pain (16%), and less frequently the short-acting oxazepam. (7%) and Iorazepam (4%), were the most commonly used agents. Barbiturates { 11% ), phenytoin ...
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ORIGINAL ARTICLES Alcohol Withdrawal" A Nationwide Survey of Inpatient Treatment Practices Richard Saitz, MD, MPH, Lawrence S. Friedman, MD, Michael F. Mayo-Smith, MD, MPH
OBJECTIVE: To describe current p r a c t i c e s e m p l o y e d in the inpatient t r e a t m e n t for a l c o h o l withdrawal. DESIGN: Survey. SETTING: I n p a t i e n t a l c o h o l i s m t r e a t m e n t programs in the United States. PARTICIPANTS: Medical directors o f 1 7 6 (69%) o f 2 5 7 eligible programs r a n d o m l y s e l e c t e d from a national listing. R E S U L T S . The medical directors e s t i m a t e d that o f all inpatients treated for a l c o h o l withdrawal at the programs, 68% received o n e o f the f o l l o w i n g m e d i c a t i o n s . B e n z o d i a z e p i n e s , including the l o n g - a c t i n g c h l o r d i a z e p o x i d e (33%) and diazepain (16%), a n d l e s s f r e q u e n t l y t h e s h o r t - a c t i n g o x a z e p a m (7%) and Iorazepam (4%), w e r e t h e m o s t c o m m o n l y u s e d agents. Barbiturates { 11% ), p h e n y t o i n ( 10% ), c l o n i d i n e (7%), [~-blockers (3%), carbamazepine (1%), and antlpsychotics (1%) were less frequently given. Drug w a s m o s t o f t e n g i v e n o n a fixed dosing s c h e d u l e w i t h additional m e d i c a t i o n "as n e e d e d " (52% of the programs). Only 31% o f the programs r o u t i n e l y used a standardized withdrawal severity scale to m o n i t o r patients. Mean duration o f sedative t r e a t m e n t w a s three days; inpatient treatment, f o u r days. Use o f f i x e d - s c h e d u l e regim e n s was a s s o c i a t e d with longer sedative t r e a t m e n t {mean four vs three days, p < 0 . 0 1 } . N o r t h e a s t c e n s u s region location and psychiatrist program director were s i g n i f i c a n t l y associated with longer sedative and i n p a t i e n t t r e a t m e n t duration. CONCLUSIONS: The m o s t c o m m o n l y reported r e g i m e n for alcohol withdrawal i n c l u d e d three days o f l o n g - a c t i n g benz o d i a z e p i n e s on a fixed s c h e d u l e with additional m e d i c a t i o n "as needed." S t a n d a r d i z e d m o n i t o r i n g o f the severity o f withdrawal was n o t c o m m o n practice. The directors reported using a variety o f o t h e r r e g i m e n s , s o m e n o t k n o w n to p r e v e n t the major c o m p l i c a t i o n s o f withdrawal. A l t h o u g h g e o g r a p h i c location and director s p e c i a l t y were s i g n i f i c a n t l y a s s o c i a t e d with treatment duration, m u c h o f the variation in t r e a t m e n t for alcohol withdrawal r e m a i n s u n e x p l a i n e d .
KEY WORDS: a l c o h o l withdrawal; t r e a t m e n t practices; practice variation; b e n z o d i a z e p i n e s ; s e d a t i v e s ; prescribing. J GEN INTERN MED 1 9 9 5 ; 1 0 : 4 7 9 - - 4 8 7 .
ithdrawal from alcohol is the m o s t c o m m o n withdrawal s y n d r o m e n e c e s s i t a t i n g p h y s i c i a n m a n agement. ~ M a n a g e m e n t strategies i n c l u d e p h a r m a c o -
w
logic a n d nonpharmacologic a n d i n p a t i e n t a n d o u t p a t i e n t detoxifications. ~ More t h a n 100 different m e d i c a t i o n s a n d m a n y different t r e a t m e n t a n d d o s i n g strategies have been reported as t r e a t m e n t for alcohol withdrawal. ~4 Although the efficacy for r e d u c i n g the risk of w i t h d r a w a l complications h a s b e e n c o n f i r m e d in r a n d o m i z e d trials for some m e d i c a t i o n s , m a n y o t h e r d r u g s c o n t i n u e to be r e c o m m e n d e d a n d u s e d as p r i m a r y or a d j u n c t i v e a g e n t s to m a n a g e alcohol withdrawal. '-12 In a d d i t i o n , s i n c e questions r e m a i n regarding the i n d i c a t i o n s for a n d most effective u s e s of p h a r m a c o t h e r a p y for a l c o h o l w i t h drawal, ,3 a variety of strategies are r e c o m m e n d e d . Because of the diversity of r e c o m m e n d e d treatments, a n d the n u m b e r s of p a t i e n t s e x p e r i e n c i n g alcohol withdrawal i n different s e t t i n g s , v a r i a t i o n in treatm e n t practices is likely to exist. To describe c u r r e n t t r e a t m e n t practices a n d to characterize factors associated with these practice v a r i a t i o n s , we surveyed a n a tionwide sample of alcohol t r e a t m e n t p r o g r a m directors regarding their alcohol w i t h d r a w a l t r e a t m e n t practices. Given that there are a l m o s t one m i l l i o n p a t i e n t discharges each year with the d i a g n o s i s of alcohol dependence from U.S. s h o r t - s t a y h o s p i t a l s , ' 4 the survey focused on the i n p a t i e n t m a n a g e m e n t of alcohol withdrawal.
Received f r o m the Section of General Internal Medicine, Boston City Hospital, a n d Boston University School of Medicine (RS). the Division of General Internal Medicine, N e w E n g l a n d Deaconess Hospital (LSF), Harvard Medical School (LSF, MFMS). Boston, Massachusetts; a n d the Alcohol Detoxification Unit, Department ofVeteransAffairs Medical Center (MFM-S). Manchester, New Hampshire. Dr. S a i t z w a s a F e l l o w in General Internal Medicine at the Veterans Affairs Medical Center, Manchester, N e w Hampshire, the N e w E n g l a n d Deaconess Hospital, a n d Harvard Medical School w h e n the s t u d y w a s conducted. Dr. F r i e d m a n is currently at the Division oJ-Adolescent Medicine, University of California, S a n Diego Medical Center, S a n Diego, California. Presented at the a n n u a l meeting of the Association f o r Medical Education a n d Research in S u b s t a n c e Abuse, Bethesda, Maryland, November 20, ] 993. Address correspondence a n d reprint requests to Dr. Saitz: Section of General Internal Medicine Research Unit, Boston City Hospital/Boston University Medical Center, Talbot Building. Suite 325, 82 E a s t Concord Street, Boston, MA 02118,
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(1)
6 2
30)
5(9) 10(1) ~I 7(2)
10(6)
FIGUREt. Treatment programs surveyed, by state. Numbers represent respondents, with nonrespondents in parentheses.
