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Evan Wood, MD, PhD, FRCPC, discusses the clinical examination for severe alcohol withdrawal syndrome.
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Evan Wood, MD, PhD, FRCPC, discusses the clinical examination for severe alcohol withdrawal syndrome.
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>> Hello and welcome to JAMAevidence -- our monthly podcast focused on court issues and evidence-based medicine. I'm Ed Livingston. Alcohol withdrawal for patients admitted to the hospital is a substantial problem. Many times it's difficult to differentiate between a patient going into withdrawal -- or becoming septic -- or having some other condition that might require intensive medical care. Because untreated alcohol withdrawal can lead to mortality -- it's important to recognize it early and provide treatment as soon as possible.
To do so requires predicting the occurrence of alcohol withdrawal, as it turns out how to do this is not entirely clear. A rational clinical examination article written by Dr. Evan Wood -- Professor of Medicine at the University of British Columbia in Vancouver -- summarizes the literature regarding how to predict alcohol withdrawal. In today's podcast we talk to Dr. Wood about alcohol withdrawal -- how to predict its occurrence and what to do about it when it occurs. [ Music ] >> We start with understanding how alcohol effects the brain, and how it can result in a withdrawal syndrome, this is explained by Dr. Wood.
>> Alcohol Withdrawal is essentially -- the result of the chronic effects of alcohol on the brain -- that is -- somewhat and completely understood, but essentially involves the neurotransmitter GABA, which is an inhibitory neurotransmitter in our brains -- that with chronic exposure to alcohol is downregulated. And if alcohol use is abruptly stopped, because people choose to seek treatment for their alcohol use disorder or for other reasons, the lack of that inhibitory neurotransmitter GABA leads to a, sort of overexcited state neurologically that contributes to the development of delirium, can contribute to alcohol withdrawal seizure, and a global sort of alcohol withdrawal syndrome involving autonomic hyperactivity, difficulty sleeping, anxiety, and a number of other symptoms in the syndrome complex that can really be -- quite anxiety inducing for patients, and actually are a medical emergency in terms of the high mortality rate that's associated with severe alcohol withdrawal syndrome.
>> So, you described -- a constellation of delirium, autonomic findings, and whatnot, but could you describe in more -- basic terms what a patient like this looks like? A classic presentation in the hospital in the early stages of alcohol withdrawal would normally be somebody is being fidgety in bed. You may ask them to hold their arms out and you can see an obvious tremor. It's a sort of adrenergic state that looks a lot like -- anxiety in terms of people being kind of -- shut down peripherally in terms of that -- adrenergic drive.
They may be tachycardic, they may be febrile, but -- more classically would be tachycardic, and hypertensive. It's not something that you can look at and say, "That's alcohol withdrawal," you usually have to look at that and say, "That may be alcohol withdrawal." And in ways that was among the reasons for this review. >> We need to establish a baseline amount of drinking for someone who's at risk to go into alcohol withdrawal. For men, this is someone who consumes more than four drinks on any given day or 14 per week. For women, it's those who consume more than three drinks on any given day and more than seven per week.
Dr. Wood explains that most patients don't go into withdrawal when they stop drinking and they're admitted to the hospital. The vast majority of people who consume a lot of alcohol and I, you know, daily -- multiple drinks per day use of alcohol won't develop this syndrome. So, you have situation where it's -- a small fraction of people that would develop this. In -- population studies, about 1% of people report alcohol withdrawal syndrome symptoms in the last year -- in patients presenting to acute care -- environments -- general medical environments, it's more like 2%.
So, it's a small fraction that will develop it, but at the same time it's a medical emergency when it happens. Now, if our treatments were benign, we could just treat everybody. But, unfortunately it's a scenario where -- certainly in my clinical experience I've been called to the ward with the invitation to help with a patient who uses alcohol and who's delirious, and then you look at the medical administration record and they've received a lot of benzodiazepine, and it's difficult to know -- are they delirious because of benzodiazepine prophylaxis intended to -- prevent delirium?
