Community pharmacists' experience of gabapentin misuse and abuse: A quantitative study from Jordan.

Gabapentin is an anticonvulsant that has an abuse potential. The aim of this study was to investigate the misuse and abuse of gabapentin in Jordan from the perspective of community pharmacists. A cross-sectional survey using a self-reported structured questionnaire was used with a convenience sample of pharmacists employed by various independent and chain community pharmacies. An online technique was used in this study using Google forms. A total of 215 questionnaires were completed, with 200 respondents (93%) reporting awareness of cases of gabapentin abuse in their pharmacies. Less than half of the respondents (n = 94; 43.7%) indicated that gabapentin requests were not accompanied by prescriptions. Almost two-thirds of respondents (63.6%) noticed an increased pattern of gabapentin abuse/misuse during the last 6 months. The study underscores the need for regulatory efforts and pharmacovigilance to manage potential gabapentin abuse, along with pharmacist and patient education at the community pharmacy, regarding potential abuse of gabapentin.

Understanding Long-Stay Gabapentin Use Increases: A National Nursing Home Clinician Survey on Prescribing Intent.

OBJECTIVES: Explore the indications for long-stay gabapentin use and elucidate the factors spurring the rapid increase in gabapentin prescribing in nursing homes (NHs). METHODS: National cross-sectional survey of NH prescribers distributed anonymously using SurveyMonkey. Sampling for convenience was obtained through crowdsourcing, leveraging collaborations with NH clinician organizations. Developed by a multidisciplinary team, pilot data/existing literature informed survey content. RESULTS: A total of 131 surveys completed. Participants: 71% white, 52% female, 71% physicians. Off-label gabapentin prescribing was ubiquitous. Nearly every clinician used gabapentin for neuropathic pain, most for any form of pain. Many clinicians also prescribe gabapentin to moderate psychiatric symptoms and behaviors. Clinicians' prescribing was influenced by opioid, antipsychotic, and anxiolytic reduction policies because gabapentin was perceived as an unmonitored and safer alternative. CONCLUSIONS: Off-label gabapentin increases are closely linked to opioid reduction efforts as more NH clinicians utilize gabapentin as an unmonitored opioid alternative. Our results highlight, however, the less recognized significance of long-stay prescribing for psychiatric symptoms and the similar contribution of psychotropic reduction initiatives, a phenomenon warranting further scrutiny. CLINICAL IMPLICATIONS: Clinicians perceive gabapentin as safer than the drugs it is replacing. Whether this is true remains unclear; the individual- and population-level risks of increased gabapentin use are largely unknown.

Glycemic impact of gabapentin and Nucleo C.M.P in metformin-controlled diabetic patients: A case report.

This study examines the contraindications of gabapentin and Nucleo C.M.P Forte in metformin-controlled diabetic patients, focusing on their potential to induce hyperglycemia. A case report of a 65-year-old woman with type II diabetes is presented, demonstrating elevated blood glucose levels following the initiation of gabapentin and Nucleo C.M.P Forte. The literature review highlights limited data on gabapentin-induced hyperglycemia, with additional consideration of the potential effects of Nucleo C.M.P Forte. The study suggests modifying insulin therapy in diabetic patients taking gabapentin and calls for further research on this interaction.

Use of Gabapentin or Alprazolam in Cats during Postoperative, Short-Term Hospitalization.

This prospective, randomized study aimed to assess the anxiolytic efficacy of gabapentin or alprazolam in cats during short-term postoperative hospitalization. Sixty cats were randomly assigned to three groups (gabapentin-treated [100 mg per cat], alprazolam-treated [0.125 mg per cat], or placebo-treated), with treatments administered twice daily for two days. Stress levels were evaluated using Cat Stress Scores, serum cortisol, and glucose concentrations. Pain scores, food consumption, and adverse effects such as sedation were also monitored. Fifty-five cats completed the study. Both medications demonstrated similar reductions in stress levels. Cats receiving gabapentin had lower pain scores, while those receiving alprazolam exhibited significantly increased food intake on the first postoperative day. However, both medications resulted in comparable levels of sedation. In the context of postoperative hospitalization, pharmacological intervention with anxiolytics could be effective in reducing stress levels. Despite potential side effects, gabapentin and alprazolam may contribute to an improved quality of short-term hospitalization for cats.

Comparing the effects of pre-emptive oxycodone, diclofenac, and gabapentin on postoperative pain after tibia fracture surgery: A randomized clinical trail.

