Implementing screening tools, conducting brief interventions, and involving pharmacists can help manage alcohol use disorder and Alcohol Withdrawal Syndrome.
With growing rates of alcohol use disorder (AUD) in the United States, pharmacists are playing increasingly crucial roles in its management as well as the treatment of alcohol withdrawal syndrome (AWS) and severe AWS (SAWS).
Concerns about alcohol consumption are growing, according to presenter Adrian Wong, PharmD, MPH, BCCCP, FCCM, FCCP, in a session at the American Society of Health-System Pharmacists (ASHP) 2022 Midyear Clinical Meeting. A sample of US adults during the COVID-19 pandemic found that the frequency of alcohol intake in a 30-day span increased by 14%, heavy drinking increased 41%, and the Short Inventory of Problems (used to identify patients with a problem with alcohol) increased by 39%.
Importantly, Wong noted that decreasing alcohol intake may cause AWS, which can lead to mortality if not treated quickly. Complete cessation is not necessary for withdrawal or mortality. Additionally, Wong added that SAWS is not well-defined or understood.
To work on this lack of understanding, the American Thoracic Society convened a committee to develop a definition of SAWS that is intended to be operational and focused on the inpatient environment. The committee, which Wong was a member of, developed a SAWS definition that says it is “a progressive state of central nervous system hyperexcitation due to reduction or cessation of alcohol use resulting in severe signs and symptoms of hyperautonomia and hyperactive delirium.”
Wong has furthered this research with a literature review including 251 relevant articles. This review has identified a range of knowledge gaps, which Wong grouped into 5 categories based on the Translational Research Continuum.
In the basic research category, Wong noted that there is already an understanding of the pathophysiology of AUD, which could be used to develop novel therapeutic targets. Further research is needed about the patient experience, such as modeling comorbid conditions, according to Wong.
In translating care to patients, Wong said there is a significant need for the development of a clinical trial network for AUD, as well as clinical trials of SAWS evaluating short- and long-term, patient-centered outcomes. Investigators also need a better understanding of how to implement these strategies on a population level as well as data on best implementation practices for management of SAWS.
Pharmacists can be involved in the management of AUD and the treatment of AWS/SAWS in many ways, both in the emergency department (ED) and inpatient environments. In the ED, presenter David Zimmerman, PharmD, BCCCP, said pharmacists can help screen patients, conduct brief interventions, and refer patients to treatment.
There are several screening tools that can be used in the ED, including ED-DIRECT and SBIRT. Research with SBIRT has shown small reductions in alcohol consumption, injury, and repeat ED visits.
“This is a tool that we can use and it’s pretty easy to do,” Zimmerman said. “When we do this, though, we want to ensure post-ED discharge follow-up.”
Despite the availability of these resources, however, studies have shown several clinician-reported barriers to screening. These include capability (lack of knowledge), lack of opportunity, and lack of motivation or personal discomfort with the topic.
The agents disulfiram, acamprosate, and naltrexone can all be initiated in the ED and have various strategic uses. Disulfiram increases abstinence when compared to blinded studies but is often impractical in real-world use because patients often stop taking it. Acamprosate reduces cravings and risk of drinking, but 3-times-daily dosing and renal dose adjustments can be a challenge. Finally, naltrexone has been shown to decrease heavy drinking days and cravings and can be given orally daily or as a monthly injection.
Moving forward, Zimmerman suggested implementing screening tools and establishing best practices to overcome obstacles. Additionally improved education for clinicians, initiating or dispensing therapies in the ED, and involving ED pharmacists at every step can significantly improve the management of AUD and treatment of AWS/SAWS.
Wong A, Zimmerman DE. (Not) All Too Well: Seeing Red in the Management of Alcohol Use Disorder (Pharmacist’s Version). Presented at: ASHP 2022 Midyear Clinical Meeting. December 4, 2022.