METHODS Population and Sample Selection A r a n d o m s a m p l e w a s s e l e c t e d from t h e 10,805 prog r a m s listed in the 1991 N a t i o n a l Directory of Drug A b u s e a n d A l c o h o l i s m T r e a t m e n t ancl P r e v e n t i o n Programs. 1~
The directory is a 4 5 4 - p a g e listing, a l p h a b e t i c a l l y b y city a n d state, of p r o g r a m s v o l u n t a r i l y p a r t i c i p a t i n g in t h e 1990 National D r u g a n d A l c o h o l i s m T r e a t m e n t Unit S u r vey p e r f o r m e d b y t h e N a t i o n a l I n s t i t u t e on D r u g A b u s e a n d the National I n s t i t u t e o n Alcohol A b u s e a n d Alcoholism. P r o g r a m s listed a s p r o v i d i n g b o t h 2 4 - h o u r care a n d a l c o h o l i s m services were eligible to receive t h e s u r vey. In a n t i c i p a t i o n of a r e s p o n s e r a t e of a p p r o x i m a t e l y 70% a n d a s m a l l n u m b e r of p r o g r a m s ' h a v i n g b e c o m e ineligible s i n c e t h e p u b l i c a t i o n of t h e l i s t i n g b y c l o s i n g or no longer t r e a t i n g i n p a t i e n t s , we c h o s e to s u r v e y 300 p r o g r a m s , a n t i c i p a t i n g a p p r o x i m a t e l y 200 r e s p o n s e s , to m i n i m i z e the s t a n d a r d e r r o r to n o m o r e t h a n a p p r o x i mately 3.5%, a n d t h e r e f o r e t h e h a l f - w i d t h of t h e 95% confidence interval to 7%. 16 R a n d o m p a g e n u m b e r s were g e n e r a t e d u s i n g a h a n d - h e l d calculator, a n d all eligible p r o g r a m s listed on t h e p a g e s selected were i n c l u d e d in the sample. All p r o g r a m s h a d equal p r o b a b i l i t i e s of b e i n g sampled. N i n e t y - n i n e p a g e s g e n e r a t e d a list of 300 prog r a m s in 33 s t a t e s .
Data Collection The survey w a s initially piloted a m o n g p r i v a t e a n d public a l c o h o l i s m t r e a t m e n t p r o g r a m d i r e c t o r s in Mas-
s a c h u s e t t s a n d New H a m p s h i r e a n d w a s s u b s e q u e n t l y modified a n d e n d o r s e d by t h e A m e r i c a n S o c i e t y of Addiction Medicine S t a n d a r d s of Care C o m m i t t e e . We confidentially s u r v e y e d a l c o h o l i s m t r e a t m e n t p r o g r a m directors by mail in May 1992, w i t h a s e c o n d m a i l i n g to n o n r e s p o n d e r s two m o n t h s later. P r o g r a m c l o s i n g s were verified by telephone. R e s p o n s e s were b y s e l f - a d d r e s s e d , p o s t a g e - p a i d r e t u r n envelopes. T h e final v e r s i o n of t h e survey was e i g h t p a g e s a n d c o n t a i n e d 24 m u l t i p l e - c h o i c e a n d fill-in t e r m s ( A p p e n d i x A). E s t i m a t e s of m e d i c a t i o n u s e by p a t i e n t s were ext r a p o l a t e d from s u r v e y q u e s t i o n s a s k i n g for the percentage of p a t i e n t s in t h e p r o g r a m w h o received m e d i cation. T h e s e e s t i m a t e s were t h e n w e i g h t e d by p r o g r a m size.
Data Analysis S t a t i s t i c a l A n a l y s i s S y s t e m (SAS) s o f t w a r e (SAS Institute, Cary, NC} w a s u s e d to c a l c u l a t e m e a n s , m e d i a n s , percentages, a n d S p e a r m a n c o r r e l a t i o n coefficients. Because the p r o g r a m s e n t e r e d t h e s a m p l e w h e n t h e y appeared on a r a n d o m l y selected page n u m b e r , a n d because pages g r o u p e d p r o g r a m s b y state, t h e d a t a f o r m e d a cluster sample, w i t h e a c h p a g e f o r m i n g a s m a l l c l u s t e r of programs. All analyses calculating s t a n d a r d errors a n d significance t e s t s ( c h i - s q u a r e , a n a l y s i s of variance) were performed u s i n g S u r v e y D a t a A n a l y s i s (SUDAAN} software (version 6.33, R e s e a r c h T r i a n g l e Park, NC) u s i n g the Taylor s e r i e s l i n e a r i z a t i o n m e t h o d to a c c o u n t for t h e cluster s a m p l e d e s i g n effect. T h e d e s i g n effect, calcu-
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lated as the c l u s t e r s a m p l e v a r i a n c e divided by the variance for a simple r a n d o m sample, yielded a r a n g e from 1.00 to 1.77. Medications utilized were weighted by t r e a t m e n t p r o g r a m size ( n u m b e r of p a t i e n t s treated in one year). For analyses of geographic location, p r o g r a m s were a s s i g n e d to four r e g i o n s a c c o r d i n g to the d e f i n i t i o n used by the U.S. B u r e a u of the C e n s u s . ,7
RESULTS Program and Director Characteristics Of the 257 i n p a t i e n t alcoholism t r e a t m e n t p r o g r a m s still open at the time of the survey, the directors of 176 {69%) r e s p o n d e d (Fig. 1). P r o g r a m c h a r a c t e r i s t i c s appear in Table 1. Most p r o g r a m s were private (71%). The directors e s t i m a t e d t h a t a m e d i a n of 3 5 0 p a t i e n t s were treated i n their u n i t s for alcohol w i t h d r a w a l i n 1991. Ninety-five p e r c e n t of these p a t i e n t s were over 17 years of age. On average, the directors reported t h a t only 6% of the patients treated for alcohol withdrawal were treated as o u t p a t i e n t s . T w e n t y p e r c e n t of the p r o g r a m s reported a medical school affiliation; 48% of the p r o g r a m s were not hospital-based. The medical directors' specialties were divided m a i n l y a m o n g psychiatry, g e n e r a l or family practice, a n d i n t e r n a l medicine. The specialties of the rem a i n i n g p r o g r a m directors i n c l u d e d a d d i c t i o n medicine, a n e s t h e s i a , p e d i a t r i c s , p r e v e n t i v e m e d i c i n e , obstetrics a n d gynecology, p u l m o n a r y medicine, a n d
Table I Program and Director Characteristics
Program characteristics Patients treated for alcohol withdrawal per year (median)*
350 (200-750l
Public (%1 Private, nonprofit (%} Private, for-profit (%)
29 54 17
Medical school affiliation (%)
20
General-hospital-based (%) Psychiatric-hospital-based (%1 Non-hospital-based (%]
43 9 48
Director characteristics Self-reported certification in substance abuse (%)
44
Psychiatrist (%) Internist (%] General or family practitioner (%)
25 29 32
Years since medical school graduation (%) Less than 10 10-19 20-29 30-39 40 or more
13 28 32 18 9
*Median is the n u m b e r Qf p a t i e n t s . Interquartile r a n g e is in p a r e n t h e ses.
