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August 17, 1994, Vol 272, No. 7 >
ARTICLE | August 17, 1994

Individualized Treatment for Alcohol Withdrawal: Title and subTitle BreakA Randomized Double-blind Controlled Trial FREE

Richard Saitz, MD, MPH; Michael F. Mayo-Smith, MD, MPH; Mark S. Roberts, MD, MPP; Harriet A. Redmond, MS, ARNP, CARN; Donald R. Bernard, MD; David R. Calkins, MD, MPP
[+] Author Affiliations

Reprint requests to Research Unit, Section of General Internal Medicine, Talbot Bldg, Room 325, Boston City Hospital/Boston University Medical Center, 82 E Concord St, Boston, MA 02118 (Dr Saitz).


JAMA. 1994;272(7):519-523. doi:10.1001/jama.1994.03520070039035
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References

Objective.  —To assess the effect of an individualized treatment regimen on the intensity and duration of medication treatment for alcohol withdrawal.

Design.  —A randomized double-blind, controlled trial.

Setting.  —An inpatient detoxification unit in a Veterans Affairs medical center.

Patients.  —One hundred one patients admitted for the treatment of alcohol withdrawal who could give informed consent and had no history of seizures or medication use that might alter the clinical course of withdrawal.

Intervention.  —Patients were randomized to either a standard course of chlordiazepoxide four times daily with additional medication as needed (fixed-schedule therapy) or to a treatment regimen that provided chlordiazepoxide only in response to the development of the signs and symptoms of alcohol withdrawal (symptomtriggered therapy). The need for administration of "as-needed" medication was determined using a validated measure of the severity of alcohol withdrawal.

Main Outcome Measures.  —Duration of medication treatment and total chlordiazepoxide administered.

Results.  —The median duration of treatment in the symptom-triggered group was 9 hours compared with 68 hours in the fixed-schedule group (P<.001). The symptom-triggered group received 100 mg of chlordiazepoxide, and the fixed-schedule group received 425 mg (P<.001). There were no significant differences in the severity of withdrawal during treatment or in the incidence of seizures or delirium tremens.

Conclusions.  —Symptom-triggered therapy individualizes treatment, decreases both treatment duration and the amount of benzodiazepine used, and is as efficacious as standard fixed-schedule therapy for alcohol withdrawal.(JAMA. 1994;272:519-523)