Background: Postoperative pain (POP) is one of the most common and most important types of pain. Objectives: The aim of this study was to compare the effects of pre-emptive oxycodone, diclofenac, and gabapentin on postoperative pain (POP) among patients with tibia fracture surgery. Materials and Methods: This double-blind three-group randomised controlled trial was conducted in 2023. Participants were 111 candidates for tibia fracture surgery under general anaesthesia. They were randomly allocated to oxycodone, gabapentin, and diclofenac groups through block randomisation. Baseline arterial oxygen saturation, heart rate, and blood pressure were documented before surgery and POP and sedation status were measured during postoperative recovery and 2, 4, 6, 12, and 24 h after surgery. Postoperative opioid analgesic use was also documented. The data were analysed using the SPSS software (v. 20.0) at a significance level of less than 0.05. Results: Groups did not significantly differ from each other respecting participants' baseline age, gender, body mass index, arterial oxygen saturation, heart rate, blood pressure, and surgery duration (P > 0.05). Moreover, there were no significant differences among the groups respecting POP and sedation status at different measurement time points (P > 0.05), except for six hours after surgery at which the POP mean score in the gabapentin group was significantly less than the other two groups (P = 0.001). Among-group differences respecting postoperative use of opioid analgesics and medication side effects were also insignificant (P > 0.05). Conclusion: Pre-emptive oxycodone, diclofenac, and gabapentin significantly reduce POP among patients with tibia fracture surgery, though gabapentin may produce more significant analgesic effects. All these three medications can be used for pre-emptive analgesia. Of course, the best pre-emptive analgesic agent is determined based on the opinion of the treating physician.

The Impact of Gabapentinoids on Pain-Related Outcomes after Knee and Hip Surgery: A Systematic Review with Meta-Analysis of Randomized Controlled Trials.

Background: Postoperative pain remains a significant challenge after knee and hip surgeries, two of the most frequently performed procedures, preventing patients from seeking timely surgical help. Gabapentinoids, gabapentin, and pregabalin, have been gaining attention in postoperative pain management. Methods: We conducted a meta-analysis to evaluate the efficacy of gabapentinoids in pain management after knee and hip surgery. PubMed, Scopus, and Cochrane Library were searched for relevant randomized controlled trials (RCTs) published before January 2023. Results: Fifteen articles reporting 1320 patients were analyzed. Cumulative pain intensity at rest and on movement was lower in the experimental group with the mean difference (MD) = -0.30 [-0.55,-0.05], p-value = 0.02, and MD = -0.41 [-0.68,-0.13], p-value = 0.004, respectively. However, the difference was not clinically meaningful and lacked statistical significance at each time period. The gabapentinoid group required less opioid consumption in morphine equivalents (MD = -6.42 [-9.07, -3.78] mg, p-value < 0.001). There was a lower incidence of postoperative nausea in the experimental group with a risk ratio (RR) of 0.69 [0.55, 0.86], p-value < 0.001. A subgroup analysis showed that gabapentinoids reduced pain on movement on postoperative day two after total knee arthroplasty but not hip arthroplasty. There was insufficient data to examine the efficacy of gabapentinoids in the reduction of chronic postoperative pain in knee/hip surgery. Conclusions: Thus, gabapentinoids were associated with a reduction in postoperative pain intensity at rest and on movement, morphine consumption, and the incidence of postoperative nausea in the early postoperative period following knee and hip surgeries. However, pain reduction was not clinically relevant. Sedation has not been evaluated in this work and, if performed, this may have influenced the conclusions. An important limitation of this study is that different gabapentinoids, their administration times and dosages, as well as varying intraoperative management protocols, were pooled together.

Trace-level Gabapentin can induce cardiovascular developmental toxicity through apoptosis in zebrafish larvae.

Gabapentin (GBP), an antiepileptic drug to treat epilepsy and neuropathic pain, has become an emerging pollutant in aquatic environments. Previous results suggested that GBP can cause a potential toxicity on the heart development of zebrafish but its cardiovascular effects are still not clear. In the current study, zebrafish embryos were exposed to GBP at environmental relevant concentrations (0, 0.1, 10 and 1000 µg/L) to assess its impact on cardiovascular systems during the early life stage of zebrafish. GBP exposure induced an increase in heartbeat rate and blood flow. The development of blood vessels was also affected with the vascular width significantly decreased at 10 µg/L and higher concentration of GBP. GBP exposure led to an abnormal vascular development by inhibiting the expression of relevant genes (flk1, vegfr-3, gata1, vegfα, and vegfr-2). Furthermore, GBP at 0.1 µg/L elevated the levels of reactive oxygen species and antioxidant enzyme. The vascular cell apoptosis was promoted through genes like p53, bad, and bcl2. However, these adverse effects were reversible with the antioxidant N-acetyl-L-cysteine, highlighting the crucial role of oxidative damage in GBP induced vascular toxicity. This research offers new perspectives on the adverse outcome pathways of antiepileptic drugs in non-target aquatic organisms.

