1
|
Ronan MV, Gordon KS, Skanderson M, Krug M, Godwin P, Heppe D, Hoegh M, Boggan JC, Gutierrez J, Kaboli P, Pescetto M, Guidry M, Caldwell P, Mitchell C, Ehlers E, Allaudeen N, Cyr J, Smeraglio A, Yarbrough P, Rose R, Jagannath A, Vargas J, Cornia PB, Shah M, Tuck M, Arundel C, Laudate J, Elzweig J, Rodwin B, Akwe J, Trubitt M, Gunderson CG. Contemporary Management and Outcomes of Veterans Hospitalized With Alcohol Withdrawal: A Multicenter Retrospective Cohort Study. J Addict Med 2024; 18:389-396. [PMID: 38452185 DOI: 10.1097/adm.0000000000001297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
OBJECTIVES Few studies describe contemporary alcohol withdrawal management in hospitalized settings or review current practices considering the guidelines by the American Society of Addiction Medicine (ASAM). METHODS We conducted a retrospective cohort study of patients hospitalized with alcohol withdrawal on medical or surgical wards in 19 Veteran Health Administration (VHA) hospitals between October 1, 2018, and September 30, 2019. Demographic and comorbidity data were obtained from the Veteran Health Administration Corporate Data Warehouse. Inpatient management and hospital outcomes were obtained by chart review. Factors associated with treatment duration and complicated withdrawal were examined. RESULTS Of the 594 patients included in this study, 51% were managed with symptom-triggered therapy alone, 26% with fixed dose plus symptom-triggered therapy, 10% with front loading regimens plus symptom-triggered therapy, and 3% with fixed dose alone. The most common medication given was lorazepam (87%) followed by chlordiazepoxide (33%), diazepam (14%), and phenobarbital (6%). Symptom-triggered therapy alone (relative risk [RR], 0.68; 95% confidence interval [CI], 0.57-0.80) and front loading with symptom-triggered therapy (RR, 0.75; 95% CI, 0.62-0.92) were associated with reduced treatment duration. Lorazepam (RR, 1.20; 95% CI, 1.02-1.41) and phenobarbital (RR, 1.28; 95% CI, 1.06-1.54) were associated with increased treatment duration. Lorazepam (adjusted odds ratio, 4.30; 95% CI, 1.05-17.63) and phenobarbital (adjusted odds ratio, 6.51; 95% CI, 2.08-20.40) were also associated with complicated withdrawal. CONCLUSIONS Overall, our results support guidelines by the ASAM to manage patients with long-acting benzodiazepines using symptom-triggered therapy. Health care systems that are using shorter acting benzodiazepines and fixed-dose regimens should consider updating alcohol withdrawal management pathways to follow ASAM recommendations.
Collapse
Affiliation(s)
- Matthew V Ronan
- From the Medical Service, GIM Section, VA Boston Healthcare System, West Roxbury, MA (MR); Harvard Medical School, Boston, MA (MR); VA Connecticut Healthcare System, West Haven, CT (KSG, M Skanderson, BR, CGG); Yale University School of Medicine, New Haven, CT (KSG, BR, CGG); Medical Service, Boise VA Medical Center, Boise, ID (MK); University of Washington School of Medicine, Seattle, WA (MK, PBC, M Shah); Medical Service, Jesse Brown VA Medical Center, Chicago, IL (PG); University of Illinois, College of Medicine, Chicago, IL (PG); VA Eastern Colorado Health Care System, Aurora, CO (DH, MH); Department of Medicine, University of Colorado School of Medicine, Aurora, CO (DH, MH); Medical Service, Durham VA Medical Center, Durham, NC (JCB); Department of Medicine, Duke University School of Medicine, Durham, NC (JCB); Section of Hospital Medicine, Iowa City VA Healthcare System, Iowa City, IA (JG, PK); Department of Medicine, University of Iowa Health Care, Carver College of Medicine, Iowa City, IA (JG, PK); Medical Service, VA Kansas City Health Care, Kansas City, MO (MP); Medical Service, New Orleans VA Medical Center, New Orleans, LA (MG, PC); Tulane University School of Medicine, New Orleans, LA (MG, PC); Medical Service, Veteran Affairs Nebraska-Western Iowa Health Care System, Omaha, NE (CM, EE); University of Nebraska Medical Center, College of Medicine, Omaha, NE (EE); Medical Service, VA Palo Alto Healthcare System, Palo Alto, CA (NA); Stanford University School of Medicine, Palo Alto, CA (NA); Medical Service, Pittsburgh VA Medical Center, Pittsburgh, PA (JC); Pittsburgh University School of Medicine, Pittsburgh, PA (JC); Medical Service, VA Portland Healthcare System, Portland, OR (AS, AJ); Oregon Health and Science University, School of Medicine, Portland, OR (AS, AJ); Medical Service, Salt Lake City VA Medical Center, Salt Lake City, UT (PY, RR); University of Utah School of Medicine, Salt Lake City, UT (PY, RR); Medical Service, San Diego VA Medical Center, San Diego, CA (JV); Medical Service, VA Puget Sound Healthcare System, Seattle, WA (PBC, M Shah); Medical Service, VA Washington DC Health Care System, Washington, DC (MT, CA); George Washington University School of Medicine and Health Sciences, Washington, DC (MT); Georgetown University School of Medicine, Washington, DC (CA); Medical Service, White River Junction VA Medical Center, White River Junction, VT (JL, JE); Geisel School of Medicine at Dartmouth, Hanover, NH (JL, JE); Medical Service, Atlanta VA Medical Center, Atlanta, GA (JA, MT); Emory University School of Medicine, Atlanta, GA (JA, MT)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
