Clinical Institute Withdrawal Assessment Research Articles

A detox dilemma beyond benzodiazepines; clonidine's quandary in alcohol withdrawal management.

Benzodiazepines are the primary method of treatment of alcohol withdrawal, though the American Society of Addiction Medicine guidelines also include alternative agents for consideration. Observations in a Department of Veterans Affairs (VA) psychiatric emergency room noted consistent benzodiazepine use with an overall lack of use of alternative agents, even with low Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scores and in the absence of other concerning symptoms. Due to concerns of potential more-than-necessary benzodiazepine use, we analyzed adjunctive clonidine use for elevated blood pressure/pulse in alcohol withdrawal among this Veteran population. This is a single-site VA retrospective chart review of the psychiatric emergency room from July 1, 2022, to June 30, 2023, focused on patients with alcohol withdrawal managed on a CIWA protocol. Excluding concurrent opioid withdrawal and clonidine as home medication, 167 patient charts were analyzed for this study. Among 167 patients, 99 (59.3%) had comorbid hypertension. A total of 614 medication doses were given for elevated CIWA (373, 60.8%) and elevated blood pressure/pulse (241, 39.2%). Of the 241 doses for elevated blood pressure/pulse, only 2.5% were clonidine. Among all benzodiazepine doses, 75.3% were given to patients with comorbid hypertension. Clonidine was administered to 3.0% of patients, making up 2.5% of total dosing. Alcohol withdrawal management lacks optimization. Integrating adjunctive medications could reduce potential benzodiazepine overuse effectively addressing elevated blood pressure/pulse. This study sheds light on the potential underutilization of clonidine and its potential role in improving alcohol withdrawal syndrome management. By addressing elevated blood pressure/pulse and curbing potential overuse of benzodiazepines, it may contribute to further optimizing patient care.

Evaluation of the Use of Phenobarbital and Benzodiazepines in the Management of Alcohol Withdrawal Syndrome in Patients Requiring Neurological/Neurosurgical Critical Care: A Propensity-Matched Analysis.

Objective There is growing interest in the use of phenobarbital for alcohol withdrawal syndrome in critically ill patients, though experience in neurologically injured patients is limited. The purpose of this study was to compare the safety and effectiveness of phenobarbital-containing alcohol withdrawal regimens versus benzodiazepine monotherapy in the neurocritical care unit. Methods We conducted a retrospective cohort study of adult patients admitted to the neurocritical care unit from January 2014 through November 2021 who received pharmacologic treatment for alcohol withdrawal. Treatment groups were defined as benzodiazepine monotherapy versus phenobarbital alone or in combination with benzodiazepines. The primary outcome was the percentage of patients requiring intubation after receiving alcohol withdrawal treatment. Secondary outcomes included all-cause, in-hospital mortality, intensive care unit length of stay, discharge disposition, change in Glasgow Coma Scale (GCS) score, and the use of adjunctive agents. Results We analyzed data from 156 patients, with 77 (49%) in the benzodiazepine group and 79 (51%) in the phenobarbital combination group. The groups were well-balanced for baseline characteristics, though more males (67, 85%) were in the phenobarbital group. Only three (1.9%) patients received phenobarbital monotherapy, and the rest (153, 98.1%) received combination therapy. The percentage of patients requiring mechanical ventilation was significantly higher in the phenobarbital combination group compared to benzodiazepine monotherapy (39% (n=31) versus 13% (n=10); OR: 4.33, 95% CI: 1.94-9.66; p<0.001). The use of adjunctive propofol and dexmedetomidine was higher in the phenobarbital group (propofol 35% (n= 28) versus 9% (n=7) and dexmedetomidine 30% (n=24) versus 5% (n=4), respectively). Patients in the phenobarbital group also had lower GCS scores and higher Clinical Institute Withdrawal Assessment of Alcohol (CIWA-Ar) scores during their intensive care unit admission, possibly suggesting more severe alcohol withdrawal. There was no difference in intensive care unit length of stay, all-cause, in-hospital mortality, discharge disposition, or therapeutic adjuncts. Conclusions Combination therapy of phenobarbital plus benzodiazepines was associated with higher odds of requiring mechanical ventilation. Few patients received phenobarbital monotherapy. Additional studies are needed to better compare the effects of phenobarbital monotherapy versus benzodiazepines in neurocritical patients.

