Editor: Christie Lech
Background:
The prevalence of adult alcohol abuse and dependence in the United States ranges from 7% to 16% (Muncie 2013). There are an estimated 500,000 cases of alcohol withdrawal syndrome (AWS) requiring pharmacologic intervention every year (Hoffman 2015). In addition, alcoholism has a large economic burden with annual health related costs estimated to be over $220 billion (Bouchery 2006).
Emergency providers (EPs) are frequently faced with the difficult decision of whether or not to discharge home or provide these patients with inpatient detoxification, even though studies have demonstrated short length of stays and high against medical advice (AMA) discharge rates among this patient group (Stephens 2014). Outpatient alcohol detoxification programs are common however their structures and coordination with emergency departments (EDs) are highly variable. In fact, very few EDs can provide direct referral to an outpatient program. In today’s emergency medicine practice is outpatient detoxification a viable option in the treatment of alcohol withdrawal?
Evidence:
Multiple studies in the field of psychiatry and addiction medicine have investigated the efficacy of inpatient versus substance abuse intensive outpatient programs (IOPs). A comprehensive literature review of 12 of these studies performed between 1995 and 2012 showed great variation among outpatient programs. While outpatient detoxification programs generally consisted of a multidisciplinary approach involving psychiatric, social and pharmacologic agents, there would be a range in the intensities. Some programs had short weekly meetings and others with intense bi to tri-weekly sessions. Follow up also ranged from a few weeks in these studies to a few months and up to a year. Attempting to correct for these variations, the authors concluded that there were reductions in substance use and increased abstinence at close follow-up in both inpatient and outpatient treatment arms without any significant difference between the two groups. Additionally, the effectiveness of abstinence was more a reflection of “intensity and duration of treatment rather than a specific setting or patient population.” (McCarty 2012)
Similar efficacy rates of outpatient and inpatient detoxification for the treatment of alcohol withdrawal would be attractive to a variety of healthcare professionals as it could decrease resource utilization without detrimental effects to the patient. A randomized controlled trial of US military veterans presenting with alcohol abuse compared inpatient versus outpatient detoxification and showed a total decrease in cost and duration of treatment in the outpatient group. There were no serious medical complications noted in either group (Hayashida 1989).
Inpatient vs Outpatient
Determining candidates for inpatient versus outpatient detoxification is a task that EPs face on nearly every shift. It can depend on numerous factors including clinical history and presentation, physical exam, substance use history, follow up reliability, age, concurrent medical condition, co-morbidities, psychosocial dynamics, etc. The most important considerations may be the severity of past withdrawal such as history or delirium tremens, ICU admission, and large parenteral therapy requirement. Ultimately, patients may need inpatient treatment given the full clinical risk of moderate to severe may be impossible to assess upon presentation to the ED. Institutional factors also play a large role in placing patients in outpatient detoxification programs. Despite identifying appropriate candidates for these programs, EDs are often limited by oversaturation of programs, referral capabilities and other resources like personnel for patient education and transportation.
A study in the EDs at the University of North Carolina utilized a proposed standardized protocol for evaluation of patients for alcohol detoxification that combined clinical history, laboratory values, substance use and psychiatric history, and objective CIWA markers. They found that after implementation of the protocol there was a statistically significant decrease in the number of inpatient alcohol detoxification admissions per month without change in readmission rate or length of stay (Stephens 2014)
Outpatient Treatment
There are no absolute criteria for deciding which patients require inpatient alcohol withdrawal. However multiple studies have identified certain factors that suggest a patient should receive inpatient treatment (Myrick 1998, Muncie 2013)
Contraindications to Outpatient Treatment of Alcohol Withdrawal Syndrome
While there is great variation in approaches to outpatient detoxification, limited studies have shown that it can be an effective alternative to inpatient detoxification in terms of patient outcomes. Outpatient programs should be tailored to each patient with a combination of pharmacologic and psychosocial therapy in a setting that embraces autonomy with close and consistent medical follow up. Further institutional investment in these programs from a multidisciplinary approach with closer coordination with EDs is sorely needed, and could go a long way in both safely assisting these patients with long term detoxification as well as reducing their burden on the health care system as a whole.
References
Bouchery E, Henrick J et al “Economic Costs of Excessive Alcohol Consumption in the U.S., 2006” Am J Prev Med 2011; 41(5) 516-524 PMID: 22011424
Hayashida M, Alterman Al et al “Comparative effectiveness and costs of inpatient
and outpatient detoxification of patients with mild-to-moderate alcohol withdrawal
syndrome” N Engl J Med 1989 Feb 9 PMID: 2913493
Hoffman R, Weinhouse G et al “Management of moderate and severe alcohol withdrawal symptoms” UptoDate Nov 12, 2015 http://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes
McCarty D, Braude L et al “Substance Abuse Intensive Outpatient Programs: Assessing the Evidence” Psychiatry Serv. 2014 June 1; 65(6): 718-726 PMID: 24445620
Muncie HL, Yasinian Y et al “Outpatient management of alcohol withdrawal
syndrome” Am Fam Physician. 2013 Nov 1 PMID 24364635
Myrick H, Anton R “Treatment of Alcohol Withdrawal” Alcohol Health & Research World. 1998 Vol 22. No. 1 38-43 National Institute on Alcohol Abuse and Alcoholism PMID: 15706731
Stephens J, Liles EA et al “Who Needs Inpatient Detox? Development and Implementation of a Hospitalist Protocol for the Evaluation of Patients for Alcohol Detoxification” J Gen Intern Med 2014 29(4): 587-93 PMID: 24395104
