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Unplanned alcohol withdrawal: a survey of consecutive admissions to an acute medical unit in 2010 and 2011

O.M. Husain, P.S. Lynas, J.P. Totty, K. Williams, W.S. Waring
DOI: http://dx.doi.org/10.1093/qjmed/hcs175 43-49 First published online: 27 September 2012

Abstract

Background: Alcohol-related presentations to hospital have been increasing in the UK in recent years, including the occurrence of acute withdrawal. This study sought to better characterize the clinical features, patterns of treatment and outcomes in this patient group.

Methods: Patients admitted to the Acute Medical Unit of York Hospital due to acute alcohol withdrawal are normally treated according to a protocol that involves both fixed-dose and symptom-triggered drug administration. Admissions between 2010 and 2011 inclusive were studied.

Results: There were 211 admission episodes solely due to acute alcohol withdrawal, involving 127 patients (97 men, 76.4%) with median age of 45 years (interquartile range: 39–52 years). There was a high prevalence of depression (34%), alcoholic liver disease (22%) and drug misuse (12%). Total dose of chlordiazepoxide varied between 0 and 610 mg and tapered rapidly after the first day of admission. Vitamin supplements were administered to >90% of patients, including parenteral and oral in 74%, parenteral alone in 9% and oral alone in 9%. A specialist alcohol nurse reviewed patients while in hospital in 40% of cases. Approximately one-third of patients had multiple admissions for alcohol withdrawal during the study period.

Conclusions: A high prevalence of physical and mental health disorders was observed. The local policy permitted high initial chlordiazepoxide doses and prompt downward titration, with a broad range of doses between individuals. Approximately 10% required no specific therapy, and there may be opportunities for developing alternative pathways for delivery of care in an ambulatory setting for these patients.

Introduction

Alcohol-related problems pose a massive burden on healthcare provision in many countries. For example, in the UK, it is estimated that 18% of adults drink at a hazardous level, and a further 7% have evidence of physical or mental harm.1 Hospital episode statistics indicate that more than 1 million alcohol-related admissions in the UK in 2011, representing a 2-fold increase over the previous decade.2 In 2009, there were 6584 deaths attributable to alcohol in the UK, including 4154 (63%) due to alcoholic liver disease.2 The UK has recorded a 3- to 5-fold increase in deaths due to liver disease over recently years, coupled with increased alcohol consumption that is due, at least in part, to low prevailing prices compared with other European countries.3,4

One of the major causes of alcohol-related hospital admission is the occurrence of acute withdrawal symptoms or their impending onset in patients with a history of moderate-to-severe alcohol dependency.5 Alcohol withdrawal often occurs in an unplanned manner in the context of a sudden crisis, for example, an unexpected change in social or financial circumstances that prevents access to alcohol.6 A small number of patients may consciously plan to stop drinking abruptly. Very few high-quality clinical data are available to inform the optimum pharmacological management of alcohol withdrawal, and, therefore, clinical practice relies upon position statements and guidelines produced by learned bodies and expert consensus panels.7–9 Admission to hospital for medically assisted alcohol withdrawal is advised for patients with, or at risk of developing, alcohol withdrawal seizures or delirium tremens, those younger than16 years or identified as vulnerable.8,10 Hospital admission may also be required to provide urgent care for co-existent medical disorders.

Patients with low and moderate dependency may be considered to have a lower risk of developing complications, and there is no evidence that hospital admission improves clinical outcome. As many as 75% of patients with acute alcohol withdrawal may be managed safely in the community without recourse to hospital admission and is preferred by patients.11–13 Alcohol abstinence rates at 6 months are similar after inpatient and community delivery of care.14 However, rapid access to such a service is very limited in our region at present and highly inconsistent in other parts of the UK.15 There is also pressure to ensure rapid patient turnover within the emergency department. As a result, low-risk patients may also undergo hospital admission in the absence of an alternative pathway, which affords an opportunity for engagement with specialist alcohol services.

Comparatively, few data exist concerning the treatment and clinical outcomes among patients who undergo hospital admission solely to facilitate unplanned alcohol withdrawal. The role of specialist alcohol services is currently being reviewed at our hospital, and this gave us an opportunity to better characterize this patient population. The aim was to examine the presence of comorbidities, prevailing patterns of treatment and contact with the specialist alcohol nurses while in hospital, referral to specialist services after discharge and the occurrence of hospital re-admission.

