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Gottlieb M, Chien N, Long B. Managing Alcohol Withdrawal Syndrome. Ann Emerg Med 2024:S0196-0644(24)00105-7. [PMID: 38530674 DOI: 10.1016/j.annemergmed.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/28/2024]
Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL.
| | - Nicholas Chien
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX
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Beresford TP, Ronan PJ, Taub J, Learned B, Mi Z, Anderson M. Working Toward a Gold Standard: The Severity of Ethanol Withdrawal Scale (SEWS) Versus the Clinical Institute Withdrawal Assessment Alcohol Scale (CIWA-Ar). Alcohol Alcohol 2023; 58:324-328. [PMID: 36935201 PMCID: PMC10168711 DOI: 10.1093/alcalc/agad016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 02/14/2023] [Accepted: 02/14/2023] [Indexed: 03/21/2023] Open
Abstract
AIM Proving the Severity of Ethanol Withdrawal Scale (SEWS) significantly reduces Alcohol Withdrawal Syndrome (AWS) treatment Time on Medication Protocol (TOMP). METHOD Head-to-head Quality Assurance outcome compared separate cohorts of SEWS or Clinical Institute Withdrawal Assessment Alcohol Scale, Revised (CIWA-Ar) data using Student's t and Wilcoxon tests. RESULTS SEWS-driven treatment (n = 244) reduced TOMP to 2.2 days versus 3.4 days for CIWA-Ar (n = 137); P < 0.0001. CONCLUSION The SEWS is the superior measure of AWS symptoms.
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Affiliation(s)
- Thomas P Beresford
- Laboratory for Clinical and Translational Research in Psychiatry, Rocky Mountain Regional VA Medical Center, Aurora, CO 80045, USA
- Department of Psychiatry, School of Medicine, University of Colorado Denver, Aurora, CO 80045, USA
| | - Patrick J Ronan
- Research Service, Sioux Falls VA Healthcare System, Sioux Falls, SD 57105, USA
- Department of Psychiatry and Division of Basic Biomedical Research, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD 57105 USA
| | - Julie Taub
- Department of Internal Medicine, Denver Health Medical Center, Denver, CO 80204, USA
- Department of Psychiatry, School of Medicine, University of Colorado Denver, Aurora, CO 80045, USA
| | - Brenda Learned
- VHA Office of Community Care - Revenue, VISN 19: Rocky Mountain Network
| | - Zhibao Mi
- Cooperative Studies Program, Perry Point VA Medical Center, Perry Point, MD 21902, USA
- University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Mel Anderson
- Laboratory for Clinical and Translational Research in Psychiatry, Rocky Mountain Regional VA Medical Center, Aurora, CO 80045, USA
- Department of Psychiatry, School of Medicine, University of Colorado Denver, Aurora, CO 80045, USA
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Muddapah CP, Weich L. Assessing the revised Clinical Institute Withdrawal for Alcohol Scale use at Stikland Hospital. S Afr J Psychiatr 2023; 29:1915. [PMID: 36756541 PMCID: PMC9900294 DOI: 10.4102/sajpsychiatry.v29i0.1915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 09/06/2022] [Indexed: 02/04/2023] Open
Abstract
Background Alcohol use disorder (AUD) is a major public health concern in South Africa (SA). Abrupt cessation or reduction of alcohol intake in chronic users can result in withdrawal symptoms. Benzodiazepines are the treatment of choice but need to be used cautiously in patients with a lifetime history of substance abuse given their highly addictive potential. Symptom-triggered prescription of benzodiazepines during alcohol withdrawal using the Revised Clinical Institute Withdrawal for Alcohol Scale (CIWA-Ar) has been associated with improved safety and reduced benzodiazepines use. Aim To investigate if implementation of the CIWA-Ar during alcohol detoxification impacted the dose of benzodiazepines used and withdrawal-related outcomes. Setting Alcohol rehabilitation unit (ARU) at Stikland Psychiatric Hospital. Methods A retrospective cohort study of 135 admissions over a six-month period comparing two groups: before (2015) and after (2017) the implementation of the CIWA-Ar. Results The study noted no differences in sociodemographic and alcohol-associated variables between the two groups, and there were no recorded complications in either group. The 2017 group had a lower percentage of patients that required benzodiazepines (33.8% vs. 51.4%, p = 0.04) and a lower median total amount of benzodiazepines used during alcohol withdrawal (0 mg vs. 5 mg, p = 0.01). Conclusions The CIWA-Ar rating scale was an effective alternative to prescribing benzodiazepines pro re nata and decreased the total dose of benzodiazepines used during alcohol withdrawal. Contribution The use of a symptom triggered regime, like the CIWA-Ar rating scale, during withdrawal can be implemented safely in a SA treatment setting for patients with low-risk AUD.
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Affiliation(s)
- Creeshen P. Muddapah
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Lize Weich
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Underwood K, Stupart D, Morgan FH, Scott B, Moxham-Smith R, Moore EM, Friedman D. Can the alcohol withdrawal scale be applied to post-operative patients? ANZ J Surg 2021; 92:1377-1381. [PMID: 34723429 DOI: 10.1111/ans.17334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/11/2021] [Accepted: 10/18/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUNDS 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. METHODS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Kirk Underwood
- Department of Surgery, Barwon Health, Surgery, University Hospital Geelong, Bellarine Street, University Hospital Geelong, Geelong, Victoria, Australia
| | - Douglas Stupart
- Department of Surgery, Barwon Health, Surgery, Geelong, Victoria, Australia
| | | | - Benjamin Scott
- Department of Surgery, Barwon Health, Geelong, Victoria, Australia
| | | | - Eileen Mary Moore
- Deakin University School of Medicine, Surgery, Barwon Health, Surgery, Geelong, Victoria, Australia
| | - Deborah Friedman
- Department of Infectious Diseases, Barwon Health, Infectious Diseases, Geelong, Victoria, Australia
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Pribék IK, Kovács I, Kádár BK, Kovács CS, Richman MJ, Janka Z, Andó B, Lázár BA. 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. Drug Alcohol Depend 2021; 220:108536. [PMID: 33503582 DOI: 10.1016/j.drugalcdep.2021.108536] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 12/11/2020] [Accepted: 12/26/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Although 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. METHODS 1054 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. RESULTS The 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). CONCLUSIONS Our 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.
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Affiliation(s)
- Ildikó Katalin Pribék
- Addiction Research Group, Department of Psychiatry, University of Szeged, 8-10 Korányi fasor, Szeged, H-6720, Hungary.
| | - Ildikó Kovács
- Department of Psychiatry, University of Szeged, 8-10 Korányi fasor, Szeged, H-6720, Hungary
| | - Bettina Kata Kádár
- Addiction Research Group, Department of Psychiatry, University of Szeged, 8-10 Korányi fasor, Szeged, H-6720, Hungary
| | - Csenge Sára Kovács
- Addiction Research Group, Department of Psychiatry, University of Szeged, 8-10 Korányi fasor, Szeged, H-6720, Hungary
| | - Mara J Richman
- Department of Psychiatry and Psychotherapy, Semmelweis University, Balassa Street 8, H-1085, Budapest, Hungary; Endeavor Psychology, 10 Newbury Street, Boston, MA, 02116, USA
| | - Zoltán Janka
- Department of Psychiatry, University of Szeged, 8-10 Korányi fasor, Szeged, H-6720, Hungary
| | - Bálint Andó
- Addiction Research Group, Department of Psychiatry, University of Szeged, 8-10 Korányi fasor, Szeged, H-6720, Hungary
| | - Bence András Lázár
- Addiction Research Group, Department of Psychiatry, University of Szeged, 8-10 Korányi fasor, Szeged, H-6720, Hungary.