Alcohol Withdrawal Severity Measures for Identifying Patients Requiring High-Intensity Care.

Alcohol withdrawal syndrome (AWS) may progress to require high-intensity care. Approaches to identify hospitalized patients with AWS who received higher level of care have not been previously examined. This study aimed to examine the utility of Clinical Institute Withdrawal Assessment Alcohol Revised (CIWA-Ar) for alcohol scale scores and medication doses for alcohol withdrawal management in identifying patients who received high-intensity care. A multicenter observational cohort study of hospitalized adults with alcohol withdrawal. University of Chicago Medical Center and University of Wisconsin Hospital. Inpatient encounters between November 2008 and February 2022 with a CIWA-Ar score greater than 0 and benzodiazepine or barbiturate administered within the first 24 hours. The primary composite outcome was patients who progressed to high-intensity care (intermediate care or ICU). None. Among the 8742 patients included in the study, 37.5% (n = 3280) progressed to high-intensity care. The odds ratio for the composite outcome increased above 1.0 when the CIWA-Ar score was 24. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) at this threshold were 0.12 (95% CI, 0.11-0.13), 0.95 (95% CI, 0.94-0.95), 0.58 (95% CI, 0.54-0.61), and 0.64 (95% CI, 0.63-0.65), respectively. The OR increased above 1.0 at a 24-hour lorazepam milligram equivalent dose cutoff of 15 mg. The sensitivity, specificity, PPV, and NPV at this threshold were 0.16 (95% CI, 0.14-0.17), 0.96 (95% CI, 0.95-0.96), 0.68 (95% CI, 0.65-0.72), and 0.65 (95% CI, 0.64-0.66), respectively. Neither CIWA-Ar scores nor medication dose cutoff points were effective measures for identifying patients with alcohol withdrawal who received high-intensity care. Research studies for examining outcomes in patients who deteriorate with AWS will require better methods for cohort identification.

Screening for Alcohol Use Disorder and Management of Alcohol Withdrawal Syndrome in Critical Care Patients.

Evidence-based research indicates that subjective questionnaires should be eliminated in screening for alcohol use disorder and management of alcohol withdrawal syndrome in critical care patients. However, transitioning clinicians away from these screening tools remains challenging. To improve screening for alcohol use disorder and management of alcohol withdrawal syndrome in the critical care setting by implementing an evidence-based alcohol use disorder screening tool and alcohol withdrawal syndrome protocol for critical care patients. The project site was a 17-bed adult medical intensive care unit in a large, southeastern US teaching hospital. Interventions consisted of the elimination of previously used tools such as the Clinical Institute Withdrawal Assessment for Alcohol-Revised and implementation of the Prediction of Alcohol Withdrawal Severity Scale for alcohol use disorder screening and the Richmond Agitation-Sedation Scale and symptom-triggered benzodiazepine administration for alcohol withdrawal syndrome management. Alcohol use disorder screening among the critical care patient population increased by 49% from before to after the intervention. Of the patients at risk for withdrawal, 79% had an order for monitoring with the new intensive care unit alcohol withdrawal protocol in the postintervention group, compared with 35% who had an order for monitoring with the Clinical Institute Withdrawal Assessment for Alcohol-Revised in the preintervention group. The elimination of previously used tools and the implementation of the Prediction of Alcohol Withdrawal Severity Scale and the new intensive care unit alcohol withdrawal protocol improved alcohol use disorder screening and alcohol withdrawal syndrome management among critical care patients.

Characterization of alcohol-related seizures in withdrawal syndrome.

