Management Of Alcohol Withdrawal Research Articles

Baclofen Neurotoxicity: A Metabolic Encephalopathy Susceptible to Exacerbation by Benzodiazepine Therapy.

Baclofen has been reported to cause both a metabolic encephalopathy and nonconvulsive status epilepticus. Baclofen is typically used in the management of muscle spasticity but is being increasingly used to manage alcohol withdrawal and opiate dependency. Given the increasing use of baclofen we describe the clinical and electrographical features of baclofen neurotoxicity seen at our institution. The clinical and EEG features of patients with an encephalopathy in the setting of baclofen therapy were analyzed. Patients were identified via our hospital EEG database. Fourteen patients were identified having presented with an acute confusional state without identifiable cause other than baclofen use. Five patients took a deliberate overdose, three of whom were baclofen naive, two patients presented after medication prescription error, and seven patients were on stable doses (30-140 mg daily). All patients presented with an encephalopathy, one patient was reported to have clinical seizures, and seven had multifocal myoclonus. EEGs were abnormal in all patients and showed moderate to severe generalized slowing. Generalized triphasic waves occurring at 1 to 2 Hz, sometimes with an anterior to posterior phase lag, were present in 10 patients (71%), and intermittent generalized suppression of the background was seen in three patients. Three patients received small doses of intravenous benzodiazepines, resulting in a marked depression of consciousness and respiration. All patients recovered within 48 hours of baclofen discontinuation. Baclofen toxicity can produce an acute encephalopathy even at modest doses, with the EEG showing generalized slowing and triphasic waves consistent with a toxic encephalopathy. Management consists of supportive care and cessation of baclofen. Patients with baclofen neurotoxicity exhibit a marked vulnerability to the depressant effects of benzodiazepines.

Alcoholic Liver Disease: Implications for the Advanced Practice Provider

Alcoholic liver disease is a largely preventable condition that contributes to mortality in the United States and worldwide. This article discusses the pathogenesis, risk factors, diagnosis, screening tools, clinical presentation, and predictors of mortality. Medical management using the most recent clinical guidelines from the 2018 American College of Gastroenterology and the American Gastroenterological Association Institute are reviewed. Supportive care, abstinence promotion, cognitive behavioral therapy, nutritional needs, pharmacotherapy, alcohol withdrawal management, intensive care, and liver transplantation are discussed, as well as future research directions. Finally, practice implications to better address this population’s needs using a multidisciplinary approach are addressed.

Use of Phenobarbital in Alcohol Withdrawal Management – A Retrospective Comparison Study of Phenobarbital and Benzodiazepines for Acute Alcohol Withdrawal Management in General Medical Patients

Benzodiazepine-based protocols offer a standard of care for management of alcohol withdrawal, though they may not be safe or appropriate for all patients. Phenobarbital, a long-acting barbiturate, presents an alternative to conventional benzodiazepine treatment, though existing research offers only modest guidance to the safety and effectiveness of phenobarbital in managing alcohol withdrawal syndrome (AWS) in general hospital settings. To compare clinical effectiveness of phenobarbital versus benzodiazepines in managing symptoms of alcohol withdrawal, we conducted a retrospective chart review of 562 patients admitted over a 2-year period to a general hospital and treated for AWS. The development of AWS-related complications (seizures, alcoholic hallucinosis, and alcohol withdrawal delirium) post-treatment initiation was the primary outcome examined in both treatment groups. Additional outcomes measured included hospital length of stay, intensive care unit (ICU) admission rates/length of stay, medication-related adverse events, and discharge against medical advice. Despite being significantly more likely to have a history of prior complications related to AWS (including seizures and delirium), patients initiated on phenobarbital (n = 143) had overall similar primary and secondary treatment outcomes to those in the benzodiazepine treatment protocol (n = 419). Additionally, a subset of patients (n = 16) initially treated with benzodiazepines displayed signs of treatment nonresponse, including significantly higher rates of AWS-related delirium and ICU admission rates, but were well-managed following transition to the phenobarbital protocol. The data from this retrospective chart review lend further support to effectiveness and safety of phenobarbital for the treatment and management of AWS. Further randomized controlled trials are warranted.