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Beyraghi N, Sadeghipour Meybodi S, Noorani Yazdi SS, Janani M, Banihashem SS, Bahri R, Noroozi A. Results from the first inpatient alcohol withdrawal management program in Iran: An observational study. Alcohol 2020; 88:43-47. [PMID: 32698051 DOI: 10.1016/j.alcohol.2020.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND AIMS The consumption of alcohol is prohibited in Iran; however, concerns regarding alcohol-related harm have led to the development of national policies supporting the establishment of officially endorsed alcohol treatment settings. As a part of these policies, the Iranian Ministry of Health supported the establishment of the first alcohol withdrawal management unit in the psychosomatic unit of Taleghani Hospital in 2015. The purpose of this study is to report on this pilot project. METHODS This was an observational and descriptive study, conducted on 83 patients with alcohol use disorder based on DSM 5 who were consecutively admitted to the unit for alcohol withdrawal management, from March 2017 to March 2018. The demographic data, alcohol use history, comorbid physical and psychiatric conditions, completion of inpatient treatment, length of hospital stay, and adverse events were extracted from the patients' records using a checklist developed by the authors. RESULTS 95.2% of the patients were male. The mean age was 45.3 (±12.2) years. Study participants reported using 38.7 (±29.6) standard drinks in a drinking day during the last year. Mean length of stay was 9.01 (±6.8) days. 81.7% of patients completed the inpatient treatment episode. Six patients (7.2%) had a complicated withdrawal (delirium), and no incidents of a withdrawal seizure were reported during the period of this study. CONCLUSIONS This is the first study providing preliminary results on the safety and effectiveness of symptom-triggered alcohol withdrawal management in Iran. The clinical and policy level implications of these findings have been discussed.
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Chernyavsky S, Dharapak P, Hui J, Laskova V, Merrill E, Pillay K, Siau E, Rizk D. Alcohol and the Hospitalized Patient. Med Clin North Am 2020; 104:681-694. [PMID: 32505260 DOI: 10.1016/j.mcna.2020.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Alcohol use is a common social and recreational activity in our society. Misuse of alcohol can lead to significant medical comorbidities that can affect essentially every organ system and lead to high health care costs and utilization. Heavy alcohol use across the spectrum from binge drinking and intoxication to chronic alcohol use disorder can lead to high morbidity and mortality both in the long and short term. Recognizing and treating common neurologic, gastrointestinal, and hematological manifestations of excess alcohol intake are essential for those who care for hospitalized patients. Withdrawal is among the most common and dangerous sequela associated with alcohol use disorder.
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Affiliation(s)
- Svetlana Chernyavsky
- Department of Medicine, Mt Sinai Beth Israel, Icahn School of Medicine, 16th Street and 1st Avenue, New York, NY 10010, USA
| | - Patricia Dharapak
- Department of Medicine, Mt Sinai Beth Israel, Icahn School of Medicine, 16th Street and 1st Avenue, New York, NY 10010, USA
| | - Jennifer Hui
- Department of Medicine, Mt Sinai Beth Israel, Icahn School of Medicine, 16th Street and 1st Avenue, New York, NY 10010, USA
| | - Violetta Laskova
- Department of Medicine, Mt Sinai Beth Israel, Icahn School of Medicine, 16th Street and 1st Avenue, New York, NY 10010, USA
| | - Eve Merrill
- Department of Medicine, Mt Sinai Beth Israel, Icahn School of Medicine, 16th Street and 1st Avenue, New York, NY 10010, USA
| | - Kamana Pillay
- Department of Medicine, Mt Sinai Beth Israel, Icahn School of Medicine, 16th Street and 1st Avenue, New York, NY 10010, USA
| | - Evan Siau
- Department of Medicine, Mt Sinai Beth Israel, Icahn School of Medicine, 16th Street and 1st Avenue, New York, NY 10010, USA
| | - Dahlia Rizk
- Department of Medicine, Mt Sinai Beth Israel, Icahn School of Medicine, 16th Street and 1st Avenue, New York, NY 10010, USA.
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8
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Nurse-Led Initiative to Improve Addiction Services: An Interdisciplinary Approach. Nurs Adm Q 2020; 44:192-197. [PMID: 32511177 DOI: 10.1097/naq.0000000000000421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Local efforts to provide treatment for individuals with substance use disorder have had some success in addressing the continued nationwide drug epidemic. A nurse-led withdrawal and stabilization program was developed that includes an interdisciplinary team of physicians, advanced practice providers, nurses, social workers, and substance abuse counselors. Utilizing a shared vision of optimal patient care, we describe how principles of high reliability were incorporated to build a successful program within a community hospital setting from the design of the unit, development of treatment protocols, staffing, and ongoing program refinement that is based on patient and program staff feedback to final thoughts for future program changes.
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Melkonian A, Patel R, Magh A, Ferm S, Hwang C. Assessment of a Hospital-Wide CIWA-Ar Protocol for Management of Alcohol Withdrawal Syndrome. Mayo Clin Proc Innov Qual Outcomes 2019; 3:344-349. [PMID: 31485573 PMCID: PMC6713876 DOI: 10.1016/j.mayocpiqo.2019.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To determine if a hospital-wide symptom-based alcohol withdrawal protocol may result in significant clinical improvements to patient outcomes, safety, and hospital efficiency. Methods Retrospective/prospective cohort study between January 1, 2016 and December 31, 2016 (pre-protocol), and between March 1, 2017 and August 7, July 2017 (post-protocol). Pre-protocol patients were identified retrospectively using International Classification of Diseases, 10th revision codes (F10.1, F10.2, and Z71.4). Post-protocol patients were identified by the use of a unique alcohol withdrawal order set in their electronic medical record. The primary endpoint was average length of stay. Secondary outcomes included death, escalation of care as defined as requiring intensive care unit (ICU) consultation or the rapid response team, average ICU length of stay, respiratory failure, average benzodiazepine usage, and incidence of seizures. Results The study included 276 patients in the pre-protocol group and 145 patients in the post-protocol group. There was a significant reduction found in the primary endpoint of average length of stay (7.15 ± 6.5 days vs 5.7 ± 5.6 days; P=.02). There was a significant reduction in the average benzodiazepine use, use of adjunctive medications, need for ICU consultation or rapid response team, respiratory failure, average ICU length of stay, use of neurologic imaging, and the need for lumbar puncture. Conclusion Implementation of a Clinical Institute Withdrawal Assessment for Alcohol, Revised–based alcohol withdrawal protocol may significantly improve quality of care, patient safety, and treatment effectiveness in a large, mixed medical/surgical, urban community-based academic medical center.
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Affiliation(s)
| | - Reenal Patel
- Department of Cardiology, Newark Beth Israel Medical Center, NJ
| | - Albert Magh
- Department of Pulmonary and Critical Care, Orlando Regional Medical Center, FL
| | - Sampson Ferm
- Department of Gastroenterology, New York Presbyterian/Queens, Flushing
| | - Calvin Hwang
- Department of Medicine, Weill Cornell Medical College, Flushing, NY
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Quelch D, Pucci M, Marsh A, Coleman J, Bradberry S. Elective alcohol detoxification - a resource and efficacy evaluation. Future Healthc J 2019; 6:137-142. [PMID: 31363521 PMCID: PMC6616188 DOI: 10.7861/futurehosp.6-2-137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
An evaluation was performed to assess efficacy and resource utilisation of an elective inpatient alcohol detoxification service at a large inner-city teaching hospital. Abstinence rates at 3, 6 and 12 months post-detoxification were 68.1, 44.7 and 36.2%, respectively. Relapse was associated with referrals from acute hospital services, previous detoxifications, longer time between referral and admission for detoxification, presence of alcohol in the blood on the day of admission and requirement for benzodiazepines during withdrawal. The service operates within the national 18-week referral target and runs at a cost substantially lower than that of residential alcohol detoxification facilities but with similar sobriety rates. We demonstrate that elective detoxification with specialist follow-up provides an effective service both in terms of patient outcomes and resource use. Further investment in these services at both local and national level should be considered.
