Addiction Psychiatry

Hospital-wide implementation, clinical outcomes, and safety of phenobarbital for alcohol withdrawal
Benjamin J Wolpaw, Hannah Oren, Laura Quinnan-Hostein, Katharine A Bradley, Nicholas J Johnson, Kevin A Hallgren, Ayushi Gupta, H Nina Kim, Marion A Granich, Tessa L Steel

Abstract:

Importance: Phenobarbital monotherapy is increasingly used to treat alcohol withdrawal syndrome (AWS) in hospitalized patients, but its implementation outside academic emergency departments (EDs) and intensive care units (ICUs) remains understudied.

Objective: To evaluate the implementation, clinical outcomes, and safety of an electronic health record (EHR) order set for intravenous weight-based phenobarbital loading (10 or 15 mg/kg) across all care locations (ED, acute care, and ICU) of a community hospital.

Design, setting, and participants: This retrospective quality improvement study was conducted at a 281-bed community hospital in Seattle, Washington, including all hospitalized adults treated for AWS 11 months before and 12 months after implementation of the phenobarbital EHR order set (April 1, 2021, to March 31, 2023). Data analysis occurred in May 2024.

Exposure: Initiation of AWS treatment before vs on or after March 24, 2022.

Main outcomes and measures: Implementation was assessed by order set use and cumulative phenobarbital and benzodiazepine exposure. Clinical outcomes included daily maximum Clinical Institute Withdrawal Assessment of Alcohol Scale Revised (CIWA-Ar) scores, AWS treatment duration (time from first to last medication), and time from AWS treatment initiation to hospital discharge. Safety outcomes included prolonged use of physical restraints (>1 day), intubation, and in-hospital mortality. Logistic and negative binomial regression models were used to estimate differences in each outcome, before vs after implementation, adjusting for baseline group differences.

Results: Among 254 patients, the pre-implementation (154 patients) and post-implementation (100 patients) groups were similar in terms of baseline characteristics; most were middle-aged (mean [SD] age, 53.0 [14.9] years), male (177 men [66.9%]), and publicly insured (186 patients [73.2%]). After implementation, the phenobarbital order set was used for 67 patients (67.0%), predominantly in ED and acute care locations. AWS symptoms resolved more rapidly after implementation, with a 4.2- to 5.0-point reduction in daily maximum CIWA-Ar scores at 24 to 96 hours from hospital presentation, 30.1-hour reduction in AWS treatment duration (95% CI, 16.7-43.5 hours), and 2.2-day reduction in time to hospital discharge (95% CI, 0.7-3.7 days). Safety outcomes did not significantly differ before and after implementation.

Conclusions and relevance: In this quality improvement study, implementation of a weight-based phenobarbital order set for AWS in all care locations of a community hospital was associated with faster symptom resolution, shorter length of stay, and no differences in safety outcomes. These findings support the broader adoption of phenobarbital-based AWS treatment across diverse hospital settings.

Annotation

The findings:

This hospital-wide quality-improvement study evaluated the implementation and outcomes of a weight-based intravenous phenobarbital monotherapy electronic health record (EHR) order set for alcohol withdrawal syndrome (AWS) across all care settings (ED, acute care, ICU) in a 281-bed community hospital with limited prior phenobarbital experience. Comparing 11 months pre-implementation (n = 154) to 12 months post-implementation (n = 100), the authors found rapid uptake (67% of post-implementation patients), substantial reductions in benzodiazepine exposure (by 22.4 lorazepam-equivalent mg), and increased phenobarbital use consistent with protocolized loading (median approx. 12.6 mg/kg). Clinically, phenobarbital implementation was associated with faster symptom resolution, reflected in a 4.2 to 5.0 point reduction in daily maximum CIWA-Ar scores from 24 to 96 hours, shorter AWS treatment duration (by 30.1 hours), and shorter time to hospital discharge (by 2.2 days). Importantly, no increase in safety events—including intubation, prolonged restraints, or in-hospital mortality—was observed, supporting the feasibility of phenobarbital use beyond specialized academic ED or ICU settings.