Table 2 Medication Use by Alcohol Withdrawal Patients*
Chlordiazepoxide Diazepam Magnesium Barbiturates Phenytoin Clonidine Oxazepam Lorazepam p-blockers Carbamazepine Haloperidol Phenothiazines Paraldehyde Other benzodiazepines
33 16 16 11 10 7 7 4 3 1 1 1 0.04 6
*Results are p e r c e n t a g e s of all 97,713 p a t i e n t s treated a s i n p a t i e n t s f o r alcohol w i t h d r a w a l at the p r o g r a m s s u r v e y e d receiving a p a r t i c u l a r medication. P e r c e n l a g e s w e r e e s t i m a t e d b y e a c h t r e a t m e n t p r o g r a m ' s m e d i c a l director a n d t h e n w e i g h t e d b y p r o g r a m s i z e . R e s p o n s e s total m o r e t h a n 100% s i n c e t h e y are n o t m u t u a l l y e x c l u s i v e .
urology. T h e i r m e a n year of g r a d u a t i o n from medical school was 1969 ( s t a n d a r d deviation 10.76).
Medications Utilized Of all the i n p a t i e n t s treated for alcohol w i t h d r a w a l at the surveyed facilities, 68% were treated with at least one of the m e d i c a t i o n s listed in Table 2. Of the inpatients reported to have received a p a r t i c u l a r m e d i c a t i o n for the m a n a g e m e n t or prophylaxis of alcohol withdrawal, the h i g h e s t p e r c e n t a g e s were given l o n g - a c t i n g benzodiazepines (chlordiazepoxide 33%, diazepam 16%). While some programs treated 100% of their p a t i e n t s with benzodiazepines, barbiturates, c l o n i d i n e , m a g n e s i u m , or p h e n y t o i n , n o p r o g r a m reported t r e a t i n g all of its p a t i e n t s with 13-blockers, c a r b a m a z e p i n e , a n t i p s y c h o t ics, or paraldehyde.
Dosing Regimens When b e n z o d i a z e p i n e s or b a r b i t u r a t e s were given for the i n p a t i e n t m a n a g e m e n t of alcohol withdrawal, 52% (84/161) of the p r o g r a m s m o s t c o m m o n l y gave the d r u g on a fixed d o s i n g s c h e d u l e with a d d i t i o n a l m e d i c a t i o n "as needed," w h e r e a s 30% (48/161 ) m o s t c o m m o n l y u s e d a regimen of a s - n e e d e d m e d i c a t i o n only. Fewer p r o g r a m s were u s i n g fixed d o s i n g s c h e d u l e s w i t h o u t a s - n e e d e d m e d i c a t i o n (9%, 14/161) or the f r o n t - l o a d i n g t e c h n i q u e (9%, 15/161), in w h i c h h i g h doses of d r u g are given repeatedly early i n the course of withdrawal. Of the programs that reported ever u s i n g fixed-schedule dosing, either alone or as a c o m p o n e n t of a t r e a t m e n t strategy, the m e d i c a t i o n s most c o m m o n l y u s e d in s u c h r e g i m e n s included chlordiazepoxide (51%, 64/125), diazepam ( 17%, 21/125), oxazepam (8N, 10/125), p h e n o b a r b i t a l (8%, 10/125), clorazepate (5%, 6/125), a n d c l o n i d i n e (1%, 1/1251.
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Table 3 Percentage of Program Directors Reporting That the Following Affected Their Decisions to Prescribe Medication for Alcohol Withdrawal
Reason Routinely given History of alcohol withdrawal seizures History of seizures unrelated to alcohol History of delirium tremens Severity of current episode of withdrawal Outpatient vs inpatient Low magnesium level
MagneSedatives* Phenytoin slum (n = 176) (n = f75) (n = 175] 20
2
9
70
40
15
43
73
7
64
9
13
85 22 --
16 ---
20 60
*Sedatives include barbiturates a n d benzodiazepmes. Responses total more than 100%since they are not mutually exclusive.
Neither p r o g r a m o w n e r s h i p (private or public), size ( n u m b e r of p a t i e n t s t r e a t e d i n 1991 for alcohol withdrawal), site (hospital-based or freestanding), or medical school affiliation, n o r medical director specialty, certification i n s u b s t a n c e a b u s e t r e a t m e n t (self-reported), or year of medical school g r a d u a t i o n was associated with the t r e a t m e n t r e g i m e n m o s t c o m m o n l y given. However, the p r o g r a m s i n the W e s t e r n c e n s u s region were less likely to give d r u g o n a fixed d o s i n g s c h e d u l e with additional m e d i c a t i o n "as needed" (32%, 10/31) t h a n were the p r o g r a m s i n the N o r t h e a s t (69%, 22/32), Midwest (51%, 28/55), a n d S o u t h (56%, 24/43) (p = 0.05). Only 31% of all the p r o g r a m s r o u t i n e l y u s e d s t a n dardized alcohol w i t h d r a w a l severity scales to m o n i t o r patients. More of the p r o g r a m s u s i n g the f r o n t - l o a d i n g approach (60%, 9/15) r o u t i n e l y u s e d a s t a n d a r d i z e d withdrawal severity scale, compared with only 24 % (20/83) of the p r o g r a m s u s i n g s c h e d u l e d a n d a s - n e e d e d medication, 30% (14/46) u s i n g a s - n e e d e d m e d i c a t i o n only, a n d 36% (5/14) u s i n g s c h e d u l e d m e d i c a t i o n only (p = 0.05). Only 31% (45/146) of the p r o g r a m s ever giving asneeded m e d i c a t i o n u s e d severity scales to decide w h e n to give m e d i c a t i o n .