Abstract TP408: Alcohol Withdrawal is Associated With Poorer Outcome in Ischemic Stroke

Objective: Prevalence of alcohol abuse (AA) in the United States (US) is on the increase. AA patients may develop alcohol withdrawal (AW) during hospitalization, but it remains unknown how AW influences acute ischemic stroke (AIS) outcome. Methods: All adult AIS admissions in the US from 2004–2014 were identified from the National Inpatient Sample (NIS) (weighted N=4,438,968). Multivariable-adjusted models were used to evaluate the association of AW with in-hospital medical complications, mortality, cost, and length-of-stay in patients with AIS. Results: During this period, 3.9% of all AIS admissions had comorbid codes for AA but prevalence differed significantly by age; 10.6% of AA patients, representing 0.4% of all AIS, developed AW. Prevalence of AA and AW in AIS increased by 45.2% and 40.0%, respectively, over time (p-value for trend <0.001). AA patients were predominantly men (80.2%), white (65.9%), and in the 40–59-year (44.6%) and 60–79-year (45.6%) age groups. After multivariable adjustment, AIS patients with AW had >50% increased odds of urinary tract infection, pneumonia, sepsis, gastrointestinal bleeding, deep venous thrombosis, and acute renal failure compared to those without AW. Patients with AW were also 32% more likely to die during their AIS hospitalization compared to those without AW (OR 1.32, 95% CI 1.11–1.58). AW was associated with 15-day increase in length-of-stay and $5,000 increase in hospitalization cost (p-values <0.001). Conclusions: AW is associated with increased cost, longer hospitalizations, and higher odds of medical complications and in-hospital mortality following AIS. Proactive surveillance and management of AW may be important in improving outcomes in these patients.

Pregabalin misuse in a 75-year-old woman

Pregabalin is a drug that has been used in the management of partial epilepsy, generalized anxiety disorder, neuropathic pain, and fibromyalgia. Recently, it has found usefulness in the management of alcohol withdrawal. The use of pregabalin in the elderly is scarce, and data on the same are not easily available. We report herewith the case of pregabalin misuse in a 75-year-old woman with depression and anxiety.

Alcohol withdrawal-related outcomes associated with gabapentin use in an inpatient psychiatric facility.

IntroductionLimited evidence exists evaluating the impact of gabapentin in conjunction with benzodiazepines for the management of alcohol withdrawal. A review of outcomes associated with combination gabapentin and benzodiazepine therapy may illuminate new therapeutic uses in clinical practice.MethodsThis retrospective study evaluated the impact of gabapentin on as-needed use of benzodiazepines in inpatients being treated for acute alcohol withdrawal. The treatment cohort consisted of patients prescribed gabapentin while on a symptom-triggered alcohol withdrawal protocol. The control cohort consisted of patients on symptom-triggered alcohol withdrawal protocol without concurrent gabapentin use. Secondary objectives included length of hospital stay, duration on alcohol withdrawal protocol, frequency of complicated withdrawal, and use of additionally prescribed as-needed or scheduled benzodiazepines.ResultsThe gabapentin cohort was on the alcohol withdrawal protocol for a similar duration, compared with the control cohort (median of 4 [interquartile range: 2,6] days vs 3 [2,4] days, P = .09, respectively). Similarly, the gabapentin cohort required a median of 1 [1,2] benzodiazepine dose for alcohol withdrawal symptoms compared with a median of 1 [1,2] dose in the control cohort, P = .89. No significant difference was found between cohorts for as-needed and scheduled benzodiazepine use. Length of stay in hospital was similar between groups.DiscussionThese results suggest that gabapentin use, in conjunction with benzodiazepines, impacts neither the time on alcohol withdrawal protocol or the number of benzodiazepine doses required for withdrawal. Larger, prospective studies are needed to detect if gabapentin alters benzodiazepine usage and to better elucidate gabapentin's role in acute alcohol withdrawal.