2
|
Airagnes G, Valter R, Ducoutumany G, Vansteene C, Trabut JB, Gorwood P, Dubertret C, Matta J, Charles-Nelson A, Limosin F. Magnesium in the treatment of alcohol withdrawal syndrome: a multicenter randomized controlled trial. Alcohol Alcohol 2023; 58:329-335. [PMID: 37012631 DOI: 10.1093/alcalc/agad021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 04/05/2023] Open
Abstract
OBJECTIVE Alcohol withdrawal syndrome (AWS) is a frequent and potentially life-threatening condition experienced in alcohol use disorder. Since hypomagnesemia is involved in AWS's severity, we conducted a multicenter double-blind randomized placebo-controlled trial to examine the efficacy of oral magnesium supplementation as an adjuvant therapy of AWS. MATERIAL AND METHODS Inpatients were recruited in six different centers if they had a baseline score higher than eight on the Revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar). The experimental treatment was magnesium lactate dehydrate, administrated three times per day providing a total of 426.6 mg per day and up to 15 days. The primary endpoint was the significant between-group difference of the CIWA-Ar total score change from baseline to 3 days later. The treatment group and baseline score were introduced as covariables in an analysis of covariance. RESULTS A total of 98 inpatients were included {71.4% of men; mean age of 49.1 years [standard deviation (SD): 10.3]}. In the intention-to-treat population, the mean reduction of the CIWA-Ar score in the experimental group between baseline and 3 days later was 10.1 (SD: 5.2), whereas it was 9.2 (SD: 3.9) in the control group. The absolute difference of the adjusted mean in the experimental group compared with the control group was -0.69 (SD: 0.72), which did not correspond to a significant between-group difference (P = 0.34). Per-protocol analysis and sensitivity analyses also supported this result. Supplementary analyses found no significant difference regarding benzodiazepine consumption, magnesium blood concentration, and satisfaction to care. CONCLUSIONS The present study does not support the rationale of systematic oral magnesium supplementation in patients with AWS.
Collapse
Affiliation(s)
- Guillaume Airagnes
- Department of Psychiatry and Addictology, AP-HP, Centre-Université Paris Cité, 20 rue Leblanc, 75015 Paris, France
- Faculté de Santé, UFR de Médecine, Université Paris Cité, 15 Rue de l'École de Médecine, 75006 Paris, France
- INSERM UMS011, Population-based Epidemiological Cohorts, Hôpital Paul Brousse Bât. 15/16, 16 avenue Paul Vaillant-Couturier, 94807 Villejuif Cedex, France
| | - Rémi Valter
- Department of Psychiatry and Addictology, AP-HP, Centre-Université Paris Cité, 20 rue Leblanc, 75015 Paris, France
| | - Géraldine Ducoutumany
- Department of Psychiatry and Addictology, AP-HP, Centre-Université Paris Cité, 20 rue Leblanc, 75015 Paris, France
| | - Clément Vansteene
- GHU Paris Psychiatrie et Neurosciences, CMME, Hôpital Sainte-Anne, 1 rue Cabanis, 75014 Paris, France
| | - Jean-Baptiste Trabut
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Hôpital Emile ROUX, Department of Addictology, 1 Avenue de Verdun, 94450 Limeil-Brévannes, France
| | - Philip Gorwood
- Faculté de Santé, UFR de Médecine, Université Paris Cité, 15 Rue de l'École de Médecine, 75006 Paris, France
- GHU Paris Psychiatrie et Neurosciences, CMME, Hôpital Sainte-Anne, 1 rue Cabanis, 75014 Paris, France
- Institute of Psychiatry and Neuroscience of Paris (IPNP), INSERM U1266, 1 rue Cabanis, 75014 Paris, France
| | - Caroline Dubertret
- Faculté de Santé, UFR de Médecine, Université Paris Cité, 15 Rue de l'École de Médecine, 75006 Paris, France
- Institute of Psychiatry and Neuroscience of Paris (IPNP), INSERM U1266, 1 rue Cabanis, 75014 Paris, France
- Department of Psychiatry and Addictology, AP-HP, Centre-Université Paris Cité, University Hospital Louis Mourier, 178 Rue des Renouillers, 92700 Colombes, France