Decisions to Use Medications Factors affecting the d e c i s i o n to u s e sedatives reported by m o s t of the p r o g r a m directors i n c l u d e d the severity of alcohol withdrawal, a h i s t o r y of w i t h d r a w a l or other seizures, a n d a history of delirium t r e m e n s (Table 3). Only 20% of the directors reported t h a t sedatives were given r o u t i n e l y to i n p a t i e n t s . Whereas only 2% u s e d p h e n y t o i n r o u t i n e l y for alcohol withdrawal, 40% reported t h a t a h i s t o r y of alcohol withdrawal seizures would affect t h e i r d e c i s i o n s to adm i n i s t e r p h e n y t o i n . A m i n o r i t y reported t h a t a h i s t o r y of delirium t r e m e n s or the severity of the c u r r e n t with-
drawal episode would affect t h e i r p h e n y t o i n a d m i n i s tration decisions. Although m o s t (60%) reported t h a t a low m a g n e s i u m level would i n f l u e n c e t h e i r d e c i s i o n s to give magn e s i u m , only 9% r o u t i n e l y gave m a g n e s i u m . Few reported their m a g n e s i u m a d m i n i s t r a t i o n d e c i s i o n s to be influenced by the severity of w i t h d r a w a l (20%), a h i s t o r y of withdrawal s e i z u r e s (15%), or a h i s t o r y of d e l i r i u m t r e m e n s (13%).
Treatment Duration The m e a n of the reported average n u m b e r of days d u r i n g which p a t i e n t s a d m i t t e d for alcohol w i t h d r a w a l received sedative-hypnotic a g e n t s was 3.24 days. The most c o m m o n d o s i n g r e g i m e n (fixed-schedule d o s i n g with a d d i t i o n a l as-needed m e d i c a t i o n ) was a s s o c i a t e d with a longer d u r a t i o n of m e d i c a t i o n t r e a t m e n t ( m e a n 3.88 days vs 3.64, 2.94, a n d 3.20, for fixed-schedule only, as-needed only, a n d front-loading, respectively, p < 0.01). Medical school affiliation was a s s o c i a t e d with a longer d u r a t i o n of sedative u s e ( m e a n 3.71 days vs 3.15 days, p = 0.01). P r o g r a m location b y c e n s u s region was also associated with t r e a t m e n t d u r a t i o n ( m e a n s 3.72 days in the Northeast, 3.51 days i n the S o u t h , 3.11 days in the West, a n d 2.86 days i n the Midwest, p = 0.02). Program o w n e r s h i p , site, a n d size were n o t a s s o c i a t e d with d u r a t i o n of sedative t r e a t m e n t . Excluding four p r o g r a m s r e p o r t i n g 21 to 28 days, the m e a n of the reported average l e n g t h s of the detoxification c o m p o n e n t of i n p a t i e n t t r e a t m e n t for alcohol withdrawal was 4.16 days. Program ownership, site, size, medical school affiliation, a n d m o s t c o m m o n l y u s e d t r e a t m e n t r e g i m e n were n o t a s s o c i a t e d with the l e n g t h of i n p a t i e n t t r e a t m e n t . The p r o g r a m s i n the Northeast reported a longer d u r a t i o n of t r e a t m e n t ( m e a n 4.6 days), whereas those i n the Midwest h a d a s h o r t e r l e n g t h of t r e a t m e n t (3.54 days), c o m p a r e d with 4.49 days i n the West a n d 4.46 days i n the S o u t h (p < 0.01). Although the year of g r a d u a t i o n from medical school did not correlate with t r e a t m e n t d u r a t i o n , the specialty of the p r o g r a m director was associated w i t h b o t h the d u r a t i o n of sedative t r e a t m e n t a n d the d u r a t i o n of inp a t i e n t t r e a t m e n t for alcohol w i t h d r a w a l (p = 0.05 for both comparisons). C o m p a r e d with the i n t e r n i s t s (3.42 days of sedative u s e a n d 3.47 days of i n p a t i e n t treatment), the p s y c h i a t r i s t s reported longer t r e a t m e n t dur a t i o n s (3.89 days of sedative u s e a n d 4.88 days of inp a t i e n t t r e a t m e n t ) , w h i l e the g e n e r a l or f a m i l y practitioners reported s h o r t e r t r e a t m e n t d u r a t i o n s (2.99 days of sedative u s e a n d 3.47 days of i n p a t i e n t treatment).
DISCUSSION In this s a m p l e of t r e a t m e n t p r o g r a m s , m o s t p a t i e n t s a d m i t t e d for alcohol w i t h d r a w a l were treated w i t h a medication, most f r e q u e n t l y a l o n g - a c t i n g b e n z o d i a z e p i n e .