Alcohol Withdrawal Management and Relapse Prevention in Pregnancy

ABSTRACT Objectives: The aim of this is to provide a clinical example of acute alcohol withdrawal management and alcohol use disorder (AUD) relapse prevention, followed by a systematic review of the existing literature that provides clinicians with suggestions regarding treatment of this common clinical scenario. Methods: A case report was prepared with respect to the medical management of a patient that had been seen by our team. We searched “PubMed” and “The UBC Library Online Collections” using the search limits of subject terms for “alcohol withdrawal,” and “pregnancy,” and all fields for “management,” NOT “opioid.” We also reviewed medications frequently used in treating AUD as per the existing literature. Results: One case report met our search criteria. We also reviewed the recently published guidelines by the American Psychiatric Association. Several medications used in acute alcohol withdrawal and relapse prevention are known teratogens. However, several medications appear to be compatible with pregnancy and were found to be Category C and their use may outweigh the risks. Conclusions: There is a paucity of synthesized literature pertaining to alcohol withdrawal treatment and pregnancy. Given the relatively high prevalence of AUD in the population, further investigation is warranted. The current data supports a thorough consideration of the risks of medications against the known teratogenicity of alcohol. We suggest only brief use of benzodiazepines to manage the acute withdrawal from alcohol. Gabapentin, naltrexone, or acamprosate could be considered for AUD relapse prevention. Objectifs: L’objectif est de fournir un exemple clinique de gestion du sevrage alcoolique aigu et de prévention des rechutes liées à l’usage de l’alcool, suivi d’un examen systématique de la littérature existante fournissant aux cliniciens des suggestions concernant le traitement de ce scénario clinique courant. Méthodes: Un rapport de cas a été préparé concernant la gestion médicale d’un patient vu par notre équipe. Nous avons effectué une recherche dans «PubMed» et «Les collections en ligne de la bibliothèque de l’UBC» en limitant la recherche des termes utilisés pour «sevrage alcoolique» et «grossesse» et tous les champs pour «gestion», excluant «opioïdes». Nous avons également passé en revue les médicaments fréquemment utilisés dans le traitement des troubles liés à la consommation d’alcool, conformément à la littérature existante. Résultats: Une analyse de cas répondait à nos critères de recherche. Nous avons également examiné les lignes directrices récemment publiées par l’American Psychiatric Association. Plusieurs médicaments utilisés dans le sevrage alcoolique aigu et la prévention des rechutes sont connus comme agents tératogènes. Cependant, plusieurs médicaments semblent être compatibles avec la grossesse et se sont avérés être de la catégorie C et les effets bénéfiques l’emportaient sur les risques. Conclusion: Il existe peu d’études synthétisées sur le traitement de sevrage alcoolique en lien avec la grossesse. Compte tenu de la prévalence relativement élevée de troubles liées à la consommation d’alcool dans la population, des investigations supplémentaires sont nécessaires. Les données actuelles justifient un examen approfondi des risques des médicaments contre la tératogénicité connue de l’alcool. Nous suggérons de n’utiliser que brièvement les benzodiazépines pour gérer le sevrage aigu de l’alcool. La gabapentine, la naltrexone ou l’acamprosate pourraient être envisagés pour la prévention des rechutes liées à l’alcoolisme.

Evaluation of a Web-based Educational Program to Teach the Identification and Management of Alcohol Withdrawal in the Emergency Department.

Ideal management of alcohol withdrawal syndrome (AWS) incorporates a symptom-driven approach, where patients are regularly assessed using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised [CIWA-Ar]) and treated according to severity. Accurate administration of the CIWA-Ar requires experience, yet there is no training program to teach this competency. The objective of this study was to develop and evaluate a curriculum to teach clinicians how to accurately assess and treat AWS. This was a three-phase education program consisting of a series of e-learning modules containing core competency material, an in-person seminar to orient learners to high-fidelity simulation, and a summative evaluation in an objective structured clinical examination setting using a standardized patient. To determine the impact of the AWS curriculum, we recorded how often the CIWA-Ar was appropriately applied in the emergency department (ED) before and after training. A CIWA-Ar protocol breach was defined as inappropriate administration of benzodiazepines (CIWA-Ar<10) and failure to administer benzodiazepines when required (CIWA-Ar ≥ 10). ED length of stay, amount of benzodiazepines administered in the ED, discharge prescriptions, and unit doses (take-away bottle of four tablets) of benzodiazepine given were recorded. Seventy-four ED nurses completed the curriculum over an 8-week period. In the 5 months prior to the educational program delivery, we identified 144 of 565 (25.5%) CIWA-Ar protocol breaches, compared to 64 of 547 (11.7%) in the 5 months after training (∆13.8%, 95% confidence interval [CI]= 9.3%-18.3%). Program completion resulted in a reduction in the median total dose of diazepam administered in the ED (40mg vs. 30mg, ∆10mg, 95% CI= 0-20mg) and no change was detected in ED length of stay and benzodiazepines prescribed. Completion of this curriculum resulted in better compliance with the CIWA-Ar protocol by those who administer the CIWA-Ar; however, changes in inappropriate benzodiazepine prescribing practice will require future interdisciplinary initiatives.

Early recovery following traumatic brain injury and alcohol withdrawal management.