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Affiliation(s)
| | - Mark Pucci
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alexander Marsh
- Cardiff University and Cardiff & Vale University Health Board, Cardiff, UK
| | - Jamie Coleman
- University of Birmingham School of Medical and Dental Sciences, Edgbaston, and University Hospitals Birmingham NHS Foundation Trust, UK
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Sepede G, Lorusso M, Spano MC, Di Nanno P, Di Iorio G, Di Giannantonio M. Efficacy and Safety of Atypical Antipsychotics in Bipolar Disorder With Comorbid Substance Dependence: A Systematic Review. Clin Neuropharmacol 2018; 41:181-191. [PMID: 30036197 DOI: 10.1097/wnf.0000000000000297] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Bipolar disorder (BD) patients with a comorbid substance use disorder (SUD) are notoriously difficult to treat. Atypical antipsychotics (AAPs) are widely prescribed in BD, but their efficacy in patients with comorbid SUD is still debated. The aim of the present article is to systematically review the literature findings on the efficacy and safety of AAPs in BD patients with comorbid SUD. METHODS We searched PubMed to identify original studies focused on the treatment of dual diagnosed BD with AAPs. RESULTS Ten articles met our inclusion/exclusion criteria, involving a total of 969 subjects, 906 affected by BD and 793 with comorbid SUD: 4 were randomized controlled trials, 4 were open label trials and 2 were observational studies, published between 2002 and 2017. The most commonly abused substances were alcohol and cocaine. The AAPs used to treat patients were quetiapine (n = 337), asenapine (n = 119), olanzapine (n = 80), risperidone (n = 62), and aripiprazole (n = 48). In terms of safety, AAPs were usually well tolerated. Atypical antipsychotics were usually efficacious on acute mood symptoms, whereas their impact on substance-related issues was reported only in those studies without a placebo comparison. CONCLUSIONS According to our results, even though AAPs are widely used and efficacious in treating the clinical symptoms of BD, there are not enough data to suggest their adjunctive benefit on craving and substance consumption.
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Affiliation(s)
- Gianna Sepede
- Department of Neuroscience, Imaging and Clinical Science, "G. d'Annunzio" University of Chieti
| | - Marco Lorusso
- Department of Neuroscience, Imaging and Clinical Science, "G. d'Annunzio" University of Chieti
| | - Maria Chiara Spano
- Department of Neuroscience, Imaging and Clinical Science, "G. d'Annunzio" University of Chieti
| | - Piero Di Nanno
- Department of Neuroscience, Imaging and Clinical Science, "G. d'Annunzio" University of Chieti
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Quelch D, Pucci M, Coleman J, Bradberry S. Hospital Management of Alcohol Withdrawal: Elective versus Unplanned Admission and Detoxification. ALCOHOLISM TREATMENT QUARTERLY 2018. [DOI: 10.1080/07347324.2018.1527664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Darren Quelch
- School of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Mark Pucci
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Jamie Coleman
- School of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Sally Bradberry
- West Midlands Poisons Unit, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom
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13
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Day E, Patel J, Georgiou G. Evaluation of a symptom-triggered front-loading detoxification technique for alcohol dependence: A pilot study. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.28.11.407] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and MethodsA pilot study was set up to compare a symptom-triggered ‘front-loading’ detoxification technique with the usual fixed dosage method. A group of 23 in-patients with alcohol dependence were randomised to receive either the intervention technique using diazepam or the standard chlordiazepoxide taper over 10 days.ResultsThe intervention group received a mean dosage of 74 mg diazepam (equivalent to 222 mg chlordiazepoxide) compared with 700 mg chlordiazepoxide in those receiving usual treatment. There was no statistical difference in the severity of alcohol withdrawal symptoms in the two groups, and the intervention group were slightly more satisfied with their treatment than the group undergoing the usual detoxification treatment. Feedback from the nursing staff was positive towards the new approach but highlighted some potential problems for its wider implementation.Clinical ImplicationsIt was possible to use a simple randomised trial design to introduce a new technique for alcohol detoxification to a specialist unit. Symptom-triggered front-loading detoxification using diazepam was as effective as a standard taper technique in terms of withdrawal severity reduction, and was acceptable to both patients and staff. This is potentially a useful technique for busy acute psychiatric wards.
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Soravia LM, Wopfner A, Pfiffner L, Bétrisey S, Moggi F. Symptom-Triggered Detoxification Using the Alcohol-Withdrawal-Scale Reduces Risks and Healthcare Costs. Alcohol Alcohol 2018; 53:71-77. [PMID: 29281047 DOI: 10.1093/alcalc/agx080] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 09/18/2017] [Indexed: 11/14/2022] Open
Abstract
Aims As there are only a few existing experimental studies on symptom-triggered therapy for patients with alcohol withdrawal, we investigated the effectiveness of symptom-triggered detoxification regarding the use and dosage of benzodiazepine and withdrawal complications in a naturalistic clinical setting of a specialized treatment center for alcohol use disorder. Methods In total, 301 charts of patients who entered residential treatment for alcohol withdrawal were included in the retrospective analysis. Charts of 176 patients treated with the Alcohol Withdrawal-Scale (AWS) were compared to the charts of 125 patients treated with treatment as usual (TAU) before the implementation of AWS. Sociodemographical and clinical variables, previous detoxifications and complications, duration of treatment, use and dose of benzodiazepine and other withdrawal medication, complications and premature discontinuation of treatment were abstracted from the patients' medical records. Results The two groups did not differ in any demographical or clinical variables measured upon treatment admission. The total percentage of patients being treated with benzodiazepines during detoxification decreased from 78.4 to 38.6% after the implementation of the AWS. The implementation of the AWS significantly reduced the duration of the acute detoxification from 136 to 66 h, and the use, duration and dose of benzodiazepine by nearly two-thirds while complications and treatment discontinuation remained unvaryingly. Healthcare costs for detoxification were reduced by half per patient. Conclusions The findings indicate that symptom-triggered treatment for alcohol withdrawal is safe and effective in a naturalistic clinical setting and significantly reduces healthcare costs and the risk for overmedicating patients.
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Affiliation(s)
- Leila M Soravia
- University Hospital of Psychiatry, University of Bern, Switzerland.,Suedhang Clinic, Center for Treatment of Addictive Disorders, Suedhang 1, 3038 Kirchlindach, Switzerland
| | | | - Luzius Pfiffner
- Suedhang Clinic, Center for Treatment of Addictive Disorders, Suedhang 1, 3038 Kirchlindach, Switzerland
| | - Sophie Bétrisey
- Suedhang Clinic, Center for Treatment of Addictive Disorders, Suedhang 1, 3038 Kirchlindach, Switzerland
| | - Franz Moggi
- University Hospital of Psychiatry, University of Bern, Switzerland
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Eloma AS, Tucciarone JM, Hayes EM, Bronson BD. Evaluation of the appropriate use of a CIWA-Ar alcohol withdrawal protocol in the general hospital setting. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2017; 44:418-425. [PMID: 28981333 DOI: 10.1080/00952990.2017.1362418] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-Ar) is an assessment tool used to quantify alcohol withdrawal syndrome (AWS) severity and inform benzodiazepine treatment for alcohol withdrawal. OBJECTIVES To evaluate the prescribing patterns and appropriate use of the CIWA-Ar protocol in a general hospital setting, as determined by the presence or absence of documented AWS risk factors, patients' ability to communicate, and provider awareness of the CIWA-Ar order. METHODS This retrospective chart review included 118 encounters of hospitalized patients placed on a CIWA-Ar protocol during one year. The following data were collected for each encounter: patient demographics, admitting diagnosis, ability to communicate, and admission blood alcohol level; and medical specialty of the clinician ordering CIWA-Ar, documentation of the presence or absence of established AWS risk factors, specific parameters of the protocol ordered, service admitted to, provider documentation of awareness of the active protocol within 48 h of initial order, total benzodiazepine dose equivalents administered and associated adverse events. RESULTS 57% of patients who started on a CIWA-Ar protocol had either zero or one documented risk factor for AWS (19% and 38% respectively). 20% had no documentation of recent alcohol use. 14% were unable to communicate. 19% of medical records lacked documentation of provider awareness of the ordered protocol. Benzodiazepine associated adverse events were documented in 15% of encounters. CONCLUSIONS The judicious use of CIWA-Ar protocols in general hospitals requires mechanisms to ensure assessment of validated alcohol withdrawal risk factors, exclusion of patients who cannot communicate, and continuity of care during transitions.
