Hospital management of alcohol withdrawal: elective vs unplanned admission and detoxification

Quelch D., Pucci M., Coleman J. & Bradberry S. (2018) Alcohol Treatment Quarterly, (published online). doi: 10.1080/07347324.2018.1527664. Click here to read.

Measuring the outcomes of unplanned and elective admissions for alcohol detoxification.

This small observational study retrospectively compared the patient outcomes of two different alcohol detoxification pathways in the West Midlands. 20 patients presenting to the emergency department (ED) with alcohol withdrawal were rapidly discharged from ED, assessed at an outpatient clinic and electively admitted to the West Midlands Poisons Unit (WMPU) for symptom-triggered alcohol detoxification. They were also signposted to community outreach services and provided with outpatient follow-up post-discharge. A second group of 20 patients was admitted to University Hospitals Birmingham NHS Foundation Trust (UHB) for an unplanned fixed-dose benzodiazepine regimen after presenting to the ED with alcohol withdrawal. These patients were referred to community outreach services but given no outpatient follow-up. Patient characteristics between the two groups were not significantly different.

Length of stay was 4.0 days for WMPU (interquartile range [IQR] 3.0-5.0) and 3.0 days for UHB (IQR 1.9-5.5). Readmissions to hospital with alcohol intoxication or withdrawal approximately 1-year post-detoxification were 13 for WMPU and 47 for UHB. The average number of readmissions per patient was 0.7 for WMPU and 2.4 for UHB, with 40% of WMPU patients being readmitted compared to 100% of UHB patients.

These findings suggest that patients managed with an elective approach to alcohol detoxification, following work-up with a dedicated alcohol team and post-detox follow-up, are less likely to be readmitted to hospital with alcohol intoxication or withdrawal than patients receiving admission for an unplanned detox.

Commentary by Tom Jones, Alcohol Nurse Specialist:

For anyone who works in drug and alcohol hospital liaison services these findings will come as no surprise. With the ongoing closure of specialist NHS and third sector detox units across the UK, more alcohol detoxes are taking place in acute medical settings. However, not all acute medical settings are equipped to safely manage alcohol detoxification, with many staff lacking the specialist skills necessary to care for these patients.

This study has clearly shown that unplanned detoxification is ineffective at maintaining long-term abstinence from alcohol. Given the readmission rates to hospital post-detox it is also not cost-effective. Sometimes a patient with alcohol dependence will need to be admitted to hospital, either due to complications arising from their alcohol use or due to an unrelated acute medical need, and their withdrawal symptoms will need to be managed pharmacologically. However, it is a common misconception in the acute medical setting that a detox is the best treatment for alcohol dependence. A detox is absolutely essential, and the best treatment we have available, for treating one physiological aspect of alcohol dependence; withdrawal. However, withdrawal is only one feature of dependence. A detox will not address the underlying behavioural and psychological aspects of addiction, and is no more likely to cure someone of their alcohol dependence than telling someone to "cheer up" is to cure them of their depression. A shift in thinking must therefore occur in order to reduce the number of unplanned detoxes in acute medical settings, and hospital liaison alcohol care teams are probably best placed to provide the training and education needed to achieve this culture change.

One of the perils of an unplanned detox in an acute medical setting, especially if there is no specialist addictions expertise in the hospital, is that the patient does not receive the psychosocial interventions that are essential during (and pre- and post-) detoxification. These interventions allow patients to explore coping mechanisms for cravings, and can equip them with some of the skills necessary for managing abstinence. The implementation of alcohol care teams goes some way to addressing this gap in service provision, however more needs to be done with regards to joint working with community services and assertive outreach so that, when an unplanned detox is unavoidable, appropriate care and follow-up can be provided. Without this psychosocial input, when a patient is discharged back to the environment they were previously in, with no support and all the same triggers and risks as before, relapse is the predictable outcome. But this cycle is eminently harmful, not only to the motivation of the patient who will likely feel that they have failed, but also due to the kindling effect, whereby each episode of withdrawal and detox heightens the predisposition to severe withdrawal symptoms such as seizures and delirium tremens. It basically gets harder and more risky each time someone has a detox.

Aside from the main difference between groups in this study (elective vs. unplanned admission), there were several key differences in the levels of care each group received, which likely influenced the outcomes. The WMPU group received the gold-standard symptom-triggered benzodiazepine treatment, where doses of medication were administered according to each patient’s individual withdrawal symptoms as rated using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar). In contrast, the UHB group received a fixed-dose benzodiazepine regimen. There is no further detail in the paper regarding what doses these patients received, how their withdrawal symptoms were assessed, and whether or not additional ‘as required’ doses were available for uncontrolled symptoms. The two groups also received treatment at different hospitals, where the quality of care may have differed. Bias can therefore not be ruled out.

Although the differences in length of stay were not statistically significant, the shorter admissions in the UHB group may indicate that some patients did not receive an adequate detox. Readmissions may therefore be a result of inadequate symptom control and failed detoxification. If a patient did not receive an appropriate amount of medication (either due to infrequent assessment or lack of staff expertise), they may have simply self-medicated with alcohol to alleviate withdrawal symptoms once discharged from hospital. It would be helpful to have more information about detox completion rates between groups.

The importance of post-detoxification follow-up must not be understated. The WMPU group received a much more robust package of care, with pre-detox work-up, signposting to an outreach team and outpatient follow-up, though it is not clear whether the outreach team or the hospital team provided the outpatient follow-up. In contrast, the UHB patients were simply referred to community services. It is not specified whether patients received an appointment or had to attend a drop-in clinic, as is the requirement of many community service providers. One can make the argument that patients must be motivated to engage with treatment and should therefore take the first step into treatment themselves, for example by presenting to a drop-in clinic at a community drug and alcohol service. However, this places the onus wholly on the patient and ignores the fact that the very nature of a severe substance use disorder presents a few impracticalities and barriers to engaging in treatment. It is also a rather convenient approach to take when funding is shrinking and services are struggling to treat those patients who do self-present, never mind the many who never make it to through the door.

It is important to note that rates of relapse and measures of abstinence were not collected in this study, and readmission to hospital is used as a proxy measure for relapse. Whilst an alcohol-related readmission is a fairly reliable measure of relapse, those patients not readmitted may not necessarily be abstinent from alcohol or may have been readmitted to a different hospital. The authors also highlight that the patients assessed as suitable for elective admission may represent those most likely to have a successful outcome. Future studies should use randomisation to eliminate this risk of bias.

Whilst this is an illuminating piece of research, further studies are required to replicate the findings with larger samples. This will help to strengthen the case for investment in services, and the development of new models of care and pathways for alcohol detoxification. What these findings do suggest is that having a planned elective admission affords patients the opportunities for better care through preparation, an appropriate setting with skilled staff, and robust follow-up. I suspect there are many working in the substance misuse sector who already know this, and who might be questioning why so many specialist detox units have been closed down in recent years.

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