Or are they delirious because of the alcohol withdrawal? Alternatively, as your listeners will know, benzodiazepines are very rewarding and can be addictive for some. So, we try to avoid medications like that in -- people with alcohol addiction. And then, of course, there's just the issue of falls, you know, a classic scenario would be someone comes in, there's some suspicion of alcohol withdrawal, they get put on something like the CIWA protocol to prevent alcohol withdrawal, and then they get up in the night to go to the bathroom and have a fall and break their hip.
So, really the best case scenario would be there'd be some way to differentiate -- those high-risk patients who really are indeed at risk. And because alcohol withdrawal at least in the early stages can be so similar to many other presentations in terms of, it's a -- sort of a generic anxiety type presentation, but, we could differentiate those who are high-risk for withdrawal and use this treatment that does carry some risk. And in others take a more -- benzodiazepine sparing approach, and an approach that's maybe a little more cautious acknowledging the risks of trying to prevent alcohol withdrawal.
>> You mentioned a CIWA protocol, what is that? >> So, the Clinical Institute for Withdrawal Scale is probably the most widely used, certainly up here in Canada, and I suspect down in the states as well, which is essentially a symptom triggered approach for prophylaxis treatment of alcohol withdrawal -- that is sort of covering orders in many ways that could be left for nursing and other staff to essentially be vigilant and watch for the emergence of alcohol withdrawal and try and get on top of that, stay ahead of it through benzodiazepine prophylaxis.
The problem is, is that -- the CIWA can result in that sort of overtreatment of people getting benzodiazepines when they don't need them. So, it's sort of a blunt instrument, but certainly can be helpful in cases where you're really worried about the development of alcohol withdrawal syndrome. >> Could you tell us how you diagnose alcohol withdrawal -- which is basically what the whole paper's about, but could you summarize it for us? >> Yeah. I -- mean, this is one of the situations where there is a Diagnostic of And Statistical Manual of Mental Disorders diagnostic criteria -- for sever alcohol withdrawal or alcohol withdrawal in general.
Why don't I just go to that section in the paper to make sure that -- I don't muddle this. So, yeah, the diagnosis of alcohol withdrawal syndrome is through the Diagnostic of -- And Statistical Manual of Mental Disorders, of which we're on the fifth iteration now. And essentially, involves the cessation or would allow for reduction in alcohol use that's been heavy and prolonged. And then, require two or more of the following symptoms develop upon cessation or reduction in use.
So, that would be autonomic hyperactivity -- in the form of tremor, hypertension, or tachycardia. Insomnia, nausea or vomiting, and then people can also develop transient visual tactile or auditory hallucinations or illusions. And then, psychomotor agitation, anxiety, or generalized tonic-clonic seizures would be sort of the classic and progressive severity of symptoms. And then, in addition to that, the signs and symptoms have to cause significant distress or impairment in social, occupational, or other important areas of functioning.
And then, the sort of exclusionary criteria that the signs and symptoms are not attributable to another medical condition or better explained by another mental disorder, including intoxication or withdrawal from another substance. That was a DSM-5, but what did you find in -- your article in terms of the practical ability to diagnose the disease in a hospitalized patient? Yeah, so, we undertook a systematic review of the literature and identified about 530 potentially eligible studies of which -- we -- closely reviewed 50 -- that resulted in 14 high-quality studies.
Hard to generalize about that number, but there were actually, within those 14 high-quality studies, over 70,000 patients and over 1300 -- cases of severe alcohol withdrawal. And what we found is that when we looked at the individual -- symptoms and signs -- there weren't really great individual symptoms and signs. A history of delirium tremens and a baseline systolic blood pressure greater than 140 were marginally useful. And there were essentially no symptoms or signs that helped exclude the diagnosis.
But there have been a number of risk scoring tools that have been developed, and unfortunately, there hasn't been a great deal of validation of those, but -- the risk scoring tools that use a range of measures appear to be quite useful, of which a scoring tool called the PAWSS or the prediction of alcohol withdrawal severity scale, developed by Jose Maldonado at Stanford -- is really probably the most useful at least based on our calculations in this review. It had a -- likelihood ration of 174.