Alcohol-related seizures (ARS) are one of the most important consequences of alcohol withdrawal syndrome (AWS). However, demographic and clinical characteristics, and furthermore, the relationship of ARS with delirium tremens (DT), have not yet been evaluated in detail. Therefore, the aim of the present study was to reveal the correlates of ARS and examine the interaction of ARS with the occurrence of DT and with the severity of AWS. In the retrospective study (Study 1) 2851 medical charts of inpatient admissions characterized by AWS and DT were listed. Demographic and clinical variables of ARS were assessed. In the follow-up study (Study 2), patients admitted with AWS without (N = 28) and with (N = 18) ARS were enrolled. Study 1 was performed between 2008 and 2023, and Study 2 was performed in 2019 in Hungary. To determine the severity of AWS, the Clinical Institute Withdrawal Assessment Scale for Alcohol, Revised (CIWA-Ar) was used. ARS is a provoked, occasional seizure; therefore, patients with epilepsy syndrome were excluded from the two studies. Statistical analyses were performed by the means of chi-square tests, multinomial logistic regressions, mixed ANOVA, and derivation. The occurrence of DT, the history of ARS, and somatic co-morbidities were found to be risk factors for the appearance of ARS. ARS was proved to be a risk factor for the development of DT. In the follow-up study, there was no difference in the decrease of CIWA-Ar scores between the groups. Our present findings support the likelihood of kindling, which is one of the most important mechanisms underlying the development of ARS, but do not directly prove its presence. Additionally, our results revealed that the severity of AWS is not influenced by the presence of ARS. Provoked, occasional seizures during AWS are defined as ARS. In the present study, predictors and interactions of these seizures with DT-the most severe form of withdrawal-and with the severity of withdrawal were examined in retrospective and follow-up studies. The present study shows that a history of withdrawal seizures, the occurrence of DT, and somatic comorbidities are predictors of the development of seizures. Furthermore, our findings suggest that the presence of seizures does not influence the severity of withdrawal.

Phenobarbital Versus Benzodiazepines for the Treatment of Severe Alcohol Withdrawal.

Phenobarbital may offer advantages over benzodiazepines for severe alcohol withdrawal syndrome (SAWS), but its impact on clinical outcomes has not been fully elucidated. The purpose of this study was to determine the clinical impact of phenobarbital versus benzodiazepines for SAWS. This retrospective cohort study compared phenobarbital to benzodiazepines for the management of SAWS for patients admitted to progressive or intensive care units (ICUs) between July 2018 and July 2022. Patients included had a history of delirium tremens (DT) or seizures, Clinical Institute Withdrawal Assessment of Alcohol-Revised (CIWA-Ar) >15, or Prediction of Alcohol Withdrawal Severity Scale (PAWSS) score ≥4. The primary outcome was hospital length of stay (LOS). Secondary outcomes included progressive or ICU LOS, incidence of adjunctive pharmacotherapy, and incidence/duration of mechanical ventilation. The final analysis included 126 phenobarbital and 98 benzodiazepine encounters. Patients treated with phenobarbital had shorter median hospital LOS versus those treated with benzodiazepines (2.8 vs 4.7 days; P < 0.0001); a finding corroborated by multivariable analysis. The phenobarbital group also had shorter median progressive/ICU LOS (0.7 vs 1.3 days; P < 0.0001), and lower incidence of dexmedetomidine (P < 0.0001) and antipsychotic initiation (P < 0.0001). Fewer patients in the phenobarbital group compared to the benzodiazepine group received new mechanical ventilation (P = 0.045), but median duration was similar (1.2 vs 1.6 days; P = 1.00). Scheduled phenobarbital was associated with decreased hospital LOS compared to benzodiazepines for SAWS. This was the first study to compare outcomes of fixed-dose, nonoverlapping phenobarbital to benzodiazepines in patients with clearly defined SAWS and details a readily implementable protocol.

Factors Inducing Alcohol Seeking Behaviors in Patients Dependent on Alcohol-A Case-control Analysis

Abstract Context: Alcohol use has increased to the extent that it has become a menace to society. There are certain external or social factors which linger an individual around alcohol despite efforts to cut its consumption. Furthermore, the ingrained factors as an individual’s personality and associated comorbid psychiatric disorders render alcohol-seeking behaviors. These factors further lead to problems in help-seeking, adjustment in society, and continuation of treatment. Although studies in the past have highlighted these risk factors, this study was conducted to understand the role of social factors, personality, and simultaneously occurring illness in patients of alcohol dependence with healthy controls. Aim: The aim of this study was to study the factors inducing alcohol-seeking behaviors in patients dependent on alcohol. Settings and Design: This case–control study was conducted among 100 male patients. It included 50 patients diagnosed with alcohol use disorder and other 50 patients as healthy controls. Subjects and Methods: Participants were assessed clinically and the Clinical Institute Withdrawal Assessment of Alcohol Scale-Revised scale, Alcohol, Smoking, and Substance Involvement Screening Test, Mini-international neuropsychiatric interview, and International Personality Disorder Evaluation scales were administered. Statistical Analysis: A Chi-square test was applied for the categorical variable. Univariate linear regression was done for the independent variable. Results: Marital status, occupation, and residential area significantly affect alcohol use behavior. Affective disorders (22%) were the most common comorbidity and dissocial personality disorders (24%) were most prevalent. Conclusions: While addressing the issues related to dependence a focused approach including social, biological, and psychological factors must be considered.