A Randomized Double-Blinded Study To Compare the Efficacy of Propofol and Thiopentone To Prevent Succinylcholine-Induced Fasciculation and Myalgia in Gabapentin-Premedicated Patients.

BACKGROUND: Succinylcholine is the most used short-acting depolarizing muscle relaxant for rapid sequence induction. However, its use is associated with adverse effects, like fasciculations and myalgia. Thus, many pretreatment modalities were used to minimize or prevent these adverse effects. Our aim for this study was to compare the efficacy of propofol and thiopentone in preventing succinylcholine-induced fasciculation and myalgia in gabapentin-premedicated patients.  Methods: Eighty patients with American Society of Anesthesiologists (ASA) physical status I/II, either male or female, in the aged group of 18-60 years, and scheduled to undergo elective abdominal surgery under general anesthesia were randomly allocated into either the propofol (P) or thiopentone (T) group. Anesthesia was induced with IV fentanyl 2 µg/kg, IV succinylcholine 2 mg/kg, and either IV propofol (2 mg/kg) in group P or IV thiopentone (5 mg/kg) in group T. In both groups, oral gabapentin 600 mg was given two hours before the surgery. All patients were observed and graded for intraoperative fasciculations and myalgia during 24 postoperative hours by a blinded observer. Fasciculation grade, myalgia grade, total tramadol consumption, and demographic data were compared using a test of proportion and chi-squared test. RESULTS: Study results demonstrated that the use of propofol significantly decreases the severity of fasciculation at one, two, and three minutes (P < 0.001) and myalgia at two, six, and 12 hours (P < 0.001) more than thiopentone in gabapentin-premedicated patients. Tramadol consumption in both groups was insignificant (P = 0.658). CONCLUSIONS: Propofol (2 mg/kg) is more effective than thiopentone (5 mg/kg) in decreasing the severity of fasciculation and myalgia following succinylcholine administration in gabapentin-premedicated patients.

Gabapentin improves neuropathic pain in Minamata disease model rats.

BACKGROUND: Methylmercury (MeHg), the causative agent of Minamata disease, damages the cranial nervous system and causes specific sensory disturbances, especially hypoesthesia, in the extremities. However, recent reports demonstrate that patients with chronic Minamata disease conversely develop neuropathic pain in the lower extremities. Studies on our established Minamata disease model rats showed that MeHg-mediated neurodegeneration might induce neuropathic pain by over time through inducing rewiring with neuronal activation in the somatosensory cortex via microglial activation in the spinal dorsal horn. METHODS: In this study, the effects of gabapentin, a potentially effective treatment for neuropathic pain, was evaluated using this Minamata disease model rats. To further elucidate the mechanism of its medicinal effects, histochemical and biochemical analyses of the nervous system of Minamata disease model rats were conducted. RESULTS: Gabapentin treatment restored the reduction in the pain threshold caused by MeHg exposure in rats. Histochemical and biochemical analyses revealed that gabapentin showed no effect on MeHg-induced neurodegeneration in entire nervous system and microglial activation in the spinal dorsal horn. However, it was shown that gabapentin may reduce excessive synaptogenesis through its antagonist action on the alpha2-delta-1 subunit of calcium channels in the somatosensory cortex. CONCLUSIONS: These results indicate that gabapentin may alleviated neuropathic pain in MeHg poisoning, as typified by Minamata disease, by reversibly modulation synaptic rewiring in the somatosensory cortex.

Efficacy of pregabalin, amitriptyline, and gabapentin for neuropathic pain.

