Introduction: Navigating alcohol withdrawal is a complex facet of addiction medicine, marked by persistent debates and uncertainties. Despite ongoing efforts, achieving perfect management for patients withdrawing from alcohol remains elusive. Benzodiazepines persist as the mainstay of treatment, although alternative medications like clonidine continue to be subjects of exploration. This study delves into the prevalent practice of administering benzodiazepines within CIWA protocols, specifically for elevated blood pressure and/or heart rate, even when CIWA scores fall below the treatment threshold.
Background and Aim: The ASAM guidelines advocate for a comprehensive approach to alcohol withdrawal, encompassing various medications for adjunctive treatment. However, observed clinical practices may not align with these recommendations. Clonidine, an alpha-2 adrenergic agonist, remains a source of contention in the context of alcohol withdrawal. Despite ASAM guidelines suggesting consideration of clonidine for autonomic symptoms in the absence of other withdrawal symptoms, its utilization is limited. This study aims to assess the frequency of benzodiazepine administration within CIWA protocols, notably for elevated blood pressure/heart rate, when the CIWA scoring is below the treatment threshold.
Methods: Patients included in the study presented with alcohol withdrawal on a CIWA protocol. Exclusions comprised those with concurrent opioid withdrawal (COWS protocol) and those receiving continued clonidine as a home medication. Data, focusing on individual doses of medications, excluded continuous/scheduled doses and incomplete records. The study encompassed 167 patients over one year, revealing insights into the medication administration practices pertaining to alcohol withdrawal management.
Results: Of the 167 patients studied, 59.28% (99) had a pre-existing hypertension diagnosis. A total of 614 medication doses were administered, either on an "as needed" or "one-time" basis for elevated CIWA scores or blood pressure/heart rate. Notably, 60.75% (373) of doses were for elevated CIWA scores, all of which were benzodiazepines. The remaining 39.25% (241) targeted autonomic instability. Strikingly, 97.5% (235) of these latter doses were benzodiazepines (223 lorazepam, 12 diazepam), and only 2.5% (6) of doses were clonidine that were given to a total of 5 patients, among whom all except 1 had a hypertension diagnosis. Of the benzodiazepine doses for autonomic instability, 75.32% (177) were administered to patients with a hypertension diagnosis.
Conclusion: This study underscores a significant discrepancy between established ASAM guidelines and observed clinical practices, revealing a predominant reliance on benzodiazepines, even in cases of elevated blood pressure/heart rate where alternative medications could be considered. Notably, most patients with alcohol withdrawal also had underlying hypertension, emphasizing the potential role of adjunctive medications in optimizing patient care and potentially reducing benzodiazepine usage. Further exploration of alternative strategies is crucial to enhance the management of alcohol withdrawal, aligning with evidence-based guidelines and ultimately improving patient outcomes.
Learning Objectives:
Recognize guidelines for adjunctive treatment for AWS
Explore reducing benzo use via adjunctive treatment
Consider comorbidities/med adherence in Tx decisions
