Eric Chavez
Med Inf 406
Assignment 2
Decision Analysis Using the PROACTIVE Approach
The Management of Alcohol Withdrawal Syndrome
Problem
The prevalence of alcohol use disorder was estimated to be 7.4% of the U.S. population in 1992 (Bayard
2004). Cessation of chronic and heavy alcohol consumption can lead to a characteristic alcohol
withdrawal syndrome. Symptoms can present anywhere from a few to 72 hours after cessation of alcohol
intake and may be mild to severe. These symptoms can include discomfort (tremor, nausea, vomiting,
insomnia), autonomic dysfunction (heart rate, blood pressure, and temperature changes), psychiatric
(anxiety, psychomotor agitation, hallucinations), and neurologic (seizure, delirium tremens). The alcohol
withdrawal syndrome is caused by a readjustment of central nervous system homeostasis due to
hyperactivity of the glutamate system and hypoactivity of the gama-amniobutyric acid system. In 2000,
approximately 225,000 patients were discharged from acute care hospitals (excluding Veterans
Administration and other federal facilities) with a diagnosis of an alcohol withdrawal syndrome (Bayard,
2004). Bayard also reports that only about 10-20% of people experiencing alcohol withdrawal syndrome
will be treated in an acute care hospital, and it is estimated that up to 2 million people in the U.S. will
experience alcohol withdrawal syndrome each year.
Alcohol withdrawal may be managed in a variety of ways in both inpatient and outpatient settings. In
cases of mild symptoms, no treatment may be necessary as the condition will resolve itself in a matter of
hours to days. In the case of more severe symptoms, pharmacologic interventions may be used to
prevent seizures and delirium tremens and to reduce patient suffering. Preventing seizures and delirium
tremens is desirable to avoid morbidity (potential long-term neurologic sequelae and secondary injury
from falls or from an agitated state) and to prevent mortality. The rate of death during delirium tremens
has been estimated to be 1 to 5% and largely depends on the health status of the patient (Bayard, 2004).
It is important to note that treatment of alcohol withdrawal syndrome is not the same as treatment of
alcohol use disorders (alcohol dependence and alcohol abuse). Alcohol use disorder are treated with
long-term substance abuse treatment programs and community mutual-help organizations such as
Alcoholics Anonymous.
Reframe
Patients with severe symptoms will likely want to be admitted to inpatient units for management and
physicians are likely to insist that severely symptomatic patients be admitted to monitored units. On
monitored inpatient units patients can be either observed (provided supportive care but not treated with
medications) or they can be pharmacologically managed. When patient are pharmacologically managed
they may be put on a scheduled tapering dose of medications or they may be given medications as
needed according to an alcohol withdrawal symptoms scale. Research has shown that patients treated
with a scheduled tapering program usually end up taking a higher total dose of medication and have a
longer hospital stay than those given medication only when their symptoms warrant (Bayard, 2004).
Patients with mild or moderate symptoms may prefer to be managed on an outpatient basis. This still
usually requires daily evaluations with the physician. If patients managed on an outpatient basis are
treated with medications, they should be treated with a scheduled tapering dose of medications since
they have no one at home to monitor symptoms and dose medications according to the withdrawal scale.
From a healthcare cost perspective, it is much less expensive to manage patients on an outpatient basis.
If the goal is to make treatment as inexpensive as possible, then patients with mild or moderate
symptoms should be managed as outpatients. Inpatients given scheduled tapering doses of medications
will have the longest hospital stays and overall highest cost. From a cost management perspective,
Eric Chavez
Med Inf 406
Assignment 2
inpatient treatment should be reserved for patients with severe symptoms, who have a history of seizure
or delirium during withdrawal, or who have pregnancy or another serious medical condition.
An argument can be made from a social perspective that inpatient treatment should be recommended.
Patients treated in an inpatient setting are more likely to have less suffering. These patients will be
monitored carefully; therefore relapse to use of alcohol can be prevented. Patient can be referred to
substance abuse treatment programs easily after a detoxification program. Outpatients have a higher risk
of relapsing to alcohol use, have a risk of abusing their detoxification medications, and may be lost to
follow up. It may be more difficult to convince outpatient to transfer to a substance abuse treatment
program after the withdrawal syndrome has been treated.