Neuropathic pain largely influences the well-being of patients. Anticonvulsant and antidepressant medications, such as Pregabalin, Gabapentin, and Amitriptyline, are routinely prescribed as initial treatments for neuropathic pain. The study sample has a total of 270 patients who meet the inclusion criteria and are further distributed into three equally sized groups (A, B, and C). Group A was administered with Gabapentine 300mg, Group B with Pregabalin 75 mg, and Amitriptyline 10 mg to Group C. The occurrence of any adverse drug response was documented using the ADR reporting form, while the pain of the patient's post-medication was recorded using a numerical pain rating scale (NPRS). The comparison of the NPRS scores of all three groups "by using ANOVA test" both at baseline and after 15 days reveal that the differences between the three groups are statistically insignificant (p > 0.089). However, after one month of continuous use, the difference becomes slightly significant (I.e., p = 0.003). Gabapentin, pregabalin, and amitriptyline demonstrate similar effectiveness in alleviating neuropathic (NeP) pain. The study concludes that gabapentin is superior to both pregabalin and amitriptyline with fewer adverse effects, leading to improved patient adherence for long-term use.

The Effect of Concurrent Use of Opioids and Gabapentin on Fall Risk in Older Adults.

Falls pose a significant threat to older adults, resulting in injuries and mortality. Concurrently prescribed opioids and gabapentin for pain management may increase fall risks in older patients. This study aimed to estimate fall risks associated with the concurrent use of gabapentin and opioids, comparing them to opioid monotherapy in older adults. A retrospective case-control study of 1,813 patients aged 65-89 on chronic opioid therapy (2017-2020), excluding those with a fall history, analysis focused on the first fall occurrence. Logistic regression assessed the association between concurrent gabapentin and opioid use and fall events. Out of eligible patients, 122 (6.73%) experienced falls during opioid therapy, with 232 (12.80%) having concurrent gabapentin use. Concurrent use significantly increased fall risk (AOR = 1.73; 95% CI: 1.08-2.78). Being female, aged ≥81, and having more chronic conditions also increased risk. Mitigating fall risk in older adults requires education on prevention, exploring alternative pain management, and careful consideration of prescribing. Further research is crucial to understand adverse events linked to combined opioid and gabapentin use in the geriatric population.

Gabapentin and Rapidity of Recovery Among Patients Undergoing Minimally Invasive Ambulatory Uro-Oncologic Surgeries.

INTRODUCTION: Gabapentin has been used in enhanced recovery after surgery (ERAS) pathways for pain control for patients undergoing ambulatory uro-oncologic surgery; however, it may cause undesirable side effects. We studied the causal association between gabapentin and rapidity of recovery and perioperative pain management after minimally invasive uro-oncologic surgery. METHODS: We identified 2397 patients ≤ 65 years undergoing prostatectomies or nephrectomies between 2018 and 2022; 131 (5.5%) did not receive gabapentin. We tested the effect of gabapentin use on time of discharge and perioperative opioid consumption, respectively, using multivariable linear regression adjusting for potential confounders including age, gender, BMI, American Society of Anesthesiologists score, and surgery type. RESULTS: On adjusted analysis, we found no evidence of a difference in discharge time among those who did vs did not receive gabapentin (adjusted difference 0.07 hours shorter on gabapentin; 95% CI -0.17, 0.31; P = .6). There was no evidence of a difference in intraoperative opioid consumption by gabapentin receipt (adjusted difference -1.5 morphine milligram equivalents; 95% CI -4.2, 1.1; P = .3) or probability of being in the top quartile of postoperative opioid consumption within 24 hours (adjusted difference 4.2%; 95% CI -4.8%, 13%; P = .4). We saw no important differences in confounders by gabapentin receipt suggesting causal conclusions are justified. CONCLUSIONS: Our confidence intervals did not include clinically meaningful benefits from gabapentin, when used with an ERAS protocol, in terms of length of stay or perioperative opioid use. These results support the omission of gabapentin from ERAS protocols for minimally invasive uro-oncologic surgeries.

Effectiveness of Gabapentin as a Benzodiazepine-Sparing Agent in Alcohol Withdrawal Syndrome.