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These m e d i c a t i o n s were m o s t c o m m o n l y given b o t h o n a schedule a n d w i t h a d d i t i o n a l m e d i c a t i o n "as needed." Alleviation of c o m m o n w i t h d r a w a l s y m p t o m s , r a n d o m ized trial evidence of seizure a n d d e l i r i u m t r e m e n s prevention, s a n d expert r e c o m m e n d a t i o n s L 2. 13 m a y acc o u n t for the p o p u l a r i t y of the b e n z o d i a z e p i n e s . Barb i t u r a t e s a c c o u n t e d for the n e x t m o s t p o p u l a r g r o u p of m e d i c a t i o n s u s e d to m a n a g e alcohol withdrawal. Despite greater p o t e n t i a l for excessive s e d a t i o n a n d greater difficulties with a d m i n i s t r a t i o n , these d r u g s m a y be in use b e c a u s e of their desirable cross-tolerance a n d s o m e evidence (albeit limited) of efficacy. 2, s. 9 Clonidine, [3blockers, a n d c a r b a m a z e p i n e were less c o m m o n l y u s e d d e s p i t e t h e i r a b i l i t y to a m e l i o r a t e s o m e w i t h d r a w a l symptoms, p e r h a p s b e c a u s e of the lack of evidence t h a t they have a n effect o n the m o r e s e r i o u s c o m p l i c a t i o n s of withdrawal. 7 s. J~ A s i g n i f i c a n t p r o p o r t i o n of the program directors, however, reported t h a t a h i s t o r y of alcohol withdrawal seizures w o u l d i n f l u e n c e t h e i r decisions to give p h e n y t o i n , despite its p r o b a b l e lack of effectiveness i n this setting.12 T h e a l c o h o l w i t h d r a w a l t r e a t m e n t p r a c t i c e s reported by the medical directors of alcohol t r e a t m e n t programs varied widely. Most p r o g r a m s did n o t u s e s t a n dardized w i t h d r a w a l severity scales to m o n i t o r p a t i e n t s or to guide d r u g a d m i n i s t r a t i o n . The p r o g r a m s u s i n g the newer f r o n t - l o a d i n g t e c h n i q u e were more likely to be m o n i t o r i n g p a t i e n t s w i t h a s t a n d a r d i z e d w i t h d r a w a l severity scale. Of note, the m o s t p o p u l a r r e g i m e n , w h i c h included fixed-schedule medication, was associated with a longer d u r a t i o n of t r e a t m e n t . The average l e n g t h of stay for detoxification was four days, i n c l u d i n g three days of m e d i c a t i o n t r e a t m e n t ; a n d geographic location, medical director specialty, a n d medical school affiliation were all s i g n i f i c a n t l y a s s o c i a t e d w i t h t r e a t m e n t d u r a tion. P a t i e n t s ' psychiatric c o m o r b i d i t y m a y explain the longer d u r a t i o n of t r e a t m e n t i n the p r o g r a m s directed by the psychiatrists. Some of the v a r i a t i o n i n t r e a t m e n t r e g i m e n s or duration m a y reflect the severity of alcohol withdrawal. We did not have d a t a available d e s c r i b i n g i n d i v i d u a l patients a n d their withdrawal severities. Therefore, we could not confirm t h a t p a t i e n t s i n fact received the medications with the frequency reported by the medical director r e s p o n d e n t s . The d a t a do, however, describe c u r r e n t t r e a t m e n t practices as reported by detoxification program medical directors, a n d offer a n e s t i m a t e of how m a n y p a t i e n t s are exposed to these t r e a t m e n t practices by a c c o u n t i n g for the n u m b e r s of p a t i e n t s cared for i n the surveyed p r o g r a m s . We were also u n a b l e to m e a s u r e the r e l a t i o n s h i p b e t w e e n t r e a t m e n t practices a n d severity of w i t h d r a w a l or to report how the i n d i v i d u a l variability in w i t h d r a w a l severity m i g h t have affected practice variation. Having i n f o r m a t i o n a b o u t the severity of withdrawal m i g h t help e x p l a i n the practice v a r i a t i o n s observed to the e x t e n t t h a t severity is correlated w i t h director a n d p r o g r a m c h a r a c t e r i s t i c s , a n d t r e a t m e n t is
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d e t e r m i n e d by severity. Since p r o g r a m site (i.e., location in a hospital) did n o t i n f l u e n c e t r e a t m e n t choice or duration, however, the severity of w i t h d r a w a l a n d psychiatric c o m o r b i d i t y are n o t likely to explain all of the practice variation. Our sample was limited to p r o g r a m s offering inpatient alcohol w i t h d r a w a l t r e a t m e n t n a t i o n w i d e . The sample is s i m i l a r in o w n e r s h i p a n d client age g r o u p to programs s a m p l e d in the 1989 National D r u g a n d Alcohol T r e a t m e n t Unit Survey. is Although the results may be generalizable to p r o g r a m s listed in a n a t i o n a l directory,~S they describe c u r r e n t reported b u t n o t observed alcohol withdrawal t r e a t m e n t practices, a n d they m a y not be representative of alcohol w i t h d r a w a l t r e a t m e n t practices in general h o s p i t a l s or other settings. However, we targeted a g r o u p of p h y s i c i a n s with expertise in s u b stance abuse, b e c a u s e we t h o u g h t they would be more likely to achieve c o n s e n s u s r e g a r d i n g the t r e a t m e n t for alcohol withdrawal. F i n d i n g s of significant variation, use of ineffective therapies, a n d u n d e r u s e of severity scales are more s t r i k i n g c o n s i d e r i n g the g r o u p surveyed. To o u r knowledge, this report is the only survey t h a t describes c u r r e n t t r e a t m e n t practices for alcohol withdrawal n a t i o n w i d e . The r e s p o n s e s to this survey demo n s t r a t e t h a t there is v a r i a t i o n i n the m e d i c a t i o n s a n d regimens used to m a n a g e alcohol w i t h d r a w a l a n d in the d u r a t i o n of t r e a t m e n t . A l t h o u g h s o m e p r o g r a m a n d director c h a r a c t e r i s t i c s were related to d u r a t i o n of treatment, there is n o clear e x p l a n a t i o n in the d a t a for why t r e a t m e n t s vary from p r o g r a m to program. We believe that the v a r i a t i o n i n t r e a t m e n t r e g i m e n s u s e d for alcohol withdrawal m a y reflect severity of illness a n d comorbidity, variation i n r e i m b u r s e m e n t , differing r e c o m m e n d a t i o n s for t r e a t m e n t s in the literature, 2-4 7 lo. 19 very flexible p u b l i s h e d r e c o m m e n d a t i o n s , 1.2o a n d the lack of p u b l i s h e d practice g u i d e l i n e s of w h i c h we are aware for the m a n a g e m e n t of alcohol withdrawal. Based on c u r r e n t practices a n d s u p p o r t e d by a red u c t i o n in seizures a n d d e l i r i u m t r e m e n s i n the largest methodologically s o u n d s t u d y of alcohol w i t h d r a w a l t r e a t m e n t s , l o n g - a c t i n g b e n z o d i a z e p i n e s s u c h as chlordiazepoxide or d i a z e p a m a d m i n i s t e r e d o n a fixed d o s i n g schedule with a d d i t i o n a l m e d i c a t i o n as n e e d e d s h o u l d be considered the preferred s t a n d a r d regimen. 