To compare recovery experienced during inpatient rehabilitation among individuals with traumatic brain injury (TBI) based on whether their acute care included the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol. Participants included 234 individuals with TBI who completed inpatient rehabilitation at a TBI Model Systems site. Of these, 67 patients were treated using the CIWA protocol (TBI + CIWA); 167 patients were treated for TBI alone (TBI only). Demographic, injury, and treatment variables between the 2 groups were compared. A repeated-measures analysis of variance (ANOVA) compared Disability Rating Scale (DRS) scores between the groups at admission and discharge from inpatient rehabilitation. The 2 groups did not significantly differ on DRS scores at admission to inpatient rehabilitation: TBI + CIWA, M = 9.6 (SD = 3.5) vs. TBI only, M = 10.1 (SD = 4.2). There was a significant difference in DRS scores at discharge, with the TBI + CIWA group having lower scores: TBI + CIWA, M = 6.4 (SD = 1.9) vs. TBI only, M = 7.0 (SD = 2.2). A repeated-measures ANOVA of DRS scores from admission to discharge revealed a significant between-subjects effect based on patients' Mississippi categorization of posttraumatic amnesia (PTA) duration (p < .001) and age (p = .016) but not based on their CIWA status (p = .068). A post hoc comparison including age as a covariate revealed a significant difference based on CIWA status (p = .013) within the "moderate" injury group at discharge, with the TBI + CIWA group having lower discharge DRS scores. Given the significant symptom overlap between alcohol withdrawal and PTA, it is likely that these 2 delirium presentations are confounded during the initial recovery from TBI, leading to "overestimation" of injury severity-particularly among individuals with moderate TBI. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Symptom-triggered therapy for assessment and management of alcohol withdrawal syndrome in the emergency department short-stay clinical decision unit

IntroductionWe previously reported that benzodiazepine detoxification for alcohol withdrawal using symptom-triggered therapy (STT) with oral diazepam reduced length of stay (LOS) and cumulative benzodiazepine dose by comparison with standard fixed-dose...

MP43: Evaluation of an innovative web-based educational program to teach the management of alcohol withdrawal

Introduction: Ideal management of alcohol withdrawal syndrome (AWS) incorporates a symptom driven approach, whereby patients are regularly assessed using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised; CIWA-Ar) and treated according to severity. Accurate administration of the CIWA-Ar requires experience, yet there is no training program to teach this competency. The objective of this study was to develop and evaluate a web-based curriculum to teach clinicians how to accurately assess and treat AWS. Methods: This was a three-phase educational program consisting of a series of 3 e-learning modules of core competency material, in-person seminar to orient learners to high fidelity simulation, and summative evaluation in an OSCE setting using a standardized patient. To determine the ED impact of the AWS curriculum, we recorded how often the CIWA-Ar was appropriately applied in the ED pre and post training. ED length of stay, total dose of benzodiazepines administered in the ED, and number of prescriptions and unit benzodiazepine doses given upon discharge were also recorded. Results: 74 nurses from an academic ED completed the AWS curriculum. There were 130 and 126 patients in the pre and post AWS training periods, respectively. Management of AWS was not compliant with CIWA-Ar protocol in 78 (60.0%) and 46 (36.5%) patients pre and post AWS training, respectively ( 23.5%; 95% CI: 11.3%, 34.7%), resulting in administration of benzodiazepine when it was not required, or not giving benzodiazepines with a CIWA-Ar score of 10. There was an average of 4 CIWA-Ar scores per patient in both the pre and post implementation periods. Prior to AWS training, 144/560 (25.5%) CIWA-Ar scores resulted in a breach of protocol, compared to 64/547 (11.7%) following AWS training ( 13.8%; 95% CI: 9.3%, 18.3%). Median total dose of benzodiazepines administered in the ED was lower after the implementation of the AWS curriculum (40mg vs 30mg; 10 mg; 95% CI: 0mg, 20mg). ED length of stay and the amount of benzodiazepines given to patients at discharge were similar between groups. Conclusion: This AWS curriculum appears to be an effective way to train ED clinicians on the proper administration of the CIWA-Ar protocol, and results in improved patient care.

