Pharmacologic Treatment of Alcohol Withdrawal

To the Editor.  —In their meta-analysis, Dr Mayo-Smith and colleagues¹ stated that alcohol withdrawal occurred in a wide variety of settings but did not comment on the appropriateness of their suggested guidelines for outpatients vs inpatients. The authors noted that the Clinical Institute Withdrawal Assessment, Alcohol (CIWA-A)² and the CIWA-A, revised (CIWA-Ar)³ had been used for patients admitted to the hospital (detoxification units, psychiatry units, and general hospital medical/surgical wards), but they did not specify whether these structured assessment scales had been used or were applicable to outpatient settings. Three of the 10 questions on the CIWA-A scale pertain to tactile, auditory, and visual hallucinations,² symptoms that often merit observation in inpatient rather than outpatient settings.⁴ Thus, these scales might be more applicable to inpatient settings.Symptom-triggered detoxification also might require modification for outpatients. In an outpatient setting, patients might not be assessed for symptoms of withdrawal as