Symptom-Triggered Detoxification Using the Alcohol-Withdrawal-Scale Reduces Risks and Healthcare Costs.

AIMS: As there are only a few existing experimental studies on symptom-triggered therapy for patients with alcohol withdrawal, we investigated the effectiveness of symptom-triggered detoxification regarding the use and dosage of benzodiazepine and withdrawal complications in a naturalistic clinical setting of a specialized treatment center for alcohol use disorder. METHODS: In total, 301 charts of patients who entered residential treatment for alcohol withdrawal were included in the retrospective analysis. Charts of 176 patients treated with the Alcohol Withdrawal-Scale (AWS) were compared to the charts of 125 patients treated with treatment as usual (TAU) before the implementation of AWS. Sociodemographical and clinical variables, previous detoxifications and complications, duration of treatment, use and dose of benzodiazepine and other withdrawal medication, complications and premature discontinuation of treatment were abstracted from the patients' medical records. RESULTS: The two groups did not differ in any demographical or clinical variables measured upon treatment admission. The total percentage of patients being treated with benzodiazepines during detoxification decreased from 78.4 to 38.6% after the implementation of the AWS. The implementation of the AWS significantly reduced the duration of the acute detoxification from 136 to 66 h, and the use, duration and dose of benzodiazepine by nearly two-thirds while complications and treatment discontinuation remained unvaryingly. Healthcare costs for detoxification were reduced by half per patient. CONCLUSIONS: The findings indicate that symptom-triggered treatment for alcohol withdrawal is safe and effective in a naturalistic clinical setting and significantly reduces healthcare costs and the risk for overmedicating patients.

The effect of alcohol abuse and alcohol withdrawal on short-term outcomes and cost of care after head and neck cancer surgery.

OBJECTIVES/HYPOTHESIS: Alcohol abuse is associated with an increased incidence of postoperative complications in surgical patients and is a significant risk factor for the development of head and neck cancer (HNCA). We sought to determine the relationship between alcohol abuse and in-hospital mortality, postoperative complications, length of stay, and costs in HNCA surgery. STUDY DESIGN: Retrospective cross-sectional study. METHODS: Discharge data from the Nationwide Inpatient Sample for 92,312 patients aged 18 years and older who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm in 2003 to 2008, were analyzed using cross-tabulations and multivariate regression modeling. RESULTS: Patients who abused alcohol were more likely to have advanced comorbidity, undergo major surgical procedures, and require medical care at another facility or home healthcare after discharge. The development of alcohol withdrawal symptoms (AWS) was associated with an increased incidence of acute medical complications (odds ratio [OR]: 5.6, P < .001) and surgical complications (OR: 2.3, P < .001). After controlling for all other variables, there was no significant association of alcohol abuse or AWS with in-hospital mortality; however, alcohol abuse and AWS were associated with significantly increased length of hospitalization and hospital-related costs, with AWS having the single largest impact on length of stay and costs. CONCLUSIONS: Alcohol withdrawal is associated with an increase in postoperative medical and surgical complications, length of hospitalization, and hospital-related costs in HNCA surgical patients. Aggressive measures to prevent the development of AWS in patients who abuse alcohol are warranted.

Management of alcohol withdrawal delirium. An evidence-based practice guideline.

BACKGROUND: Alcohol withdrawal delirium is the most serious manifestation of alcohol withdrawal. Evidence suggests that appropriate care improves mortality, but systematic reviews are unavailable. METHODS: Articles with original data on management of alcohol withdrawal delirium underwent structured review and meta-analysis. RESULTS: Meta-analysis of 9 prospective controlled trials demonstrated that sedative-hypnotic agents are more effective than neuroleptic agents in reducing duration of delirium and mortality, with a relative risk of death when using neuroleptic agents of 6.6. Statistically significant differences among various benzodiazepines and barbiturates were not found. No deaths were reported in 217 patients from trials using benzodiazepines or barbiturates. CONCLUSIONS: Control of agitation should be achieved using parenteral rapid-acting sedative-hypnotic agents that are cross-tolerant with alcohol. Adequate doses should be used to maintain light somnolence for the duration of delirium. Coupled with comprehensive supportive medical care, this approach is highly effective in preventing morbidity and mortality.

