When do you decide to put someone on Ativan Protocol for EtOH Withdrawal?

[Blitz2006]

So I am getting conflicting info from Attendings

What factors /criteria should I look at?
Frequency of alcohol?
Amount of alcohol?
Duration of alcohol abuse?

Do I put someone on standing protocol if they abuse >2 weeks? More than 5 drinks/day?

When to put on standing ativan vs. PRN?

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[TexasPhysician]

I'm unaware of a consensus report on the matter. Some doctors prefer a scheduled taper and others prefer prn.

 

[FlowRate]

I thought we just had a thread on alcohol withdrawal in the past few months?

My favorite institutional protocol (we have several since we work in multiple different institutions) is #standardized drinks/day / 2 = Ativan mg per day. Then divide that into 4-6 doses. More frequency especially if using IV. Decrease by 25-33% per day as tolerated. 1-2mg PRN CIWA > 8 (depending on what standing dose they get.)

That plan is more difficult if you think you're in a situation where patients may not be forthcoming regarding drinking amount. The above protocol is a medical detox unit.

 

[Armadillos]

So I am getting conflicting info from Attendings

What factors /criteria should I look at?
Frequency of alcohol?
Amount of alcohol?
Duration of alcohol abuse?

Do I put someone on standing protocol if they abuse >2 weeks? More than 5 drinks/day?

When to put on standing ativan vs. PRN?

One important thing I would mention is that a lot of the super evidenced based medicine types love to talk about how great symptom triggered detox is, but I question if they have stepped foot in a real psych unit in the last 5 years to see how understaffed and overworked the nurses are many places. With that in mind if I'm spending more than a few seconds considering if a pt needs standing benzos, I just start them and can quickly back off if needed.

As far as who needs them, instead of trying to get someone to reliably tell me how much they are drinking and somehow decide on that, I personally focus much more on
- How the patient looks right now in the context of timing of last drink, current BAL and current vitals.
-Patients past withdrawal histories.

Just curious, are your attendings complaining you are putting too many people on standing benzos or too few people on them?

Edit: All this is from the context of place where we do the vast majority of our detoxing on a general psychiatric unit, so if you get behind you and the patient are in trouble.

 

[FlowRate]

One important thing I would mention is that a lot of the super evidenced based medicine types love to talk about how great symptom triggered detox is, but I question if they have stepped foot in a real psych unit in the last 5 years to see how understaffed and overworked the nurses are many places. With that in mind if I'm spending more than a few seconds considering if a pt needs standing benzos, I just start them and can quickly back off if needed.

As far as who needs them, instead of trying to get someone to reliably tell me how much they are drinking and somehow decide on that, I personally focus much more on
- How the patient looks right now in the context of timing of last drink, current BAL and current vitals.
-Patients past withdrawal histories.

Just curious, are your attendings complaining you are putting too many people on standing benzos or too few people on them?

Edit: All this is from the context of place where we do the vast majority of our detoxing on a general psychiatric unit, so if you get behind you and the patient are in trouble.

The actual papers for symptom triggered aren't great, either.

 

[ExcaliburPrime1]

Nearly finished with PGY-1. I find that there are no set criteria, at least where I work. I will typically recommend standing if a person is forthcoming about a long history of alcohol use (e.g. years of consistent intake of a fifth of vodka or more), if they have any history of withdrawal seizures/DTs, or if I know there will be reduced staffing (admitting someone on Friday or before a holiday).

In theory, if everyone is doing their job (not just the nurses doing the CIWA, but you or the resident on duty who looks at the patient for 30 seconds and looks at their vitals), then everything will be fine regardless.

 

[Jules A]

I tend to add the CIWA with prn Ativan on anyone with a known hx of ETOH or elevated BAL upon admission at least until I've been able to see them. If geri without a known hx of w/d symptoms I consider reducing the prn dose to 0.5mg for CIWA <15 to avoid delirium in cases of no or unknown withdrawal history. I also add to notify me any time a patient scores over 15 so I can discuss with staff and likely order IM at that point.

