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A Simplified Protocol for the Treatment of Alcohol Withdrawal

Feeney, Colin MD, FACP; Alter, Harrison J. MD, FACEP, MS; Jacobsen, Elke BA; Rehrer, Matthew MD; Shao, Shirley MD; Subramanian, Indhu MD, FACP; Clements, R. Carter MD

doi: 10.1097/ADM.0000000000000167
Original Research

Objectives: The aim of the study was to evaluate a novel simplified tool for symptom-triggered treatment of alcohol withdrawal.

Methods: This retrospective cohort study involved inpatients in a county hospital with an International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis of alcohol withdrawal syndrome (AWS) or delirium tremens between January 1, 2007 and December 31, 2008. The study used the Highland Alcohol Withdrawal Protocol (HAWP)—a simplified derivative of the Revised Clinical Institute Withdrawal Assessment for Alcohol. Multivariable regression analysis was performed to compare severity of withdrawal to hospital length of stay, total dose of sedative given, and risk of complications.

Results: The study identified 442 patients with a primary diagnosis of AWS or delirium tremens, and those with another primary medical diagnosis complicated by alcohol withdrawal. After adjusting for demographic variables, each one-point increase in the initial and maximum HAWP scores correlated with an increase in the hospital length of stay of 0.3 days [95% confidence interval (95% CI), 0.17 to 0.43 days] and 0.45 days (95% CI, 0.32–0.57 days), and a 15.8 mg (95% CI, 6.6–25.1 mg) and 19.8 mg (95% CI, 11.1–28.5 mg) increase in the total dose of lorazepam given, respectively. The complication rate of seizures, intubations, pneumonia, and death was 13.1%, 12.9%, 6.1% and 0.9%, respectively; a composite endpoint of these outcomes also correlated with initial and maximum HAWP scores (odds ratio 1.09, 95% CI, 1.03%–1.14%).

Conclusions: The HAWP correlates with medication received and complications, and as such appears to give an indication of AWS severity. It is feasible and shorter than prior scales, and merits further study to confirm its effectiveness as part of symptom-triggered protocols to manage alcohol withdrawal in the hospital.

Department of Medicine (C.F., E.J., I.S.); Department of Emergency Medicine (H.J.A., R.C.C.); Highland Hospital—Alameda Health System and the Department of Emergency Medicine Kaiser East Bay (M.R.), Oakland, CA; SUNY Downstate College of Medicine (S.S.), Brooklyn, NY; and Department of Medicine, University of California (C.F., H.J.A., I.S.), San Francisco, CA.

Send correspondence and reprint requests to: Colin Feeney, MD, Department of Internal Medicine, Highland Hospital, 1411 E 31st St., Oakland, CA 94602. E-mail:

Received 29 July, 2015

Accepted 4 August, 2015

The only financial support for this study was a grant from the Department of Internal Medicine, Highland Hospital for $3255 for data collection.

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© 2015 American Society of Addiction Medicine