Methods

York Hospital serves a semi-rural catchment population of approximately 400 000 people. The Acute Medical Unit is a 25-bed facility that receives approximately 1000 patients per month by General Practitioner referrals and the emergency department. An adjacent short-stay ward has 30 beds for patients with an estimated date of discharge ≤72 h.5 Patients admitted due to alcohol withdrawal are often managed solely in these clinical areas and may be transferred to a general ward if co-existing medical disorders require prolonged or specialized treatment. Between 9 am and 5 pm on Monday to Friday, a specialist alcohol nurse provides inpatient clinical review and liaison with community alcohol services.

Alcohol withdrawal treatment

The Clinical Institute Withdrawal Assessment for Alcohol revised (CIWA-Ar) score is a 10-item measure of severity of alcohol withdrawal that permits dose adjustment according to individual patient requirements.16,17 Implementation of a symptom-based chlordiazepoxide regimen is associated with a lower dose requirement and shorter duration of hospital stay than fixed-dose administration.18 The current policy incorporates a standardized hospital proforma and is used across York Hospital that sets out specific criteria for administration of chlordiazepoxide and vitamin supplementation. In brief, patients may receive chlordiazepoxide at regular fixed intervals and symptom-triggered doses according to the CIWA-Ar score. A fixed-dose regimen is used for patients with a history of alcohol withdrawal seizures, history of severe withdrawal symptoms or delirium tremens or an initial CIWA-Ar score >10 (chlordiazepoxide 30 mg four times a day, followed by 20 mg four times a day, then 10 mg four times a day, then 10 mg three times a day and 10 mg twice a day). Additional chlordiazepoxide is available and based on the CIWA-Ar score: score >20 chlordiazepoxide, score 16–20 chlordiazepoxide 30 mg and score 11–15 chlordiazepoxide 20 mg, subject to hourly review. Patients who do not meet the criteria for the fixed-dose regime are treated according to the symptom-based regimen alone. Therefore, patients with only minor symptoms of alcohol withdrawal might not require chlordiazepoxide administration.

The decision to administer oral or parenteral vitamin supplementation is based on the presence of Wernicke–Korsakoff syndrome and whether the patient is deemed at high risk according to specified criteria. Wernicke–Korsakoff syndrome is considered in patients with a history of alcohol excess and ophthalmoplegia, ataxia, encephalopathy or delirium; patients are considered at high risk if there is a history of moderate-to-severe alcohol dependence (severity of alcohol dependence questionnaire score >19) and alcohol-related liver disease, symptoms of acute alcohol withdrawal, clinical impression of malnourishment, anorexia or vomiting, weight loss or hospitalized for acute illness. Patients with suspected Wernicke–Korsakoff syndrome receive regular parenteral vitamin supplementation until cognitive function improves or the diagnosis is excluded, and other patients considered at high risk may receive a single administration of parenteral vitamin supplements followed by oral thiamine. Patients considered at low risk of Wernicke–Korsakoff syndrome may receive oral thiamine alone.

Study protocol

The primary reason for presentation to the Acute Medical Unit is recorded in a ward database. This was examined for referrals between January 2010 and December 2011 inclusive, and the diagnosis of acute alcohol withdrawal was confirmed by examination of the casenotes. A standardized data collection sheet was used to record age, gender, source of referral, prior alcohol consumption, duration of hospital stay, co-existent acute medical problems, background chronic illness, medications prescribed, daily dose of chlordiazepoxide and intravenous thiamine, contact with the specialist alcohol nurse, referral to community alcohol services and re-admission to hospital.

Statistical analyses

Data were presented as median and interquartile range (IQR), or mean and standard deviation, where appropriate, and trend analyses were performed using Cochran–Armitage tests by MedCalc software (version 11.1.1.0; Gent, Belgium).19 P values <0.05 were considered statistically significant. The protocol was considered by the hospital Clinical Effectiveness Team to be a clinical service review, and formal ethical approval was not required.

Results

There were 241 admissions for acute alcohol withdrawal, representing 0.5% of all Acute Medical Unit admissions during the same period. There were 43 patients (33.1%) with repeated admissions due to acute alcohol withdrawal during the study period; the median (IQR) interval between episodes was 69 (36–163) days (Figure 1). In 30 admission episodes, there was a co-existing medical disorder that also necessitated hospital admission: decompensated alcoholic liver disease (22), hematemesis (3), myopathy (2), pancreatitis (2) and paracetamol overdose requiring treatment (1). In the remaining 211 cases, unplanned alcohol withdrawal was the sole medical reason for admission, and these formed the main study population. Recent self-reported alcohol consumption was a median quantity of 48 units per week (IQR: 36–79 units), and the interval between the last drink and admission was 2 (IQR: 1.1–4.3) days. The first recorded CIWA-Ar score was 10 (IQR: 7–12) and highest recorded score was 11 (7–12). The admission episodes involved 127 patients, including 97 men (76.4%), and median age was 45 (IQR: 39–52) years; patient characteristics are outlined in Table 1.