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Affiliation(s)
- Amanda S Eloma
- a Stony Brook University , School of Pharmacy and Pharmaceutical Sciences , Stony Brook , NY , USA
| | | | - Edmund M Hayes
- a Stony Brook University , School of Pharmacy and Pharmaceutical Sciences , Stony Brook , NY , USA
| | - Brian D Bronson
- c Department of Psychiatry , Stony Brook University, School of Medicine , Stony Brook , NY , USA
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Beresford T, Anderson M, Pitts B, Learned B, Thumm B, Maravilla F, Emrick C, Taub J. The Severity of Ethanol Withdrawal Scale in Scale-Driven Alcohol Withdrawal Treatment: A Quality Assurance Study. ALCOHOLISM TREATMENT QUARTERLY 2017. [DOI: 10.1080/07347324.2017.1322418] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Thomas Beresford
- Laboratory for Clinical and Translational Research in Psychiatry, Department of Veterans Affairs, Denver, Colorado, USA
- Psychiatry Service Department of Veterans Affairs, Department of Psychiatry, Denver, Colorado, USA
| | - Mel Anderson
- Medicine Service Department of Veterans Affairs, Denver, Colorado, USA
- Department of Medicine, School of Medicine, University of Colorado Denver, Denver, Colorado, USA
| | - Brian Pitts
- Laboratory for Clinical and Translational Research in Psychiatry, Department of Veterans Affairs, Denver, Colorado, USA
| | - Brenda Learned
- Quality Assurance Program, Department of Veterans Affairs, Denver, Colorado, USA
| | - Brie Thumm
- Laboratory for Clinical and Translational Research in Psychiatry, Department of Veterans Affairs, Denver, Colorado, USA
| | - Francisco Maravilla
- Laboratory for Clinical and Translational Research in Psychiatry, Department of Veterans Affairs, Denver, Colorado, USA
| | - Chad Emrick
- Laboratory for Clinical and Translational Research in Psychiatry, Department of Veterans Affairs, Denver, Colorado, USA
| | - Julie Taub
- Department of Medicine, School of Medicine, University of Colorado Denver, Denver, Colorado, USA
- Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA
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Sutton LJ, Jutel A. Alcohol Withdrawal Syndrome in Critically Ill Patients: Identification, Assessment, and Management. Crit Care Nurse 2017; 36:28-38. [PMID: 26830178 DOI: 10.4037/ccn2016420] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Management of alcohol withdrawal in critically ill patients is a challenge. The alcohol consumption histories of intensive care patients are often incomplete, limiting identification of patients with alcohol use disorders. Abrupt cessation of alcohol places these patients at risk for alcohol withdrawal syndrome. Typically benzodiazepines are used as first-line therapy to manage alcohol withdrawal. However, if patients progress to more severe withdrawal or delirium tremens, extra adjunctive medications in addition to benzodiazepines may be required. Sedation and mechanical ventilation may also be necessary. Withdrawal assessment scales such as the Clinical Institute of Withdrawal Assessment are of limited use in these patients. Instead, general sedation-agitation scales and delirium detection tools have been used. The important facets of care are the rapid identification of at-risk patients through histories of alcohol consumption, management with combination therapies, and ongoing diligent assessment and evaluation. (Critical Care Nurse. 2016;36[1]:28-39).
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Affiliation(s)
- Lynsey J Sutton
- Lynsey Sutton is an associate charge nurse manager of a level 3 intensive care unit, Capital and Coast District Health Board, Wellington Regional Hospital, Riddiford, Wellington, New Zealand. She is a guest teaching assistant in the postgraduate nursing program at Victoria University of Wellington, New Zealand.Annemarie Jutel works at Victoria University of Wellington. She is also a locum emergency nurse in Central Otago, New Zealand.
| | - Annemarie Jutel
- Lynsey Sutton is an associate charge nurse manager of a level 3 intensive care unit, Capital and Coast District Health Board, Wellington Regional Hospital, Riddiford, Wellington, New Zealand. She is a guest teaching assistant in the postgraduate nursing program at Victoria University of Wellington, New Zealand.Annemarie Jutel works at Victoria University of Wellington. She is also a locum emergency nurse in Central Otago, New Zealand
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Eberly ME, Lockwood AG, Lockwood S, Davis KW. Outcomes After Implementation of an Alcohol Withdrawal Protocol at a Single Institution. Hosp Pharm 2016; 51:752-758. [PMID: 27803505 DOI: 10.1310/hpj5109-752] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background: There are varying dosing strategies for the administration of benzodiazepines in the setting of alcohol withdrawal. In October 2014, a symptom-based alcohol withdrawal protocol (AWP) using the Clinical Institute Withdrawal Assessment of Alcohol, Revised (CIWA-Ar) scale was implemented at one institution. Objective: To evaluate the safety and efficacy of the AWP. Methods: Retrospective chart review was completed, including patients receiving at least one dose of diazepam for alcohol withdrawal pre- and post-protocol. The primary outcome of this study was the average daily and cumulative dose of diazepam during hospital stay. Secondary outcomes included length of stay and occurrence of seizures or delirium tremens. Results: The average daily dose and the average cumulative dose of diazepam were significantly lower in the post-protocol group (5.4 vs 12.1 mg, p < .001; 35.0 vs 77.6 mg, p < .001, respectively). Length of stay was similar between groups (6.5 vs 6.4 days, p = .91), however, duration of benzodiazepine use was decreased in the post-protocol group (2.2 vs 4.7 days, p < .001). Despite using reduced doses of benzodiazepines, there was no increase in adverse events. Conclusions: The implementation of a symptom-based AWP using the CIWA-Ar scale was associated with a reduced average daily and cumulative dose of diazepam without any apparent safety issues.
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Abstract
Unhealthy alcohol use is common and routine screening is essential to identify patients and initiate appropriate treatment. At-risk or hazardous drinking is best managed with brief interventions, which can be performed by any provider and are designed to enhance patients' motivations and promote behavioral change. Alcohol withdrawal can be managed, preferably with benzodiazepines, using a symptom-triggered approach. Twelve-step programs and provider-driven behavioral therapies have robust data supporting their effectiveness and patients with alcohol use disorder should be referred for these services. Research now support the use of several FDA-approved medications that aid in promoting abstinence and reducing heavy drinking.
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Affiliation(s)
- Stephen Holt
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, 1450 Chapel Street, New Haven, CT 06511, USA.
| | - Jeanette Tetrault
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, 367 Cedar Street, New Haven, CT 06510, USA
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Morley K, Baillie A, Leung S, Sannibale C, Teesson M, Haber P. Is Specialized Integrated Treatment for Comorbid Anxiety, Depression and Alcohol Dependence Better than Treatment as Usual in a Public Hospital Setting? Alcohol Alcohol 2015; 51:402-9. [DOI: 10.1093/alcalc/agv131] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 11/16/2015] [Indexed: 11/15/2022] Open
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21
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Hillmer AT, Mason GF, Fucito LM, O'Malley SS, Cosgrove KP. How Imaging Glutamate, γ-Aminobutyric Acid, and Dopamine Can Inform the Clinical Treatment of Alcohol Dependence and Withdrawal. Alcohol Clin Exp Res 2015; 39:2268-82. [PMID: 26510169 DOI: 10.1111/acer.12893] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 08/29/2015] [Indexed: 12/29/2022]
Abstract
Neuroimaging studies have dramatically advanced our understanding of the neurochemical basis of alcohol dependence, a major public health issue. In this paper, we review the research generated from neurochemical specific imaging modalities including magnetic resonance spectroscopy, positron emission tomography, and single-photon emission computed tomography in studies of alcohol dependence and withdrawal. We focus on studies interrogating γ-aminobutyric acid (GABA), glutamate, and dopamine, as these are prominent neurotransmitter systems implicated in alcohol dependence. Highlighted findings include diminished dopaminergic functioning and modulation of the GABA system by tobacco smoking during alcohol withdrawal. Then, we consider how these findings impact the clinical treatment of alcohol dependence and discuss directions for future experiments to address existing gaps in the literature, for example, sex differences and smoking comorbidity. These and other considerations provide opportunities to build upon the current neurochemistry imaging literature of alcohol dependence and withdrawal, which may usher in improved therapeutic and relapse prevention strategies.
