Treatment of opioid and alcohol withdrawal in a cohort of emergency department patients

Mahmoud, S. A.; Anderson, Eric G.; Vosooghi, Aidan; Herring, Andrew A.

doi:10.1016/j.ajem.2020.12.074

Cited by 6 publications

(8 citation statements)

References 7 publications

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“…In a retrospective cohort study of ED presentations ( n = 16) receiving treatment for both opioids (treated with buprenorphine) and alcohol (treated with either lorazepam or phenobarbital) withdrawal, Mahmoud et al 36 found no significant differences in rates of hospital/ICU admission or duration of hospital/ED stay. In this study, only 10 patients were given intravenous (IV) phenobarbital in conjunction with buprenorphine and/or lorazepam at doses for phenobarbital ranging from 260 to 1040 mg.…”

Section: Resultsmentioning

confidence: 99%

“…There was also evidence that combined treatment with phenobarbital and benzodiazepines lowered the likelihood of returning to the ED within 3 days but also lowered the total amount of benzodiazepines required during AWS management 33 . Limited adverse events were reported, but one study on concurrent AWS and opioid withdrawal reported a serious adverse event in which one patient receiving buprenorphine and lorazepam required intubation within 30 min of buprenorphine administration 36 …”

Section: Resultsmentioning

confidence: 99%

“…33 Limited adverse events were reported, but one study on concurrent AWS and opioid withdrawal reported a serious adverse event in which one patient receiving buprenorphine and lorazepam required intubation within 30 min of buprenorphine administration. 36 Sullivan et al 34 For return ED visits within 3 days, the benzodiazepine group had the highest percentage at 25%, whereas the phenobarbital and combination groups had return rates of 13% and 10%, respectively. A similar pattern was present for ED visits within 7 days.…”

Section: Findings From Retrospective Cohort Studiesmentioning

confidence: 99%

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SAEM GRACE: Phenobarbital for alcohol withdrawal management in the emergency department: A systematic review of direct evidence

Punia,

Scott,

Manuja

et al. 2023

Academic Emergency Medicine

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ObjectivesAlcohol withdrawal syndrome (AWS) is a commonly presenting condition in the emergency department (ED) and can have severe complications, including mortality. Benzodiazepines are first‐line medications for treating AWS, but may be unavailable or insufficient. This systematic review evaluates the direct evidence assessing the utility of phenobarbital for treating AWS in the ED.MethodsA systematic search was conducted and designed according to the patient‐intervention‐control‐outcome (PICO) question: (P) Adults (≥18 years old) presenting to the ED with alcohol withdrawal; (I) Phenobarbital (including adjunctive); (C) Benzodiazepines or no intervention; (O) AWS complications, admission to a monitored setting, control of symptoms, adverse effects, and adjunctive medications. Two reviewers independently assessed articles for inclusion and conducted risk of bias assessments for included studies.ResultsFrom 70 potentially relevant articles, seven studies met inclusion criteria: (three retrospective cohort studies, two retrospective chart reviews, and two randomized controlled trials [RCTs], one examining phenobarbital monotherapy and one examining adjunctive phenobarbital). Across the retrospective cohort studies, treatment of AWS with phenobarbital resulted in lower odds of a subsequent ED visit. The retrospective chart reviews indicated that phenobarbital was associated with higher discharge rate compared to benzodiazepine‐only treatments. For the two RCTs, phenobarbital did not differ significantly from benzodiazepine for most outcomes, although concomitant treatment with phenobarbital was associated with lower benzodiazepine use and intensive care unit admission. The heterogeneous designs and small number of studies prevented quantitative synthesis.ConclusionsRelatively few studies provide direct evidence on the utility of phenobarbital for AWS in the ED, but the evidence that exists generally suggests that it is a reasonable and appropriate approach. Additional RCTs and other methodologically rigorous investigations are needed for more definitive direct evidence.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Findings From Retrospective Cohort Studiesmentioning

confidence: 99%

See 1 more Smart Citation

SAEM GRACE: Phenobarbital for alcohol withdrawal management in the emergency department: A systematic review of direct evidence

Punia,

Scott,

Manuja

et al. 2023

Academic Emergency Medicine

View full text Add to dashboard Cite

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“…The most common contraindication was recent methadone use, likely due to the risk of BUP‐precipitated withdrawal 3,24 . Other listed contraindications, such as alcohol and/or benzodiazepine withdrawal or use, may be viewed as complicating factors of withdrawal or a misunderstanding of risk 36 . Although SAMHSA listed BUP allergy as its only contraindication, only 4 sites did so in their protocols 24…”

Section: Discussionmentioning

confidence: 99%

“…3,24 Other listed contraindications, such as alcohol and/or benzodiazepine withdrawal or use, may be viewed as complicating factors of withdrawal or a misunderstanding of risk. 36 Although SAMHSA listed BUP allergy as its only contraindication, only 4 sites did so in their protocols. 24 Pregnancy was not a contraindication to ED-initiated BUP in any protocol; however, pregnancy was mentioned in most protocols as a special consideration or as a required lab test before initiation, likely because of prior recommendations to use BUP monotherapy in pregnancy to avoid prenatal exposure to naloxone and to provide appropriate, rapid follow-up.…”