Background and Objectives: Gabapentin has shown promise as a potential agent for the treatment of alcohol withdrawal syndrome. We aimed to evaluate the effectiveness of gabapentin as a benzodiazepine-sparing agent in patients undergoing alcohol withdrawal treatment in all the hospitals of a large tertiary healthcare system. Materials and Methods: Medical records of patients admitted to the hospital for alcohol withdrawal management between 1 January 2020 and 31 August 2022 were reviewed. Patients were divided into two cohorts: benzodiazepine-only treatment who received benzodiazepines as the primary pharmacotherapy and gabapentin adjunctive treatment who received gabapentin in addition to benzodiazepines. The outcomes assessed included the total benzodiazepine dosage administered during the treatment and the length of hospital stay. The statistical models were calibrated to account for various factors. Results: A total of 4364 patients were included in the final analysis. Among these, 79 patients (1.8%) received gabapentin in addition to benzodiazepines, and 4285 patients (98.2%) received benzodiazepines only. Patients administered gabapentin required significantly lower average cumulative benzodiazepine dosages, approximately 17.9% less, compared to those not receiving gabapentin (median 2 mg vs. 4 mg of lorazepam equivalent dose (p < 0.01)). However, there were no significant differences in outcomes between the two groups. Conclusions: Our findings demonstrate that using gabapentin with benzodiazepine was associated with a reduction in the cumulative benzodiazepine dosage for alcohol withdrawal. Considering gabapentin as an adjunctive therapy holds promise for patients with comorbidities who could benefit from reducing benzodiazepine dose. This strategy warrants further investigation.

Preoperative Gabapentin for Pain Control: A Randomized, Placebo-controlled Clinical Trial in Patients Undergoing Inguinal Hernioplasty.

PURPOSE: The perioperative use of gabapentin has been suggested to reduce postoperative pain and opioid consumption. However, there is a variation in clinical practice, the type of surgery and the administration time seem to be distinct between the available studies. We assess whether gabapentin administered before surgery reduces postoperative pain in patients who have undergone inguinal hernioplasty. DESIGN: This is a double-blind, randomized, and placebo-controlled trial. METHODS: Seventy-seven patients scheduled for inguinal hernioplasty were randomized in two groups to receive gabapentin (900 mg) or placebo in the perioperative period. The primary outcome was analgesia measured by visual analog scale up to 30 days after surgery. The secondary outcomes such as morphine consumption, nausea, headache, and sedation have been also described. FINDINGS: Patients who received gabapentin had lower postoperative pain scores compared to the control group, P < .001. The postoperative morphine use was significantly lower in the gabapentin (5.3%) versus placebo group (74.4%), P < .001. No significant difference between groups was observed for the occurrence of adverse events. CONCLUSIONS: The perioperative administration of gabapentin was effective in reducing postoperative pain and had an important effect in decreasing morphine use. Together, our data reveal a long-lasting opioid-sparing effect of gabapentin in patients who underwent inguinal hernioplasty.

Association of Opioid Use Disorder Diagnosis with Management of Acute Low Back Pain: A Medicare Retrospective Cohort Analysis.

BACKGROUND: Practice guidelines recommend nonpharmacologic and nonopioid therapies as first-line pain treatment for acute pain. However, little is known about their utilization generally and among individuals with opioid use disorder (OUD) for whom opioid and other pharmacologic therapies carry greater risk of harm. OBJECTIVE: To determine the association between a pre-existing OUD diagnosis and treatment of acute low back pain (aLBP). DESIGN: Retrospective cohort study using 2016-2019 Medicare data. PARTICIPANTS: Fee-for-service Medicare beneficiaries with a new episode of aLBP. MAIN MEASURES: The main independent variable was OUD diagnosis measured prior to the first LBP claim (i.e., index date). Using multivariable logistic regressions, we assessed the following outcomes measured within 30 days of the index date: (1) nonpharmacologic therapies (physical therapy and/or chiropractic care), and (2) prescription opioids. Among opioid recipients, we further assessed opioid dose and co-prescription of gabapentin. Analyses were conducted overall and stratified by receipt of physical therapy, chiropractic care, opioid fills, or gabapentin fills during the 6 months before the index date. KEY RESULTS: We identified 1,263,188 beneficiaries with aLBP, of whom 3.0% had OUD. Two-thirds (65.8%) did not receive pain treatments of interest at baseline. Overall, nonpharmacologic therapy receipt was less prevalent and opioid and nonopioid pharmacologic therapies were more common among beneficiaries with OUD than those without OUD. Beneficiaries with OUD had lower odds of receiving nonpharmacologic therapies (aOR = 0.62, 99%CI = 0.58-0.65) and higher odds of prescription opioid receipt (aOR = 2.24, 99%CI = 2.17-2.32). OUD also was significantly associated with increased odds of opioid doses ≥ 90 morphine milligram equivalents/day (aOR = 2.43, 99%CI = 2.30-2.56) and co-prescription of gabapentin (aOR = 1.15, 99%CI = 1.09-1.22). Similar associations were observed in stratified groups though magnitudes differed. CONCLUSIONS: Medicare beneficiaries with aLBP and OUD underutilized nonpharmacologic pain therapies and commonly received opioids at high doses and with gabapentin. Complementing the promulgation of practice guidelines with implementation science could improve the uptake of evidence-based nonpharmacologic therapies for aLBP.

