Phenobarbital Versus Benzodiazepines for the Treatment of Severe Alcohol Withdrawal.

BACKGROUND: Phenobarbital may offer advantages over benzodiazepines for severe alcohol withdrawal syndrome (SAWS), but its impact on clinical outcomes has not been fully elucidated. OBJECTIVE: The purpose of this study was to determine the clinical impact of phenobarbital versus benzodiazepines for SAWS. METHODS: This retrospective cohort study compared phenobarbital to benzodiazepines for the management of SAWS for patients admitted to progressive or intensive care units (ICUs) between July 2018 and July 2022. Patients included had a history of delirium tremens (DT) or seizures, Clinical Institute Withdrawal Assessment of Alcohol-Revised (CIWA-Ar) >15, or Prediction of Alcohol Withdrawal Severity Scale (PAWSS) score ≥4. The primary outcome was hospital length of stay (LOS). Secondary outcomes included progressive or ICU LOS, incidence of adjunctive pharmacotherapy, and incidence/duration of mechanical ventilation. RESULTS: The final analysis included 126 phenobarbital and 98 benzodiazepine encounters. Patients treated with phenobarbital had shorter median hospital LOS versus those treated with benzodiazepines (2.8 vs 4.7 days; P < 0.0001); a finding corroborated by multivariable analysis. The phenobarbital group also had shorter median progressive/ICU LOS (0.7 vs 1.3 days; P < 0.0001), and lower incidence of dexmedetomidine (P < 0.0001) and antipsychotic initiation (P < 0.0001). Fewer patients in the phenobarbital group compared to the benzodiazepine group received new mechanical ventilation (P = 0.045), but median duration was similar (1.2 vs 1.6 days; P = 1.00). CONCLUSION AND RELEVANCE: Scheduled phenobarbital was associated with decreased hospital LOS compared to benzodiazepines for SAWS. This was the first study to compare outcomes of fixed-dose, nonoverlapping phenobarbital to benzodiazepines in patients with clearly defined SAWS and details a readily implementable protocol.

A case of a patient requiring medically supervised withdrawal after ingestion of witch hazel toner as a surrogate alcohol.

Key Clinical Message: Standardized alcohol withdrawal treatments, such as the phenobarbital taper protocol, are effective in the management of alcohol withdrawal syndromes associated with surrogate alcohols including witch hazel toner. Abstract: Ingestion of alcohol not intended for consumption, also known as surrogate alcohols, is well-documented in patients with alcohol use disorder. Ingestion of surrogate alcohols may lead to higher morbidity and mortality than standard alcohol consumption alone. However, management of complications such as withdrawal syndromes in individuals consuming surrogate alcohols has received little attention in the literature. We present the case of a patient with alcohol use disorder who required medically supervised withdrawal following ingestion of witch hazel toner as a surrogate alcohol. Review of patient's history revealed routine ingestion of witch hazel toner as a substitute to traditional alcohols. Witch hazel toner is a non-FDA regulated product designed for topical use; it is commonly sold in a steam distilled formulation containing 13%-15% ethanol and small amounts of essential oil components, such as carvacrol and eugenol. During hospitalization the patient received treatment of alcohol withdrawal with a phenobarbital taper protocol and was discharged in stable condition. He also received resources for alcohol use disorder to follow-up in the outpatient setting. To our knowledge this is the first reported case of a patient requiring medically supervised withdrawal following ingestion of witch hazel toner and sheds light on the potential complications and management of patients who present following ingestion.

Medical Student Attitudes Toward Patients With Substance Use Disorder After Experiential Learning on an Addiction Psychiatry Consultation-Liaison Service: A Pilot Study.

BACKGROUND: Stigma surrounding substance use disorder (SUD) is highly prevalent in health care. Negative attitudes toward patients with SUD have been shown to negatively impact patient care. Addressing SUD stigma in medical students is a promising approach, however, few curricula include experiential learning on addiction psychiatry clinical services. We describe a medical student rotation on an addiction psychiatry clinical service and examine its effect on attitudes toward patients with SUD. METHODS: Medical students were integrated onto an addiction psychiatry consultation-liaison service serving medically/surgically hospitalized patients with co-occurring SUD and other psychiatric disorders. Students learned and practiced in-person assessment of patients and received instruction on basic principles of psychiatry and evaluation and management of SUD. A targeted anti-stigma curriculum was included. Attitudes toward patients with SUD were measured with the Medical Condition Regard Scale (MCRS) before and after the experience. Each item of the MCRS and an overall composite attitude score were analyzed. RESULTS: Of the 36 students on the clinical rotation, 33 completed the survey. Attitudes showed widespread improvement toward patients with SUD. Mann-Whitney U tests showed significant improvement in most items of the MCRS. Further analysis of composite scores showed an improvement in overall attitudes toward patients with SUD. CONCLUSIONS: Inclusion of medical students on an addiction psychiatry consult service as part of the core psychiatry clerkship may hold promise for helping improve student attitudes and decrease stigma toward patients with SUD. Controlled study is needed to compare other clinical experiences and determine specific causative effects.

Malignant Catatonia in the Setting of Acute Methamphetamine and Cocaine Intoxication.

BACKGROUND: Malignant catatonia is a potentially lethal neuropsychiatric syndrome characterized by psychomotor abnormalities and autonomic instability. Patients with this syndrome require immediate treatment. Various psychiatric conditions and nonpsychiatric medical problems can trigger malignant catatonia. Use of psychostimulant drugs, including methamphetamine and cocaine, has not been previously reported to precipitate malignant catatonia. CASE SUMMARY: This case concerns a 35-year-old man hospitalized for psychosis due to methamphetamine and cocaine intoxication. He developed malignant catatonia the day after admission. He was treated with lorazepam for malignant catatonia, and his blood pressure was controlled with clonidine. Over 7 days, his condition resolved, and his mental status and vital signs returned to baseline. He was discharged to the community in stable condition and has returned to his baseline functional status. He remains free of catatonia and has maintained abstinence from methamphetamine and cocaine. CONCLUSIONS: Acute intoxication with psychostimulant drugs is a possible trigger for malignant catatonia, and administration of high potency first-generation antipsychotics in this setting may increase the risk. Patients hospitalized for stimulant intoxication should be monitored for signs and symptoms of catatonia, and D2 receptor antagonist medications should be used with caution in this population. Our case supports the potential role of altered dopamine and norepinephrine signaling in the pathogenesis of malignant catatonia. The patient provided written and verbal consent to publish the information in this case report.