If I know the patient and know they will attempt to hit the crapper I'll also add a standing order taper of Ativan or Valium if their LFTs support in addition to the CIWA. I also do that for anyone the RNs or ED staff tell me doesn't look good because getting behind that 8-ball is not a place I'm willing to be. Once you've seen and/or attempted to treat someone in full blown DTs it is not something you will ever want to revisit. Issues I have with CIWA alone in patients with known significant ETOH use or complicated w/d hx include that they don't tend to be willing to get up in staff's face with somatic complaints as compared to the opiate w/d patients who are in not in a medically compromised state. Staff can be run ragged by the opiate patients' demands while the low key alcoholic starts seizing alone in their room. The CIWA can be skewed either too much for anxiety or too little if there is RN bias that a patient is "drug seeking" and I believe patients feel more comfortable with a standing order benzo in addition to prn based on CIWA scores.

Ideally I will taper the standing order effectively and avoid the need for CIWA based prns. I only use Librium as a 1x dose before d/c in the cases of patients who are still likely to have symptoms and for whatever reason have to be discharged because I prefer the taper flexibility of the shorter 1/2 life meds.

 

[WingedOx]

I prefer scheduled, just because that's what I was taught in residency and it's what I'm comfortable with, but my current place of employment uses CIWA.

The one thing I hate with CIWA is the inter rater reliability of "agitation" and the subjective report of "anxiety" can skew the score. I remember getting a page from an inpatient nurse about a high CIWA where 13 points were given for these, and when I went to see the patient it was because he was manic as a bouncy ball.

Plus I've got a polysub addict on the addiction floor right now who never reports his anxiety as anything but a 7/7. I'm not primary to him right now so I'm limited in what I can do with this guy, but I know I'm going to get slammed with calls from him when he's d/c'd on Friday with no benzos after finding ways to get Ativans throughout his stay.

 

[NickNaylor]

We use CIWA at all of the institutions we rotate at - it's implemented with variable degrees of success depending on the unit. If I'm covering overnight and admitting folks, I pretty much order CIWA for anyone for whom there is a remote possibility of significant alcohol use and allow the day team to sort if out later. I would rather the nurses hate me for having to do CIWA checks than miss withdrawal.

I have never done a scheduled regimen, but the only real situations I would think about it is 1) if I don't trust the staff to reliably perform CIWA and/or 2) there is a history of withdrawal seizures. None of the faculty I've run into are fans of scheduled tapers with only very rare exceptions.

 

[Blitz2006]

One important thing I would mention is that a lot of the super evidenced based medicine types love to talk about how great symptom triggered detox is, but I question if they have stepped foot in a real psych unit in the last 5 years to see how understaffed and overworked the nurses are many places. With that in mind if I'm spending more than a few seconds considering if a pt needs standing benzos, I just start them and can quickly back off if needed.

As far as who needs them, instead of trying to get someone to reliably tell me how much they are drinking and somehow decide on that, I personally focus much more on
- How the patient looks right now in the context of timing of last drink, current BAL and current vitals.
-Patients past withdrawal histories.

Just curious, are your attendings complaining you are putting too many people on standing benzos or too few people on them?

Edit: All this is from the context of place where we do the vast majority of our detoxing on a general psychiatric unit, so if you get behind you and the patient are in trouble.

Thanks for all the responses.

Main issue in our hospital is that everyone reflexively puts people on ativan tapers. I mean, its the easy thing to do right? So I'm trying to see how I can avoid putting people on tapers.....

But thats my question, what is the criteria to start protocol based on these findings of "How the patient looks right now in the context of timing of last drink, current BAL and current vitals."?

As in, do you start protocol if their last drink was 2 days ago, but not 5 days ago? Do you start protocol if HR is 110 but not when it is 90? Do you start if they have been drinking 3 weeks straight, but not if it has only been for 3 days straight?

I understand it is subjective/grey area, but I'm trying to figure out if there are some concrete cutoffs relatively?