When individuals have four or more findings on the PAWSS, and a negative likelihood ration of 0.07 when there are three or fewer findings. So, that was really the -- conclusion is that, individual symptoms and signs don't really help differentiate high-risk from low-risk patients, but -- for some of these scoring systems, of which there are several, and the PAWSS is the best, really look like they're quite helpful. >> Yeah, in fact, those likelihood ratios are really strong.
Those are highly predictive, aren't they? >> Yeah, I mean, that -- if the PAWSS could be further validated and could be validated in different populations, I think it would be an exceptional tool for being able to look at a patient, for instance, and I think this is a fairly common scenario, where someone will be admitted to hospital for -- any number of acute conditions, commonly something like pneumonia or a COPD exacerbation, they're a known individual who uses a lot of alcohol -- something like the CIWA protocol would be initiated.
And then after sort of 24 hours of observation, an individual's responding to your therapy for the medical condition why they've come in, and everyone's sort of scratching their head saying, "Okay, are we worried that this individual is going to go on to develop server alcohol withdrawal, and do we need to keep them in-hospital to monitor this?" And if we could have scoring systems that could say, "You know, what, we don't even need the CIWA protocol in this instance, because we can be pretty confident that this individual won't develop sever alcohol withdrawal," I think that would be quite helpful.
>> Once you make the diagnosis of withdrawal, how do you treat it? So, there's a -- number of ways that clinicians can treat severe alcohol withdrawal, but certainly by far and away, the most common is to use benzodiazepines, which effect the GABA system, and essentially work much like alcohol and affect the GABA system in that way. And can -- have a market reduction in the severity of severe alcohol withdrawal -- preventing the likelihood of delirium tremens or alcohol withdrawal seizure.
And then, a -- tapering of benzodiazepine regimen in that context is probably the most common way. There was a time, once upon a time when alcohol would be used, ethyl alcohol could be used to prevent and tapered in that context. And then there's some more, I wouldn't say experimental, but at least regimens that don't have the same degree of evidence in terms of being able to prevent withdrawal in terms of clonidine and carbamazepine, and some of the other medications that are used off label in this context.
>> I'm old enough to have been around where the VA -- just a few years before I was an intern in 1985, had taken away the beer from the -- refrigerators of the wards, which was the prime treatment for withdrawal -- because the house staff were stealing all the beer. [ Laughter ] >> That's a history of medicine anecdote. >> Yeah, I mean, it was -- one of those things when you're an intern it's like, "Damn, we just missed it." [ Laughter ] >> Yeah, I think ethyl alcohol administered in a controlled way intravenously once upon a time was -- an approach to a prophylaxis.
So, benzodiazepine has certainly made things simpler, at the same time, the risk of using benzodiazepine, you know, really shouldn't be understated. Not just the risk of falls and delirium from benzodiazepines, but such a common presentation I see an individual with severe alcohol addiction that's been put chronically on benzodiazepines, which is essentially a -- you know, a double hit in terms of the risk of severe alcohol withdrawal. So, some well-meaning clinician usually in the community without -- the expertise in this area will see someone, they've got shaky hands, they're saying, "Hey, Doc, I'm trying to cut down on my alcohol, can you help me?" And then, they'll get a prescription for a benzodiazepine, and will end up on a chronic benzodiazepine.
So -- It's certainly for things like the CIWA protocol and being able to withdraw people safely off of alcohol it's helpful, but there's certainly an issue with the overuse of benzodiazepines in this context as well. >> Could you give me a sense of what the mortality risk is here, just so I can put this in the context of why people need to worry about this? >> Yeah, This is a -- condition that's been studied for a long time, and -- again, sort of referring to the history of medicine, there's some really interesting old, you know, articles you can dig up from the 1950s describing the syndrome.
and with improvements in medical care, mortality rates have gone down. So, historically you'll see for individuals who develop -- severe alcohol withdrawal the mortality rate's quoted in the literature around 15%. In the -- era of sort of more modern therapies and closer medical monitoring, and access to intensive care units and that kind of thing, the mortality rate is down closer to sort of, less than 5%, and from our review, probably closer to about 3%. So, not insignificant, but lower than the historical numbers that people quote.