Use of a Gabapentin Protocol for the Management of Alcohol Withdrawal: A Preliminary Experience Expanding From the Consultation-Liaison Psychiatry Service

Benzodiazepines are the conventional mainstay to manage alcohol withdrawal; however, patients are subsequently at increased risk for poor sleep, cravings, and return to drinking. Research on alternative pharmacologic agents to facilitate safe alcohol withdrawal is scant. Gabapentin is one medication shown in small studies to reduce the need for benzodiazepines in the setting of alcohol withdrawal. The continuation of gabapentin after alcohol withdrawal appears to be safe during early sobriety and may aid in reducing alcohol-related cravings or returning to alcohol consumption. Use of a gabapentin-based, benzodiazepine-sparing protool began in early 2015 by the Mayo Clinic, Rochester, Consultation-Liaison Psychiatry Service. A retrospective chart review was conducted to detect any safety concerns with use of a gabapentin protocol for alcohol withdrawal syndrome. Secondary outcomes were derived by comparing a matched cohort of patients who received benzodiazepines for alcohol withdrawal syndrome. Seventy-seven patients had their alcohol withdrawal managed via a gabapentin protocol during the study period. No patients required transfer to a higher level of care or had a documented withdrawal seizure. Length of stay between the gabapentin protocol group and benzodiazepine group were similar. This preliminary data has supported the frequent use of this protocol in the general internal medicine practice and formalization of an institutional order set of this protocol for mild to moderate alcohol withdrawal syndrome. Prospective studies are required to validate findings.

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.

Ketogenic Diet Suppresses Alcohol Withdrawal Syndrome in Rats.

Alcohol use disorder is underdiagnosed and undertreated, and up to 50% of alcohol-abstinent patients diagnosed with alcohol dependence relapse within the first year of treatment. Current treatments for the maintenance of alcohol abstinence in patients with alcohol use disorder have limited efficacy, and there is an urgent need for novel treatment strategies. Decreased cerebral glucose metabolism and increased brain uptake of acetate were recently reported in heavy drinkers, relative to controls. Given the switch of metabolic fuel from glucose to acetate in the alcohol-dependent brain, we investigated the potential therapeutic benefit of a ketogenic diet in managing alcohol withdrawal symptoms during detoxification. Male Sprague Dawley rats fed either ketogenic or regular diet were administered ethanol or water orally, twice daily for 6days while the diet conditions were maintained. Abstinence symptoms were rated 6, 24, 48, and 72hours after the last alcohol administration. Maintenance on a ketogenic diet caused a significant decrease in the alcohol withdrawal symptoms' "rigidity" and "irritability." Our preclinical pilot study suggests that a ketogenic diet may be a novel approach for treating alcohol withdrawal symptoms in humans.

Development and implementation of an alcohol withdrawal protocol using a 5-item scale, the Brief Alcohol Withdrawal Scale (BAWS)

ABSTRACTBackground: The standard of care for management of alcohol withdrawal is symptom-triggered treatment using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar). Many items of this 10-question scale rely on subjective assessments of withdrawal symptoms, making it time-consuming and cumbersome to use. Therefore, there is interest in shorter and more objective methods to assess alcohol withdrawal symptoms. Methods: A 6-item withdrawal scale developed at another institution was piloted. Based on comparison with the CIWA-Ar, this was adapted into a 5-item scale named the Brief Alcohol Withdrawal Scale (BAWS). The BAWS was compared with the CIWA-Ar and a withdrawal protocol utilizing the BAWS was developed. The new protocol was implemented on an inpatient unit dedicated to treating substance withdrawal. Data was collected on the first 3 months of implementation and compared with the 3 months prior to that. Results: A BAWS score of 3 or more predicted CIWA-Ar score ≥8 with a sensitivity of 85.3% and specificity of 65.8%. The demographics of the patients in the 2 time periods were similar: the mean age was 45.9; 70.6% were male; 30.9% received concurrent treatment for opioid withdrawal; and 14.2% were receiving methadone maintenance. During the BAWS phase, patients received significantly less diazepam (mean dose 81.4 vs. 60.3 mg, P < .001). There was no significant difference in length of stay. No patients experienced a seizure, delirium, or required transfer to a higher level of care during any of the 664 admissions in either phase. Conclusions: This simple protocol utilizing a 5-item withdrawal scale performed well in this setting. Its use in other settings, particularly with patients with concurrent medical illnesses or more severe withdrawal, needs to be explored further.

Baclofen for alcohol withdrawal.