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Affiliation(s)
- Ansel T Hillmer
- Departments of Psychiatry and Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Graeme F Mason
- Departments of Psychiatry and Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Lisa M Fucito
- Departments of Psychiatry and Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Stephanie S O'Malley
- Departments of Psychiatry and Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Kelly P Cosgrove
- Departments of Psychiatry and Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut
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Factor analysis and correlation between CIWA-Ar protocol and biochemical-hematic profile in patients with alcohol withdrawal syndrome. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2015. [DOI: 10.1016/j.hgmx.2015.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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23
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Sachdeva A, Choudhary M, Chandra M. Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond. J Clin Diagn Res 2015; 9:VE01-VE07. [PMID: 26500991 DOI: 10.7860/jcdr/2015/13407.6538] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 07/03/2015] [Indexed: 11/24/2022]
Abstract
Alcohol dependence is an increasing and pervasive problem. Alcohol withdrawal symptoms are a part of alcohol dependence syndrome and are commonly encountered in general hospital settings, in most of the departments. Alcohol withdrawal syndrome ranges from mild to severe. The severe complicated alcohol withdrawal may present with hallucinations, seizures or delirium tremens. Benzodiazepines have the largest and the best evidence base in the treatment of alcohol withdrawal, and are considered the gold standard. Others, such as anticonvulsants, barbiturates, adrenergic drugs, and GABA agonists have been tried and have evidence. Supportive care and use of vitamins is essential in the management. Symptom triggered regime is favoured over fixed tapering dose regime, although monitoring through scales is cumbersome. This article aims to review the evidence base for appropriate clinical management of the alcohol withdrawal syndrome. We searched Pubmed for articles published in English on 'Alcohol withdrawal syndrome' in humans during the last 10 years. A total of 1182 articles came up. Articles not relevant to clinical utility and management were excluded based on the titles and abstract available. Full text articles, meta-analyses, systematic reviews and randomized controlled trials were obtained from this list and were considered for review.
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Affiliation(s)
- Ankur Sachdeva
- Assistant Professor, Department of Psychiatry, ESIC Medical College and Hospital , Faridabad, Haryana, India
| | - Mona Choudhary
- Senior Resident, Department of Psychiatry and Drug De-addiction, Post Graduate Institute of Medical Education and Research, Dr Ram Manohar Lohia Hospital , New Delhi, India
| | - Mina Chandra
- Chief Medical Officer (NFSG), Department of Psychiatry and Drug De-addiction, Post Graduate Institute of Medical Education and Research, Dr Ram Manohar Lohia Hospital , New Delhi, India
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24
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Shu JE, Lin A, Chang G. Alcohol Withdrawal Treatment in the Medically Hospitalized Patient: A Pilot Study Assessing Predictors for Medical or Psychiatric Complications. PSYCHOSOMATICS 2015; 56:547-55. [DOI: 10.1016/j.psym.2014.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 11/28/2014] [Accepted: 12/01/2014] [Indexed: 10/24/2022]
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Tobacco smoking interferes with GABAA receptor neuroadaptations during prolonged alcohol withdrawal. Proc Natl Acad Sci U S A 2014; 111:18031-6. [PMID: 25453062 DOI: 10.1073/pnas.1413947111] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Understanding the effects of tobacco smoking on neuroadaptations in GABAA receptor levels over alcohol withdrawal will provide critical insights for the treatment of comorbid alcohol and nicotine dependence. We conducted parallel studies in human subjects and nonhuman primates to investigate the differential effects of tobacco smoking and nicotine on changes in GABAA receptor availability during acute and prolonged alcohol withdrawal. We report that alcohol withdrawal with or without concurrent tobacco smoking/nicotine consumption resulted in significant and robust elevations in GABAA receptor levels over the first week of withdrawal. Over prolonged withdrawal, GABAA receptors returned to control levels in alcohol-dependent nonsmokers, but alcohol-dependent smokers had significant and sustained elevations in GABAA receptors that were associated with craving for alcohol and cigarettes. In nonhuman primates, GABAA receptor levels normalized by 1 mo of abstinence in both groups--that is, those that consumed alcohol alone or the combination of alcohol and nicotine. These data suggest that constituents in tobacco smoke other than nicotine block the recovery of GABAA receptor systems during sustained alcohol abstinence, contributing to alcohol relapse and the perpetuation of smoking.
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26
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Taheri A, Dahri K, Chan P, Shaw M, Aulakh A, Tashakkor A. Evaluation of a Symptom-Triggered Protocol Approach to the Management of Alcohol Withdrawal Syndrome in Older Adults. J Am Geriatr Soc 2014; 62:1551-5. [DOI: 10.1111/jgs.12932] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Asal Taheri
- Pharmaceutical Sciences; St. Paul's Hospital; Vancouver British Columbia Canada
| | - Karen Dahri
- Pharmaceutical Sciences; Vancouver General Hospital; Vancouver British Columbia Canada
- Faculty of Pharmaceutical Sciences; University of British Columbia; Vancouver British Columbia Canada
| | - Peter Chan
- Division of Geriatric Psychiatry; Department of Psychiatry; University of British Columbia; Vancouver British Columbia Canada
| | - Maureen Shaw
- School of Nursing; University of British Columbia; Vancouver British Columbia Canada
| | - Amneet Aulakh
- Pharmaceutical Sciences; Vancouver General Hospital; Vancouver British Columbia Canada
| | - Amir Tashakkor
- Department of Medicine; Faculty of Medicine; University of British Columbia; Vancouver British Columbia Canada
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27
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Reeves RR, Link MN. Attempts to Falsely Alter Assessment of Autonomic Activity During Alcohol Withdrawal. J Psychosoc Nurs Ment Health Serv 2014; 52:15-6. [DOI: 10.3928/02793695-20140219-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Roy R. Reeves
- G.V. (Sonny) Montgomery VA Medical Center, Professor of Psychiatry and Neurology, University of Mississippi School of Medicine, Jackson, Mississippi
| | - Melody N. Link
- Inpatient Psychiatry, G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi
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28
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Sachdeva A, Chandra M, Deshpande SN. A Comparative Study of Fixed Tapering Dose Regimen versus Symptom-triggered Regimen of Lorazepam for Alcohol Detoxification. Alcohol Alcohol 2014; 49:287-91. [DOI: 10.1093/alcalc/agt181] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Integrated care for comorbid alcohol dependence and anxiety and/or depressive disorder: study protocol for an assessor-blind, randomized controlled trial. Addict Sci Clin Pract 2013; 8:19. [PMID: 24245491 PMCID: PMC4175484 DOI: 10.1186/1940-0640-8-19] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 11/14/2013] [Indexed: 11/22/2022] Open
Abstract
Background A major barrier to successful treatment in alcohol dependence is psychiatric comorbidity. During treatment, the time to relapse is shorter, the drop-out rate is increased, and long-term alcohol consumption is greater for those with comorbid major depression or anxiety disorder than those with an alcohol use disorder with no comorbid mental disorder. The treatment of alcohol dependence and psychological disorders is often the responsibility of different services, and this can hinder the treatment process. Accordingly, there is a need for an effective integrated treatment for alcohol dependence and comorbid anxiety and/or depression. Methods/Design We aim to assess the effectiveness of a specialized, integrated intervention for alcohol dependence with comorbid anxiety and/or mood disorder using a randomized design in an outpatient hospital setting. Following a three-week stabilization period (abstinence or significantly reduced consumption), participants will undergo complete formal assessment for anxiety and depression. Those patients with a diagnosis of an anxiety and/or depressive disorder will be randomized to either 1) integrated intervention (cognitive behavioral therapy) for alcohol, anxiety, and/or depression; or 2) usual counseling care for alcohol problems. Patients will then be followed up at weeks 12, 16, and 24. The primary outcome measure is alcohol consumption (total abstinence, time to lapse, and time to relapse). Secondary outcome measures include changes in alcohol dependence severity, depression, or anxiety symptoms and changes in clinician-rated severity of anxiety and depression. Discussion The study findings will have potential implications for clinical practice by evaluating the implementation of specialized integrated treatment for comorbid anxiety and/or depression in an alcohol outpatient service. Trial registration ClinicalTrials.gov Identifier: NCT01941693
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30
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Zeier KL, Connell R, Resch W, Hanson ST, Thomas CJ. A retrospective chart review of a symptom-triggered alcohol withdrawal protocol versus previous standard of care at a veterans hospital. Ment Health Clin 2013. [DOI: 10.9740/mhc.n172309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Alcohol is a commonly abused substance, and it is important that healthcare facilities properly manage alcohol withdrawal. Studies have found that the most efficient way to manage alcohol withdrawal is to use a symptom-triggered approach and only administer medications if symptoms surpass a specific threshold determined by a clinician administered rating scale. Alternatively, a standard fixed-dose medication regimen can be utilized. This study assessed if a new symptom-triggered protocol, utilizing the Clinical Institute Withdrawal for Alcohol, Revised (CIWA-Ar) scale for the assessment of symptoms, resulted in the anticipated patient outcomes of decreased length of hospital stay, less benzodiazepine administered per patient, and a shorter administration time from first dose of benzodiazepine given to last dose, when compared to the previous standard of care. A retrospective chart review was performed for 70 patients who had been treated for alcohol withdrawal. Patients who were treated with the symptom-triggered protocol had a decreased length of hospital stay when compared to the previous standard of care (−2.62 days, p = 0.0054). Both secondary efficacy outcomes were also statistically significant in favor of the symptom-triggered group. This retrospective chart review adds to the body of evidence supporting the use of symptom-triggered protocols as opposed to fixed-dose protocols in the management of alcohol withdrawal.