Does phenobarbital reduce the hospital length of stay for patients suffering from severe alcohol withdrawal? A retrospective comparison of phenobarbital to lorazepam infusions

IntroductionData suggest that phenobarbital is as effective as benzodiazepines at managing withdrawal via its direct activation of the gamma-aminobutyric acid receptor and modulating glutamate-mediated stimulation of the N-methyl-D-aspartate receptor. There are little data evaluating the effect of phenobarbital on severe withdrawal syndromes. ObjectiveThe purpose of this study was to evaluate the effect of phenobarbital compared with protocolized, symptom-driven, benzodiazepine administration on hospital length of stay (LOS) in patients experiencing severe withdrawal. MethodsThis is a retrospective chart review of patients evaluated in the emergency department for the treatment of severe alcohol withdrawal syndrome, defined as a Clinical Institute Withdrawal Assessment for Alcohol – Revised score of 20 or greater during their visit. The primary outcome measure was the difference in hospital LOS between those receiving phenobarbital and those receiving continuous lorazepam infusions. Secondary outcomes include intensive care unit (ICU) admission, ICU LOS, need for mechanical ventilation, and incidence of oversedation. ResultsIn all, 298 patients met inclusion, with 131 treated with phenobarbital and 167 initiated on a lorazepam infusion. Hospital LOS was found to be statistically significantly greater in the lorazepam infusion cohort (7.6 ± 5.3 vs. 5.2 ± 4.5 days, P < 0.001) than the phenobarbital cohort. Patients treated with lorazepam were found to have increased admissions to the ICU (risk ratio [RR] 1.79 [95% CI 1.27–2.92]) and higher rates of oversedation (RR 1.71 [95% CI 2.09–4.25]). There were no differences in ICU LOS and need for mechanical ventilation. ConclusionData from this study suggest that phenobarbital may be associated with a decrease in hospital LOS in severe alcohol withdrawal and should be considered as an alternative to benzodiazepine infusions in these patients.

Thiamine utilization and the lack of prescribing standardization: A critical examination

ObjectivesThiamine is often prescribed for thiamine deficiency during hospitalization despite the lack of US-based clinical guidelines. This study aims to evaluate thiamine prescribing patterns and key characteristics associated with the deficiency to address gaps in care. MethodsData were obtained from electronic health records of hospitalized patients between September 1, 2021, and March 30, 2022. Alcohol use disorder (AUD) was defined by a positive Clinical Institute Withdrawal Assessment score or a positive serum alcohol level upon admission. Geriatric patients were defined as age ≥65. Cohort 1 was defined as: AUD, albumin <4 g/L, INR >1.5, and total bilirubin >3 mg/dL. Cohort 2 was defined as: age >65, albumin <4 g/L, hemoglobin <15 g/dL, and folate <4 ng/mL. A multivariable LASSO regression model was used to identify characteristics associated with higher thiamine dosing (>100 mg/day). ResultsAmong 780 patients, 520 (66.7%) were identified as AUD, of which 265 (50.1%) were between the ages of 45–64 years. The AUD cohort was significantly different (p < 0.05) in the mean serum albumin 4.16 g/L (IQR: 3.8–4.5), AST 73.55 U/L (23.75–82.00), ALT 52.57 U/L (17.00–57.00), total bilirubin 0.98 (0.3–1.0), and INR 1.1 (0.99–1.12), compared to non-AUD patients with a mean serum albumin 3.75 g/L (3.3–4.2), AST 35.07 U/L (11.00–42.00), ALT 32.77 U/L (5.00–34.00), total bilirubin 0.89 (0.2–0.9), and INR 1.21 (1.0–1.22). In the geriatric cohort, 136 patients (17%) had a mean serum albumin 3.77 g/L (3.4–4.2), AST 38.66 U/L (14.0–41.0), ALT 29.36 U/L (9.0–37.0), total bilirubin 0.62 mg/dL (0.30–0.90), and direct bilirubin 0.12 mg/dL (0.00–0.20), compared to the non-geriatric cohort with a mean serum albumin 4.10 g/L (3.8–4.40), AST 66.44 U/L (21.0–75.0), ALT 50.03 U/L (16.00–53.75), total bilirubin 1.02 mg/dL (0.30–1.00), and direct bilirubin 0.31 mg/dL (0.00–0.20). In cohort 1, 40.6% patients were between 51 and 64 years old, (66.5%) male, and had a BMI <25 (36.4%). In cohort 2, 52.6% were between 65 and 70 years old, (57.9%) male, and had a BMI <25 (57.9%). Cohort 1 were prescribed a dose of 100 mg (47.7 %), oral (63.5%), intramuscular (18.2%), daily (58.9%), one-day duration (49.4%) most frequently. Cohort 2 were prescribed a dose of 100 mg (56.0%), oral (77.2%), daily (77.2%), one-day duration (29.8%) most frequently. The AUD was significantly associated with having a higher dosage (e.g., >100 mg) of thiamine prescribed per day OR 1.62 (1.11–2.37) (p < 0.01). ConclusionsThis study confirms that thiamine prescribing patterns vary during hospitalization and suggest specific laboratory findings may aid in identifying cohorts associated with the deficiency.

