclofen compared to placebo in the management of AUD, and additionally explores the possible dose-effect relation of baclofen in reducing alcohol craving. Method A single-blinded randomized placebo-controlled trial is being conducted with three arms (placebo, baclofen 30 mg/day and baclofen 60 mg/day) in 90 treatment-seeking AUD patients, for 7 consecutive days. During the study, patients can receive additional diazepam as-needed by protocol, primarily based on the Clinical Institute Withdrawal Assessment for Alcohol Revised (CIWA-ar) scale score. Assessment takes place every two hours during the first three days, and every four hours during the last four days. The primary outcome measure is the amount of patients who received additional diazepam during these 7 days, analyzed using a Chi-Square test. Secundary outcome measures include the amount of additional diazepam, analyzed with ANOVA. Results So far, 29 patients were included in the study. Fewer patients receiving baclofen 60 mg/dayneeded additional diazepam (2 out of 12) compared to those receiving either baclofen 30 mg/day (3 out of 8) or placebo (6 out of 9), but this did not reach statistical significance (p = 0.061). The mean amount of diazepam needed per patient was 10 mg for placebo, 5 mg for baclofen 30 mg/day and 1.67 mg for baclofen 60 mg/day (p = 0.091). Conclusion These preliminary findings show that baclofen in a dose of 60 mg/day, may be a useful alternative to diazepam in treatment-seeking AUD patients during alcohol withdrawal. Further inclusion of patients will demonstrate if this trend is carried on and if there’s a significant difference to be found.

The Severity of Ethanol Withdrawal Scale in Scale-Driven Alcohol Withdrawal Treatment: A Quality Assurance Study

ABSTRACTThis quality assurance study compared two scales that drive the medicinal treatment of alcohol withdrawal syndrome (AWS): the new Severity of Ethanol Withdrawal Scale (SEWS) and the default Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar). Prospectively entered outcome data from medical intensive care (SEWS) and acute psychiatric inpatient (CIWA-Ar) units were collected and analyzed. Measures included scale administration patterns, mean lengths of time on treatment medication, and mean medication doses for the first 24 hours and for the total AWS episode. The administration patterns of the two scales were highly associated despite separate ward locations and personnel. Time-on-medication for SEWS patients shortened on average by one hospital day over the CIWA-Ar group. At the same time, however, total chlordiazepoxide doses, or the first 24 hours and over the total AWS episode, averaged twice the magnitude in the SEWS group over the CIWA-Ar. The data suggest that the SEWS shortens AWS course of treatment significantly, likely due to better assessment leading to improved medication treatment early in the course. Contributing SEWS scale factors may include item weighting, dichotomous item scoring, and ease of scale use by the nursing staff. New prospective studies should focus on these clinical metrics along with reference to biological mechanisms of an apparent improved treatment effect using the SEWS.

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.

Is gabapentin effective in the treatment of acute alcohol withdrawal?

A 52-year-old man with end-stage liver disease presents with complaints of headache, tremor, ataxia, and insomnia. He reports his last alcohol consumption was 30 hours ago. He admits to a history of 15 servings of alcohol per day and a desire to abstain from alcohol. He thinks he might have had a seizure when he went without alcohol in the past. His Clinical Institute Withdrawal Assessment for Alcohol-revised (CIWA-Ar) score is 15. Is gabapentin an appropriate and adequate agent to safely take this patient through acute alcohol withdrawal syndrome (AWS) in the inpatient setting?