Figure 1

Admission episodes and re-admissions within 2010–2011 involving unplanned acute alcohol withdrawal (n = 241).

View this table:
Table 1

Characteristics of patients admitted due to acute alcohol withdrawal (n = 211)

Characteristicsn (%)
Medical history
    Alcohol dependence163 (77.3)
    Depression71 (33.6)
    Alcoholic liver disease46 (21.8)
    Drug misuse25 (11.8)
    Memory impairment7 (3.3)
    Schizophrenia4 (1.9)
Co-existing acute problems
    Seizure51 (24.2)
    Fall or collapse41 (19.4)
    Acute intoxication34 (16.1)
    Intentional drug overdose19 (9.0)
    Hallucinations15 (7.1)
    Minor hematemesis9 (4.3)
    Generalized abdominal pain3 (1.4)
    Ataxia2 (0.9)
    Anxiety symptoms2 (0.9)

Medication charts were available for review in 204 patient episodes (96.7%), and overall prescribing patterns are summarized in Table 2. Chlordiazepoxide dose was highest on the first day of admission and gradually decreased across successive days (Figure 2). The total chlordiazepoxide dose administered during the admission episode showed a non-Gaussian distribution (Figure 3); median (IQR) dose in men and women was 160 (80–220) and 170 (120–220) mg, respectively (P = 0.728). There were 155 patients (73.5%) that received both parenteral and oral vitamin supplements, 18 (8.5%) parenteral alone, 18 (8.5%) oral alone and 20 (9.5%) that received none. In patients who received intravenous thiamine, the dose was greatest within the first 2 days of admission (Figure 4).

Figure 2

Daily dose in patients treated with oral chlordiazepoxide presented as the mean and standard deviation (n = 177).

Figure 3

Total chlordiazepoxide dose administered presented as a frequency histogram in men (light) and women (dark); patients who absconded or self-discharged before treatment completion were excluded (n = 169).

Figure 4

Daily dose in patients treated with intravenous thiamine presented as the mean and standard deviation number of ampoules (n = 178).

View this table:
Table 2

Summary of medication use in patients admitted due to acute alcohol withdrawal

Medicationn (%)
Parenteral vitamin supplements178 (87.3)
Chlordiazepoxide177 (86.8)
Thiamine176 (86.3)
Vitamin B Co Strong®161 (78.9)
Omeprazole or lansoprazole77 (37.7)
Paracetamol67 (32.8)
Antiemetic47 (23.0)
    Cyclizine (26)
    Metoclopramide (20)
    Domperidone (1)
Antidepressant38 (18.6)
    Citalopram (25)
    Fluoxetine (13)
Antipsychotic16 (7.8)
    Haloperidol (14)
    Olanzapine (1)
    Risperidone (1)
Hypnotic26 (12.7)
    Lorazepam (14)
    Diazepam (11)
    Zopiclone (1)
Acamprosate5 (2.5)
Gabapentin2 (1.0)
  • Complete drug chart is based on review in 204 of 211 patient episodes.

Generalized seizures were reported in 51 patients before admission; there were no further occurrences, and seizures did not emerge in any other patient. None of the patients required admission to a critical care area. Overall median length of hospital stay was 2 (IQR: 1–5) days (Figure 5). The specialist alcohol nurse provided inpatient review in 84 admissions (39.8%); this did not occur during periods when the nurse was unavailable, or if patients declined referral, or if they absconded before review could take place. Outcomes after the acute admission episode are summarized in Table 3.

Figure 5

Duration of hospital stay in patients for whom the sole medical reason for admission was acute alcohol withdrawal (n = 211), presented as the number of days beyond midnight.