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.

Electrocardiographic Changes During and After Alcohol Withdrawal.

Our study aimed to examine the possible risk of ventricular arrhythmia and sudden cardiac death by calculating the electrocardiographic changes and indicators of ventricular repolarization during and after alcohol withdrawal. One hundred participants who were identified with alcohol withdrawal and who met the inclusion criteria were included in the study. Data were collected between July 2020 and August 2020. The distance interval between Q and T waves, corrected distance interval between Q and T waves, T peak/distance interval between Q and T waves, and T peak/corrected distance interval between Q and T waves interval ratios ratios were measured in 12-lead electrocardiographic measurements during the withdrawal period and after withdrawal symptoms subsided in patients with a Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised score >7 and a Framingham heart risk score <10%. There was a significant difference between the patient's heart rate, distance interval between Q and T waves, corrected distance interval between Q and T waves interval, and T peak/distance interval between Q and T waves values during withdrawal (input) and after alcohol withdrawal (output) (P < .05). The mean corrected distance interval between Q and T waves interval input value (433.63 ± 17.79) is significantly different and higher than the output value of the mean corrected distance interval between Q and T waves (420.67 ± 13.78) (P < .05). Similarly, the mean T peak input value (81.36 ± 5.90) is significantly different and higher than the mean T peak output value (79.94 ± 5.39) (P < .05) and the mean T peak/input value of the distance interval between Q and T waves (0.222 ± 0.00) than the mean T peak / output value of the distance interval between Q and T waves (0.214 ± 0.00) (P < .001). These consequences suggest the risk for an accelerated hazard of ventricular arrhythmias in participants with alcohol withdrawal. Significantly, considering the improvement of the electrocardiographic changes of the patients after terminating alcohol intake, a possible cardiac arrhythmia may be more common during this period. Close monitoring of electrocardiograms and timely withdrawal treatment can prevent life-threatening arrhythmias in alcohol withdrawal patients.

Novel paradigms for the gut-brain axis during alcohol withdrawal, withdrawal-associated depression, and craving in patients with alcohol use disorder.