Could you tell me, do you empirically treat these people with the, what we used to call the yellow cocktail? When you're asked to see a patient with -- alcohol withdrawal, do you empirically give them thiamine and vitamins, and all that? >> We do. We do. I think that sort of -- you know, the historical risks for Wernicke's and I can't say the malnourishment that traditionally -- historically in the literature has gone along with -- sever alcohol addiction where, you know, individuals are just drinking and not -- getting the type of nutrition that is important.
But I think that's just a carryover, it's a low-risk intervention, and -- something that can be quite important in that context when individuals are coming in. I, you know, I see sort of, you know, upper class individuals that look very well nourished that are still getting that intervention, and thinking it's probably not necessary, but very low risk kind of intervention. So, it probably should be offered to all patients. >> Yeah, it's sort of a -- that when I trained and were told, "Just do it. Just give it to them." But -- >> Wow.
>> -- interestingly enough, the whole Wernicke scene has been replaced by bariatric surgical patients, because -- Roux-en-Y gastric bypass patients get that. >> Right. Right. Very interesting, yeah, it's -- I think it's just an evolution from where, you know, people living in poverty, street entrenched -- you know, drinking -- alcohol -- There'd would be, you know, still be considered to be really high-risk.
But, alcohol use is so prevalent in our society that there's probably overtreatment with that in many ways. >> before we go, could you tell us how you administer PAWSS? >> The Prediction of Alcohol Withdrawal Severity Scale is something that could be administered, and really, you know, a minute or two. That essentially has a threshold criteria to determine if the individual's been drinking within the last 30 days or if they have a positive blood alcohol level in an acute environment, then you would go on and administer to -- the rest of the PAWSS.
I certainly do see this clinically, where individuals haven't been drinking and they're not at risk, and yet, they still get put on the CIWA protocol. So -- that's sort of -- the threshold criteria. And then, you 'd -- just some quick questions that you want to ask the patient that are, I think really just broad markers of risk in terms of have they ever experienced a -- previous episode of alcohol withdrawal?
Have they had seizures or delirium tremens? Have they ever been in treatment for alcohol addiction? Have they ever had blackouts? And then, if they've combined alcohol with other -- drugs like benzodiazepines. And then, on physical exam you're looking for any increased autonomic activity -- Or they also get a point if their blood alcohol level is greater than 200. So, it's essentially a 10 point scale, and in the meta-analysis we found that if you had four or more points on this 10 point scale, that gave you that really high likelihood ratio of 174.
And if you had three or less, then the negative likelihood ratio of 0.07. >> Yeah. It seems like it's a very, very simple instrument to implement. It's only got 10 questions -- very easy. So, I think that's a good finding from your paper, that's something that -- people can use. >> Yeah. In our jurisdiction, we're just sort of really starting to take note of this. And I had one of my colleagues who spent -- a week about two weeks ago, working in the local Withdrawal Management Center, and I said, you know, "Do you mind doing an informal audit of how many patients have a PAWSS less than 4." And he said, you know, "Very commonly there's patients that have been admitted for in-patient withdrawal management with a PAWSS of 2.
So, they're, you know, there's a wait list to get into detox, there's patients that don't need to be there. So, I think -- locally we're really going to look to pilot the expansion of this tool to try and preserve the resource for individuals that really need, and save patients having to be admitted into a Withdrawal Management Program when it's not necessary. And ideally do some quality improvement and assess what the impacts of that are from a health economic and a patient experience perspective as well. >> Dr. Wood, thanks for joining me today in this discussion.
