In this report, we present a case series involving four patients placed on the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) protocol for alcohol or sedative-hypnotic withdrawal syndromes, who developed delirium on sustained or increasing symptom-triggered benzodiazepine dosages. In each of the four cases, delirium was not present on admission and resolved in the hospital itself with fixed benzodiazepine tapers. Cases were selected from an electronic medical record database of patients admitted to a United States-based university hospital and placed on CIWA-Ar between 2017 and 2018. This case series illustrates the major limitations of CIWA-Ar including its subjective nature, its susceptibility to inappropriate patient selection, and its requirement for providers to consider alternative etiologies to alcohol and benzodiazepine withdrawal syndromes. These cases demonstrate the necessity of considering other assessment and treatment options such as objective alcohol withdrawal scales, fixed benzodiazepine tapers, and even antiepileptics. An effective systems-based approach to overcoming these challenges may include setting time limits on CIWA-Ar orders within the electronic health record (EHR) system.
Health disparity is defined as a type of health difference that is closely linked with social, economic and/or environmental disadvantage. Over the past two decades, major efforts have been undertaken to mitigate health disparities and promote health equity in the United States. Within pharmacy practice, health disparities have also been identified to play a role in influencing pharmacists' practice across various clinical settings. However, well-characterized solutions to address such disparities, particularly within pharmacy practice, are lacking in the literature. Recognizing that a significant amount of work will be necessary to reduce or eliminate health disparities, the University of California, Irvine (UCI) School of Pharmacy and Pharmaceutical Sciences held a webinar in June 2021 to explore pertinent issues related to this topic. During the session, participants were given the opportunity to propose and discuss innovative solutions to overcome health disparities in pharmacy practice. The goal of this perspective article is to distill the essence of the presentations and discussions from this interactive session, and to synthesize ideas for practical solutions that can be translated to practice to address this public health problem.
Background
Methamphetamine is an addictive stimulant that may induce symptoms of agitation and psychosis. The estimated rate of methamphetamine use is 6.6 per 1000 people. Currently, no treatment guidelines exist to support the optimal management of patients presenting with methamphetamine-induced agitation. Emergency department (ED) providers may prescribe various benzodiazepines (BZDs) and antipsychotics (APs) as first-line agents to stabilize these agitated patients. This study aims to determine the effectiveness of a protocol to guide management of this condition.
Methods
This was a retrospective, pre- and poststudy conducted from July 2020 to March 2021 at a large academic medical center. A multidisciplinary protocol was designed to help manage methamphetamine-induced agitation in the ED. The primary outcome of the study was a reduction in the number of BZDs and APs used for the treatment of methamphetamine-induced agitation. This was measured by the incidence of overprescribing, defined as 3 or more APs or BZDs administered within 30 minutes. Secondary outcomes included the use of physical restraints, ED length of stay, and adverse events.
Results
We did not observe a significantly lower incidence of overprescribing, adverse events, or ED length of stay when comparing pre- and postprotocol groups. A subgroup analysis demonstrated that when protocol was followed, there was a statistically significant reduction in overprescribing (P = .001).
Discussion
We did not find any differences among our primary and secondary outcomes, which may be attributed to protocol nonadherence. Full compliance to the protocol may reduce the rate of overprescribing APs or BZDs in patients with methamphetamine-induced agitation.
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