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Treatment variability and outcome differences in the emergency department management of alcohol withdrawal

Published online by Cambridge University Press:  21 May 2015

Meldon Kahan*
Affiliation:
St. Joseph’s Health Centre, Toronto, Ont.
Bjug Borgundvaag
Affiliation:
Mount Sinai Hospital, Toronto, Ont.
Deana Midmer
Affiliation:
Department of Family and Community Medicine, University of Toronto, Toronto, Ont.
Diane Borsoi
Affiliation:
Centre for Addiction and Mental Health, Toronto, Ont.
Carol Edwards
Affiliation:
Centre for Addiction and Mental Health, Toronto, Ont.
Noor Ladhani
Affiliation:
University of Western Ontario, London, Ont.
*
Addiction Medicine Service, St. Joseph’s Health Centre, 33 The Queensway, Toronto ON M6R 1B5; 416 530-6860, fax 416 530-6160, [email protected]

Abstract

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Objective:

Evidence suggests that symptom-triggered benzodiazepine treatment for patients with alcohol withdrawal reduces complication rates and emergency department lengths of stay. Our objective was to describe the management of alcohol withdrawal in 2 urban emergency departments.

Methods:

A structured chart audit was performed for patients with alcohol-related problems who presented to 2 Toronto hospitals over a 2-year period.

Results:

A total of 209 emergency department charts were audited. Patient characteristics were similar in both hospitals. None of the patients had been assessed using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale. Patients at one hospital received substantially higher mean diazepam doses (64 mg v. 26 mg; p < 0.001) than did the patients at the other hospital, and the patients at the first hospital had fewer seizures during their emergency department stay (1% v. 9%; p = 0.012). Patients spent an average of 9 hours and 40 minutes in the emergency department.

Conclusion:

There is significant variability in the documentation and treatment of alcohol withdrawal. Lower benzodiazepine doses are associated with higher rate of withdrawal seizures and prolonged emergency department length of stay. A standardized approach using symptom-triggered management is likely to improve outcomes for patients presenting with alcohol withdrawal.

Type
EM Advances • Innovations en MU
Copyright
Copyright © Canadian Association of Emergency Physicians 2005