| | - Joane Matta
- INSERM UMS011, Population-based Epidemiological Cohorts, Hôpital Paul Brousse Bât. 15/16, 16 avenue Paul Vaillant-Couturier, 94807 Villejuif Cedex, France
| | - Anais Charles-Nelson
- INSERM, Centre d'Investigation Clinique 1418 Épidémiologie Clinique, AP-HP, Hôpital Européen Georges-Pompidou, Unité de Recherche Clinique, 20 rue Leblanc, 75015 Paris, France
| | - Frédéric Limosin
- Department of Psychiatry and Addictology, AP-HP, Centre-Université Paris Cité, 20 rue Leblanc, 75015 Paris, France
- Faculté de Santé, UFR de Médecine, Université Paris Cité, 15 Rue de l'École de Médecine, 75006 Paris, France
- Institute of Psychiatry and Neuroscience of Paris (IPNP), INSERM U1266, 1 rue Cabanis, 75014 Paris, France
| |
Collapse
|
3
|
Addiction Services for Veterans: Opportunities in Acute Care. J Addict Med 2023; 17:42-46. [PMID: 35914119 DOI: 10.1097/adm.0000000000001026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This study aimed to estimate the proportion of total hospital discharges that involved a primary or secondary substance-related diagnosis code (SubDx) on inpatient medicine, psychiatry, and surgery services as part of a needs assessment for inpatient addiction consultation at our large, academic-affiliated Veterans Affairs (VA) hospital. METHODS We first calculated the percentage of total and service-specific discharges with a primary or secondary substance-related International Classification of Disease, Tenth Revision , code on all inpatient services (medicine, psychiatry, and surgery) in Fiscal Year 2017, 2018, and 2019, using facility-level data. Second, we calculated the proportion of total discharges that involved alcohol- and opioid-related diagnoses. RESULTS Over the 3 years studied, 29% of total discharges had a SubDx (4469 of 15,575). The proportion of total discharges that involved a SubDx was 23% (1246 of 5449) in 2017, 31% (1664 of 5332) in 2018, and 33% in 2019 (1559 of 4794), a statistically significant increase ( P < 0.001). As a percentage of service-specific discharges, 65% of discharges from psychiatry (1446 of 2217) had a SubDx, compared with 25% from medicine (2469 of 9713), and 15% from surgery (554 of 3645). Medicine services had the most discharges with SubDx, with a year-over-year increase in the number of discharges with SubDx. The percentage of total discharges that involved alcohol- and opioid-related diagnoses was 14% and 4%, respectively. CONCLUSIONS Substance-related diagnoses are prevalent at our hospital and are increasing over time. The largest number of discharges with SubDx was found on medicine services. Alcohol-related diagnoses were nearly 4 times more prevalent than opioid-related diagnoses. We found focused need around alcohol use and alcohol withdrawal.
Collapse
|
4
|
Seshadri A, Appelbaum R, Carmichael SP, Farrell MS, Filiberto DM, Jawa R, Kodadek L, Mandell S, Miles MVP, Paul J, Robinson B, Michetti CP. Prevention of alcohol withdrawal syndrome in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open 2022; 7:e001010. [PMCID: PMC9680182 DOI: 10.1136/tsaco-2022-001010] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/02/2022] [Indexed: 11/23/2022] Open
Abstract
Alcohol withdrawal syndrome is a common and challenging clinical entity present in trauma and surgical intensive care unit (ICU) patients. The screening tools, assessment strategies, and pharmacological methods for preventing alcohol withdrawal have significantly changed during the past 20 years. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews the best practices for screening, monitoring, and prophylactic treatment of alcohol withdrawal in the surgical ICU.
Collapse
Affiliation(s)
- Anupamaa Seshadri
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rachel Appelbaum
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Samuel P Carmichael
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | | | - Dina M Filiberto
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Randeep Jawa
- Department of Surgery, Stony Brook University, Stony Brook, New York, USA
| | - Lisa Kodadek
- Surgery, Yale University School of Medicine, New Haven, Connecticut, USA,Department of Surgery, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Samuel Mandell
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - M Victoria P Miles
- College of Medicine Chattanooga, The University of Tennessee Health Science Center, Chattanooga, Tennessee, USA
| | - Jasmeet Paul
- Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Bryce Robinson
- Department of Surgery, Harborview Medical Center, Seattle, Washington, USA
| | | |
Collapse
|