Letters to the Editor - September 1, 2000 - American Family Physician

Letters to the Editor

Measurement of Alcohol Withdrawal

TO THE EDITOR: In the article by Drs. Prater and Miller, "Outpatient Detoxification of the Addicted or Alcoholic Patient,"¹ measurement of the patient's heart rate (HR) and blood pressure (BP) were cited as key elements in assessing the severity of alcohol withdrawal. These recommendations go against a significant volume of research that has demonstrated these measures to be poor predictors of alcohol withdrawal severity that should not be used as treatment guidelines.

Since 1973, multiple scales for measuring the severity of alcohol withdrawal syndrome have been developed and refined. Currently, the most widely used assessment scale is the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar).² This scale is a 10-item quiz that measures tremor, anxiety, diaphoresis and hallucinations. The scale is a condensed version of the 15-item CIWA-A scale.³ The originators of both scales considered inclusion of HR and BP in the measurement parameters; however, these factors were not found to have statistical significance. "This is not to say that elevations of HR and BP did not occur in alcohol withdrawal, but that other signs and symptoms are more reliable in the assessment of alcohol withdrawal severity."²

Since publication of the CIWA-Ar scale, it has been tested by many facilities, including addiction hospitals, general psychiatric wards and general hospitals. Researchers have validated the CIWA-Ar scale and concurred with the exclusion of HR and BP as assessment factors.^3,4

Use of scales, such as the CIWA-Ar, has proved to be extremely beneficial. After introduction of the CIWA-Ar scale in their hospital, Wartenberg and colleagues⁵ saw 60 percent fewer patients receiving sedation with no increase in the frequency of delirium tremens, seizures or other severe symptoms. This means significant cost savings in medications and possible iatrogenic side effects.

For readers who want other guidance about the treatment of alcohol withdrawal, I would recommend the article by Yost,⁶ "Alcohol Withdrawal Syndrome."

CAROL L. BLACKWOOD, M.D.
Family Medicine Center
Camp Pendleton Naval Hospital
Camp Pendleton, CA 92055-5191

REFERENCES

Prater CD, Miller KE, Zylstra RG. Outpatient detoxification of the addicted or alcoholic patient. Am Fam Physician 1999;60:1175-84.

Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for alcohol scale (CIWA-Ar). Br J Addict 1989;84: 1353-7.

Stuppaeck CH, Barnas C, Falk M, Guenther V, Hummer M, Oberbauer H, et al. Assessment of the alcohol withdrawal syndrome--validity and reliability of the translated and modified Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-A). Addiction 1994;89:1287-92.

Saitz R, Mayo-Smith MF, Roberts MS, Redmond HA, Bernard DR, Calkins DR. Individualized treatment for alcohol withdrawal. A randomized, double-blinded controlled trial. JAMA 1994;272:519-23.

Wartenberg AA, Nirenberg TD, Liepman MR, Silvia LY, Begin AM, Monti PM. Detoxification of alcoholics: improving care by symptom-triggered sedation. Alcohol Clin Exp Res 1990;14:71-5.

Yost DA. Alcohol withdrawal syndrome. Am Fam Physician 1996;54:657-64,669.

IN REPLY: Although I agree that the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar)¹ is an excellent tool to use in the inpatient setting, the focus of our article² was outpatient detoxification of the addicted or alcoholic patient. In an environment that is well controlled by health care professionals, withholding substitutive treatment until patients progress further into the stage of delirium tremens (DTs) is an acceptable strategy. It is also appropriate to reduce the amount of sedation in the hospital for these patients because immediate intervention by trained health care professionals is available.

However, in order to provide detoxification in the outpatient environment, the threshold for treatment must be lower. These patients do not have trained health care professionals providing the supervision of their treatment, but may have friends or family members with little or no medical training providing this service.

Although using these criteria may result in overtreating some patients, it will significantly reduce the number of patients who progress to the later stages of DTs. This aggressive treatment strategy reduces the risk for catastrophic outcomes in the outpatient setting when detoxing the addicted or alcoholic patient. Therefore, outpatient detoxification requires a different treatment strategy than when detoxification is performed in an inpatient environment.