1.5 No other drug h a s b e e n f o u n d to have s u p e r i o r efficacy a n d safety as m o n o t h e r a p y . Adjunctive t h e r a p i e s (atenolol for additional control of h y p e r a u t o n o m i a , or haloperidol for m a n a g e m e n t of h a l l u c i n a t i o n s ) play m i n o r roles, a n d p h e n y t o i n h a s n o role i n the m a n a g e m e n t of alcohol withdrawal.12. 21.22 Newer m e t h o d s of m e d i c a t i o n a d m i n istration, i n c l u d i n g f r o n t - l o a d i n g t h e r a p y a n d s y m p t o m triggered therapy (dosing w h e n signs of withdrawal reach a threshold), t h o u g h effective a n d p e r h a p s more efficient, have b e e n less well s t u d i e d in p a t i e n t s with conc u r r e n t acute illness. 23- 24 M o n i t o r i n g with s t a n d a r d i z e d scales is useful prognostically a n d m u s t be u s e d to g u i d e symptom-triggered therapies. 24 25
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et al., Alcohol
The f i n d i n g t h a t there is a lack of s t a n d a r d i z a t i o n a n d c o n s e n s u s r e g a r d i n g alcohol w i t h d r a w a l t r e a t m e n t a m o n g p h y s i c i a n s who m a n a g e the d i s o r d e r f r e q u e n t l y suggests several o p p o r t u n i t i e s for t r e a t m e n t improvement. First, practice g u i d e l i n e s s h o u l d be developed a n d d i s s e m i n a t e d . T h e g u i d e l i n e d e v e l o p m e n t process will likely expose areas where evidence o n w h i c h to base practices is deficient. Areas where knowledge is limited, s u c h as p r e d i c t i o n of complicated w i t h d r a w a l a n d choice of t r e a t m e n t strategy b a s e d o n w i t h d r a w a l severity or risk of withdrawal c o m p l i c a t i o n s , s h o u l d be p u r s u e d by researchers. Finally, t r e a t m e n t s t h a t have b e e n p r o v e n ineffective or d a n g e r o u s , s u c h as p h e n y t o i n or m o n o therapy with d r u g s t h a t do n o t have cross-tolerance with alcohol, m u s t be discouraged, while e n c o u r a g i n g the u s e of beneficial t h e r a p i e s a n d a d j u n c t s , for example, the use of b e n z o d i a z e p i n e s a n d w i t h d r a w a l severity measures. The choice of m e d i c a t i o n r e g i m e n , a d j u n c t i v e therapies, the d u r a t i o n of t r e a t m e n t , a n d the u s e of withdrawal severity scales all have i m p l i c a t i o n s for the cost a n d effectiveness of the t r e a t m e n t for alcohol withdrawal. O u r r e s u l t s s u g g e s t a n o p p o r t u n i t y to improve p a t i e n t m o n i t o r i n g , to avoid ineffective t r e a t m e n t s , a n d to s h o r t e n the c o u r s e of t r e a t m e n t for p a t i e n t s withdrawing from alcohol. F u r t h e r s t u d i e s are needed to exa m i n e the o u t c o m e s a n d costs of t r e a t m e n t for alcohol withdrawal so t h a t evidence-based g u i d e l i n e s m a y be developed a n d adopted.
Withdrawal
Practices
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Deficiencies of clinical trials of alcohol w i t h d r a w a l . Alcohol Clin Exp Res. 1 9 8 3 : 7 : 4 2 - 6 . 7. B a u m g a r t n e r GR, Rowen RC. T r a n s d e r m a l clonidine v e r s u s chlordiazepoxide in alcohol w i t h d r a w a l : a r a n d o m i z e d , controlled clinical trial. S o u t h Med J. 1 9 9 1 ; 8 4 : 3 1 2 - 2 1 . 8. Malcolm R, Ballenger JC, S t u r g i s ET, A n t o n R. Double-blind controlled trial c o m p a r i n g c a r h a m a z e p i n e to o x a z e p a m t r e a t m e n t of alcohol withdrawal. A m J Psychiatry. 1 9 8 9 : 1 4 6 : 6 1 7 - 2 1 . 9. Matz R. B a r b i t u r a t e s a n d alcohol w i t h d r a w a l [letter]. J Gen I n t e r n Med. 1990;5:182. [ E r r a t u m in J G e n I n t e r n Med. 1990;5:276.] 10. J a n d a SM, Fazio A, H e n a n n NE. IV alcohol in the p r e v e n t i o n of delirium t r e m e n s [letterl. A n n P h a r m a c o t h e r . 1990;24:545. 11. Kraus ML, Gottlieb LD, Horwitz RI, A n s c h e r M. R a n d o m i z e d clinical trial of atenolol in p a t i e n t s w i t h alcohol w i t h d r a w a l . N Engl J Med. 1985;313:905-9. 12. Alldredge BK, Lowenstein DH, S i m o n RP. Placebo-controlled trial of i n t r a v e n o u s d i p h e n y l h y d a n t o i n for s h o r t - t e r m t r e a t m e n t of alcohol w i t h d r a w a l seizures. A m J Med. 1 9 8 9 : 8 7 : 6 4 5 - 8 . 13. Institute of Medicine. P r e v e n t i o n a n d t r e a t m e n t of alcohol problems. Washington, DC: National A c a d e m y Press, 1 9 9 0 ; 2 6 8 - 9 . 14. National I n s t i t u t e on Alcohol A b u s e a n d Alcoholism. Hospital Discharges with Alcohol-related Condit ions, Hospital D i s c h a r g e S u r v e y 1 9 7 5 - 1 9 8 6 , In: U.S. Alcohol Epidemiologic Reference Manual. Rockville, MD: N1AAA, 1989. 15. National Institute on D r u g A b u s e a n d National I n s t i t u t e on Alcohol Abuse a n d Alcoholism. National Directory of D r u g A b u s e a n d Alcoholism T r e a t m e n t a n d P r e v e n t i o n P r o g r a m s . DHHS Publication No. (ADM]91-1809. Rockville, MD: NIDA/NIAAA, 1991. 16. Fowler FJ Jr. Survey Research Methods. Newbury Park, CA: Sage, 1988. 17. B u r e a u of the C e n s u s . Factfinder for the Nation, 1991(March); 8(Rev.):l. W a s h i n g t o n , DC: United S t a t e s D e p a r t m e n t of Commerce, 1991. 18. National Institute on D r u g A b u s e a n d National I n s t i t u t e on Alcohol Abuse a n d Alcoholism. National D r u g a n d Alcoholism T r e a t m e n t Unit Survey (NDATUS) 1989 Main F i n d i n g s Report. DHHS Publication No. (ADM]91-1729. Rockville, MD: NIDA/NIAAA, 1990.
