Alcohol withdrawal seizures and CIWA?

[ara96]

Hi

I was wondering how many of you use the CIWA scale in your hospitals? Have you still had a patient seize, even following the scale? Thanks

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[thoffen]

I've not had a patient seize at all from alcohol withdrawal, but I think that is generally because this is an early risk so most of that window has been out of my care. Definitely had some who seized in the ED or outside the hospital before I ever got involved in their care.

But seizure is just one possible symptom of alcohol withdrawal and not what kills people.

 

[Jules A]

I have not had a patient seize using CIWA often in combination with a standing order Ativan or Valium taper depending on the unit staff and patient risk factors. I'm also quick to give an IM order if PO isn't cutting it as we rarely have IV access.

 

[Merovinge]

Hi

I was wondering how many of you use the CIWA scale in your hospitals? Have you still had a patient seize, even following the scale? Thanks

Was raised on CIWA in med school and early residency. Later found out evidence base for it is much worse than expected. Largely because you are treating the withdrawal later than logically makes sense by waiting for sx. I am now much more a fan of proactive Ativan tapers, and would have loved to use Chlordiazepoxide but never got the chance as our newest addictionologist came on when I left inpatient work.

 

[Jules A]

Was raised on CIWA in med school and early residency. Later found out evidence base for it is much worse than expected. Largely because you are treating the withdrawal later than logically makes sense by waiting for sx. I am now much more a fan of proactive Ativan tapers, and would have loved to use Chlordiazepoxide but never got the chance as our newest addictionologist came on when I left inpatient work.

For inpatient tapers I prefer Ativan or Valium, actually Valium if their liver supports it, over the long 1/2 life of Librium.

 

[tr]

I have not had a patient seize using CIWA often in combination with a standing order Ativan or Valium taper depending on the unit staff and patient risk factors.

Yes, for established EtOH withdrawal in inpt setting I second using CIWA only as backup to scheduled taper (usually Valium or Librium for the taper and Ativan for the CIWA). CIWA alone only for situations where the extent of the person's drinking was unclear, may have been little or none, just want to cover in case.

 

[prominence]

Yes, for established EtOH withdrawal in inpt setting I second using CIWA only as backup to scheduled taper (usually Valium or Librium for the taper and Ativan for the CIWA). CIWA alone only for situations where the extent of the person's drinking was unclear, may have been little or none, just want to cover in case.

Can you describe the Diazepam taper schedule you use for inpatients in lieu of CIWAs?

 

[FlowRate]

For inpatient tapers I prefer Ativan or Valium, actually Valium if their liver supports it, over the long 1/2 life of Librium.

Our addiction med attending likes Librium as a poor man's phenobarbital. (After LFT's have been checked and after 1-2 days of ativan taper.) Hopefully the auto taper helps prevent relapse.

While the evidence for CIWA is better than standing doses, I think I've had a much better experience with usage-oriented tapers than with CIWA.

And while antipsychotics may lower the seizure threshold, they're probably OK if you gave too much benzo and the patient is benzotoxic (delirious)--after all, they have more than enough benzo on board to likely prevent a seizure. (So says again addictions attending.)

 

[Armadillos]

I wouldn't want someone who was actually withdrawing on CIWA alone, so I basically only use CIWA by itself if the patient doesn't appear to be withdrawing and I just want to guarantee nursing is going to be watching for it closely.

Otherwise generally default to standing Ativan and taper. Use Valium too, but Ativan is more popular here, so generally go with the crowd favorite

 

[Jules A]

Can you describe the Diazepam taper schedule you use for inpatients in lieu of CIWAs?

You didn't ask me but its been a while so I figured I'd answer. I don't do it in lieu of CIWA but in addition to and it depends on how the patient presents. If I'm fairly certain they will have w/d symptoms my usual is some version of 10mg TID day one, likely lower to 10mg BID day two and 5mg TID or BID day three depending on how they look and are scoring. If someone comes in looking especially rough or I know their history I may start 20mg TID and reduce as indicated. Again if PO isn't working I'll hit them with Ativan 2-4mg IM and that will usually settle them into the oral taper with CIWA monitoring.

 

[FlowRate]

Our protocol on the detox unit is total daily Ativan dose = 1mg Ativan (PO or IV) per two standard drinks per day. + Additional per CIWA.