 

[Armadillos]

Thanks for all the responses.

Main issue in our hospital is that everyone reflexively puts people on ativan tapers. I mean, its the easy thing to do right? So I'm trying to see how I can avoid putting people on tapers.....

But thats my question, what is the criteria to start protocol based on these findings of "How the patient looks right now in the context of timing of last drink, current BAL and current vitals."?

As in, do you start protocol if their last drink was 2 days ago, but not 5 days ago? Do you start protocol if HR is 110 but not when it is 90? Do you start if they have been drinking 3 weeks straight, but not if it has only been for 3 days straight?

I understand it is subjective/grey area, but I'm trying to figure out if there are some concrete cutoffs relatively?

I don't think there are hard and fast rules for this. What are your main concerns about treating a condition (alcohol withdrawal) with its gold standard treatment (benzos)?

If your in a hospital where the nurses are able to consistently, reliably and accurately manage PRN benzos based on CIWA scores and the night coverage is able to give a lot of attention to the detoxers then that is absolutely a great choice to go straight symptom triggered. But most people don't practice in a setting that reliable, so we err towards keeping our patients safe. As others have said once you get behind its really bad news.

Anecdotally, the non-psych services at our medical hospital seem to have this idea that you push the CIWA+prn Ativan button in the EMR and now you have managed the withdrawal and everything is great. Then a couple days later they are playing catch-up and teetering on needing the ICU. While in our psych hospital we tend to lean towards standing benzos and we have very few issues despite the patients having much less nursing attention.

 

[ExcaliburPrime1]

Thanks for all the responses.

Main issue in our hospital is that everyone reflexively puts people on ativan tapers. I mean, its the easy thing to do right? So I'm trying to see how I can avoid putting people on tapers.....

But thats my question, what is the criteria to start protocol based on these findings of "How the patient looks right now in the context of timing of last drink, current BAL and current vitals."?

As in, do you start protocol if their last drink was 2 days ago, but not 5 days ago? Do you start protocol if HR is 110 but not when it is 90? Do you start if they have been drinking 3 weeks straight, but not if it has only been for 3 days straight?

I understand it is subjective/grey area, but I'm trying to figure out if there are some concrete cutoffs relatively?

Unfortunately, I don't think you're going to get some black and white answers here. In the grand scheme of things, as long as the patient can tolerate Ativan (e.g. not incredibly old, has a prior documented adverse effect, or severe liver dysfunction), they're not going to be too badly impacted (not the best standard though!!) with such a taper.

More than anything, I'm surprised that the taper is reflexively initiated, because that nearly guarantees a 4-5 day stay just for the taper to run its course (or face having to complete the taper as an outpatient).

The only black and white thing here is if their last drink was 5 days ago and they have no withdrawal symptoms, they're out of the window, so no taper!

 

[Blitz2006]

Unfortunately, I don't think you're going to get some black and white answers here. In the grand scheme of things, as long as the patient can tolerate Ativan (e.g. not incredibly old, has a prior documented adverse effect, or severe liver dysfunction), they're not going to be too badly impacted (not the best standard though!!) with such a taper.

More than anything, I'm surprised that the taper is reflexively initiated, because that nearly guarantees a 4-5 day stay just for the taper to run its course (or face having to complete the taper as an outpatient).

The only black and white thing here is if their last drink was 5 days ago and they have no withdrawal symptoms, they're out of the window, so no taper!

So is 5 days your cutoff, for last drink?

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[ExcaliburPrime1]

So is 5 days your cutoff, for last drink?

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There are no absolutes in medicine, but if they're reliably five days out of their last drink and are not symptomatic, I would not using standing Ativan. I would put in CIWA with PRN Ativan if they had a history of seizures/DTs or if I thought their 5-day mark was unreliable. Remember though, PGY-1 here.

 

[Jules A]

More than anything, I'm surprised that the taper is reflexively initiated, because that nearly guarantees a 4-5 day stay just for the taper to run its course (or face having to complete the taper as an outpatient).