More information on this topic is available in the Rational Clinical Examination and on our website JAMAevidence.com, where you can listen to our entire roster of podcasts. I'm Ed Livingston, and I'll be back soon with another episode of JAMAevidence.
Segment:0 .
>> Hello and welcome to JAMAevidence -- our monthly podcast focused on court issues and evidence-based medicine. I'm Ed Livingston. Alcohol withdrawal for patients admitted to the hospital is a substantial problem. Many times it's difficult to differentiate between a patient going into withdrawal -- or becoming septic -- or having some other condition that might require intensive medical care. Because untreated alcohol withdrawal can lead to mortality -- it's important to recognize it early and provide treatment as soon as possible.
To do so requires predicting the occurrence of alcohol withdrawal, as it turns out how to do this is not entirely clear. A rational clinical examination article written by Dr. Evan Wood -- Professor of Medicine at the University of British Columbia in Vancouver -- summarizes the literature regarding how to predict alcohol withdrawal. In today's podcast we talk to Dr. Wood about alcohol withdrawal -- how to predict its occurrence and what to do about it when it occurs. [ Music ] >> We start with understanding how alcohol effects the brain, and how it can result in a withdrawal syndrome, this is explained by Dr. Wood.
>> Alcohol Withdrawal is essentially -- the result of the chronic effects of alcohol on the brain -- that is -- somewhat and completely understood, but essentially involves the neurotransmitter GABA, which is an inhibitory neurotransmitter in our brains -- that with chronic exposure to alcohol is downregulated. And if alcohol use is abruptly stopped, because people choose to seek treatment for their alcohol use disorder or for other reasons, the lack of that inhibitory neurotransmitter GABA leads to a, sort of overexcited state neurologically that contributes to the development of delirium, can contribute to alcohol withdrawal seizure, and a global sort of alcohol withdrawal syndrome involving autonomic hyperactivity, difficulty sleeping, anxiety, and a number of other symptoms in the syndrome complex that can really be -- quite anxiety inducing for patients, and actually are a medical emergency in terms of the high mortality rate that's associated with severe alcohol withdrawal syndrome.
>> So, you described -- a constellation of delirium, autonomic findings, and whatnot, but could you describe in more -- basic terms what a patient like this looks like? A classic presentation in the hospital in the early stages of alcohol withdrawal would normally be somebody is being fidgety in bed. You may ask them to hold their arms out and you can see an obvious tremor. It's a sort of adrenergic state that looks a lot like -- anxiety in terms of people being kind of -- shut down peripherally in terms of that -- adrenergic drive.
They may be tachycardic, they may be febrile, but -- more classically would be tachycardic, and hypertensive. It's not something that you can look at and say, "That's alcohol withdrawal," you usually have to look at that and say, "That may be alcohol withdrawal." And in ways that was among the reasons for this review. >> We need to establish a baseline amount of drinking for someone who's at risk to go into alcohol withdrawal. For men, this is someone who consumes more than four drinks on any given day or 14 per week. For women, it's those who consume more than three drinks on any given day and more than seven per week.
Dr. Wood explains that most patients don't go into withdrawal when they stop drinking and they're admitted to the hospital. The vast majority of people who consume a lot of alcohol and I, you know, daily -- multiple drinks per day use of alcohol won't develop this syndrome. So, you have situation where it's -- a small fraction of people that would develop this. In -- population studies, about 1% of people report alcohol withdrawal syndrome symptoms in the last year -- in patients presenting to acute care -- environments -- general medical environments, it's more like 2%.
So, it's a small fraction that will develop it, but at the same time it's a medical emergency when it happens. Now, if our treatments were benign, we could just treat everybody. But, unfortunately it's a scenario where -- certainly in my clinical experience I've been called to the ward with the invitation to help with a patient who uses alcohol and who's delirious, and then you look at the medical administration record and they've received a lot of benzodiazepine, and it's difficult to know -- are they delirious because of benzodiazepine prophylaxis intended to -- prevent delirium?