 

[HarryMTieboutMD]

This is a pretty embarrassing discussion for a psychiatry board... this is basic medicine that I make sure all my med students have down

1) If your patient is in EtOH and has seizure, you have FAILED as a doctor. See below. Also, you need to consider other things in the differential (separate seizure disorder, concominant benzo withdrawal that doesn't have a predictable course- need history bc Klonopin doesn't show up on most UDSs, surreptitious psychostimulant use, etc etc etc... and then lots of things before you call tox and they dx serotonin syndrome and tell you to Rx cyproheptadine- have seen this done erroneously)

2) There is a bulk of literature showing symptom trigger protocols (eg, CIWA) result in faster detoxes with lower amounts of benzos used. The CAVEAT is that the scales need to be closely monitored by trained nurses who know what they are doing. This is not the case for most floor nurses (they tried to implement it in my hospital- huge 1000+ bed mega academic center, and it has thus far been a disaster).

3) For the reasons above, scheduled tapers (pick your intermediate/long acting benzo if LFTs are ok; if not use ativan) with PRNs available are simplest the way to go.

4) There is absolutely no reason to use anything besides a benzodiazpine in 95% of cases (eg they are getting methadone for whatever reason, detox unit loses controlled substance license, etc). Some psychiatrists try to act cute and "fringe" with phenobarb, Depakote, Gabapentin, Tegretol, etc, but there really is no need, and the literature strongly supports benzos. Your job is to safely detox the patient, not brag about how you can practice cowboy medicine (happens all the time btw).

5) If you can't stabilize vital signs, etc with PO benzos, and assuming the patient doesn't have absorption problems, he or she needs to go to the unit for an ativan ggt, phenobarb/pentobarb (given by an ICU dr who knows how to dose it), precedex augmentation, etc.

 

[Jules A]

this is basic medicine that I make sure all my med students have down

In all sincerity you appear to be one of the rock star attendings especially with regard to addictions so there's that. I appreciate the time you spent adding your comprehensive reply as it was both educational and spot on, imo. My take was the OP is a resident and I'd rather see them seek clarification here then slog along and eff it up down the road. 🙂

 

[Merovinge]

This is a pretty embarrassing discussion for a psychiatry board... this is basic medicine that I make sure all my med students have down

1) If your patient is in EtOH and has seizure, you have FAILED as a doctor. See below. Also, you need to consider other things in the differential (separate seizure disorder, concominant benzo withdrawal that doesn't have a predictable course- need history bc Klonopin doesn't show up on most UDSs, surreptitious psychostimulant use, etc etc etc... and then lots of things before you call tox and they dx serotonin syndrome and tell you to Rx cyproheptadine- have seen this done erroneously)

2) There is a bulk of literature showing symptom trigger protocols (eg, CIWA) result in faster detoxes with lower amounts of benzos used. The CAVEAT is that the scales need to be closely monitored by trained nurses who know what they are doing. This is not the case for most floor nurses (they tried to implement it in my hospital- huge 1000+ bed mega academic center, and it has thus far been a disaster).

3) For the reasons above, scheduled tapers (pick your intermediate/long acting benzo if LFTs are ok; if not use ativan) with PRNs available are simplest the way to go.

4) There is absolutely no reason to use anything besides a benzodiazpine in 95% of cases (eg they are getting methadone for whatever reason, detox unit loses controlled substance license, etc). Some psychiatrists try to act cute and "fringe" with phenobarb, Depakote, Gabapentin, Tegretol, etc, but there really is no need, and the literature strongly supports benzos. Your job is to safely detox the patient, not brag about how you can practice cowboy medicine (happens all the time btw).

5) If you can't stabilize vital signs, etc with PO benzos, and assuming the patient doesn't have absorption problems, he or she needs to go to the unit for an ativan ggt, phenobarb/pentobarb (given by an ICU dr who knows how to dose it), precedex augmentation, etc.

You might think it is basic medicine but seeing the number of times this was botched by IM at a major academic institute well known for their IM program/attendings makes me feel differently. Also, could not agree more with CIWA being completely different in well-trained nurses with favorable pt ratios compared to reality where it's a **** show. I always stress that this can be a literally life saving intervention and has to be taken seriously but I've seen many services feel differently when they admit heavy alcohol use disordered pts.

