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Am Fam Physician. 2000;62(5):954-957

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.”

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.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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