Or are they delirious because of the alcohol withdrawal? Alternatively, as your listeners will know, benzodiazepines are very rewarding and can be addictive for some. So, we try to avoid medications like that in -- people with alcohol addiction. And then, of course, there's just the issue of falls, you know, a classic scenario would be someone comes in, there's some suspicion of alcohol withdrawal, they get put on something like the CIWA protocol to prevent alcohol withdrawal, and then they get up in the night to go to the bathroom and have a fall and break their hip.
So, really the best case scenario would be there'd be some way to differentiate -- those high-risk patients who really are indeed at risk. And because alcohol withdrawal at least in the early stages can be so similar to many other presentations in terms of, it's a -- sort of a generic anxiety type presentation, but, we could differentiate those who are high-risk for withdrawal and use this treatment that does carry some risk. And in others take a more -- benzodiazepine sparing approach, and an approach that's maybe a little more cautious acknowledging the risks of trying to prevent alcohol withdrawal.
>> You mentioned a CIWA protocol, what is that? >> So, the Clinical Institute for Withdrawal Scale is probably the most widely used, certainly up here in Canada, and I suspect down in the states as well, which is essentially a symptom triggered approach for prophylaxis treatment of alcohol withdrawal -- that is sort of covering orders in many ways that could be left for nursing and other staff to essentially be vigilant and watch for the emergence of alcohol withdrawal and try and get on top of that, stay ahead of it through benzodiazepine prophylaxis.
The problem is, is that -- the CIWA can result in that sort of overtreatment of people getting benzodiazepines when they don't need them. So, it's sort of a blunt instrument, but certainly can be helpful in cases where you're really worried about the development of alcohol withdrawal syndrome. >> Could you tell us how you diagnose alcohol withdrawal -- which is basically what the whole paper's about, but could you summarize it for us? >> Yeah. I -- mean, this is one of the situations where there is a Diagnostic of And Statistical Manual of Mental Disorders diagnostic criteria -- for sever alcohol withdrawal or alcohol withdrawal in general.
Why don't I just go to that section in the paper to make sure that -- I don't muddle this. So, yeah, the diagnosis of alcohol withdrawal syndrome is through the Diagnostic of -- And Statistical Manual of Mental Disorders, of which we're on the fifth iteration now. And essentially, involves the cessation or would allow for reduction in alcohol use that's been heavy and prolonged. And then, require two or more of the following symptoms develop upon cessation or reduction in use.
So, that would be autonomic hyperactivity -- in the form of tremor, hypertension, or tachycardia. Insomnia, nausea or vomiting, and then people can also develop transient visual tactile or auditory hallucinations or illusions. And then, psychomotor agitation, anxiety, or generalized tonic-clonic seizures would be sort of the classic and progressive severity of symptoms. And then, in addition to that, the signs and symptoms have to cause significant distress or impairment in social, occupational, or other important areas of functioning.
And then, the sort of exclusionary criteria that the signs and symptoms are not attributable to another medical condition or better explained by another mental disorder, including intoxication or withdrawal from another substance. That was a DSM-5, but what did you find in -- your article in terms of the practical ability to diagnose the disease in a hospitalized patient? Yeah, so, we undertook a systematic review of the literature and identified about 530 potentially eligible studies of which -- we -- closely reviewed 50 -- that resulted in 14 high-quality studies.
Hard to generalize about that number, but there were actually, within those 14 high-quality studies, over 70,000 patients and over 1300 -- cases of severe alcohol withdrawal. And what we found is that when we looked at the individual -- symptoms and signs -- there weren't really great individual symptoms and signs. A history of delirium tremens and a baseline systolic blood pressure greater than 140 were marginally useful. And there were essentially no symptoms or signs that helped exclude the diagnosis.
But there have been a number of risk scoring tools that have been developed, and unfortunately, there hasn't been a great deal of validation of those, but -- the risk scoring tools that use a range of measures appear to be quite useful, of which a scoring tool called the PAWSS or the prediction of alcohol withdrawal severity scale, developed by Jose Maldonado at Stanford -- is really probably the most useful at least based on our calculations in this review. It had a -- likelihood ration of 174.