 

[smalltownpsych]

I've not had a patient seize at all from alcohol withdrawal, but I think that is generally because this is an early risk so most of that window has been out of my care. Definitely had some who seized in the ED or outside the hospital before I ever got involved in their care.

But seizure is just one possible symptom of alcohol withdrawal and not what kills people.

What is it that most typically kills someone in withdrawal from ETOH?

 

[HarryMTieboutMD]

In all sincerity you appear to be one of the rock star attendings especially with regard to addictions so there's that. I appreciate the time you spent adding your comprehensive reply as it was both educational and spot on, imo. My take was the OP is a resident and I'd rather see them seek clarification here then slog along and eff it up down the road. 🙂

Thanks but I'm still a resident! I've just had stellar attendings who 1) taught me well and 2) implored me to carefully read and think about the literature

You might think it is basic medicine but seeing the number of times this was botched by IM at a major academic institute well known for their IM program/attendings makes me feel differently. Also, could not agree more with CIWA being completely different in well-trained nurses with favorable pt ratios compared to reality where it's a **** show. I always stress that this can be a literally life saving intervention and has to be taken seriously but I've seen many services feel differently when they admit heavy alcohol use disordered pts.

That's my point. It gets misdiagnosed/improperly treated/etc all the time, and it shouldn't. Psychiatrists, of all people, should have this down without question.

What is it that most typically kills someone in withdrawal from ETOH?

DTs- the severe autonomic instability can lead to cardiovascular compromise, stroke, etc

 

[Shikima]

I had one attending muse that DTs were an intrusion of REM sleep during wakefulness. Kind of a different way to think about it.

 

[VA Hopeful Dr]

You might think it is basic medicine but seeing the number of times this was botched by IM at a major academic institute well known for their IM program/attendings makes me feel differently. Also, could not agree more with CIWA being completely different in well-trained nurses with favorable pt ratios compared to reality where it's a **** show. I always stress that this can be a literally life saving intervention and has to be taken seriously but I've seen many services feel differently when they admit heavy alcohol use disordered pts.

No kidding. In every hospital I've worked in, CIWA was restricted to the ICU for just this reason.

 

[FlowRate]

2) There is a bulk of literature showing symptom trigger protocols (eg, CIWA) result in faster detoxes with lower amounts of benzos used

But those outcomes are only really important to hospital administrators.

Our addiction med attending doesn't even trust the nurses on the detox unit to do CIWA-driven detox properly. That should say something about the variability even among specifically experienced nurses. (As you already pointed out.)

 

[Merovinge]

No kidding. In every hospital I've worked in, CIWA was restricted to the ICU for just this reason.

You've worked in good hospitals then. I remember getting a page from a nurse on a new patient I had not yet seen around 0730. "Doctor, can we get an order for Zofran for pt xyz?" "Probably, let me go see him quick, he is new". Now pt has a known hx of heavy EtOH use I find out when I finally get to read the chart. His ED EtOH level was only in the mid 200's so he was placed on CIWA. Guy is on the floor of his room, covered in his own vomit, shaking, minimally responsive. After the RRT got him to medicine his BP was found to be 180/110.

If I had just ordered him the Zofran and seen him an hour later, could have been bad news.

 

[FlowRate]

You've worked in good hospitals then. I remember getting a page from a nurse on a new patient I had not yet seen around 0730. "Doctor, can we get an order for Zofran for pt xyz?" "Probably, let me go see him quick, he is new". Now pt has a known hx of heavy EtOH use I find out when I finally get to read the chart. His ED EtOH level was only in the mid 200's so he was placed on CIWA. Guy is on the floor of his room, covered in his own vomit, shaking, minimally responsive. After the RRT got him to medicine his BP was found to be 180/110.

If I had just ordered him the Zofran and seen him an hour later, could have been bad news.

The worst I've seen was a tremulous, anxious, agitated (wouldn't stopt moving/stay in his room) patient--admitted specifically for alcohol withdrawal--who was being scored 0 on CIWA by his nurse...

When I asked his nurse why, she said "well he didn't say he was anxious."

 

[HarryMTieboutMD]

You've worked in good hospitals then. I remember getting a page from a nurse on a new patient I had not yet seen around 0730. "Doctor, can we get an order for Zofran for pt xyz?" "Probably, let me go see him quick, he is new". Now pt has a known hx of heavy EtOH use I find out when I finally get to read the chart. His ED EtOH level was only in the mid 200's so he was placed on CIWA. Guy is on the floor of his room, covered in his own vomit, shaking, minimally responsive. After the RRT got him to medicine his BP was found to be 180/110.

