- Design
- Multiple-methods study: surveys and focus groups
- Population
- 33 hospitalists from 27 US tertiary hospitals
- Primary outcome
- Reported treatment practices and decision-making for alcohol withdrawal
- Effect
- Phenobarbital used in 67% of emergency departments and 44% of medical units
Thirty-three hospitalists from 27 US tertiary hospitals took part in surveys and focus groups on how they treat moderate to severe alcohol withdrawal. Benzodiazepines remained the commonest choice, but phenobarbital was reported in use in two thirds of their emergency departments and in 44% of inpatient medical units.
The hospitalists described choosing treatment by local habit, drug shortages and logistics such as nursing workload and monitoring, rather than by evidence, and said patients were rarely involved in the choice.
This is a small qualitative study and says nothing about which drug is better. Its value is in naming the problem: a sedative-hypnotic with a long half-life and a narrow margin is being adopted unevenly. Any ward using phenobarbital needs a written protocol covering dosing by weight, contraindications, respiratory monitoring and who can prescribe it.
- Use a written protocol for alcohol withdrawal on your unit, whichever drug it specifies.
- Check for hepatic impairment, respiratory disease and concurrent sedatives before choosing phenobarbital.
- Plan monitoring for oversedation for longer with phenobarbital, given its long half-life.
- Give thiamine to every patient treated for alcohol withdrawal.
Why it matters
Practice has moved faster than evidence, leaving each hospital to decide alone.
Don't overread it
A focus-group study of 33 hospitalists describes practice; it does not compare drugs.
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