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Affiliation(s)
- Katy L. Zeier
- 1 Clinical Pharmacy Specialist in Mental Health and Pain Management, Oscar G. Johnson Veterans Affairs Medical Center, Mountain, MI
| | - Robert Connell
- 2 Clinical Pharmacy Specialist in Psychiatry, Jefferson Barracks Veterans Affairs Medical Center, St. Louis, MO
| | - William Resch
- 3 Consult Liaison Psychiatrist, Chillicothe Veterans Affairs Medical Center, Mental Health Care Line, Chillicothe, OH
| | - Stephen Todd Hanson
- 4 Clinical Pharmacy Specialist in Internal Medicine, Chillicothe Veterans Affairs Medical Center Department of Pharmacy, Chillicothe, OH
| | - Christopher J. Thomas
- 5 Clinical Pharmacy Specialist in Psychiatry & Residency Program Director, Chillicothe Veterans Affairs Medical Center Department of Pharmacy, Chillicothe, OH
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Assessment of Alcohol Withdrawal in Native American Patients Utilizing the Clinical Institute Withdrawal Assessment of Alcohol Revised Scale. J Addict Med 2013; 7:196-9. [DOI: 10.1097/adm.0b013e31828b3cc3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ng K, Dahri K, Chow I, Legal M. Evaluation of an alcohol withdrawal protocol and a preprinted order set at a tertiary care hospital. Can J Hosp Pharm 2012; 64:436-45. [PMID: 22479099 DOI: 10.4212/cjhp.v64i6.1085] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Alcohol withdrawal protocols involving symptom-triggered administration of benzodiazepine have been established to reduce the duration of treatment and the cumulative benzodiazepine dose (relative to usual care). However, the effects of a protocol combining fixed-schedule and symptom-triggered benzodiazepine dosing are less clear. OBJECTIVE To assess the efficacy and safety of a combination fixed-scheduled and symptom-triggered benzodiazepine dosing protocol for alcohol withdrawal, relative to usual care, for medical inpatients at a tertiary care hospital. METHODS A chart review of admissions to the internal medicine service for alcohol withdrawal was conducted to compare treatment outcomes before (October 2005 to April 2007) and after (October 2007 to April 2009) implementation of the combination protocol. The primary outcome was duration of benzodiazepine treatment for alcohol withdrawal. The secondary outcomes were cumulative benzodiazepine dose administered, safety implications, and use of adjunctive medications. RESULTS A total of 159 patients met the inclusion criteria. Assessable data were available for 71 charts from the pre-implementation period and 72 charts from the post-implementation period. The median duration of benzodiazepine treatment was 91 h before implementation and 57 h after implementation (p < 0.001). Use of the protocol was also associated with a significant reduction in severe complications of alcohol withdrawal (50% versus 33%, p = 0.019), median cumulative benzodiazepine dose (in lorazepam equivalents) (20.0 mg versus 15.5 mg, p = 0.026), and use of adjunctive medications (65% versus 38%, p = 0.001). The incidence of serious adverse outcomes of treatment with benzodiazepines was not significantly different between the 2 groups. CONCLUSIONS Implementation of an alcohol withdrawal protocol with a combination of fixed-schedule and symptom-triggered benzodiazepine dosing in a medical ward was associated with a shorter duration of benzodiazepine use and a lower incidence of severe complications of alcohol withdrawal.
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Affiliation(s)
- Karen Ng
- , BSc(Pharm), ACPR, was, at the time this study was performed, a Clinical Pharmacist, Richmond Hospital, Richmond, British Columbia. She is now a PharmD student in the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
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McPherson A, Benson G, Forrest EH. Appraisal of the Glasgow assessment and management of alcohol guideline: a comprehensive alcohol management protocol for use in general hospitals. QJM 2012; 105:649-56. [PMID: 22328545 DOI: 10.1093/qjmed/hcs020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Guidelines exist for the management of alcohol withdrawal syndrome (AWS) but few have been assessed as to their suitability for general hospitals. The Glasgow Assessment and Management guideline for alcohol has been specifically developed for use in this context. AIM To determine if this alcohol assessment guideline aids the management of AWS in general hospitals. DESIGN The four components of the Glasgow Assessment and Management of Alcohol guideline were evaluated. This included the use of the Fast Alcohol Screening Test (FAST) to identify at risk patients, a risk stratification strategy to indicate fixed dose or symptom-triggered benzodiazepine treatment, the Glasgow Modified Alcohol Withdrawal Scale (GMAWS) for symptom-triggered treatment and a clear recommendation for vitamin prophylaxis of Wernicke's encephalopathy. METHODS FAST scores were assessed along with the CAGE (cut down, annoyed, guilty and eye-opener) screening tool to ascertain if a single screening tool could identify hazardous and dependent drinking. The GMAWS and Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) were compared between two medical units. A staff survey of the two AWS tools was also carried out. RESULTS FAST was able to identify both probable hazardous and dependent drinking. The GMAWS was reliable and gauged both physical and cognitive aspects of AWS. Staff generally preferred the GMAWS-based treatment as opposed to CIWA-Ar management and welcomed the Guideline as a whole. CONCLUSION The Glasgow Guideline aids the management of patients with AWS in an acute hospital setting. It allows early identification of at risk patients and directs effective therapeutic intervention.
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Affiliation(s)
- A McPherson
- Acute Addiction Liaison Team, Glasgow Addiction Services, Legal House, 101 Gorbals Street, Glasgow, G5 9DW, UK.
