EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal

Clinical Question

What is the optimal strategy for the outpatient use of benzodiazepines in the treatment of acute alcohol withdrawal when discharging patients from the emergency department?

Background

Clinicians frequently discharge patients from the ED who meet outpatient treatment for alcohol withdrawal. In all cases, it is beneficial to have outpatient psychosocial support, if available, but this clinical question specifically addresses those for whom there is not a near-term detox facility readily available. Frequently, these patients have received PO or IV benzodiazepines in the ED. However, there is ongoing debate regarding the appropriate use of oral benzodiazepines (e.g. Ativan, Librium, or Valium) as outpatient treatment.

Strategy 1: Give no benzodiazepines

Pro Argument

The argument for not giving outpatient benzos to patients with alcohol withdrawal rests on the bedrock medical principle of primum non nocere (first, do no harm). Patient who have significant enough alcohol withdrawal symptoms to require treatment almost by definition have an alcohol abuse problem. As such, one should assume that they are unable to rationally self-titrate GABA-agonists (ethanol, benzos, etc.), otherwise they would not have an alcohol abuse problem. Thus, practitioners should assume that such patients may take all prescribed benzos at the same time (potentially with additional alcohol), which could result in a possibly fatal overdose (especially due to the synergistic effect when mixed with alcohol). As such, the risks of outpatient benzo prescriptions outweigh the benefits, especially in chronic alcoholic when the vast majority will go out and again start drinking.

Con Argument

If we don't give benzos to patients who are trying to quit alcohol or who are otherwise in a borderline withdrawal state, then we are either driving them to drink upon discharge or are forcing ourselves to admit these patients. So far, no one has posted literature to suggest that giving outpatient benzos are unsafe for patients.

Strategy 2: Give a 2-3 day course of benzodiazepines to all patients with alcohol withdrawl

Pro Argument

This treatment strategy is a compromise between giving no benzos to patients and giving longer courses of outpatient benzos. The idea is that if patients are really trying to quit, then several days of benzos should be sufficient to get them through acute withdrawal. However, if they are not and continue to drink with the benzos, the total amount is not enough to be likely to kill the patient in an overdose (especially if they are chronic alcoholics and have a high tolerance. We are not aware of any documented poor outcomes associated with this, empirically derived, strategy.

Con Argument

One argument against this practice is that (empirically) most patients seen in the ED for alcohol withdrawal are chronic alcoholics and most are not actually trying to quit drinking. Thus, there is potential harm from giving benzos to all of them (potential overdose) with limited benefit (as they are going to continue drinking).

Additionally, this encourages chronic alcoholics to come to the ER for benzos, even if only having mild withdrawal, as a cheaper alternative to buying alcohol. Thus, taking up a bed that another patient may need.

Strategy 3: Give a 2-3 day course of benzodiazepines only to patients who are trying to quit alcohol

Pro Argument

This treatment strategy is similar to strategy #2, however gives the benzos to a subset of patients (only those who endorse wanting to quit alcohol and/or those who the clinician feels is actually trying to quit alcohol). It has the benefit of minimizing risk from overdose (by giving a shorter course of benzos) and improves the risk/benefit ratio by excuding those patients from outpatient treatment who are more likely to overdose.

Con Argument

There are, to our knowledge, no studies of this strategy and it is unclear what the best way is to identify the subset of patients who are at lower risk for benzo/alcohol overdose (self report, clinician opinion, etc). This strategy may increase the risk of withdrawal in patients not receiving benzos.

Strategy 4: Give a longer tapered course of benzodiazepines to all patients with alcohol withdrawl

Pro Argument

Con Argument

Strategy 5: Give a longer tapered course of benzodiazepines only to patients who are trying to quit alcohol

Pro Argument

Con Argument

Criticisms & Further Discussion

As yet, we are aware of only one paper[1] partially related to this topic, which is comparison of outpatient vs. inpatient detox programs. However, as the patients in the outpatient program "were evaluated medically and psychiatrically and then were prescribed decreasing doses of oxazepam on the basis of daily clinic visits" this is not directly related to the current clinical question, as most EDs do not have such programs to refer patients to and the current question is regarding the prescribing of larger amounts of benzos to the patients.

External Links

WikEM:Now

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See Also

Sources

  1. Comparative effectiveness and costs of inpatient and outpatient detoxification of patients with mild-to-moderate alcohol withdrawal syndrome. New England Journal of Medicine. 03/1989; 320(6):358-65. DOI: 10.1056/NEJM198902093200605

Authors:

Ross Donaldson