The authors thank Timothy Heeren, PhD, for his expert statistical assistance.
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1985:313:905-9. 22. Rathlev NK. D'Onofrio G, Fish SS, et at. T h e lack of efficacy of phenytoin in the p r e v e n t i o n of r e c u r r e n t alcohol w i t h d r a w a l seizures.
Monti PM. Detoxification of alcoholics: i m p r o v i n g care by s y m p t o m triggered sedation. Alcohol Clin Exp Res. 1 9 9 0 : 1 4 : 7 l - 5 . 4. National I n s t i t u t e on Alcohol A b u s e a n d Alcoholism. Alcohol withdrawal s y n d r o m e . Alcohol Alert. 1 9 8 9 : 2 7 0 P H ( 5 ) : 1 - 4 . 5. Kaim SC, Klett C J, Rothfeld B. T r e a t m e n t of the a c u t e alcohol withdrawal state: a c o m p a r i s o n of four d r u g s . A m J Psychiatry. 1969; 125:1640-6. 6. Moskowitz G, C h a l m e r s TC. S a c k s HS, F a g e r s t r o m RM, S m i t h H.
Ann E m e r g Med. 1 9 9 4 ; 2 3 : 5 1 3 - 8 . 23. Sellers EM, Naranjo CA, H a r r i s o n M, Devenyl P, Roach C, S y k o r a K. D i a z e p a m loading: simplified t r e a t m e n t of alcohol w i t h d r a w a l . Clin P h a r m a c o l T h e r . 1 9 8 3 : 3 4 : 8 2 2 - 6 . 24. Saitz R. Mayo-Smith MF. Roberts MS, R e d m o n d HA. B e r n a r d DR, Catkins DR. Individualized t r e a t m e n t for alcohol w i t h d r a w a l . A randomized double-blind controlled trial. JAMA. 1 9 9 4 : 2 7 2 : 5 1 9 - 2 3 . 25. Foy A. March S, D r i n k w a t e r V. Use of a n objective clinical scale in the a s s e s s m e n t a n d m a n a g e m e n t of alcohol w i t h d r a w a l in a large general hospital. Alcohol Clin Exp Res. 1988; 1 2 : 3 6 0 - 4 .
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APPENDIX A The Survey
Instrument
A. The following q u e s t i o n s refer to the t r e a t m e n t s prescribed for i n p a t i e n t s treated for alcohol w i t h d r a w a l at your t r e a t m e n t facility. Feel free to e s t i m a t e or u s e a "best guess.'" Make a n "X'" in the boxes. 1. When b e n z o d i a z e p i n e s or b a r b i t u r a t e s are given d u r i n g the t r e a t m e n t or prophylaxis of alcohol withdrawal in inpatients, w h a t best describes how the d r u g is m o s t commonly given? (make a n "X" in o n e box only)
a. haloperidol (Haldol) ...................................
D
b. chlorpromazine (Thorazine) or o t h e r p h e n o t h i a z i n e ...........................................
D
%
%
[ ] On a p r e d e t e r m i n e d schedule o n l y (i.e., a m e d i c a t i o n every 6 h o u r s for 3 days) [ ] On a n as-needed ("PRN") b a s i s o n l y [ ] On a schedule a n d with additional medication as needed [ ] Front-loading t e c h n i q u e (i.e., a m e d i c a t i o n initially, repeated hourly as needed) [ ] None of the a b o v e - - D E S C R I B E (how given):
!
I
2. When benzodiazepines or b a r b i t u r a t e s are given "as needed" to i n p a t i e n t s b e i n g treated for alcohol withdrawal, is a s t a n d a r d i z e d alcohol withdrawal severity scale used to decide w h e n to give the m e d i c a t i o n s ?
7. What percentage of i n p a t i e n t s receive the following medications d u r i n g the t r e a t m e n t or prophylaxis of alcohol withdrawal? (please write a n u m b e r from 0 to 100 in e a c h box. Please be sure to write in "0" if no p a t i e n t s receive the drug)
a. chlordiazepoxide (Librium) ......................... I 1 ~
b. oxazepam (Serax) .......................................
I 1 ~
c. diazepam (Vellum} .....................................
D
%
d. lorazepam (Ativan) .....................................
D
%
e. other benzodiazepine ..................................
D
%
f, p h e n o b a r b i t a l or o t h e r b a r b i t u r a t e ............... ~
%
g. paraldehyde ...............................................
%
[ ] No [ ] Yes [ ] Never given "'as needed" 3. When drug is given for alcohol withdrawal on a predeterm i n e d s c h e d u l e , w h i c h d r u g is m o s t c o m m o n l y u s e d ? Specify: (name of drug)
[ m
~
[ ] Never given on a p r e d e t e r m i n e d s c h e d u l e 4. When m e d i c a t i o n s for alcohol withdrawal are given on a p r e d e t e r m i n e d s c h e d u l e , is there a m i n i m u m d u r a t i o n of drug t h e r a p y ? I
[ ] Y e s - - p l e a s e write in n u m b e r of days: ]
I
8. What is the average n u m b e r of days d u r i n g w h i c h p a t i e n t s a d m i t t e d for alcohol detoxification receive a b e n z o d i a z e p i n e or barbiturate for alcohol withdrawal t r e a t m e n t or prophylaxis? (please write in the n u m b e r of days)
I Days
[ ] No
Days
[ ] Never given on a schedule 5. Is a s t a n d a r d i z e d alcohol withdrawal severity scale u s e d routinely to m o n i t o r i n p a t i e n t s b e i n g treated for alcohol withdrawal?