Objectives focus
The fundamental objectives of treating alcohol withdrawal syndrome are to prevent death from the most
severe form of withdrawal and to engage the patient into a long-term therapeutic process of treating his
alcohol use disorder. The means objectives are reducing patient suffering and preventing morbidity. From
a social perspective, active treatment of alcohol withdrawal may be worth the increased cost if more
patients become engaged in long-term treatment. The long-term treatment of alcohol use disorders will
improve social functioning of those who suffer from alcohol use disorders. Treatment will help to reduce
the lifetime societal costs of repeated treatment episodes, accidents, injuries, deaths, and reduced worker
productivity due to alcohol problems.
Consequences table for observation of alcohol withdrawal.
Consequences
Discomfort
Autonomic arousal
Psychiatric symptoms
Neurologic symptoms
Relapse to alcohol use
Engagement in treatment
Medication concerns
Inpatient Observation
Symptoms can be managed nonpharmacologically by nursing
staff
Patient can be monitored for lifethreatening cardiac events and
staff can intervene if needed
Hospital staff can offer
reassurance and monitor for
safety
Hospital staff can immediately
intervene if necessary to stop
seizures or delirium tremens
Reduced risk of relapse since
patient is on a monitored unit
Patient is more likely to proceed
to longer-term treatment in
substance abuse treatment
program
N/A
Outpatient Observation
Patient may have increased
suffering
Patient may suffer cardiac event
without immediate help available
Patient may have severe anxiety
or hallucinations, there may be a
suicide risk
Patient may have seizure or
delirium tremens without
immediate assistance, patient
may suffer secondary injury, risk
of death is 1-5%
Patient is at increased risk of
relapsing on alcohol
Patient may feel disconnected
from care, high risk of relapse
and being lost to follow-up care
N/A
Eric Chavez
Med Inf 406
Assignment 2
Consequences table for pharmacological management of alcohol withdrawal.
Consequences
Discomfort
Autonomic arousal
Psychiatric symptoms
Neurologic symptoms
Relapse to alcohol use
Engagement in treatment
Medication concerns
Inpatient Pharmacologic
Management
Discomfort is minimized
Symptoms are controlled,
minimizing cardiac risk
Symptoms are controlled
Symptoms are controlled,
minimizing secondary injury and
death
Reduced risk of relapse since
patient is on a monitored unit
Patient is more likely to proceed
to longer-term treatment in
substance abuse treatment
program
Medications are managed by
medical staff, over-sedation can
be minimized
Outpatient Pharmacologic
Management
Discomfort is minimized
Symptoms are controlled,
minimizing cardiac risk
Symptoms are controlled
Symptoms are controlled,
minimizing secondary injury and
death
Patient is at increased risk of
relapsing on alcohol
Patient may be more likely to
proceed to longer-term care, but
risk of relapse and being lost to
follow-up is still high
Medications are self-managed,
there is risk of over-sedation or
abuse of medications
Alternatives
The first decision to make in the management of alcohol withdraw is to decide whether to treat the patient
in an inpatient setting or outpatient setting. After the treatment setting is determined, the provider must
choose whether to observe the patient or to actively treat with pharmacologic management.
Decision tree for alcohol withdrawal management.
Alternatives exist for pharmacologic management. As reported by Amato (2011) the most widely used
medications to treat alcohol withdrawal are benzodiazepines. Benzodiazepines have been proven to be
effective at reducing symptoms and at preventing seizure and delirium tremens. Other medications that
are used with varying degrees of efficacy include anticonvulsants and antipsychotics.
Eric Chavez
Med Inf 406
Assignment 2
Decision tree for pharmacologic management of alcohol withdrawal.
Consequences and estimate the chances
A Cochrane review of the pharmacologic treatment of alcohol withdrawal (Amato, 2011) makes it clear
that benzodiazepines are more effective at preventing seizures than placebo or other medications, and
treatment with benzodiazepines leads to fewer dropouts. No treatment (use of a placebo) and treatment
with anticonvulsant medications showed a lower incidence of adverse effects as compared to treatment
with benzodiazepines.