Strength and weaknesses:

Strengths include a pragmatic, real-world design; adherence to STROBE and SQUIRE 2.0 guidelines; granular EHR-derived outcome measures; and adjustment for baseline imbalances using standardized mean differences rather than overreliance on p-values. The inclusion of diverse care locations and prescriber types meaningfully extends prior phenobarbital literature, which has largely focused on academic EDs and ICUs. Supplemental analyses clarify protocol details, education strategies, and implementation adaptations (e.g., removal of telemetry monitoring after no observed adverse events), enhancing reproducibility. However, the pre/post observational design limits causal inference, with potential residual confounding and susceptibility to secular trends, including a contemporaneous benzodiazepine shortage that may have increased phenobarbital uptake. The single-site setting and predominantly White, non-Hispanic population constrain generalizability, and the absence of clinician-reported outcomes or patient-centered measures leaves unanswered questions regarding workflow burden and subjective tolerability. Finally, despite encouraging results, the study does not resolve the broader evidence gap created by the lack of head-to-head randomized trials comparing phenobarbital monotherapy to benzodiazepine-based regimens in general medical wards.

Relevance:

For C-L psychiatrists, this study is highly actionable. AWS is among the most common and resource-intensive psychiatric conditions encountered in medical hospitals, and benzodiazepine-based protocols remain deliriogenic, labor-intensive, and inconsistently applied. This work demonstrates that phenobarbital monotherapy—when embedded in a structured EHR order set—can be safely implemented by non-specialists, reduce symptom burden, shorten length of stay, and potentially decrease downstream complications that drive psychiatric consultation (e.g., agitation, restraints, delirium). The findings support C-L psychiatrists’ roles as systems-level consultants, helping hospitals transition toward standardized, neurobiologically rational AWS protocols that minimize CIWA-Ar dependence and benzodiazepine exposure. More broadly, the study provides an implementation blueprint—education, protocolization, and iterative safety monitoring—that aligns closely with the consult psychiatrist’s interface function between psychiatry, medicine, nursing, and hospital leadership.

Evaluation and management of alcohol-intoxicated patients with suicide risk in the emergency department: a scoping review
Priyanka Amin, Darya Dehkan, Jennifer Peltzer-Jones, Nasuh Malas, Victor Hong, Ahmad Shobassy, Keith Stowell

Abstract:

Background: The severity of suicide risk in patients who present to the emergency department (ED) with co-occurring complaints of suicidal ideation and alcohol intoxication is neither well-understood nor well-recognized by ED staff. While suicide screening has become a standard expectation in ED care, there lacks consensus on standard care practices for the evaluation and management of patients with suicidal ideation and/or attempt and alcohol intoxication.

Objective: To conduct a scoping review of the care of ED patients with suicidality and alcohol intoxication.

Methods: This is a scoping review describing the evaluation and management of ED patients with suicidality and alcohol intoxication. PubMed, Ovid MEDLINE, APA PsycInfo, and CINAHL were searched using relevant terms to describe this ED population. 110 total articles were found and underwent full-text review. Twenty-nine articles met criteria for inclusion.

Results: Patients with suicide-related complaints while intoxicated are less likely to receive a psychiatric evaluation or to be admitted psychiatrically. This is concerning given that alcohol use is demonstrated to be both a proximal and long-term risk factor for suicide attempt(s). Existing literature includes recommendations to evaluate patients while intoxicated and to re-evaluate when sober. To create safe plans of care for these patients, clinicians need to identify the patterns of alcohol use: alcohol use to facilitate suicide, binge drinking episodes, or alcohol use disorder. ED interventions can then build from understanding of how the alcohol use and suicidality interact. Though no specific ED-based interventions were found for this patient subpopulation, interventions shown to mitigate suicide risk and/or decrease alcohol use include: brief interventions (e.g., Screening, Brief Intervention, and Referral to Treatment), peer navigators, crisis safety plans, discussion about restricting access to lethal means, and/or inpatient psychiatric admission.

Conclusions: There is a lack of published guidelines, standards of care, and best practices to help consultation-liaison, emergency psychiatrists, and ED providers in the management of this population, despite overwhelming literature linking alcohol intoxication and suicide attempt/death. Further research is needed to (1) elucidate the core elements for standardized assessments and (2) develop evidence-based interventions to improve outcomes/decrease rates of intoxicated suicide completion.

Keywords: alcohol intoxication; alcohol use disorder; emergency medicine; emergency psychiatry; suicide.