Baclofen shows potential for rapidly reducing symptoms of severe alcohol withdrawal syndrome (AWS) in people with alcoholism. Treatment with baclofen is easy to manage and rarely produces euphoria or other pleasant effects, or craving for the drug. This is an updated version of the original Cochrane Review published in 2015, Issue 4. To assess the efficacy and safety of baclofen for people with AWS. We updated our searches of the following databases to March 2017: the Cochrane Drugs and Alcohol Group Specialised Register, CENTRAL, PubMed, Embase, and CINAHL. We also searched registers of ongoing trials. We handsearched the references quoted in the identified trials, and sought information from researchers, pharmaceutical companies, and relevant trial authors about unpublished or uncompleted trials. We placed no restrictions on language. We included all randomised controlled clinical trials (RCTs) evaluating baclofen versus placebo or any other treatment for people with AWS. We excluded uncontrolled, non-randomised, or quasi-randomised trials. We included both parallel group and cross-over studies. We used standard methodological procedures expected by Cochrane. We included three RCTs with 141 randomised participants. We did not perform meta-analyses due to the different control interventions. For the comparison of baclofen and placebo (1 study, 31 participants), there was no significant difference in Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) scores (very low quality evidence). For the comparison of baclofen and diazepam (1 study, 37 participants), there was no significant difference in CIWA-Ar scores (very low quality evidence), adverse events (risk difference (RD) 0.00, 95% confidence interval (CI) -0.10 to 0.10; very low quality evidence), dropouts (RD 0.00, 95% CI -0.10 to 0.10; very low quality evidence), and dropouts due to adverse events (RD 0.00, 95% CI -0.10 to 0.10; very low quality evidence). For the comparison of baclofen and chlordiazepoxide (1 study, 60 participants), there was no significant difference in CIWA-Ar scores (mean difference (MD) 1.00, 95% CI 0.70 to 1.30; very low quality evidence), global improvement (MD 0.10, 95% CI -0.03 to 0.23; very low quality evidence), adverse events (RD 2.50, 95% CI 0.88 to 7.10; very low quality of evidence), dropouts (RD 0.00, 95% CI -0.06 to 0.06; very low quality evidence), and dropouts due to adverse events (RD 0.00, 95% CI -0.06 to 0.06; very low quality evidence). No conclusions can be drawn about the efficacy and safety of baclofen for the management of alcohol withdrawal because we found insufficient and very low quality evidence.

Evaluating the benefits of using a scoring system to aid management of alcohol withdrawal at an NHS district general hospital

To assess whether incorporating the Clinical Institute Withdrawal Assessment of Alcohol scale, revised (CIWA-Ar) into hospital guidelines for managing alcohol withdrawal increases staff confidence and knowledge of managing this condition. Two recent cases were identified where patients with alcohol

This Is the Year to Listen to Yourself.

This Is the Year to Listen to Yourself.

Nalmefene and opioids: A contra-indication to remember

Nalmefene (NMF – SELINCRO®), a drug for alcohol withdrawal management (AWM), is both a partial agonist and an antagonist of opioids receptors. Inherent to the latter activity, NMF is contra-indicated in patients with opioid treatment. However, despite this contra-indication, cases of opioid withdrawal syndrome (OWS) in patients treated with opioid maintenance therapy (OMT) are reported [1] , [2] . We aim to report 2 additional cases. A 46 and a 34-year-old men, with a history of alcoholism and opioid dependence, had OMT with methadone since a few years and were prescribed NMF. Thirty minutes after their single first dose of NMF, they experienced nausea, diarrhoea, vomiting and psychomotor excitement. First patient also had clonus, abundant sweating and anxiety. Both were transferred to the emergency department where OWS was diagnosed. They both received intravenous morphine, plus oxazepam (first patient) or a mix of benzodiazepines and neuroleptics (second patient). On the following day, first patient still presented digestive symptoms leading to hypokalaemia. A symptomatic treatment was initiated, morphine was stopped and methadone was reintroduced. He totally recovered on the 3 rd day and was discharged. The second patient was transferred into intensive care unit (ICU) as he required intubation and sedation. Two days later, morphine was stopped and methadone was reintroduced. The patient had totally recovered and was discharged two days later. Our two cases must be added to the nine other recently reported cases of OWS soon after a single first NMF intake in opioid dependent patients [1] , [2] . This condition always required hospitalization and sometimes ICU stay. No patient died. The summary of product characteristics of Selincro® has been updated in July 2015 with a clearer additional assertion to emphasize the need for healthcare professionals to be aware of their patients’ opioid consumption, especially OMT, before prescribing or delivering NMF. As co-existence of alcoholism and OMT is not rare, healthcare professionals really need to be vigilant about the contra-indication of NMF in patients under OMT.

Psychiatric Emergencies for Clinicians: Emergency Department Management of Alcohol Withdrawal

Psychiatric Emergencies for Clinicians: Emergency Department Management of Alcohol Withdrawal