Risks of congenital malformations and neonatal intensive care unit admissions with gabapentin use in pregnancy: A cohort study and scoping review with meta-analysis.

BACKGROUND: The increasing and prevalent use of gabapentin among pregnant people highlights the necessity to assess its neonatal safety. OBJECTIVES: This study aimed to investigate the foetal safety of gabapentin during pregnancy using a cohort study and scoping review with a meta-analysis of published evidence. METHODS: We conducted a population-based cohort study using the Manitoba health databases between 1995 and 2019. We examined the association between gabapentin use during pregnancy and the prevalence of major congenital malformations, cardiac and orofacial malformations, and neonatal intensive care unit (NICU) admissions using multivariate regression models. We searched the literature in MEDLINE and EMBASE databases from inception to October 2022 to identify relevant observational studies and conducted a meta-analysis using random-effects models, including our cohort study results. RESULTS: Of the 289,227 included pregnancies, 870 pregnant people were exposed to gabapentin. Gabapentin exposure during the First trimester was not associated with an increased risk of any malformations (adjusted relative risk [aRR]) 1.16 (95% confidence interval [CI] 0.92, 1.46), cardiac malformations (aRR 1.29, 95% CI 0.72, 2.29), orofacial malformations (aRR 1.37, 95% CI 0.50, 3.75), and major congenital malformations (aRR 1.00, 95% CI 0.73, 1.36). whereas exposure during any trimester was associated with an increased NICU admission risk (aRR, 1.99 [95% CI 1.70, 2.32]). The meta-analysis of unadjusted results revealed an increased risk of major congenital malformations (RR 1.44, 95% CI 1.28, 1.61, I2 = 0%), cardiac malformations (RR 1.66, 95% CI 1.11, 2.47, I2 = 68%), and NICU admissions (RR 3.15, 95% CI 2.90, 3.41, I2 = 10%), and increased trend of orofacial malformations (RR 1.98, 95% CI 0.79, 5.00, I2 = 0%). CONCLUSIONS: Gabapentin use was associated with an increased risk of NICU admissions in the cohort study and pooled meta-analysis. Clinicians should prescribe gabapentin with caution during pregnancy and further studies are warranted.

Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department.

The fourth Society for Academic Emergency Medicine (SAEM) Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4) is on the topic of the emergency department (ED) management of nonopioid use disorders and focuses on alcohol withdrawal syndrome (AWS), alcohol use disorder (AUD), and cannabinoid hyperemesis syndrome (CHS). The SAEM GRACE-4 Writing Team, composed of emergency physicians and experts in addiction medicine and patients with lived experience, applied the Grading of Recommendations Assessment Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding six priority questions for adult ED patients with AWS, AUD, and CHS. The SAEM GRACE-4 Writing Team reached the following recommendations: (1) in adult ED patients (over the age of 18) with moderate to severe AWS who are being admitted to hospital, we suggest using phenobarbital in addition to benzodiazepines compared to using benzodiazepines alone [low to very low certainty of evidence]; (2) in adult ED patients (over the age of 18) with AUD who desire alcohol cessation, we suggest a prescription for one anticraving medication [very low certainty of evidence]; (2a) in adult ED patients (over the age of 18) with AUD, we suggest naltrexone (compared to no prescription) to prevent return to heavy drinking [low certainty of evidence]; (2b) in adult ED patients (over the age of 18) with AUD and contraindications to naltrexone, we suggest acamprosate (compared to no prescription) to prevent return to heavy drinking and/or to reduce heavy drinking [low certainty of evidence]; (2c) in adult ED patients (over the age of 18) with AUD, we suggest gabapentin (compared to no prescription) for the management of AUD to reduce heavy drinking days and improve alcohol withdrawal symptoms [very low certainty of evidence]; (3a) in adult ED patients (over the age of 18) presenting to the ED with CHS we suggest the use of haloperidol or droperidol (in addition to usual care/serotonin antagonists, e.g., ondansetron) to help with symptom management [very low certainty of evidence]; and (3b) in adult ED patients (over the age of 18) presenting to the ED with CHS, we also suggest offering the use of topical capsaicin (in addition to usual care/serotonin antagonists, e.g., ondansetron) to help with symptom management [very low certainty of evidence].