In regards to inpatient versus outpatient treatment, Hayashida (1989) reported that significantly more
patients completed inpatient detoxification programs than completed outpatient programs. He also
reported that the average length of time for an outpatient detoxification program was shorter at 6.5 days
versus for an inpatient program which was 9 days. The cost of inpatient treatment was greater ($3319 to
$35665) than for outpatient treatment ($175 to $388).
Incidence of negative outcome in alcohol withdrawal treatment placebo vs. benzodiazepine
(Amato, 2011).
Seizure
Adverse medication effect
Dropout
Placebo
80 per 1000
28 per 1000
164 per 1000
Benzodiazepine
13 per 1000
92 per 1000
105 per 1000
Incidence of negative outcome in alcohol withdrawal treatment placebo vs. anticonvulsant
(Amato, 2011).
Seizure
Adverse medication effect
Dropout
Placebo
101 per 1000
50 per 1000
89 per 1000
Anticonvulsant
53 per 1000
78 per 1000
73 per 1000
Relative risk of negative outcome in alcohol withdrawal treatment.
Seizure
Adverse medication effect
Dropout
Benzodiazepine
0.16
3.28
0.64
Anticonvulsant
0.52
1.56
0.82
Eric Chavez
Med Inf 406
Assignment 2
Clinical balance sheet for alternatives to managing alcohol withdrawal syndrome.
Potential benefits
Patient comfort
Patient engagement
Patient preference
Potential risks
Seizure risk
Adverse medication
effect
Withdrawal symptoms
Secondary injury
Cost
Observation
Benzodiazepines
Anticonvulsants
Least comfort
High degree of patient
comfort
May jeopardize patient
engagement if there is
discomfort and suffering
Some may prefer
observation if symptoms
are minor and risk of
medication adverse
effects is high
May improve patient
engagement
Moderate to high
degree of patient
comfort
May improve patient
engagement
Many will opt for
benzodiazepines
because they offer
nearly immediate relief
of symptoms, some may
not like the sedation
effects
Can offer symptom
relief without sedation,
may shorten overall
time in treatment
Relatively high risk
No risk
Lowest risk
Relatively high risk
Lower risk
Relatively moderate risk
High risk for symptoms
High risk if seizure or
delirium
Lowest cost, but still
significant especially
inpatient > outpatient
Low risk of symptoms
Moderate risk due to
sedation
Increased cost,
especially inpatient >
outpatient and
scheduled taper > prn
dosing, additional costs
to manage any adverse
effects
Low risk of symptoms
Low risk
Increased cost,
especially inpatient >
outpatient, probably
lower cost than
benzodiazepine due to
reduce risk of adverse
effects, and shorter
inpatient stays due to
less sedation
Trade-offs
Inpatient vs. Outpatient trade-offs: Patients will lose autonomy but gain safety if they are treated as
inpatients. Physicians will have more control managing patients in the inpatient setting and can reduce
the risk of a negative outcome, however costs will be higher. There is a good chance that patients will
become more engaged in long-term treatment if they have a relatively comfortable detoxification on an
inpatient unit; however this is more disruptive to their lives and requires a higher level of motivation and
willingness.
Observation vs. Pharmacologic management trade-offs: Withdrawal symptoms can be stopped almost
immediately with active pharmacologic treatment; however total time in treatment will be longer and there
is a risk of adverse medication effects. Observation only is cheaper and requires less total time in
treatment but comes with a risk of seizure or delirium tremens and more patient discomfort.
Benzodiazepine vs. other medication treatment trade-offs: Benzodiazepines greatly reduce the risk of
seizure and dropout rate, but come with a higher risk of adverse medication effects. Benzodiazepines are
more effective at managing the symptoms and risks of alcohol withdrawal but they can also be abused
whereas anticonvulsants and other medications are less effective but safer in terms of abuse potential,
sedation, and other adverse medication effects.