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Finn KM, Greenwald J. Hospitalists and alcohol withdrawal: yes, give benzodiazepines but is that the whole story? J Hosp Med 2011; 6:435-7. [PMID: 21990171 DOI: 10.1002/jhm.966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Gray S, Borgundvaag B, Sirvastava A, Randall I, Kahan M. Feasibility and reliability of the SHOT: A short scale for measuring pretreatment severity of alcohol withdrawal in the emergency department. Acad Emerg Med 2010; 17:1048-54. [PMID: 21040105 DOI: 10.1111/j.1553-2712.2010.00885.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Use of a symptom-triggered scale to measure the severity of alcohol withdrawal could reduce the rate of seizures and other complications. The current standard scale, the Clinical Institute of Withdrawal Assessment (CIWA), takes a mean (±SD) of 5 minutes to complete, requiring 30 minutes of nursing time per patient when multiple measures are required. OBJECTIVES The objective was to assess the feasibility and reliability of a brief scale of alcohol withdrawal severity. METHODS The SHOT is a brief scale designed to assess alcohol withdrawal in the emergency department (ED). It includes four items: sweating, hallucinations, orientation, and tremor (SHOT). It was developed based on a literature review and a consensus process by emergency and addiction physicians. The SHOT was first piloted in one ED, and then a prospective observational study was conducted at a different ED to measure its feasibility and reliability. Subjects included patients who were in alcohol withdrawal. One nurse administered the SHOT and CIWA, and the physician repeated the SHOT independently. The SHOT was done only at baseline, before treatment was administered. RESULTS In the pilot study (12 patients), the SHOT took 1 minute to complete on average, and the CIWA took 5 minutes. Sixty-one patients participated in the prospective study. For the SHOT and the CIWA done by the same nurse, the kappa was 0.88 (95% confidence interval [CI] = 0.52 to 1.0; p < 0.0001), and the Pearson's r was 0.71 (p < 0.001). The kappa for the nurse's CIWA score and the physician's SHOT score was 0.61 (95% CI = 0.25 to 0.97; p < 0.0006), and the Pearson's r was 0.48 (p = 0.002). The SHOTs performed by the nurse and physician agreed on the need for benzodiazepine treatment in 30 of 37 cases (82% agreement, kappa = 0.35, 95% CI = 0.03 to 0.67; p < 0.02). The mean (±SD) time taken by nurses and physicians to complete the SHOT was 1 (± 0.52) minute (median = 0.6 minutes). Seventeen percent of patients scored positive on the SHOT for hallucinations or disorientation. CONCLUSIONS The SHOT has potential as a feasible and acceptable tool for measuring pretreatment alcohol withdrawal severity in the ED. Further research is needed to validate the SHOT, to assess the utility of serial measurements of the SHOT, and to demonstrate that its use reduces length of stay and improves clinical outcomes.
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Affiliation(s)
- Sara Gray
- Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
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Corfee FA. Alcohol withdrawal in the critical care unit. Aust Crit Care 2010; 24:110-6. [PMID: 20870419 DOI: 10.1016/j.aucc.2010.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Revised: 08/19/2010] [Accepted: 08/31/2010] [Indexed: 11/29/2022] Open
Abstract
Managing acute alcohol withdrawal in critical care presents a unique challenge to the critical care nurse. The prominence of alcohol use within the Australian community means that many critical care admissions involve acute alcohol withdrawal, an alcohol induced illness, or indeed an unrelated admission with underlying heavy alcohol intake. Current statistics suggest 1 in 5 Australians drink to 'risky' levels each month. This suggests that most critical care nurses will encounter a patient who is experiencing active withdrawal from alcohol, often without clear physiological symptomatology. Acute alcohol withdrawal delirium can be difficult to distinguish from other forms of delirium and in the absence of a comprehensive history, alcohol withdrawal and its sequelae may go untreated. Contemporary management guidelines for alcohol withdrawal suggest a common framework of first line benzodiazepine usage, with emerging research focusing on adjunctive therapy aimed at reducing benzodiazepine doses, and therefore reducing length of stay in the critical care unit. The controversial therapy of ethanol infusion and common assessment and withdrawal scales are examined in relation to their usefulness in critical care. Alcohol withdrawal management in critical care necessitates careful nursing assessment, including alcohol usage history, delirium management, withdrawal assessment and symptomatic relief using an evidence-based protocol.
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Affiliation(s)
- Flora A Corfee
- Australian Catholic University (Aquinas), School of Nursing and Midwifery, Ballarat, Victoria, Australia.
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Ward D, Murch N, Agarwal G, Bell D. A multi-centre survey of inpatient pharmacological management strategies for alcohol withdrawal. QJM 2009; 102:773-80. [PMID: 19700439 DOI: 10.1093/qjmed/hcp116] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND It is well recognized that alcohol is a growing problem in the UK with significant morbidity and mortality and associated resource implications for the National Health Service (NHS). The inpatient management of alcohol withdrawal is felt to be variable between hospitals. The aim of this study was to assess the variation in pharmacological management and acute inpatient alcohol services across NHS hospitals in the UK. METHOD A web-based survey was distributed to Society for Acute Medicine (SAM) members and others with an interest in Acute Medicine between January and March 2008. RESULTS The results suggest poor utilization of guidelines, variable drug regimens and differences in acute alcohol-related support services. CONCLUSION In response to these findings, we suggest that a simplified national approach is required for what is now recognized to be an epidemic problem.
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Affiliation(s)
- D Ward
- Royal London Hospital, London, UK
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Abstract
Alcohol dependence and alcohol abuse or harmful use cause substantial morbidity and mortality. Alcohol-use disorders are associated with depressive episodes, severe anxiety, insomnia, suicide, and abuse of other drugs. Continued heavy alcohol use also shortens the onset of heart disease, stroke, cancers, and liver cirrhosis, by affecting the cardiovascular, gastrointestinal, and immune systems. Heavy drinking can also cause mild anterograde amnesias, temporary cognitive deficits, sleep problems, and peripheral neuropathy; cause gastrointestinal problems; decrease bone density and production of blood cells; and cause fetal alcohol syndrome. Alcohol-use disorders complicate assessment and treatment of other medical and psychiatric problems. Standard criteria for alcohol dependence-the more severe disorder-can be used to reliably identify people for whom drinking causes major physiological consequences and persistent impairment of quality of life and ability to function. Clinicians should routinely screen for alcohol disorders, using clinical interviews, questionnaires, blood tests, or a combination of these methods. Causes include environmental factors and specific genes that affect the risk of alcohol-use disorders, including genes for enzymes that metabolise alcohol, such as alcohol dehydrogenase and aldehyde dehydrogenase; those associated with disinhibition; and those that confer a low sensitivity to alcohol. Treatment can include motivational interviewing to help people to evaluate their situations, brief interventions to facilitate more healthy behaviours, detoxification to address withdrawal symptoms, cognitive-behavioural therapies to avoid relapses, and judicious use of drugs to diminish cravings or discourage relapses.
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Affiliation(s)
- Marc A Schuckit
- Department of Psychiatry, University of California, San Diego, CA, USA
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Prince V, Turpin KR. Treatment of alcohol withdrawal syndrome with carbamazepine, gabapentin, and nitrous oxide. Am J Health Syst Pharm 2008; 65:1039-47. [PMID: 18499876 DOI: 10.2146/ajhp070284] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To evaluate the potential use of carbamazepine, gabapentin, and nitrous oxide as alternatives to symptom-triggered benzodiazepine administration for the treatment of alcohol withdrawal syndrome (AWS), a literature review was conducted. SUMMARY English-language reports of clinical trials of these agents in AWS, particularly trials that compared them with benzodiazepines or anticonvulsants or used them as benzodiazepine-sparing therapy, were reviewed. Six randomized, double-blind trials compared carbamazepine with agents used in the United States. The results suggest that carbamazepine may be useful for this indication, particularly in outpatient settings, although adverse effects and drug interactions may limit its usefulness. The role of gabapentin is unclear because of the lack of randomized, double-blind, controlled trials and the conflicting results of existing case series and open-label trials. Two poorly designed trials of nitrous oxide had conflicting results. CONCLUSION Because of the limitations in evidence accrued so far, the routine use of carbamazepine and gabapentin for the treatment of AWS cannot be recommended, and nitrous oxide should be avoided for this indication.
