Alcohol Withdrawal Treatment: Bring Back Phenobarbital?

This protocol is certainly easier than many of the benzodiazepine-based protocols. Better yet, some recent data suggest that this approach may even decrease intubation rates. This was suggested (though hardly proven) in a study published in Critical Care Medicine.¹

On our recent show, we discussed why the lower intubation rates might be occurring in the patients getting phenobarbital only. While we can’t be sure, it is a distinct possibility that phenobarbital isn’t better than the fairly aggressive diazepam-based protocol suggested in Goldfrank’s Toxicology Emergencies. Sure, phenobarbital hits NMDA receptors in addition to GABA and that might confer some advantage over benzos. However, it might just be that people aren’t that comfortable following the Goldfrank-inspired protocol—which is a shame because it works well. Many facilities feel uneasy giving escalating doses of diazepam (starting from 5 mg and rising to 10 mg, 20 mg, 40 mg, and even 80 mg per dose) every five minutes to a patient in alcohol withdrawal. Instead, the patients get under-dosed, and they end up progressing to delirium tremens and, not infrequently, require intubation for airway protection.

Interestingly, after we published our podcast, the feedback we got was divergent. Younger physicians tended to find the idea of ditching benzodiazepines in favor of phenobarbital monotherapy to be sort of crazy, but kind of awesome. As usual, the up-and-comers are excited by anything that sounds edgy, especially when it involves controlled substances, but the more seasoned emergency physicians were less impressed, albeit somewhat enthusiastic. One of the more experienced critical care physicians we spoke to said, “Yeah, we used to use phenobarbital monotherapy all the time, and it was easy and worked great. We should definitely consider going back to that. I hate CIWA scores [Clinical Institute Withdrawal Assessment for Alcohol scale, a tool to assess withdrawal severity]!”

So, we guess what’s old again is new again. FOAMed has many faces and facets, and we at FOAMcast are pleased to bring it to our listeners.

Do you have any effective old-school treatments that make you feel like a dinosaur? Let us know, and as always, share any evidence and your experience. We’d love to cover it in a future show.

Dr. Faust (@JeremyFaust) is a clinical instructor at Harvard Medical School and an attending physician in department of emergency medicine at Brigham & Women’s Hospital, Boston, Massachusetts.

Dr. Westafer (@Lwestafer) is an attending physician and research fellow at Baystate Medical Center, clinical instructor at the University of Massachusetts Medical School in Worcester, and co-host of FOAMcast.