Patients with alcohol use disorder (AUD) exhibit symptoms such as alcohol withdrawal, depression, and cravings. The gut-immune response may play a significant role in manifesting these specific symptoms associated with AUD. This study examined the role of gut dysfunction, proinflammatory cytokines, and hormones in characterizing AUD symptoms. Forty-eight AUD patients [men (n = 34) and women (n = 14)] aged 23-63 years were grouped using the Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA) as clinically significant (CS-CIWA [score > 10] [n = 22]) and a clinically not-significant group (NCS-CIWA [score ≤ 10] [n = 26]). Clinical data (CIWA, 90-day timeline followback [TLFB90], and lifetime drinking history [LTDH]) and blood samples (for testing proinflammatory cytokines, hormones, and markers of intestinal permeability) were analyzed. A subset of 16 AUD patients was assessed upon admission for their craving tendencies related to drug-seeking behavior using the Penn-Alcohol Craving Score (PACS). CS-CIWA group patients exhibited unique and significantly higher levels of adiponectin and interleukin (IL)-6 compared to NCS-CIWA. In the CS group, there were significant and high effects of association for the withdrawal score with gut-immune markers (lipopolysaccharide [LPS], adiponectin, IL-6, and IL-8) and for withdrawal-associated depression with gut-immune markers (scored using MADRS with LPS, soluble cells of differentiation type 14 [sCD14], IL-6, and IL-8). Craving (assessed by PACS, the Penn-Alcohol Craving Scale) was significantly characterized by what could be described as gut dysregulation (LBP [lipopolysaccharide binding protein] and leptin) and candidate proinflammatory (IL-1β and TNF-α) markers. Such a pathway model describes the heavy drinking phenotype, HDD90 (heavy drinking days past 90 days), with even higher effects (R2 = 0.955, p = 0.006) in the AUD patients, who had higher ratings for cravings (PACS > 5). The interaction of gut dysfunction cytokines involved in both inflammation and mediating activity constitutes a novel pathophysiological gut-brain axis for withdrawal symptoms and withdrawal-associated depression and craving symptoms in AUD. AUD patients with reported cravings show a significant characterization of the gut-brain axis response to heavy drinking. ClinicalTrials.gov, identifier: NCT# 00106106.

Assessment of alcohol withdrawal syndrome: new perspectives

Alcohol withdrawal syndrome is one of the most important consequences of alcohol use disorder, a complex neuropsychiatric disorder, which is firstly treated in non-specific and secondly in psychiatric/addictive in- or outpatient units. On the other hand, alcohol withdrawal syndrome is one of the most important outcomes of the severity of alcohol use disorder, further, it can lead to the development of alcohol-related seizure and delirium tremens. Hence, early recognition and optimal treatment of alcohol withdrawal syndrome have a critical importance. Therefore, the main goal of the present review was - by systematically summarizing the scientific data published during the past two decades - to form a unique diagnostic and therapeutic algorithm. During the recognition and the course of alcohol withdrawal syndrome, the Clinical Institute Withdrawal Assessment for Alcohol, Revised scale, while in the risk assessment the Prediction of Alcohol Withdrawal Severity Scale are the recommended psychometric tools. Benzodiazepines are the key elements of the pharmacotherapy of alcohol withdrawal syndrome. Many studies have evaluated that diazepam, chlordiazepoxide, lorazepam and oxazepam with distinct indications have sufficient evidence in the treatment of alcohol withdrawal syndrome. However, in the past few years some authors have recommended the importance of non-benzodiazepine medications. The efficacy of propofol, phenobarbital, carbamazepin, oxcarbamazepin and alpha-2 receptor agonists in the treatment of alcohol withdrawal syndrome have been revealed. Furthermore, it has been evaluated that benzodiazepines are recommended in the treatment of alcohol-related seizure and delirium tremens. In the present review, our aim was to construct a unique, up-to-date diagnostic and therapeutic algorithm by summarizing the related papers published during the past two decades. Hence this scheme may be useful in the optimal treatment of patients diagnosed with alcohol use disorder and it could help to conduct further clinical researches. Orv Hetil. 2023; 164(38): 1487-1496.

Predictors of Escalation to Intensive Care Unit Level of Care Among Admissions for Alcohol Withdrawal.

According to the 2019 National Survey on Drug Use and Health, 14.5 million people ages 12 and older had alcohol abuse disorder. Alcohol withdrawal syndrome (AWS) can be defined as a collection of physical symptoms experienced due to abrupt cessation of alcohol after long-term dependence. In instances where regular inpatient management fails to control AWS symptoms, patients are shifted to intensive care units (ICUs) for closer monitoring and prevention of life-threatening complications like withdrawal seizures and delirium tremens (DTs), labeled as severe alcohol withdrawal syndrome (SAWS). Although this represents a significant healthcare burden, minimal studies have been conducted to determine objective predictors. In this study, we aim to determine the effect of patient demographics, socio-economic status, biochemical parameters, and clinical factors on the need for escalation to ICU level of care among admissions for AWS. Our study showed that factors such as a history of DTs or alcohol-related seizures, the initial protocol of management, degree of reported alcohol usage, activation of rapid response teams, mean corpuscular value, alcohol level on admission, highest Clinical Institute Withdrawal Assessment Alcohol Revised (CIWA-Ar) scored during the hospital stay, and the total amount of sedatives used were significantly associated with escalation to ICU level of care. Clinicians must use these objective parameters to identify high-risk patients and intervene early. We encourage further studies to establish a scoring algorithm incorporating biochemical parameters to tailor management algorithms that might better suit high-risk patients.

