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Strayerisms – Preventing Alcohol Withdrawal

Reuben Strayer, MD
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11:57
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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN
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03:15

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EM:RAP 2017 January Written Summary 926 KB - PDF

Reuben gives his strategy of managing acute alcohol withdrawal. Don't treat, he says, prevent.

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brendanC -

In a select few I will provide an oral loading dose of phenobarbital along with 2 take home valium 5 mg at discharge. No Rx. This makes for a sedated, less likely to drink patient, who can have valium if urge/symptoms develop. Little risk of OD and better chance of compliance with not drinking. Only do this if conversation suggests earnest desire to stop and no inpatient beds available. (which Is the usual).

Brendan C

Reuben Strayer (@emupdates) -

thanks for your comment Brendan. this type of front-loaded detox makes a lot of sense in carefully selected patients. the concern many providers have in this population–I think justified–is that your patient then decides to add to his phenobarb load with a fifth of vodka, then top it off with a couple of the valium tabs. I agree no inpatient beds available is usual; in my experience earnest desire to stop is much less usual. So, yes, with emphasis on what you call _a select few_.

Ravi S. -

Dr. Strayer,
I follow your approach re preventing alcohol withdrawal in the ED. I make use of our chemical dependency counselor or refer to OP detox which is available here for many.
I am unable to convince colleagues that they need to give benzos to the uncomplicated alcohol intox pt, who is alert, oriented, walking, talking, who is nearing d/c from the ED and says that he/she is approaching withdrawal (CIWA < 9).
i am unable to find references to support this approach. Are you able to give me any references?
thanks much and I always learn from you.
Ravi

Reuben Strayer (@emupdates) -

Thanks for your comment Ravi. There isn't any data to support that approach, I'm not sure exactly what that data would look like, actually. By definition, all alcohol-dependent patients who stop drinking will at some point develop withdrawal. The majority of alcohol-dependent, alcohol-intoxicated people brought to the ED will sober, wake up, leave, and return immediately to drinking. ideally all these people would be approached about helping them with sobriety, discussion with a peer, offered naltrexone, other medical/social/addiction concerns addressed, etc. In reality a small minority of these patients receive this sort of care (or are interested in this sort of care) in most centers. So, for the vast majority of these patients, they sober, get up, leave, return to drinking. There's no reason to dose those patients with a benzodiazepine.

The prophylactic/early withdrawal benzo dose comes into play when there is some reason why the alcohol-dependent patient who was brought in intoxicated but is now sober can't be discharged to return to drinking. for example, they are suicidal and need to see a psychiatrist, they have trauma that requires management, they have pneumonia, etc. these are the patients where you want to prevent withdrawal (and perhaps an unneeded admission) with a prophylactic benzo.

The other case is the alcoholic who wishes to stop drinking and has the ability/social support to do so. they should be dosed and discharged with librium.

reuben

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