If I had just ordered him the Zofran and seen him an hour later, could have been bad news.

The worst I've seen was a tremulous, anxious, agitated (wouldn't stopt moving/stay in his room) patient--admitted specifically for alcohol withdrawal--who was being scored 0 on CIWA by his nurse...

When I asked his nurse why, she said "well he didn't say he was anxious."

These examples reify that alcohol withdrawal syndrome is a clinical diagnosis that should be made by a physician based on history, physical, with appropriate r/o differential, etc. CIWA is used to track non-specific symptoms but is not a diagnostic tool.

 

[Blitz2006]

Any time I should consider Phenobarb taper over Ativan/Librium?

 

[FlowRate]

Any time I should consider Phenobarb taper over Ativan/Librium?

When you're in the ICU.

There is some thought that phenobarb is also good for truly resistant benzo or alcohol withdrawal. There is not good data to support this.

 

[Shikima]

I remember phenobarb being IV pushed back in the 80s and 90s. The nurse would have to stand there for like 10 mins slowly pushing it in.

 

[Liquid8]

this is basic medicine that I make sure all my med students have down

Excellent. Also used to give a tutorial on the subject when I had medical students. All our interns are required to rotate through a general medicine, emergency and surgical term as compulsory rotations, so even those who aren't interested in psychiatry are likely to encounter patients with alcohol related issues at some stage in their career.

You might think it is basic medicine but seeing the number of times this was botched by IM at a major academic institute well known for their IM program/attendings makes me feel differently. Also, could not agree more with CIWA being completely different in well-trained nurses with favorable pt ratios compared to reality where it's a **** show. I always stress that this can be a literally life saving intervention and has to be taken seriously but I've seen many services feel differently when they admit heavy alcohol use disordered pts.

Sad to say I've noticed this as well. One of the worse cases of inappropriately managed alcohol withdrawal I remember seeing was a patient on the medical ward who had been written up for 120mg diazepam a day as a regular dose for a week, then dropped to 30mg for a couple of days before being ceased. I was working on the C/L team at the time, and it was only brought to our attention after the nurse I was with was checking up a different patient, and noticed that the individual next to them was very agitated. Being nosy, we looked at the chart and were taken aback - basically a case of swapping one kind of withdrawal for another.

Anyway, agree with comments about using high dose benzodiazepene taper regimes with additional PRN based on alcohol withdrawal scores. Just don't forget to reduce the taper, and don't forget thiamine.

 

[HarryMTieboutMD]

Any time I should consider Phenobarb taper over Ativan/Librium?

When you're in the ICU.

There is some thought that phenobarb is also good for truly resistant benzo or alcohol withdrawal. There is not good data to support this.

As a psychiatrist, absolutely NOT- see my above posts. The only reason psychiatrists do this is to say that they can do it, but it's completely unnecessary FlowRate is dead on https://www.ncbi.nlm.nih.gov/pubmed/20682133?dopt=Abstract. (look at the data; paper itself is poorly written)

In the unit, they will typically use ativan GGTs, precedex, and propofol for severe cases. Some ICU doctors will use IV barbiturates as well (basically you just need top flood them with a GABA agonist- but you have capabilities of airway support in the unit), but again, doing it as a psychiatrist is reckless and stupid. Here is a nice review of withdrawal delirium by Marc Schuckit at UCSD a few years ago http://www.nejm.org/doi/full/10.1056/NEJMra1407298

 

[Salpingo]

Sorry to be that guy, but CIWA is a scale, and is not synonymous with symptom-triggered treatment. You can use CIWA to inform fixed schedule dosing, and you can have symptom-triggered protocols that don't use CIWA.

But those outcomes are only really important to hospital administrators.

Our addiction med attending doesn't even trust the nurses on the detox unit to do CIWA-driven detox properly. That should say something about the variability even among specifically experienced nurses. (As you already pointed out.)

But the likely reason STT reduces hospital length of stays and delirium incidence is due to diminished benzodiazepine toxicity, which we should care about. That being said, there are certain patients that CIWA-based STT should not be used, including patients with history of withdrawal-induced seizures and other incidents of complicated withdrawal.