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.

Assessment of a modified MINDS-based protocol for management of alcohol withdrawal syndrome on an inpatient medical service.

To determine if a novel symptom-based alcohol withdrawal syndrome (AWS) protocol in a US Veterans cohort leads to significant clinical improvements in patient outcomes and safety. Prior studies of AWS management, oftentimes using the revised version of the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) index, have demonstrated the effectiveness of symptom-triggered therapy for AWS. The Minnesota Detoxification Scale (MINDS) is an alternative to the CIWA-Ar index but remains unevaluated outside of the intensive care unit (ICU) setting. This study assesses outcomes in AWS management prior to and after the implementation of a novel MINDS-based AWS protocol (SDAWP) utilizing a revised MINDS index (MINDS-rev) in an inpatient medical ward setting. Retrospective cohort study including encounters prior to (n = 342) and after (n = 338) the implementation of the protocol. Pre- and post-protocol encounters were selected by combinations of diagnostic codes and charting elements. Outcome measures of AWS management were obtained in both groups. The primary endpoint was median total benzodiazepine exposure. Secondary outcomes included median length of hospitalization, median duration of benzodiazepine administration, and the incidence of complications. The median total benzodiazepine exposure in the post-SDAWP group was significantly lower than the pre-SDAWP group (21.2 vs. 12.0 mg, p < 0.0001) and for a significantly shorter median duration of time (4.0 vs. 3.0 days, p < 0.0001). There was no significant difference in the median length of stay (4.0 vs. 4.0 days, p = 0.50). The incidence of delirium tremens (21 vs. 7, p = 0.01) and need for transfer to a higher level of care (33 vs. 12, p = 0.002) was significantly lower in the post-SDAWP group. The SDAWP has provided significant improvements in AWS management in our institution and may potentially serve as a template for wider use in other inpatient settings.

Treatment of high dose of intravenous midazolam abuse: a case report.

This study reports a rare case of high-dose midazolam abuse and Munchausen Syndrome. A 48-year-old female physician was referred by a psychiatrist to the Toxicology Department of Imam Reza Hospital for abstaining from 300 mg/day of parenteral midazolam. She had mimicked the symptoms of Crohn's disease; therefore, she had undergone 15 colonoscopies and 40 times MRI or CT scan, all of which were normal. Six months earlier, she had switched oral methadone to 30 mg/day of intravenous midazolam. She also had several skin lesions on injection sites that she considered pyoderma gangrenosum. When the total daily dose of intravenous midazolam was switched to oral bioequivalence of clonazepam, she could not tolerate withdrawal (Clinical Institute Withdrawal Assessment Scale-Benzodiazepines = 68). Therefore, she received midazolam again as a continuous intravenous infusion. Within 7 days, the whole dose was replaced by the bioequivalence oral dose of clonazepam. She was also treated with carbamazepine and cognitive behavior therapy. Afterward, she was transferred to the psychiatric ward for further psychiatric treatment. Dependency on a high dose of midazolam could be treated by tapering off the long-acting benzodiazepine.

Alcohol Withdrawal with Delirium Tremens.