[Adjuvant therapy with parenteral piracetam in alcohol withdrawal delirium]. / Piracetam infúziós alkalmazása adjuváns kezelésként alkoholmegvonásos delirium kezelésében.

The author reports his results of parenteral piracetam treatment in 193 patients admitted to the Psychiatric Department of Semmelweis Hospital with alcohol withdrawal delirium. Alcohol withdrawal delirium is a complex metabolic disorder, the disturbance of the highest cerebral integrative functions, which is caused by the impairment of cerebral oxidative metabolism. Piracetam is effective on most neurotransmitter systems, without a specific receptor agonism or antagonism, increases the effectivity of different biogenic amine systems, has also an effect on membrane permeability, increases the concentration of NMDA (methyl-D-aspartate) receptors in the impaired brain and improves cognitive functions. In the patients suffered from alcohol dependence piracetam produces positive morphologic changes, by decreasing lipofuscin accumulation. In early stage it prevents the development of delirium. Despite of the great number (approximately 150) of medication that were tried in the treatment of delirium, the ideal one still has not been found. Among the accessible therapeutic possibilities the author searched for methods which make the treatment more effective. The administration of parental piracetam, therefore was brought into his therapeutical protocol. Parenteral piracetam--similarly to literature data--proved to be effective in the treatment of alcohol withdrawal delirium. Considering the present--insufficient--hospital financing, it is remarkable that though the costs of the new therapy are higher than the traditional meprobamat therapy, through less side effect it is more economical (overall costs lower) and by decreasing the time of delirium it is more humane to the patients.

The alcohol hangover.

PURPOSE: To review the cause, pathophysiologic characteristics, cost, and treatment of alcohol-induced hangover. DATA SOURCES: A MEDLINE search of English-language reports (1966 to 1999) and a manual search of bibliographies of relevant papers. STUDY SELECTION: Related experimental, clinical, and basic research studies. DATA EXTRACTION: Data in relevant articles were reviewed, and relevant clinical information was extracted. DATA SYNTHESIS: The alcohol hangover is characterized by headache, tremulousness, nausea, diarrhea, and fatigue combined with decreased occupational, cognitive, or visual-spatial skill performance. In the United States, related absenteeism and poor job performance cost $148 billion annually (average annual cost per working adult, $2000). Although hangover is associated with alcoholism, most of its cost is incurred by the light-to-moderate drinker. Patients with hangover may pose substantial risk to themselves and others despite having a normal blood alcohol level. Hangover may also be an independent risk factor for cardiac death. Symptoms of hangover seem to be caused by dehydration, hormonal alterations, dysregulated cytokine pathways, and toxic effects of alcohol. Physiologic characteristics include increased cardiac work with normal peripheral resistance, diffuse slowing on electroencephalography, and increased levels of antidiuretic hormone. Effective interventions include rehydration, prostaglandin inhibitors, and vitamin B6. Screening for hangover severity and frequency may help early detection of alcohol dependency and substantially improve quality of life. Recommended interventions include discussion of potential therapies and reminders of the possibility for cognitive and visual-spatial impairment. No evidence suggests that alleviation of hangover symptoms leads to further alcohol consumption, and the discomfort caused by such symptoms may do so. Therefore, treatment seems warranted. CONCLUSIONS: Hangover, a common disorder, has substantial morbidity and societal cost. Appropriate management may relieve symptoms in many patients.

Prolonged delirium tremens requiring massive doses of medication.

Delirium tremens might last for weeks and treatment requires massive benzodiazepine doses, yet it is possible to manage patients with this condition successfully. In this case of delirium tremens, standard agents at the usual recommended doses were not sufficient to achieve control of confusion and agitation or to stabilize neurologic and cardiovascular parameters. The patient required extraordinarily high doses of central nervous system depressants for an extended period. Midazolam, a short-acting benzodiazepine, was used but was associated with metabolic acidosis and was extremely expensive. Although high-dose midazolam should probably be avoided, extremely high dose benzodiazepine use for an extended period might be necessary in some cases. In this circumstance we advise diazepam because of its low cost and relative safety. The tendencies to withhold large doses for fear of side effects or to give up in cases requiring prolonged intensive support must be resisted to minimize the mortality from this severe illness.