View this table:
Table 3

Summary of planned destination after discharge and subsequent arrangements for patient follow-up (n = 211)

n (%)
Destination after discharge
    Home (planned discharge)162 (76.8)
    Home (patient absconded or self-discharged)35 (16.6)
    Temporary social housing11 (5.2)
    Psychiatry institution3 (1.4)
Follow-up after discharge
    Community alcohol services65 (30.8)
    Gastroenterology clinic17 (8.1)
    Community mental health services16 (7.6)
    Outpatient endoscopy2 (0.9)
    Neurology clinic1 (0.5)
    Dietician review1 (0.5)

Discussion

The present findings characterize a cohort of patients who were admitted to hospital due to acute alcohol withdrawal. More than two-thirds had a previously established diagnosis of alcohol dependence, and approximately one-third had multiple hospital admissions for alcohol withdrawal during the 2-year study period. As expected, there was a high prevalence of both physical and mental health disorders, particularly alcoholic liver disease, drug misuse and depression. The majority of patients required only a short course of chlordiazepoxide, and a small number did not require any treatment. This may reflect that some patients had presented late in the course of the withdrawal episode or had only minor withdrawal symptoms.

Benzodiazepines are used primarily to prevent generalized seizures, and administration is normally directed towards the period of greatest risk, namely the first few days after abrupt withdrawal. Treatment may not be needed in regular drinkers that consume fewer than 10–15 units per day or in periodic ‘binge’ drinkers if the last drinking bout was <1 week long.20 The optimum dose and duration vary substantially between individuals, so that a measure of withdrawal severity, such as the CIWA-Ar score, allows the dose regimen to be personalized.21 Our hospital practice has recently changed from a fixed-dose schedule in all patients to the use of symptom-based treatment in certain patients. It is likely that our future policies may include symptom-based treatment in all patients, as have been successful in other hospitals. Almost 90% of the present population received chlordiazepoxide, and generalized seizures were not observed after admission. The lack of adverse outcomes raises the possibility of over-treatment by chlordiazepoxide, and further work is required to allow a more detailed comparison of outcomes between fixed-dose and symptom-triggered administration regimens in our patient population. The broad range of inter-individual doses that were observed indicates careful use of the symptom-based prescribing tool and clinical judgement.

A higher than expected number of patients received intravenous vitamin supplementation when, according to our local policy this should be administered only if Wernicke–Korsakoff syndrome is suspected or patients are deemed to be at high risk according to specific criteria. In many instances, this appeared to be a safe and precautionary approach where intravenous therapy was initiated in the emergency department or Acute Medical Unit and then discontinued after senior medical review.

Brief alcohol interventions may reduce alcohol consumption by as much as 50% in the following year and significantly reduce hospital re-attendance.21,22 Only ∼40% of patients were reviewed by the specialist alcohol nurse in this study; some patients declined support or self-discharged before they could be reviewed. Notwithstanding, an opportunity is identified for improving patient access to specialist nurse review in hospital. This is currently under review, and it is anticipated that an extended 7-day service might allow greater involvement during the acute inpatient episode and permit more prompt discharge from hospital in some cases. A further change that is being considered is providing prompt access to a new clinic for early assessment and follow-up of patients who present to hospital. At present, there are often several weeks between referral to community alcohol services and an appointment being offered. Elsewhere, approximately two-thirds of patients who attended the emergency department accepted a specialist alcohol clinic appointment when available on the same day, whereas less than one-third attended if the appointment was delayed by 48 h or more.22

A limitation is that the data are derived from a single hospital and might not apply to other regions with different patterns of alcohol consumption, criteria for hospital admission or access to ambulatory care pathways for community alcohol detoxification. Nonetheless, the age and gender patterns are broadly consistent with those reported more widely across the UK.2 Elsewhere, symptom-based administration is associated with lower total chlordiazepoxide dose and shorter duration of treatment, and it is likely that our local hospital policies will evolve towards this evidence-based approach in the near future.17,18 A further limitation is that the study design does not allow us to ascertain whether the decision to administer intravenous or oral vitamin supplementation was based on the local policy guidance or other factors. The study population does not include patients who attended the emergency department but who did not require hospital admission; this group are likely to have different clinical and treatment characteristics. A further limitation is that the study design did not allow us to assess whether patients intended to remain abstinent, which is an important determinant of the cost-effectiveness of hospital admissions solely to facilitate alcohol withdrawal.

In conclusion, the present data indicate that protocol-based treatment allows safe clinical management of acute alcohol withdrawal. Opportunities exist for enhancing access to the specialist alcohol nurse service for patients admitted with unplanned withdrawal. A small but significant proportion of patients did not require any specific medical treatment, and there remains scope to develop ambulatory care pathways for this selected patient group.

Conflict of interest: None declared.

References

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