Emergency medicine (EM) residents (1st year and 2nd year levels), 4th year medical students and advanced practice providers. Alcohol use has played a major role in causing significant morbidity and mortality for patients. In 2016, it was the 7th leading risk factor for deaths and disability-adjusted life years globally.1 Among heavy alcohol users admitted for hospital management, the incidence of alcohol withdrawal syndrome is estimated to be 1.9 to 6.7%.1 Alcohol withdrawal (AW) in the ED has been associated with increased use of critical care resources, and frequent ED visits for alcohol-related presentations have been associated with mortality rates that are about 1-4% when withdrawal progresses to delirium tremens (DTs).1 Patients with alcohol withdrawal can present in many different ways to the ED including anxiety, tachycardia, delirium tremens (DTs), seizures and severe autonomic dysfunction leading to severe sickness and death.2 Therefore, it is extremely important for an EM physician to recognize the signs of AW in patients and to manage the critically ill patients. In addition, Clinical Institute Withdrawal Assessment (CIWA) of alcohol was developed to assess severity of alcohol withdrawal in 1989.3 EM physicians should utilize CIWA to help determine the severity of AW. By the end of the session, learner will be able to 1) discuss the causes of altered mental status, 2) utilize CIWA scoring system to quantify AW severity, 3) formulate appropriate treatment plan for AW by treating with benzodiazepine and escalating treatment appropriately, 4) treat electrolyte abnormalities by giving appropriate medications for hypokalemia and hypomagnesemia, and 5) discuss clinical progression and timing to AW. This session was conducted using high-fidelity simulation, which was immediately followed by an in-depth debriefing session. The session was run during first year EM resident intern orientation, and it was run during two consecutive years. There was a total of 32 EM residents who participated. There was a total of 16 residents who actively managed the patient while the other 16 were observers. Each session had four learners and was run twice in two separate rooms. There was one simulation instructor running the session and one simulation technician who acted as a nurse. After the simulation and debriefing session was complete, an online survey was sent via surveymonkey.com to all the participants. The survey collected responses to the following questions: (1) the case was believable, (2) the case had right the amount of complexity (based on their Gestalt), (3) the case helped in improving medical knowledge and patient care, (4) the simulation environment gave me a real-life experience and, (5) the debriefing session after simulation helped improve my knowledge. The responses were collected using a Likert scale of 1 to 5 with 1 being "Strongly disagree" and 5 being "Strongly agree." There was a total of 15 respondents from both years. One hundred percent of them either agreed or strongly agreed that the case was beneficial in learning, in improving medical knowledge and in patient care. All of them found the post-session debrief to be very helpful. Two of them felt neutral about the case being realistic. The median response for questions 1, 3 and 5 is 5. The median response for questions 2 and 4 was 4. The range of responses for questions 1, 2, 3 and 5 was 4-5 while the range for question 4 was 3-5. This high-fidelity simulation was a cost-effective and realistic way of educating learners on how to manage AW with DTs. Learners are forced to start with a broad differential for the patient who presents with AMS. As they recognize the cause of mental status, the patient quickly decompensates into developing severe agitation and autonomic dysfunction requiring learners to manage the patient and establish an airway. Learners found the case to be beneficial in learning the management of AW. Alcohol withdrawal, delirium tremens, agitation, altered mental status.

Alcohol Withdrawal Assessment Tool (AWAT) Reliability and Validity: Implications for Nurses Caring for Inpatients With Mental Health Disorders.

Alcohol use affects 14.5 million Americans and high prevalence of use and potential for withdrawal among hospitalized patients presents a challenge for health care professionals to anticipate and manage effectively. Due to the acuity and fast-paced nature of the hospital environment, nurses need assessment tools that can be readily completed and drive efficient protocol-based treatment. The purpose of this study was to examine psychometric properties of the alcohol withdrawal assessment tool (AWAT). The aims were to examine AWAT (1) reliability, (2) validity, and (3) usability. Patients (n = 55) and nurses (n = 47) were recruited from six hospitals within one health care system in the Midwest. Psychometric testing included inter-rater reliability and criterion-related validity testing, using the Clinical Institute Withdrawal Assessment of Alcohol Scale-Revised (CIWA-Ar) as a comparison. Usability was assessed with a 5-item Likert-type scale. Findings supported strong agreement (ICC: .931) between raters on the AWAT and a moderate correlation (Pearson r: .548) between scores on the AWAT and CIWA-Ar. Nurses agreed/strongly agreed that the AWAT took 2 min or less to complete (n = 42; 89%), was easy to use for assessment (n = 42; 89%) was easy to learn (n = 40; 85%), and they were confident using the AWAT (n = 39; 83%). Study findings provide evidence of reliability, validity, and usability of the AWAT in the hospital setting. The AWAT has potential to improve assessment efficiency and nurses caring for inpatients with mental health disorders should consider implementing the tool into practice.