Section: Identification Of Treatment-eligible Patientsmentioning

confidence: 99%

Emergency department‐initiated buprenorphine protocols: A national evaluation

et al. 2021

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Objective Emergency department‐initiated buprenorphine (BUP) for opioid use disorder is an evidence‐based practice, but limited data exist on BUP initiation practices in real‐world settings. We sought to characterize protocols for BUP initiation among a geographically diverse sample of emergency departments (EDs). Methods In December 2020, we reviewed prestudy clinical BUP initiation protocols from all EDs participating in CTN0099 Emergency Department‐INitiated bupreNOrphine VAlidaTION (ED‐INNOVATION). We abstracted information on processes for identification of treatment‐eligible patients, BUP administration, and discharge care. Results All participating ED‐INNOVATION sites across 22 states submitted protocols; 31 protocols were analyzed. Identification of treatment‐eligible patients : Most EDs 22 (71%) relied on clinician judgment to determine appropriateness of BUP treatment with only 7 (23%) requiring decision support tools or diagnosis checklists. Before BUP initiation, 27 (87%) protocols required a documented Clinical Opiate Withdrawal Scale (COWS) score; 4 (13%) required a clinical diagnosis of withdrawal with optional COWS score. Twenty‐seven (87%) recommended a minimum COWS score of 8 for ED‐initiated BUP. BUP administration : Initial BUP dose ranged from 2–16 mg (mode = 4). For continued withdrawal symptoms, 27 (87%) protocols recommended an interval of 30–60 minutes between first and second BUP dose. Total BUP dose in the ED ranged from 8 to 32 mg. Discharge care : Twenty‐eight (90%) protocols recommended a BUP prescription (mode 16 mg daily) at discharge. Naloxone prescription and/or provision was suggested in 23 (74%) protocols. Conclusions In this geographically diverse sample of EDs, protocols for ED‐initiated BUP differed between sites. Future work should evaluate the association between this variation and patient outcomes.

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A Brief Educational Intervention to Increase ED Initiation of Buprenorphine for Opioid Use Disorder (OUD)

et al. 2022

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Background Despite the evidence in support of the use of buprenorphine in the treatment of OUD and increasing ability of emergency medicine (EM) clinicians to prescribe it, emergency department (ED)-initiated buprenorphine is uncommon. Many EM clinicians lack training on how to manage acute opioid withdrawal or initiate treatment with buprenorphine. We developed a brief buprenorphine training program and assessed the impact of the training on subsequent buprenorphine initiation and knowledge retention. Methods We conducted a pilot randomized control trial enrolling EM clinicians to receive either a 30-min didactic intervention about buprenorphine (standard arm) or the didactic plus weekly messaging and a monetary inducement to administer and report buprenorphine use (enhanced arm). All participants were incentivized to complete baseline, immediate post-didactic, and 90-day knowledge and attitude assessment surveys. Our objective was to achieve first time ED buprenorphine prescribing events in clinicians who had not previously prescribed buprenorphine in the ED and to improve EM-clinician knowledge and perceptions about ED-initiated buprenorphine. We also assessed whether the incentives and reminder messaging in the enhanced arm led to more clinicians administering buprenorphine than those in the standard arm following the training; we measured changes in knowledge of and attitudes toward ED-initiated buprenorphine. Results Of 104 EM clinicians enrolled, 51 were randomized to the standard arm and 53 to the enhanced arm. Clinical knowledge about buprenorphine improved for all clinicians immediately after the didactic intervention (difference 19.4%, 95% CI 14.4% to 24.5%). In the 90 days following the intervention, one-third (33%) of all participants reported administering buprenorphine for the first time. Clinicians administered buprenorphine more frequently in the enhanced arm compared to the standard arm (40% vs. 26.3%, p = 0.319), but the difference was not statistically significant. The post-session knowledge improvement was not sustained at 90 days in the enhanced (difference 9.6%, 95% CI − 0.37% to 19.5%) or in the standard arm (difference 3.7%, 95% CI − 5.8% to 13.2%). All the participants reported an increased ability to recognize patients with opioid withdrawal at 90 days (enhanced arm difference .55, 95% CI .01–1.09, standard arm difference .85 95% CI .34–1.37). Conclusions A brief educational intervention targeting EM clinicians can be utilized to achieve first-time prescribing and improve knowledge around buprenorphine and opioid withdrawal. The use of weekly messaging and gain-framed incentivization conferred no additional benefit to the educational intervention alone. In order to further expand evidence-based ED treatment of OUD, focused initiatives that improve clinician competence with buprenorphine should be explored. Trial Registration Clin...

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Treatment of opioid and alcohol withdrawal in a cohort of emergency department patients

Cited by 6 publications

References 7 publications

SAEM GRACE: Phenobarbital for alcohol withdrawal management in the emergency department: A systematic review of direct evidence

SAEM GRACE: Phenobarbital for alcohol withdrawal management in the emergency department: A systematic review of direct evidence

Emergency department‐initiated buprenorphine protocols: A national evaluation

A Brief Educational Intervention to Increase ED Initiation of Buprenorphine for Opioid Use Disorder (OUD)

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