Annotation

The findings:

This scoping review examines the assessment and management of emergency department (ED) patients presenting with suicidality in the context of acute alcohol intoxication, an area marked by high clinical risk and limited consensus. From 938 screened records, 29 studies were included. Across heterogeneous observational and epidemiologic data, alcohol was present in approximately 20–59% of suicide deaths, and a case-crossover study demonstrated a 27-fold increase in suicide attempt risk within six hours of alcohol use. Despite this elevated risk, intoxicated suicidal patients were less likely to receive psychiatric evaluation or be admitted, with several ED studies reporting lower odds of psychiatric hospitalization following alcohol-related attempts (e.g., OR ≈ 0.45). The review emphasizes initiating suicide risk assessment at presentation, even during intoxication, followed by serial reassessment as intoxication resolves. The authors caution against rigid blood alcohol concentration thresholds, advocating instead for evaluation of clinical sobriety, decisional capacity, and the functional role of alcohol in the suicidal crisis.

Strength and weaknesses:

Strengths include the use of a scoping methodology well-suited to a fragmented literature, comprehensive multi-database searching, reference snowballing, and transparent grading of evidence quality. The review effectively synthesizes findings from diverse observational, post-mortem, and qualitative studies into clinically actionable themes. However, heterogeneity across study designs, populations, and settings limits comparability, and many cited estimates derive from non-ED-specific observational data, precluding quantitative synthesis. As expected for a scoping review, there is no pooled effect estimation or formal risk-of-bias assessment. The evidence base remains largely Level C, with no ED-specific randomized trials, systematic reviews, or formal practice guidelines—leaving gaps in standards for capacity assessment, timing of evaluation, and intervention effectiveness.

Relevance:

For C-L psychiatrists—particularly those practicing in EDs, trauma centers, and VA or safety-net hospitals—this review reframes acute alcohol intoxication as an independent and time-sensitive suicide risk factor, rather than a reason to defer psychiatric evaluation. Clinically, it supports a structured approach that includes (1) immediate medical stabilization and an initial suicide risk formulation using all available data (collateral, chart review, observation), (2) iterative reassessment throughout the ED stay as intoxication resolves, and (3) explicit characterization of alcohol’s role in the suicidal crisis (facilitating disinhibition, binge-related affective collapse, or chronic AUD-related despair). The review reinforces evidence-based C-L interventions such as safety planning, lethal means counseling—particularly regarding firearms, which are more commonly used when alcohol is involved—and ED-initiated alcohol-use interventions (e.g., SBIRT, motivational interviewing, peer navigation). Overall, it argues that meaningful suicide risk reduction in this population requires simultaneous attention to suicidality and alcohol use, spanning the ED encounter and transitions of care.

The need for oversight over apps for substance use reduction
Alex M Russell, Jason B Colditz, Jon-Patrick Allem

Abstract:

No abstract available

Annotation (unstructured):

This JAMA Viewpoint argues that although mobile health apps and generative AI tools hold promise for reducing substance use by lowering barriers to care, the current public app marketplace is largely unregulated and saturated with untested, misleading, or potentially harmful products, posing significant public health risks. The authors review evidence showing that while rigorously studied digital interventions can produce small but meaningful reductions in substance use in controlled trials, most commercially available substance use reduction apps fail to incorporate evidence-based approaches, often make unsubstantiated health claims, and may even promote substance use through advertising-driven design. These problems are compounded by weak regulatory oversight, as most apps are marketed as “wellness” products and thus fall outside FDA authority. The rapid integration of generative AI, including chatbot-based interventions, heightens concern by enabling rapid deployment of opaque, adaptive systems that have already demonstrated serious safety failures—such as generating inaccurate health information, mishandling crises, and normalizing unsafe substance-related behaviors, including among minors. The authors call for substantially stronger governance of app marketplaces, recommending FDA oversight for apps claiming to influence substance use outcomes, requirements for randomized clinical trial evidence prior to marketplace inclusion, mandatory transparency about AI use and model versions, robust crisis-response and adverse-event reporting mechanisms, additional protections for adolescents, and meaningful enforcement against noncompliant developers and distributors. Without such reforms, they argue, commercial innovation will continue to outpace safeguards, potentially delaying engagement with evidence-based treatments and undermining recovery and public health.