 

[HarryMTieboutMD]

Sorry to be that guy, but CIWA is a scale, and is not synonymous with symptom-triggered treatment. You can use CIWA to inform fixed schedule dosing, and you can have symptom-triggered protocols that don't use CIWA.



But the likely reason STT reduces hospital length of stays and delirium incidence is due to diminished benzodiazepine toxicity, which we should care about. That being said, there are certain patients that CIWA-based STT should not be used, including patients with history of withdrawal-induced seizures and other incidents of complicated withdrawal.

Huh?! There is so much nonsense and misinformation in this post, so let me break it down.

1) CIWA is the putative instrument for performing symptom triggered withdrawal treatment and has the most literature behind it, so for all intents and purposes, when people think "symptom triggered", CIWA comes to mind: http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/211434.

2) The argument of reduced delirium due to benzo toxicity because of lower amounts of benzos required is circular and nonsensical. Though the course of EtOH withdrawal is more or less predictable, the severity (ie, who will progress to seizures, DTs, etc) is based on a number of factors. Therefore, different patients may require different amounts of meds (there is some outpatient literature on not even treating it based on CIWA <8 WITH CLINICAL IMPRESSION). So, it's obvious that an individual, symptom triggered approach when administered correctly would lead to fewer benzos administered and less hospital time. Agreed that it's a clinically relevant (and not just hospital admin important) outcome

3) There is absolutely no evidence that CIWA is contra-indicated in patients with complicated withdrawal. Two of the highest impact trials included such patients http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/211434 http://jamanetwork.com/journals/jama/fullarticle/377892. Obviously since CIWA asks subjective questions the patient should be lucid. But, as I (and others) have intimated above, the biggest problem with CIWA is the nursing staff not administering it correctly

 

[clausewitz2]

Huh?! There is so much nonsense and misinformation in this post, so let me break it down.

1) CIWA is the putative instrument for performing symptom triggered withdrawal treatment and has the most literature behind it, so for all intents and purposes, when people think "symptom triggered", CIWA comes to mind: http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/211434.

2) The argument of reduced delirium due to benzo toxicity because of lower amounts of benzos required is circular and nonsensical. Though the course of EtOH withdrawal is more or less predictable, the severity (ie, who will progress to seizures, DTs, etc) is based on a number of factors. Therefore, different patients may require different amounts of meds (there is some outpatient literature on not even treating it based on CIWA <8 WITH CLINICAL IMPRESSION). So, it's obvious that an individual, symptom triggered approach when administered correctly would lead to fewer benzos administered and less hospital time. Agreed that it's a clinically relevant (and not just hospital admin important) outcome

3) There is absolutely no evidence that CIWA is contra-indicated in patients with complicated withdrawal. Two of the highest impact trials included such patients http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/211434 http://jamanetwork.com/journals/jama/fullarticle/377892. Obviously since CIWA asks subjective questions the patient should be lucid. But, as I (and others) have intimated above, the biggest problem with CIWA is the nursing staff not administering it correctly

Seems like it is very sensible to say "not sure if nursing will do this properly, so let's avoid using any symptom-triggered protocol in people at particularly high risk of having a complicated withdrawal, regardless of literature evidence under optimal conditions."

Not sure realistic risk-benefit analyses are misinformation.

 

[Salpingo]

Huh?! There is so much nonsense and misinformation in this post, so let me break it down.

1) CIWA is the putative instrument for performing symptom triggered withdrawal treatment and has the most literature behind it, so for all intents and purposes, when people think "symptom triggered", CIWA comes to mind: http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/211434.

2) The argument of reduced delirium due to benzo toxicity because of lower amounts of benzos required is circular and nonsensical. Though the course of EtOH withdrawal is more or less predictable, the severity (ie, who will progress to seizures, DTs, etc) is based on a number of factors. Therefore, different patients may require different amounts of meds (there is some outpatient literature on not even treating it based on CIWA <8 WITH CLINICAL IMPRESSION). So, it's obvious that an individual, symptom triggered approach when administered correctly would lead to fewer benzos administered and less hospital time. Agreed that it's a clinically relevant (and not just hospital admin important) outcome

3) There is absolutely no evidence that CIWA is contra-indicated in patients with complicated withdrawal. Two of the highest impact trials included such patients http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/211434 http://jamanetwork.com/journals/jama/fullarticle/377892. Obviously since CIWA asks subjective questions the patient should be lucid. But, as I (and others) have intimated above, the biggest problem with CIWA is the nursing staff not administering it correctly

Ok, kind of aggressive, but maybe I could have clarified a few points.