9. Which of the following affects the decision to a d m i n i s t e r benzodiazepines or b a r b i t u r a t e s d u r i n g the t r e a t m e n t or prophylaxis of alcohol w i t h d r a w a l ? (check all that apply)
[ ] Yes [ ] No
[ ] Routinely given to i n p a t i e n t s [ ] History of alcohol withdrawal seizures
6. What percentage of i n p a t i e n t s receive the following medications d u r i n g the t r e a t m e n t or prophylaxis of alcohol withdrawal? (please write a n u m b e r from 0 to 100 in e a c h box. Please be sure to write in "0'" if n o p a t i e n t s receive the drug)
[ ] History of seizures u n r e l a t e d to alcohol [ ] History of delirium t r e m e n s [ ] Severity of c u r r e n t episode of withdrawal [ ] Whether the p a t i e n t is a n o u t p a t i e n t or a n i n p a t i e n t
486
S a i t z . e t al., Alcohol W i t h d r a w a l Practices
10. What percentage of inpatients receive the following medications d u r i n g the t r e a t m e n t or prophylaxis of alcohol withdrawal? (please write a n u m b e r from 0 to 100 in each box. Please be sure to write in "0" if n o p a t i e n t s receive the drug)
JG1M
[ ] Routinely given to all p a t i e n t s [ ] History of alcohol withdrawal seizures [ ] History of seizures u n r e l a t e d to alcohol withdrawal [ ] History of delirium t r e m e n s [ ] Severity of c u r r e n t episode of withdrawal
a. clonidine (Catapres) ...................................
f ~
% [ ] Documented low m a g n e s i u m level
b. atenolol (Tenormin) or o t h e r beta-blocker .... f ~
%
c. c a r b a m a z e p i n e (Tegretol) ............................ f ~
%
d. p h e n y t o i n {Dilantin) ...................................
D
%
e. m a g n e s i u m ................................................
D
%
11. Which of the following affects your decision to a d m i n i s t e r p h e n y t o i n (Dilantin) d u r i n g the t r e a t m e n t or prophylaxis of alcohol w i t h d r a w a l ? {check all that apply)
13. What percentage of inpatients a d m i t t e d for alcohol withdrawal receive A N Y of the previously m e n t i o n e d medications? (i.e., including b e n z o d i a z e p i n e s , sedative hypnotics. a n t i c o n v u l s a n t s , antipsychotics, or sympatholyticsl (please e s t i m a t e a n d write in a n u m b e r from 0 to 100)
14. What percentage of p a t i e n t s a d m i t t e d for alcohol detoxification receive any b e n z o d i a z e p i n e s or b a r b i t u r a t e s after discharge, to complete t h e i r detoxifieation? {Please write in a n u m b e r , 0 - 1 0 0 ; write in "0" if n o n e receive d r u g after discharge)
[ ] Routinely given to all p a t i e n t s [ ] History of alcohol withdrawal seizures 15. Not including a n y rehabilitation component (i.e., continu i n g i n p a t i e n t t r e a t m e n t after detoxification), w h a t was the average length of t r e a t m e n t in 1991 for i n p a t i e n t s ad ~ mitted for alcohol detoxification? (i.e., the detoxification c o m p o n e n t only) (please write in the n u m b e r of days)
[ ] History of seizures u n r e l a t e d to alcohol withdrawal [ ] History of delirium t r e m e n s [ ] Severity of c u r r e n t episode of withdrawal 12. Which of the following affects the decision to a d m i n i s t e r m a g n e s i u m d u r i n g the t r e a t m e n t or prophylaxis of alcohol withdrawal? (check all that apply)
~-~
%
B. The following q u e s t i o n s refer to your s u b s t a n c e a b u s e treatment facility. Feel free to e s t i m a t e or use a "'best guess.'" Please write in the n u m b e r or percentage. 1. What percentage of all p a t i e n t s treated at your facility are: {write in a n u m b e r , O - 100) I
a. Under age 18? ..........................................
[
b. A g e l 8 - 6 4 ?
I
..............................................
1%
2. Which description b e s t c h a r a c t e r i z e s your t r e a t m e n t u n i t o w n e r s h i p ? (Make a n "X') [ ] Public
° ,ocatJon Other'sPeciyte°fI
[ ] Private for-profit
[ ] Private not-for-profit
4. Approximately how m a n y inpatients a n d outpatients were treated for alcohol w i t h d r a w a l at your t r e a t m e n t facility in 1991? (please write in the n u m b e r ) D
Patients
5. What percentage of p a t i e n t s with alcohol withdrawal seen at your facility are treated for t h e i r withdrawal as outpatients? {please e s t i m a t e a n d write in a n u m b e r , 0 to 100)
3. Where is the t r e a t m e n t p r o g r a m located? (Place a n "X" in the appropriate box.) [ ] Specialized s u b s t a n c e a b u s e t r e a t m e n t i n s t i t u t i o n [ ] General hospital-based [ ] Psychiatric h o s p i t a l - b a s e d
J
%
6. Is your facility affiliated with a medical school? [ ] Yes [ ] No
Volume 1O, September 1995
]GIM
487
C. The following q u e s t i o n s apply to the p e r s o n who d e t e r m i n e s policies regarding the medical m a n a g e m e n t of alcohol d e p e n d e n c e or withdrawal, i.e., the medical director of the s u b s t a n c e a b u s e t r e a t m e n t program. (Make a n "X" in the a p p r o p r i a t e boxes) 2. What year did you g r a d u a t e from medical school?
1. What is your specialty? (check all t h a t apply)
19 _ _
[ ] Psychiatry [ ] General or family practice [ ] Internal medicine
[] Other--specify:
(write in year)
3. Are you certified specifically in s u b s t a n c e a b u s e treatment? [ ] Y e s - - b y w h a t organization?
I
[ ] No
PLEASE RETURN IN THE ENVELOPE PROVIDED
THANK YOU!
e
ANNOUNCEMENT American Board of Internal Medicine 1996 Certification Examination in Internal Medicine Registration Period: E x a m i n a t i o n Dates:
S e p t e m b e r 1 - D e c e m b e r 1, 1995 August 2 0 - 2 1 , 1996
1996 Certification Examination for Added Qualifications in Geriatric Medicine Registration Period: E x a m i n a t i o n Date:
July 1 - N o v e m b e r 1, 1995 April 16, 1996
For more information a n d application forms, please contact: Registration Section American Board of Internal Medicine 3624 Market Street Philadelphia, PA 19104 Telephone: 1(800) 441-2246 • 1(215) 243-1500 Fax: 1(215) 382-5515
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I