When individuals have four or more findings on the PAWSS, and a negative likelihood ration of 0.07 when there are three or fewer findings. So, that was really the -- conclusion is that, individual symptoms and signs don't really help differentiate high-risk from low-risk patients, but -- for some of these scoring systems, of which there are several, and the PAWSS is the best, really look like they're quite helpful. >> Yeah, in fact, those likelihood ratios are really strong.
Those are highly predictive, aren't they? >> Yeah, I mean, that -- if the PAWSS could be further validated and could be validated in different populations, I think it would be an exceptional tool for being able to look at a patient, for instance, and I think this is a fairly common scenario, where someone will be admitted to hospital for -- any number of acute conditions, commonly something like pneumonia or a COPD exacerbation, they're a known individual who uses a lot of alcohol -- something like the CIWA protocol would be initiated.
And then after sort of 24 hours of observation, an individual's responding to your therapy for the medical condition why they've come in, and everyone's sort of scratching their head saying, "Okay, are we worried that this individual is going to go on to develop server alcohol withdrawal, and do we need to keep them in-hospital to monitor this?" And if we could have scoring systems that could say, "You know, what, we don't even need the CIWA protocol in this instance, because we can be pretty confident that this individual won't develop sever alcohol withdrawal," I think that would be quite helpful.
>> Once you make the diagnosis of withdrawal, how do you treat it? So, there's a -- number of ways that clinicians can treat severe alcohol withdrawal, but certainly by far and away, the most common is to use benzodiazepines, which effect the GABA system, and essentially work much like alcohol and affect the GABA system in that way. And can -- have a market reduction in the severity of severe alcohol withdrawal -- preventing the likelihood of delirium tremens or alcohol withdrawal seizure.
And then, a -- tapering of benzodiazepine regimen in that context is probably the most common way. There was a time, once upon a time when alcohol would be used, ethyl alcohol could be used to prevent and tapered in that context. And then there's some more, I wouldn't say experimental, but at least regimens that don't have the same degree of evidence in terms of being able to prevent withdrawal in terms of clonidine and carbamazepine, and some of the other medications that are used off label in this context.
>> I'm old enough to have been around where the VA -- just a few years before I was an intern in 1985, had taken away the beer from the -- refrigerators of the wards, which was the prime treatment for withdrawal -- because the house staff were stealing all the beer. [ Laughter ] >> That's a history of medicine anecdote. >> Yeah, I mean, it was -- one of those things when you're an intern it's like, "Damn, we just missed it." [ Laughter ] >> Yeah, I think ethyl alcohol administered in a controlled way intravenously once upon a time was -- an approach to a prophylaxis.
So, benzodiazepine has certainly made things simpler, at the same time, the risk of using benzodiazepine, you know, really shouldn't be understated. Not just the risk of falls and delirium from benzodiazepines, but such a common presentation I see an individual with severe alcohol addiction that's been put chronically on benzodiazepines, which is essentially a -- you know, a double hit in terms of the risk of severe alcohol withdrawal. So, some well-meaning clinician usually in the community without -- the expertise in this area will see someone, they've got shaky hands, they're saying, "Hey, Doc, I'm trying to cut down on my alcohol, can you help me?" And then, they'll get a prescription for a benzodiazepine, and will end up on a chronic benzodiazepine.
So -- It's certainly for things like the CIWA protocol and being able to withdraw people safely off of alcohol it's helpful, but there's certainly an issue with the overuse of benzodiazepines in this context as well. >> Could you give me a sense of what the mortality risk is here, just so I can put this in the context of why people need to worry about this? >> Yeah, This is a -- condition that's been studied for a long time, and -- again, sort of referring to the history of medicine, there's some really interesting old, you know, articles you can dig up from the 1950s describing the syndrome.
and with improvements in medical care, mortality rates have gone down. So, historically you'll see for individuals who develop -- severe alcohol withdrawal the mortality rate's quoted in the literature around 15%. In the -- era of sort of more modern therapies and closer medical monitoring, and access to intensive care units and that kind of thing, the mortality rate is down closer to sort of, less than 5%, and from our review, probably closer to about 3%. So, not insignificant, but lower than the historical numbers that people quote.