1. I'm being obnoxiously technical, but I think its worthwhile to at least be AWARE of the distinction. CIWA and CIWA-Ar are scales that are universal, wherever you go, wherever Visa is accepted. Symptom-triggered alcohol protocols will vary by institution, if they even have one, and are customized to the resources available to that place. So you could learn one protocol in residency, then tell the nurse to "start a CIWA" and they could end up doing something totally different. I'm sure the terms will converge, like Xerox + copy or Vistaril + troll, but it would be misinformation to say they are the same thing.
2. I had to re-read my post, but I still couldn't find where we disagreed, other than the statement that EtOH withdrawal is more or less predictable. But to clarify, alcohol detox is at its most complex when you're dealing with (a) the elderly and (b) delirium due to infection or encephalitis. The toughest case is when a guy shows up on the floor grabbing at his sheet and speaking nonsense, febrile and diaphoretic, with the only collateral information coming from his second cousin twice removed, who has only seen the patient at weddings when he is sloppy drunk. You give him benzos and you prolong the delirium (and the CIWA can't really distinguish between alcohol-induced delirium and delirium from other causes). A symptom-triggered treatment protocol will at least pump the brakes to keep people from schlogging him with diazepam, and thus shorten the hospital course. Similarly, the 80 year-old woman is brought in by her family after Thanksgiving to sober her up -- you want to give the absolute lowest possible amount of benzos, and STT is one way to do it. Sure, there may be additional mechanisms by which CIWA-based STT shorten the course, but the ones I outlined make the most sense to me.
3. Never said CIWA is contraindicated in patients with complicated withdrawal (and since its a scale, its really not contraindicated in ANY patient, just has varying degrees of utility). But this point could use the most exposition and relates to the OP. Alcohol-withdrawal seizures are not always preceded by the tell-tale autonomic instability typical of withdrawal (link for the psych nerds, with additional paper). So in clinical practice, you see THAT guy walk into the ED, the one who has the impression of his face permanently imprinted on the ED bathroom floor from the times he's seized and fallen, you're not going to sit around and wait to tick off boxes on a CIWA scale. You're going to warm up a nice cup of cocoa, cuddle up with your favorite book, and drop a crate of Librium into whatever orifice is available.

 

[FlowRate]

But the likely reason STT reduces hospital length of stays and delirium incidence is due to diminished benzodiazepine toxicity, which we should care about. That being said, there are certain patients that CIWA-based STT should not be used, including patients with history of withdrawal-induced seizures and other incidents of complicated withdrawal.

It's been the opposite in my experience. Like the time I got paged literally 10 times by a nurse for "resistant withdrawal" but it was really just that she kept scoring him 30 and giving him more benzos, despite myself, my resident, and our attending telling her to stop, when he was really becoming increasingly benzotoxic.

The only person I saw become slightly benzotoxic on a taper was the person who over-reported his drinking.

The literature regarding these things did not use a very sophisticated standing/taper dose schedule IIRC. (some places use a one-size-fits-all which is obviously stupid.) That's the disconnect between practice and the literature we have at the moment.

You use less benzos because it's scheduled to keep someone on the edge of symptomatic, instead of tapering them off (with relatively minimal symptoms). Simple controls theory. It's proportional control. The question is whether that's really the best thing for the patient.

 

[ExcaliburPrime1]

Basically, what I've done/seen is this:

1. If the patient is known to have heavy alcohol use and/or they have had alcohol withdrawal symptoms beyond hand tremors in the past (particularly seizures or outright DTs), then they get put on a standing Librium or Ativan dose, plus CIWA and vitals q4h with additional Ativan available for high (>8) CIWA scores. How much depends on the risk and extent of alcohol use, but having Ativan 2 mg PO q8h on day 1, then Ativan 2 mg PO q12h on day 2, then Ativan 2 mg PO x1 on day 3, with Ativan 2 mg PO q6h PRN for when CIWA is >8 is common.