Fortunately that hasn't been my experience. I adjust the dose or length based on their presentation and whether they have required additional prns. In most cases its about 2-3 days. Again not everyone gets put on it and if I find its not necessary or over sedating I'll reduce or d/c it.

 

[Armadillos]

A greatly overly conservative and simplistic theme I've seen in my own experience is that if someone's BAL is currently <20 and they have normal vitals then your unlikely to have a problematic detox using only PRNs. Obviously lots of confounding patient specific factors to this

 

[Armadillos]

Fortunately that hasn't been my experience. I adjust the dose or length based on their presentation and whether they have required additional prns. In most cases its about 2-3 days. Again not everyone gets put on it and if I find its not necessary or over sedating I'll reduce or d/c it.

Agreed, after you have gotten another 12-24 hours of info after admission you can easily change course and rapidly taper, no reason you have to be committed to a long taper. I like using a dose or two of Valium in those cases to smooth things out.

 

[TexasPhysician]

The only black and white thing here is if their last drink was 5 days ago and they have no withdrawal symptoms, they're out of the window, so no taper!

While 5 days would eliminate most patients, there is a subset that present beyond this.

 

[funklab]

So I am getting conflicting info from Attendings

What factors /criteria should I look at?
Frequency of alcohol?
Amount of alcohol?
Duration of alcohol abuse?

Do I put someone on standing protocol if they abuse >2 weeks? More than 5 drinks/day?

When to put on standing ativan vs. PRN?

I don't have the evidence in front of me, and I might be completely wrong, but I'm pretty sure there is better evidence for CIWA or similar protocols than using a standing order for bzds. Of course this depends on how much you feel you can trust your nurses to be objective in scoring CIWA. IMO standing orders run too much of a risk of underdosing them or overdosing them.

 

[ExcaliburPrime1]

I don't have the evidence in front of me, and I might be completely wrong, but I'm pretty sure there is better evidence for CIWA or similar protocols than using a standing order for bzds. Of course this depends on how much you feel you can trust your nurses to be objective in scoring CIWA. IMO standing orders run too much of a risk of underdosing them or overdosing them.

Typically with a standing taper there is also an order to do CIWA assessments (say every 6 hours) with additional PRN Ativan available as needed for CIWA scores (typically >8 would trigger the PRN). That way underdosing is out of the equation.

Overdosing is typically taken care of by holding the Ativan for sedation or low BP, so it's less of an issue as well.

 

[HarryMTieboutMD]

OK everyone is making this issue (which should be straightforward for any psychiatrist) way too complicated

1) Alcohol withdrawal is a ultimately a clinical diagnosis, and it typically presents in a predictable pattern

2) In RCTs CIWA reduces detox time and amount of benzos used with no worsening of outcomes but the diagnosis should have been made by the mD before this is instituted- the patient should actually be in withdrawal. (see point 1)

3) As other people have described above the biggest issue with CIWA is getting the nurses to do it correctly. Remember nurses don't think through differentials; they just dose by the checklist. Our hospital tried to implement a hospital wide CIWA and it turned out disastrous. If you have a patient in a detox setting with an experienced nurse who understands EtOH withdrawal, then it works.

4) Why is everyone glibly throwing around ativan? As you all hopefully learned in med school, the only reasons to use ativan are 1)liver problems, 2) absorptive problems so you need a parenteral benzo (though you can do this with diazepam), or 3) the patient has severe withdrawal and is in the unit getting an ativan ggt. Otherwise use Librium, Valium, Klonopin, etc

5) I have NEVER had a problem with a scheduled taper (e.g. Librium 25mg Q6H +25mg Q6H PRN on day 1=> 25mg Q8H + PRNs on day 2=> 25mg BID + PRNS on day 3=> 25mg on day 4 then OFF- I make sure to have the nurses call me and take vital signs before giving PRNS), and I have done this innumerable times. Different people will use slightly different dosages and dose reductions, etc but the principle is the same