Could you tell me, do you empirically treat these people with the, what we used to call the yellow cocktail? When you're asked to see a patient with -- alcohol withdrawal, do you empirically give them thiamine and vitamins, and all that? >> We do. We do. I think that sort of -- you know, the historical risks for Wernicke's and I can't say the malnourishment that traditionally -- historically in the literature has gone along with -- sever alcohol addiction where, you know, individuals are just drinking and not -- getting the type of nutrition that is important.
But I think that's just a carryover, it's a low-risk intervention, and -- something that can be quite important in that context when individuals are coming in. I, you know, I see sort of, you know, upper class individuals that look very well nourished that are still getting that intervention, and thinking it's probably not necessary, but very low risk kind of intervention. So, it probably should be offered to all patients. >> Yeah, it's sort of a -- that when I trained and were told, "Just do it. Just give it to them." But -- >> Wow.
>> -- interestingly enough, the whole Wernicke scene has been replaced by bariatric surgical patients, because -- Roux-en-Y gastric bypass patients get that. >> Right. Right. Very interesting, yeah, it's -- I think it's just an evolution from where, you know, people living in poverty, street entrenched -- you know, drinking -- alcohol -- There'd would be, you know, still be considered to be really high-risk.
But, alcohol use is so prevalent in our society that there's probably overtreatment with that in many ways. >> before we go, could you tell us how you administer PAWSS? >> The Prediction of Alcohol Withdrawal Severity Scale is something that could be administered, and really, you know, a minute or two. That essentially has a threshold criteria to determine if the individual's been drinking within the last 30 days or if they have a positive blood alcohol level in an acute environment, then you would go on and administer to -- the rest of the PAWSS.
I certainly do see this clinically, where individuals haven't been drinking and they're not at risk, and yet, they still get put on the CIWA protocol. So -- that's sort of -- the threshold criteria. And then, you 'd -- just some quick questions that you want to ask the patient that are, I think really just broad markers of risk in terms of have they ever experienced a -- previous episode of alcohol withdrawal?
Have they had seizures or delirium tremens? Have they ever been in treatment for alcohol addiction? Have they ever had blackouts? And then, if they've combined alcohol with other -- drugs like benzodiazepines. And then, on physical exam you're looking for any increased autonomic activity -- Or they also get a point if their blood alcohol level is greater than 200. So, it's essentially a 10 point scale, and in the meta-analysis we found that if you had four or more points on this 10 point scale, that gave you that really high likelihood ratio of 174.
And if you had three or less, then the negative likelihood ratio of 0.07. >> Yeah. It seems like it's a very, very simple instrument to implement. It's only got 10 questions -- very easy. So, I think that's a good finding from your paper, that's something that -- people can use. >> Yeah. In our jurisdiction, we're just sort of really starting to take note of this. And I had one of my colleagues who spent -- a week about two weeks ago, working in the local Withdrawal Management Center, and I said, you know, "Do you mind doing an informal audit of how many patients have a PAWSS less than 4." And he said, you know, "Very commonly there's patients that have been admitted for in-patient withdrawal management with a PAWSS of 2.
So, they're, you know, there's a wait list to get into detox, there's patients that don't need to be there. So, I think -- locally we're really going to look to pilot the expansion of this tool to try and preserve the resource for individuals that really need, and save patients having to be admitted into a Withdrawal Management Program when it's not necessary. And ideally do some quality improvement and assess what the impacts of that are from a health economic and a patient experience perspective as well. >> Dr. Wood, thanks for joining me today in this discussion.
More information on this topic is available in the Rational Clinical Examination and on our website JAMAevidence.com, where you can listen to our entire roster of podcasts. I'm Ed Livingston, and I'll be back soon with another episode of JAMAevidence.
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