References

1.Cherpitel, CJ, Soghikian, K, Hurley, LB. Alcohol-related health services use and identification of patients in the emergency department. Ann Emerg Med 1996;28(4):418–23.CrossRefGoogle ScholarPubMed
2.el-Guebaly, N, Armstrong, SJ, Hodgins, DC. Substance abuse and the emergency room: programmatic implications. J Addictive Diseases 1998;17(2):235.CrossRefGoogle ScholarPubMed
3.Blake, R, Brinker, M, Ursic, C, Clark, J, Cox, D. Alcohol and drug use in adult patients with musculoskeletal injuries. Am J Orthop 1997;26:704–10.Google Scholar
4.Lowenstein, SR, Weissberg, MPTerry, D. Alcohol intoxication, injuries, and dangerous behaviors and the revolving emergency department door. J Trauma 1990;30:252–8.CrossRefGoogle ScholarPubMed
5.Adams, WL, Magruder-Habib, K, Trued, S, Broome, HL. Alcohol abuse in elderly emergency department patients. J Am Geriatr Soc 1992;40(12):236–40.Google Scholar
6.Hulse, GK, Robertson, SI, Tait, RJ. Adolescent emergency department presentations with alcohol- or other drug-related problems in Perth, Western Australia. Addiction 2001;96(7):1059–67.CrossRefGoogle ScholarPubMed
7.Kriegsman, W, Anthes, W. The financial impact of alcohol-related emergencies on a rural EMS system. Alaska Med 1998;40(1):711.Google Scholar
8.Mandelberg, JH, Kuhn, RE, Kohn, MA. Epidemiologic analysis of an urban, public emergency department's frequent users. Acad Emerg Med 2000;7(6):637–46.Google Scholar
9.Brokaw, J, Olson, L, Fullerton, L, Tandberg, D, Sklar, D. Repeated ambulance use by patients with acute alcohol intoxication, seizure disorder, and respiratory illness. Am J Emerg Med 1998;16(2):141–4.CrossRefGoogle ScholarPubMed
10.Adinoff, B. Double-blind study of alprazolam, diazepam, clonidine, and placebo in the alcohol withdrawal syndrome: preliminary findings. Alcohol Clin Exp Res 1994;18(4):873–8.CrossRefGoogle ScholarPubMed
11.Naranjo, CA, Sellers, EM, Chater, K, Iversen, P, Roach, C, Sykora, K. Nonpharmacologic intervention in acute alcohol withdrawal. Clin Pharmacol Ther 1983;34(2):214–9.CrossRefGoogle ScholarPubMed
12.Devenyi, P, Harrison, ML. Prevention of alcohol withdrawal seizures with oral diazepam loading. CMAJ 1985;132(7):798800.Google Scholar
13.Sullivan, JT, Sykora, K, Schneiderman, J, Naranjo, CA, Sellers, EM. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict 1989;84(11):1353–7.CrossRefGoogle ScholarPubMed
14.Jaeger, TM, Lohr, RH, Pankratz, VS. Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients. Mayo Clin Proc 2001;76(7):695701.CrossRefGoogle ScholarPubMed
15.Wasilewski, D, Matsumoto, H, Kur, E, Dziklinska, A, Wozny, E, Stencka, K, et al. Assessment of diazepam loading dose therapy of delirium tremens. Alcohol Alcohol 1996;31(3):273–8.CrossRefGoogle ScholarPubMed
16.Saitz, R, Mayo-Smith, MF, Roberts, MS, Redmond, HA, Bernard, DR, Calkins, DR. Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial. JAMA 1994;272(7):519–23.CrossRefGoogle ScholarPubMed
17.Daeppen, JB, Gache, P, Landry, U, Sekera, E, Schweizer, V, Gloor, S, et al. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med 2002;162(10):1117–21.Google Scholar
18.Mayo-Smith, MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA 1997;278(2):144–5.CrossRefGoogle Scholar
19.Holbrook, AM, Crowther, R, Lotter, A, Cheng, C, King, D. Metaanalysis of benzodiazepine use in the treatment of acute alcohol withdrawal. CMAJ 1999;160(5):649–55.Google Scholar
20.International Classification of Diseases, 9th Revision (Clinical Modification). 5th ed. Washington: US Department of Health and Human Services; 1996. Cat no 86-72897.Google Scholar
21.Brower, KJ, Mudd, S, Blow, FC, Young, JP, Hill, EM. Severity and treatment of alcohol withdrawal in elderly versus younger patients. Alcohol Clin Exp Res 1994;18(1):196201.Google Scholar
22.Pristach, CA, Smith, CM, Whitney, RB. Alcohol withdrawal syndromes — prediction from detailed medical and drinking histories. Drug Alcohol Depend 1983;11(2):177–99.Google Scholar
23.Rathlev, NK, Ulrich, A, Fish, SS, D'Onofrio, G. Clinical characteristics as predictors of recurrent alcohol-related seizures. Acad Emerg Med 2000;7(8):886–91.Google Scholar
24.Fleming, MF, Barry, KL, Manwell, LB, Johnson, K, London, R. Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices [see comments]. JAMA 1997;277(3):1039–45.Google Scholar
25.Gentilello, LM, Rivara, FP, Donovan, DM, Jurkovich, GJ, Daranciang, E, Dunn, CW, et al. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Ann Surg 1999;230(4):473–80; discussion 480–3.Google Scholar
26.Monti, PM, Colby, SM, Barnett, NP, Spirito, A, Rohsenow, DJ, Myers, M, et al.Brief intervention for harm reduction with alcohol-positive older adolescents in a hospital emergency department. J Consult Clin Psychol 1999;67(6):989–94.Google Scholar
27.Hungerford, DW, Pollock, DA, Todd, KH. Acceptability of emergency departmentbased screening and brief intervention for alcohol problems. Acad Emerg Med 2000;7(2):1383–92.Google Scholar
28.Green, M, Setchell, J, Hames, P, Stiff, G, Touquet, R, Priest, R. Management of alcohol abusing patients in accident and emergency departments. J R Soc Med 1993;86(7):393–5.Google Scholar
29.Batel, P, Pessione, F, Bouvier, AM, Rueff, B. Prompting alcoholics to be referred to an alcohol clinic: the effectiveness of a simple letter. Addiction 1995;90(6):811–4.Google Scholar
30.Bernstein, E, Bernstein, J, Levenson, S. Project ASSERT: an ED-based intervention to increase access to primary care, preventive services, and the substance abuse treatment system. Ann Emerg Med 1997;30(2):181–9.CrossRefGoogle ScholarPubMed
31.Rumpf, HJ, Bohlmann, J, Hill, A, Hapke, U, John, U. Physicians' low detection rates of alcohol dependence or abuse: a matter of methodological shortcomings? Gen Hosp Psychiatry 2001;23(3):33–7.CrossRefGoogle ScholarPubMed
32.Foy, A, March, S, Drinkwater, V. Use of an objective clinical scale in the assessment and management of alcohol withdrawal in a large general hospital. Alcohol Clin Exp Res 1988;12(3):360–4.Google Scholar
33.Salloum, IM, Cornelius, JR, Daley, DC, Thase, ME. The utility of diazepam loading in the treatment of alcohol withdrawal among psychiatric inpatients. Psychopharmacol Bull 1995;31(2):305–10.Google Scholar