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Affiliation(s)
- Valerie Prince
- McWhorter School of Pharmacy, Samford University, Birmingham, AL 35229, USA
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Hecksel KA, Bostwick JM, Jaeger TM, Cha SS. Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital. Mayo Clin Proc 2008; 83:274-9. [PMID: 18315992 DOI: 10.4065/83.3.274] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine if hospitalized medical and surgical patients were placed inappropriately on symptom-triggered therapy (STT) for alcohol withdrawal syndrome (AWS) and if certain conditions were more likely to be associated with inappropriate STT use or adverse events. PATIENTS AND METHODS We randomly selected 124 (25%) of the 495 Mayo Clinic inpatients who received STT according to the Revised Clinical Institute for Withdrawal Assessment for Alcohol (CIWA-Ar) protocol in 2003 and assessed them for STT appropriateness, defined as having both intact verbal communication and recent alcohol use. Adverse events, including delirium tremens, seizures, or death, were correlated with CIWA-Ar appropriateness. RESULTS Of the 124 randomly selected patients, only 60 (48%) met both inclusion criteria. Of the remaining 64 patients, 9 (14%) were drinkers but could not communicate, and 35 (55%) could communicate but had not been drinking. Twenty (31%) met neither criterion. Univariate analysis identified a significant association between inappropriate initiation and chronic heart failure, postoperative status (POS), liver disease (LD), nonmetastatic cancer, and chemical dependency consultation. On multivariate analysis, only LD (P equals .02) and POS (P equals .01) retained significance, with LD more and POS less likely to predict appropriateness. Seven of 11 patients who experienced adverse events had received STT according to the CIWA-Ar protocol (P equals .05). Univariate analysis identified a significant association between adverse events and a history of alcohol dependence or AWS. Multivariate analysis showed significance only for a history of alcohol dependence (P equals .049). CONCLUSION Fewer than half of the randomly selected patients met both of the inclusion criteria for the CIWA-Ar instrument, leading us to conclude that more stringent evaluation is needed. Particularly postoperatively, alternative explanations for putative AWS should be sought. Health care professionals should more aggressively seek information on recent alcohol use from medical records, family members, and patients themselves.
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Reoux JP, Oreskovich MR. A comparison of two versions of the clinical institute withdrawal assessment for alcohol: the CIWA-Ar and CIWA-AD. Am J Addict 2006; 15:85-93. [PMID: 16449097 DOI: 10.1080/10550490500419136] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Scores from two versions of the Clinical Institute Withdrawal Assessment for Alcohol, the CIWA-Ar and CIWA-AD, were compared in 135 alcohol detoxification episodes. The paired mean score for withdrawal severity was statistically higher with the CIWA-AD (p < 0.001), but the mean difference of 0.45 (95% CI: 0.38-0.53, t = 11.74) is not likely to be clinically significant. The difference in the total score between the two scales was 1 point or less 82.6% of the time, and nearly all (97.7%) of the CIWA-AD scores were within 3 points of the paired CIWA-Ar score (range - 6 to + 6).
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Affiliation(s)
- Joseph P Reoux
- VA Puget Sound Health Care System, Seattle, Washington 98108, USA.
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Pletcher MJ, Fernandez A, May TA, Westphal JR, Gamez CA, Hersh DF, Gonzales R. Unintended Consequences of a Quality Improvement Program Designed to Improve Treatment of Alcohol Withdrawal in Hospitalized Patients. Jt Comm J Qual Patient Saf 2005; 31:148-57. [PMID: 15828598 DOI: 10.1016/s1553-7250(05)31020-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND New guidelines, accompanied by an educational campaign, introduced standardized monitoring of withdrawal severity while emphasizing prophylactic fixed-schedule benzodiazepine (BDZ) treatment of at-risk patients. EVALUATION Preliminary analysis showed more deaths during the year after introduction of the guidelines. Investigation revealed some evidence of guideline adherence and a decrease in the number of patients requiring transfer to a higher level of care. However, an 18% increase in the median length of stay was also found, as was an increase in the total dose of benzodiazepines administered to patients with cirrhosis and severe concurrent illness, and the risk of in-hospital death persisted even after adjustment for patient mix. RESPONSE This feedback led to guideline revision and redoubled educational efforts focused on safe benzodiazepine prescribing. Ongoing monitoring of patient outcomes showed no further deterioration and some evidence of improved quality of care. CONCLUSION Evaluation of such quality improvement efforts should include measurement of both treatment patterns and patient outcomes.
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Affiliation(s)
- Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California-San Francisco, USA.
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Bostwick JM, Lapid MI. False Positives on the Clinical Institute Withdrawal Assessment for Alcohol—Revised: Is This Scale Appropriate for Use in the Medically Ill? PSYCHOSOMATICS 2004; 45:256-61. [PMID: 15123853 DOI: 10.1176/appi.psy.45.3.256] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Bogenschutz MP, Geppert CMA. Pharmacologic treatments for women with addictions. Obstet Gynecol Clin North Am 2003; 30:523-44. [PMID: 14664325 DOI: 10.1016/s0889-8545(03)00070-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Physicians have a growing array of pharmacotherapies available for the treatment of substance use disorders. These medications are of central importance in the treatment of opioid and nicotine dependence and are of growing importance in the treatment of alcohol and stimulant dependence. Pharmacotherapy alone is rarely sufficient treatment for substance use disorder; appropriate psychosocial treatment or mutual help (eg, 12-step) participation is almost always indicated whether or not pharmacotherapy is used. Specialized facilities, licensing, and training are necessary for the use of some of the pharmacotherapies discussed in this article. The obstetrician gynecologist must determine the scope of his or her own practice in this area (ie, when to treat and when to refer) based on interest, training and experience, and available resources.
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Affiliation(s)
- Michael P Bogenschutz
- Department of Psychiatry, University of New Mexico School of Medicine, 2400 Tucker NE, Albuquerque, NM 87131, USA.
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Krystal JH, Petrakis IL, Mason G, Trevisan L, D'Souza DC. N-methyl-D-aspartate glutamate receptors and alcoholism: reward, dependence, treatment, and vulnerability. Pharmacol Ther 2003; 99:79-94. [PMID: 12804700 DOI: 10.1016/s0163-7258(03)00054-8] [Citation(s) in RCA: 260] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This review takes a translational neuroscience perspective on the role of glutamate systems in human ethanol abuse and dependence. Ethanol is a simple molecule with profound effects on many chemical systems in the brain. Glutamate is the primary excitatory neurotransmitter in the brain. Glutamatergic systems are targets for the actions of ethanol via its antagonism of the N-methyl-D-aspartate (NMDA) subtype of the glutamate receptor and other mechanisms. The modulation of glutamatergic function by ethanol contributes to both euphoric and dysphoric consequences of ethanol intoxication. Adaptations within glutamatergic systems appear to contribute to ethanol tolerance and dependence and to both acute and protracted features of ethanol withdrawal. Perhaps because of the important glutamatergic mediation of the behavioral effects of ethanol, glutamatergic systems appear to contribute to the vulnerability to alcoholism, and novel glutamatergic agents may play a role in the treatment of ethanol abuse and dependence.
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Affiliation(s)
- John H Krystal
- NIAAA Center for the Translational Neuroscience of Alcoholism, Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06510, USA.
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Affiliation(s)
- Thomas R Kosten
- Departments of Psychiatry, Yale University School of Medicine, New Haven, Conn., USA.
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Lange-Asschenfeldt C, Müller MJ, Szegedi A, Anghelescu I, Klawe C, Wetzel H. Symptom-triggered versus standard chlormethiazole treatment of inpatient alcohol withdrawal: clinical implications from a chart analysis. Eur Addict Res 2003; 9:1-7. [PMID: 12566792 DOI: 10.1159/000067729] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
To evaluate clinical effectiveness and safety of 2 different detoxification treatment protocols, a chart analysis of hospital inpatients consecutively admitted for alcohol withdrawal during one year was undertaken. Records of 33 patients receiving symptom-triggered treatment (using a modified version of the revised Clinical Institute Withdrawal Assessment for Alcohol Scale) were compared with those of patients treated by applying a fixed-dose regimen (n = 32). Patients (45.3 +/- 9.8 years, 21% female) of both groups were comparable regarding illness severity, epidemiologic parameters as well as complications during the observed treatment period. Under symptom-triggered therapy, chlormethiazole (CMZ) treatment duration (4.2 +/- 3.5 vs. 7.5 +/- 3.3 days, Mann-Whitney U test: p = 0.0003) and cumulative CMZ dosage (4352 +/- 4589 vs. 9921 +/- 6599 mg, Mann-Whitney U test: p = 0.0004) were significantly reduced. The daily CMZ dose was significantly lower at days 1-5 in the group receiving symptom-triggered treatment. There was no influence of age on the outcome parameters of either treatment group. In conclusion, an individualized symptom-triggered treatment of alcohol withdrawal with CMZ seems to be equally safe but more efficient than a scheduled regimen.
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