2. For patients without any withdrawal symptoms in the past and with only moderate alcohol use, I usually put a CIWA assessment with vitals qshift (so q8hours) although I've seen q4h x24 hours then q8h for the next two days, with Ativan 1 mg PO q8h PRN for CIWA >8 available, but no standing Ativan dose.

Can't vouch 100% if this is the best system, but I've never had anyone seize or have other major EtOH withdrawal symptoms on this protocol.

 

[PistolPete]

Our addictionologist uses a scheduled valium taper for pretty much everyone, unless you have liver issues, in which case you get ativan. This is on top of CIWA.

One of my attendings in residency at the VA tried to convince us that benzos are not needed for alcohol withdrawal, and that a gabapentin taper is enough... what say you guys?! (His main concern was due to high prevalence of substance abuse in the VA population)

 

[splik]

lol no one in their right mind would use gabapentin alone for anything other than mild withdrawal. if you have severe withdrawal you cannot use gabapentin alone. people abuse gabapentin so its stupid to be worried about treating alcohol withdrawal with benzos because the patients are substance abusers. gabapentin is probably fine for outpatient detox of milder uncomplicated cases.

 

[PistolPete]

lol no one in their right mind would use gabapentin alone for anything other than mild withdrawal. if you have severe withdrawal you cannot use gabapentin alone. people abuse gabapentin so its stupid to be worried about treating alcohol withdrawal with benzos because the patients are substance abusers. gabapentin is probably fine for outpatient detox of milder uncomplicated cases.

Too bad nobody could convince him back then. He's probably still doing it today. Poor VA patients...

 

[tr]

Our addictionologist uses a scheduled valium taper for pretty much everyone, unless you have liver issues, in which case you get ativan. This is on top of CIWA.

One of my attendings in residency at the VA tried to convince us that benzos are not needed for alcohol withdrawal, and that a gabapentin taper is enough... what say you guys?! (His main concern was due to high prevalence of substance abuse in the VA population)

Our C/L team is really into the gabapentin approach. Apparently there's lots of data that say it's safe. Personally I didn't train that way so I'm not comfortable with it (don't have a good sense of dosing etc.). I have found gabapentin really helpful for helping outpatients abstain after detox.

 

[HarryMTieboutMD]

Our C/L team is really into the gabapentin approach. Apparently there's lots of data that say it's safe. Personally I didn't train that way so I'm not comfortable with it (don't have a good sense of dosing etc.). I have found gabapentin really helpful for helping outpatients abstain after detox.

Yes there's data, but detoxing with it is stupid... and benzos have the most (if not only) data for actually preventing seizures and DTs. My experience is hit or miss with gabapentin, baclofen, etc for abstinence

 

[Jules A]

Yes there's data, but detoxing with it is stupid... and benzos have the most (if not only) data for actually preventing seizures and DTs. My experience is hit or miss with gabapentin, baclofen, etc for abstinence

Unfortunately abstinence seems to be hit or miss regardless of the approach. I will use gabapentin short term in those who present with the over the top hypersensitivity symptoms of someone suffering from the physical sequelae of early abstinence, those a low frustration tolerance and without one single non-pharm coping skill left in their repertoire. Anecdotally based on my SUD patients' fondness for gabapentin I initially shied away from prescribing it because as I still suspect since they love it so much it can't be good but the research I have found does seem to support it increasing abstinence rates. My goal is to make them comfortable enough so they can get into serious therapy which is where they will see the true growth. I also try to give them whatever appropriate pharm tools might be available especially because I am not a fan of long term MAT.

 

[Jules A]

Our C/L team is really into the gabapentin approach. Apparently there's lots of data that say it's safe. Personally I didn't train that way so I'm not comfortable with it (don't have a good sense of dosing etc.). I have found gabapentin really helpful for helping outpatients abstain after detox.

One of VA addictions hotshot I heard at a conference last year seemed to like it for uncomplicated detox, if there is such a thing, on an outpatient basis.

 

[FlowRate]

How much depends on the risk and extent of alcohol use, but having Ativan 2 mg PO q8h on day 1, then Ativan 2 mg PO q12h on day 2, then Ativan 2 mg PO x1 on day 3, with Ativan 2 mg PO q6h PRN for when CIWA is >8 is common.

That's a little bit of an odd taper, given ativan's limited duration of effect. (Although the half-life is long enough to make it seem more reasonable.) We usually schedule Ativan either q4 (very significant alcohol history) or q6, with varying doses.