Eric Chavez
Med Inf 406
Assignment 2
Integrate the evidence and values
In order to minimize withdrawal symptoms and to prevent seizures and delirium tremens the evidence
points to using benzodiazepines or anticonvulsants as active pharmacologic treatment rather than merely
observing. While there is a risk of adverse medication effect, this risk is relatively low. Given the suffering
and discomfort of the alcohol withdrawal syndrome and risk of potentially very harmful negative
outcomes, most patients would likely value pharmacologic treatment over observation. Using the
evidence presented above, benzodiazepines would be the treatment of choice when compared to
anticonvulsants. Patients should be made aware that total time in treatment will likely increase with active
pharmacologic management vs. observation and letting time correct the physiologic abnormalities
associated with the alcohol withdrawal syndrome. The decision to treat as an outpatient vs. an inpatient
will likely be made depending on the overall health status of the patient and the severity of the symptoms.
Those in poorer health are more at risk for negative outcomes and should be treated on inpatient units.
Inpatient treatment may help to improve treatment engagement and reduces the risk for relapse on
alcohol or abuse of detoxification medications. Patients at high risk for relapse and with low motivation
should also be considered for inpatient care.
Clinical balance sheet with rows in order of importance and with nearly identical outcomes in
strikethrough text.
Potential benefits
Patient comfort
Patient engagement
Patient preference
Potential risks
Seizure risk
Adverse medication
effect
Withdrawal symptoms
Secondary injury
Cost
Observation
Benzodiazepines
Anticonvulsants
Least comfort
High degree of patient
comfort
May jeopardize patient
engagement if there is
discomfort and suffering
Some may prefer
observation if symptoms
are minor and risk of
medication adverse
effects is high
May improve patient
engagement
Moderate to high
degree of patient
comfort
May improve patient
engagement
Many will opt for
benzodiazepines
because they offer
nearly immediate relief
of symptoms, some may
not like the sedation
effects
Can offer symptom
relief without sedation,
may shorten overall
time in treatment
Relatively high risk
No risk
Lowest risk
Relatively high risk
Lower risk
Relatively moderate risk
High risk for symptoms
High risk if seizure or
delirium
Lowest cost, but still
significant especially
inpatient > outpatient
Low risk of symptoms
Moderate risk due to
sedation
Increased cost,
especially inpatient >
outpatient and
scheduled taper > prn
dosing, additional costs
to manage any adverse
effects
Low risk of symptoms
Low risk
Increased cost,
especially inpatient >
outpatient, probably
lower cost than
benzodiazepine due to
reduce risk of adverse
effects, and shorter
inpatient stays due to
less sedation
Eric Chavez
Med Inf 406
Assignment 2
Value
Management with pharmacologic treatment is the option with the greatest safety and patient comfort
values. This option is best at minimizing the risk of negative outcomes while maximizing patient
engagement and the potential to continue longer-term substance abuse treatment. The relative risk of
seizure and dropout were lowest when using benzodiazepines vs. anticonvulsants or placebo. The value
of pharmacologic treatment on an inpatient unit is greatest for patients in poor health, with severe
symptoms, or with a history of negative outcomes during prior alcohol withdrawal syndromes. Outpatient
pharmacologic management is the most cost-effective option when treating patients with mild to moderate
symptoms who are in otherwise good health.
Explore
It would be interesting to find studies that could comment on the effectiveness of inpatient vs. outpatient
treatment for alcohol withdrawal syndrome with patients who are stratified according to risk in terms of
current medical problems and severity of withdrawal symptoms. This could further help to make the
decision about which patients should be treated on an inpatient unit and which patients should be
managed at the less restrictive level of care. It would also be interesting to see a study that follows
patients over a long period of time to determine if inpatient or outpatient detoxification leads to more
engagement in long-term substance abuse treatment programs and longer length of total abstinence.
References:
Amato Laura (2011). Efficacy and Safety of Pharmacological Interventions for the Treatment of the
Alcohol Withdrawal Syndrome. Cochrane Database of Systematic Reviews. 6, 1-26.
Bayard Max (2004). Alcohol Withdrawal Syndrome. American Family Physician. 69(6), 1443-1450.
Hayashida Motoi (1989). Comparative Effectiveness and Costs of Inpatient and Outpatient Detoxification
of Patients with Mild-to-Moderate Alcohol Withdrawal Syndrome. New England Journal of
Medicine. 320(6), 358-365.