An Exploration of Alcohol Withdrawal Protocols, with a Focus on the Use of Phenobarbital

Abstract – Objective – Severe alcohol withdrawal (SAW) is a common cause of hospital admission in the United States. There has been increased interest in phenobarbital use for SAW treatment. We aimed to investigate variability in alcohol withdrawal management protocols at different hospitals within a geographic region, with a focus on phenobarbital use. Methods – We e-mailed a survey to intensive care unit physician leadership to all New York City acute care hospitals as well as large acute care hospitals in Massachusetts regarding their protocols for SAW. Results – Of 13 respondents, eight have SAW protocols, six of whom have a distinct phenobarbital protocol. Phenobarbital load locations were in the emergency department or intensive care unit. Loading doses ranged from 8 to 15 mg/kg. Three protocols recommended an oral/intramuscular phenobarbital taper, and two protocols specified as needed phenobarbital rescue doses on hospital wards. There was some overlap in other rescue medications, but frequency and dose were not specified. Only two respondents of the survey included benzodiazepines as a rescue medication option. Conclusions – There is some evidence that phenobarbital use for SAW has comparable to improved efficacy in certain patient outcomes. It appears that current evidence may have led to the adoption of phenobarbital use in SAW protocols in several urban university hospitals. Our results demonstrate, however, that there is significant irregularity in dosing, tapers, and concomitant benzodiazepine use. Phenobarbital protocols for SAW are common among large urban hospitals, but protocols are not standardized. More research and interhospital collaboration should be undertaken to reduce variability and optimize treatment protocols.