KARL E. MILLER, M.D.
Department of Family Medicine
University of Tennessee College of Medicine
Chattanooga, TN 37403

REFERNCES

Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for alcohol scale (CIWA-Ar). Br J Addict 1989;84: 1353-7.

Prater CD, Miller KE, Zylstra RG. Outpatient detoxification of the addicted or alcoholic patient. Am Fam Physician 1999;60:1175-84.

Suggested Technique for the Clinical Breast Examination

TO THE EDITOR: An article by Barton and colleagues,¹ reviewed in "Tips from Other Journals,"² discusses the clinical breast examination. The authors correctly encourage careful technique and thorough examination. However, I would like to suggest that, during the examination, the patient should be seated on the end of the examination table with her hands on the stirrups, while leaning forward at about a 45 degree angle to allow the breast tissue to fall away from the chest wall. This position allows the examiner to place the fingers behind the deep tissue so as not to confuse a breast mass with a rib. The room should be one that can be absolutely darkened so that adequate transilluminations can be done. Physicians might be amazed at what they can see under these conditions. Highly pigmented skin will not allow the breasts to be transilluminated well.

Axillae can be examined with one hand, but the breasts are best examined with a bimanual technique using digital pads. With one hand on each breast, using the digital pads with tissue between the finger and the thumb, the examiner can compare the texture and pick up differences that would otherwise be missed. All of the examiner's findings can be conveyed to the patient during the examination and, at the same time, the physician can encourage and educate the patient about breast self-examination and desexualize the process.

The most important part of the examination is the information assimilated in the examiner's mind. The examiner must create a picture of what the fingers feel (but cannot see) in the breast structures. This is best done with the eyes closed. The patient, too, should be reminded that she must learn to differentiate between what her fingers tell her and what her breasts tell her.

I do not have any statistics to support this technique; I am just a country doctor trying to catch cancer early, but this technique enables me to know what I am doing when performing a breast examination.

JOHN R. DYKERS, JR., M.D.
Siler City, NC 27344

REFERENCES

Barton MD, Harris R, Fletcher SW. Does this patient have breast cancer? The screening clinical breast examination: should it be done? how? JAMA 1999;282:1270-80.

Should family physicians do screening breast exams? [Tips from Other Journals]. Am Fam Physician 2000;61:1469-72.

Tips for the GI Prep Based on a Physician's Own Experience

TO THE EDITOR: "Doc, the GI 'prep' is worse than the procedure." For 24 years, I'd heard this from patients. Recently, I personally learned that this was true. As a result of the experience, I believe it would be wise for all physicians who recommend gastrointestinal (GI) preps for patients to first endure one themselves.

There are several learning points. First, the taste of the oral solution is not what one would call good. My gut reaction was to chill it, squeeze the juice of a lemon into it and then use a straw to deposit it as far back in my mouth as I could. This helped tremendously.

Closely following this, I encountered another gut reaction: stuff, watery stuff, lots of watery stuff. The volume and frequency of the watery stuff (as inconvenient as it was) was not the problem, however. The problem was the intense burning in the perianal area. After about one half hour of this, I happened to notice our six-month-old child's zinc oxide. Within seconds of applying zinc oxide to the affected area, all pain was gone, and as long as I reapplied it after each gush of liquid, there was no further pain!

I highly recommend that physicians amend their colonoscopy and sigmoidoscopy protocols to add ice, lemon juice and a straw to the front end and zinc oxide to the rear end of the GI prep.

JOHN W. RICHARDS, JR., M.D.
4210 Columbia Rd., Suite 7A
Martinez, GA 30907

Corrections

An item in "Quantum Sufficit" on the cost of contraception (May 1, page 2594) contained an error. The third sentence of the fourth item on this page should read "This cost is much lower than the estimated $542,000 per 1,000 women spent on pregnancy-related absences ...."

The article "Identification and Evaluation of Mental Retardation" (February 15, page 1059) contained an error in Table 2; the correct term for the fourth entry in the diagnosis column should be velocardiofacial syndrome rather than DiGeorge syndrome.

*These corrections have been made to the online version of AFP. The links above will take you to the corrected items, which remain part of the online issues in which they were originally published.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax:913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.

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