REFERENCES

1 +
Turner RC, Lichstein PR, Peden JG Jr, Busher JT, Waivers LE.  Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation, and treatment. J Gen Intern Med . 1989;;4:432-444.
2 +
Victor M, Adams RD.  The effect of alcohol on the nervous system. Res Publ Assoc Res Nerv Ment Dis . 1953;;32:526-573.
3 +
Kaim SC, Klett CJ, Rothfeld B.  Treatment of the acute alcohol withdrawal state: a comparison of four drugs. Am J Psychiatry . 1969;;125:1640-1646.
4 +
Whitfield CL, Thompson G, Lamb A, Spencer V, Pfeifer M, Browning-Ferrando M.  Detoxification of 1024 alcoholic patients without psychoactive drugs. JAMA . 1978;;239:1409-1410.
5 +
National Institute on Alcohol Abuse and Alcoholism. Seventh Special Report to the US Congress on Alcohol and Health . Rockville, Md: National Institute on Alcohol Abuse and Alcoholism; 1990;:266.
6 +
Greenblatt DJ, Shader RI, Abernethy DR.  Current status of benzodiazepines. N Engl J Med . 1983;; 309:410-416.
7 +
Institute of Medicine. Prevention and Treatment of Alcohol Problems . Washington, DC: National Academy Press; 1990;:268-269.
8 +
Wyngaarden JB, Smith LH Jr, Bennett JC, eds. Cecil Textbook of Medicine . 18th ed. Philadelphia, Pa: WB Saunders Co; 1988;:46-47.
9 +
Wilson JD, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine . 12th ed. New York, NY: McGraw-Hill International Book Co; 1991;:2150.
10 +
Saitz R, Mayo-Smith MF, Friedman LS, Calkins DR.  Nationwide practice patterns in the treatment of alcohol withdrawal. Clin Res . 1993;;41:549A. Abstract.
11 +
Baumgartner GR, Rowen RC.  Clonidine vs chlordiazepoxide in the management of acute alcohol withdrawal syndrome. Arch Intern Med . 1987;;147: 1223-1226.
12 +
Baumgartner GR, Rowen RC.  Transdermal clonidine versus chlordiazepoxide in alcohol withdrawal: a randomized, controlled clinical trial. South Med J . 1991;;84:312-321.
13 +
Malcolm R, Ballenger JC, Sturgis ET, Anton R.  Double-blind controlled trial comparing carbamazepine to oxazepam treatment of alcohol withdrawal. Am J Psychiatry . 1989;;146:617-621.
14 +
Naranjo CA, Sellers EM, Chater K, Iversen P, Roach C, Sykora K.  Nonpharmacologic intervention in acute alcohol withdrawal. Clin Pharmacol Ther . 1983;;34:214-219.
15 +
Shaw JM, Kolesar GS, Sellers EM, Kaplan HL, Sandor P.  Development of optimal treatment tactics for alcohol withdrawal, I: assessment and effectiveness of supportive care. J Clin Psychopharmacol . 1981;;1:382-389.
16 +
Sullivan JT, Swift RM, Lewis DC.  Benzodiazepine requirements during alcohol withdrawal syndrome: clinical implications of using a standardized withdrawal scale. J Clin Psychopharmacol . 1991;; 11:291-295.
17 +
Wartenberg AA, Nirenberg TD, Liepman MR, Silvia LY, Begin AM, Monti PM.  Detoxification of alcoholics: improving care by symptom-triggered sedation. Alcohol Clin Exp Res . 1990;;14:71-75.
18 +
American Psychiatric Association, Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition . Washington, DC: American Psychiatric Association; 1987;:130.
19 +
Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM.  Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). Br J Addict . 1989;;84:1353-1357.
20 +
Sellers EM, Sullivan JT, Somer G, Sykora K.  Characterization of DSM-III-R criteria for uncomplicated alcohol withdrawal provides an empirical basis for DSM-IV. Arch Gen Psychiatry . 1991;;48: 442-447.
21 +
Stinnett JL, Schechter JO.  A Quantitative Inventory of Alcohol Disorders (QIAD): a severity scale for alcohol abuse. Am J Drug Alcohol Abuse . 1982-1983;;9:413-430.
22 +
Selzer ML, Vinokur A, van Rooijen L.  A self-administered Short Michigan Alcoholism Screening Test (SMAST). J Stud Alcohol . 1975;;36:117-126.
23 +
SAS Institute Inc. SAS/STAT User's Guide, Version 6 . 4th ed. Cary, NC: SAS Institute; 1989;.
24 +
Wilford BB. Syllabus for the Review Course in Addiction Medicine . Washington, DC: American Society of Addiction Medicine; 1990;:182-185.
25 +
Foy A, March S, Drinkwater V.  Use of an objective clinical scale in the assessment and management of alcohol withdrawal in a large general hospital. Alcohol Clin Exp Res . 1988;;12:360-364.

