Detox protocol for Alcohol

[ELOVL4]

Dear Members,

Currently I am doing addiction Psychiatry rotation. My unit use the Ativan for alcohol detox. What is your inpatient detox protocol for alcohol? What Benzodiazepines you use?
Have you ever tried anything other than Benzo's for alcohol withdrawal? How was the experience?

Thanks in advance for your valuable inputs.👍

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[vistaril]

I'll use whatever I think is ideal for the indication in terms of any scheduled meds....one component of this may be how long I think the patient will be inpatient. For short inpatient stays, I probably use ativan more frequently than anything else.

On CIWA protocol, we use ativan. Although CIWA protocol is more useful for medicine floors....usually in psych the nurses have a better sense of what to do than going by CIWA.

In general, the process of detoxing someone is very simple.

 

[novopsych]

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[splik]

hi i use chlordiazepoxide because that's what i've always used and it is longer acting and the original benzo. however we can use either librium or ativan in the CIWA protocol. in more severe withdrawal states, we use phenobarbitone.

it is interesting that vistaril thinks CIWA is more useful for medicine floors. i am more likely to give scheduled benzos if i think that the nurses are not familiar with detox, although they all seem to be familiar with CIWA round here.

 

[vistaril]

it is interesting that vistaril thinks CIWA is more useful for medicine floors. i am more likely to give scheduled benzos if i think that the nurses are not familiar with detox, although they all seem to be familiar with CIWA round here.

well with CIWA and giving scheduled benzos it's not an either/or thing. For many patients on psych floor I do both.

 

[kugel]

Every place I've worked, I've been told the CIWA represents "too much work" for it to be instituted. So I write orders to give Librium or Valium PRN with multiple VS parameters and VS to be taken q 4hr around the clock. Hmmm....really not much less work than CIWA. I'm not liked much for doing that, but I've had to send out multiple patients via 911 (we're a free standing psych hosp) for DTs and Seizures becasuse the pt's doc wrote "Ativan 2mg PO q 4hr PRN Withdrawal" and the pt. got NONE in the 72 hrs since admit. These incidents never seem too generate a discussion about how we could prevent this outcome, because everyone is happy to have the pt sent out for 8 hrs, so he's not back until the next shift.

Another strategy a peer uses in "highly resistant nursing" atmosphere is "Ativan 2mg QID, Hold if drowsy or asleep." That works pretty well with few bad outcomes.

 

[billypilgrim37]

We have CIWA protocols that use oxazepam for 5 days in varying doses or diazepam for 7 days at equivalently higher doses for taper and break through. In medical settings we usually use lorazepam, and for outpatient detox we use chlordiazepoxide. The reasons for the distinctions are meaningful but not excessively so. I do think oxazepam is under used for scheduled dosing regimens.

Our toxicology service uses the strategy of a) snow them with IV diazepam until asleep, b) let them go when they wake up. It works better than it should, despite being a little ridiculous.

 

[vistaril]

Every place I've worked, I've been told the CIWA represents "too much work" for it to be instituted. So I write orders to give Librium or Valium PRN with multiple VS parameters and VS to be taken q 4hr around the clock. Hmmm....really not much less work than CIWA. I'm not liked much for doing that, but I've had to send out multiple patients via 911 (we're a free standing psych hosp) for DTs and Seizures becasuse the pt's doc wrote "Ativan 2mg PO q 4hr PRN Withdrawal" and the pt. got NONE in the 72 hrs since admit. These incidents never seem too generate a discussion about how we could prevent this outcome, because everyone is happy to have the pt sent out for 8 hrs, so he's not back until the next shift.

Another strategy a peer uses in "highly resistant nursing" atmosphere is "Ativan 2mg QID, Hold if drowsy or asleep." That works pretty well with few bad outcomes.

well sometimes just VS parameters is better than CIWA. In fact that is an automatic CIWA order we use and nurses on some units(and in the ER) will just bypass the CIWA and just go by the vital signs component of it. An important point is that bad nursing can result in a CIWA scoring(on the subjective factors) to make a pt seem much less stable than they really are, whereas that same pt who is unstable just going by vital sign parameters would likely get more meds.....

either way I don't worry much about it. It takes a lot of incompetence and idiocy to mess up when you have an idea what you want to do with a patient.

 

[billypilgrim37]

An important point is that bad nursing can result in a CIWA scoring(on the subjective factors) to make a pt seem much less stable than they really are

Especially when patients learn to always answer yes when asked if they've had a seizure before. "I got all shaky doc!"

 

[RN2013]

Where I work ETOH detox protocol uses Librium-(with alternative Ativan for elderly although I have never seen doc switch librium to ativan). Was happy recently when the Doc switched one of my recent patient to scheduled librium since he had past hx. of detox induced seizures and severe w/d s/sx ...I have seen patient get too much Librium in past ..unfortunately some nurses don't have that critical thinking down..and one particular pt. received ALOT of librium had dx. of liver failure WELL i reported altered mental status and next shift patient declined further (surprised other shifts didn't report/notice this) none of these nurses were checking to see total dose given previous shifts....so I ended up having to call the Doc to have him sent out to med. hospital ..one psych doc changed her librium dosing orders for detox d/t this... For benzos usually start on librium unless its my fave doc he will put them on phenobarbital taper immediately..

 

[JourneyAgent]

The literature says that symptom based treatment is superior, with less drug toxicity. But at the hospital I'm working at, it would be a miracle if nursing care was tight enough to monitor sx and give meds accordingly. It's miraculous it they get their meds consistently at all.

So I wonder it what works at Betty Ford should be the method of care everywhere.

 

[tennreb]

Neurontin 400 TID + CIWA. I add standing Ativan if history of withdrawal or showing moderate to severe signs at time of assessment.

 

[nitemagi]

Our toxicology service uses the strategy of a) snow them with IV diazepam until asleep, b) let them go when they wake up. It works better than it should, despite being a little ridiculous.

This is an old addiction medicine strategy. The logic is that you're loading them until they're gaba saturated, so to speak, the point at which they're sedated on valium. It has such a long half life that they will then self taper over a normal detox period. I believe the old protocol was something like 10mg q1h until sedated. Not many feel comfortable enough to do this, though.