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Contemporary Management and Outcomes of Veterans Hospitalized With Alcohol Withdrawal: A Multicenter Retrospective
Matthew V Ronan1, Kirsha S Gordon, Melissa Skanderson
1From 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).
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.
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