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1 +
Turner RC, Lichstein PR, Peden JG Jr, Busher JT, Waivers LE.  Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation, and treatment. J Gen Intern Med . 1989;;4:432-444.
2 +
Victor M, Adams RD.  The effect of alcohol on the nervous system. Res Publ Assoc Res Nerv Ment Dis . 1953;;32:526-573.
3 +
Kaim SC, Klett CJ, Rothfeld B.  Treatment of the acute alcohol withdrawal state: a comparison of four drugs. Am J Psychiatry . 1969;;125:1640-1646.
4 +
Whitfield CL, Thompson G, Lamb A, Spencer V, Pfeifer M, Browning-Ferrando M.  Detoxification of 1024 alcoholic patients without psychoactive drugs. JAMA . 1978;;239:1409-1410.
5 +
National Institute on Alcohol Abuse and Alcoholism. Seventh Special Report to the US Congress on Alcohol and Health . Rockville, Md: National Institute on Alcohol Abuse and Alcoholism; 1990;:266.
6 +
Greenblatt DJ, Shader RI, Abernethy DR.  Current status of benzodiazepines. N Engl J Med . 1983;; 309:410-416.
7 +
Institute of Medicine. Prevention and Treatment of Alcohol Problems . Washington, DC: National Academy Press; 1990;:268-269.
8 +
Wyngaarden JB, Smith LH Jr, Bennett JC, eds. Cecil Textbook of Medicine . 18th ed. Philadelphia, Pa: WB Saunders Co; 1988;:46-47.
9 +
Wilson JD, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine . 12th ed. New York, NY: McGraw-Hill International Book Co; 1991;:2150.
10 +
Saitz R, Mayo-Smith MF, Friedman LS, Calkins DR.  Nationwide practice patterns in the treatment of alcohol withdrawal. Clin Res . 1993;;41:549A. Abstract.
11 +
Baumgartner GR, Rowen RC.  Clonidine vs chlordiazepoxide in the management of acute alcohol withdrawal syndrome. Arch Intern Med . 1987;;147: 1223-1226.
12 +
Baumgartner GR, Rowen RC.  Transdermal clonidine versus chlordiazepoxide in alcohol withdrawal: a randomized, controlled clinical trial. South Med J . 1991;;84:312-321.
13 +
Malcolm R, Ballenger JC, Sturgis ET, Anton R.  Double-blind controlled trial comparing carbamazepine to oxazepam treatment of alcohol withdrawal. Am J Psychiatry . 1989;;146:617-621.
14 +
Naranjo CA, Sellers EM, Chater K, Iversen P, Roach C, Sykora K.  Nonpharmacologic intervention in acute alcohol withdrawal. Clin Pharmacol Ther . 1983;;34:214-219.
15 +
Shaw JM, Kolesar GS, Sellers EM, Kaplan HL, Sandor P.  Development of optimal treatment tactics for alcohol withdrawal, I: assessment and effectiveness of supportive care. J Clin Psychopharmacol . 1981;;1:382-389.
16 +
Sullivan JT, Swift RM, Lewis DC.  Benzodiazepine requirements during alcohol withdrawal syndrome: clinical implications of using a standardized withdrawal scale. J Clin Psychopharmacol . 1991;; 11:291-295.
17 +
Wartenberg AA, Nirenberg TD, Liepman MR, Silvia LY, Begin AM, Monti PM.  Detoxification of alcoholics: improving care by symptom-triggered sedation. Alcohol Clin Exp Res . 1990;;14:71-75.
18 +
American Psychiatric Association, Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition . Washington, DC: American Psychiatric Association; 1987;:130.
19 +
Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM.  Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). Br J Addict . 1989;;84:1353-1357.
20 +
Sellers EM, Sullivan JT, Somer G, Sykora K.  Characterization of DSM-III-R criteria for uncomplicated alcohol withdrawal provides an empirical basis for DSM-IV. Arch Gen Psychiatry . 1991;;48: 442-447.
21 +
Stinnett JL, Schechter JO.  A Quantitative Inventory of Alcohol Disorders (QIAD): a severity scale for alcohol abuse. Am J Drug Alcohol Abuse . 1982-1983;;9:413-430.
22 +
Selzer ML, Vinokur A, van Rooijen L.  A self-administered Short Michigan Alcoholism Screening Test (SMAST). J Stud Alcohol . 1975;;36:117-126.
23 +
SAS Institute Inc. SAS/STAT User's Guide, Version 6 . 4th ed. Cary, NC: SAS Institute; 1989;.
24 +
Wilford BB. Syllabus for the Review Course in Addiction Medicine . Washington, DC: American Society of Addiction Medicine; 1990;:182-185.
25 +
Foy A, March S, Drinkwater V.  Use of an objective clinical scale in the assessment and management of alcohol withdrawal in a large general hospital. Alcohol Clin Exp Res . 1988;;12:360-364.

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