CPCP: Changing The Way We Manage Alcohol Withdrawal: Dr. Puja Toprani

Now here’s something you haven’t seen in a while; a Clinical Problems in Consultation Psychiatry (CPCP) presentation! This is an outstanding example of a reflective improvement exercise embodying the principle of lifelong learning and implementing a just-in-time clinical improvement plan. It’s by Dr. Puja Toprani, MD, a Family Medicine resident who wants to build a career in academic medicine. Thank goodness.

Alcohol withdrawal syndrome (AWS) management is a daunting challenge in any hospital and health care members have to work as team members to do it well. It’s astonishing there’s not more about how to do that in the medical literature. Dr. Toprani and I and the other members of the team discussed the desert of published research on one specific topic in this domain: how to decide whether to try outpatient detox protocols when continued inpatient stays are not justifiable.

I found one interesting article, of which Dr. Toprani was rightly critical: Stephens, J. R., Liles, E. A., Dancel, R., Gilchrist, M., Kirsch, J., DeWalt, D. A. (2014). Who Needs Inpatient Detox? Development and Implementation of a Hospitalist Protocol for the Evaluation of Patients for Alcohol Detoxification. Journal of General Internal Medicine, 29(4), 587–593. It was worth a look because it’s one of the very few studies actually looking at a question we all struggle with as physicians trying to develop the safest and most effective management plan possible for those suffering from alcohol withdrawal and requesting detoxification.

The question of how to judge patients’ “trustworthiness” arises and we’re just not sure if there’s any practical and reliable way to figure that out. The paper by Stephens and colleagues actually is a Quality Improvement (QI) project rather than a systematic review. The authors came up with an algorithm for deciding whether to detoxify patients on an inpatient or outpatient basis. While I think it’s a laudable effort and it seemed to reduce the readmission rate, we wondered why part of it recommended using the anticonvulsant carbamazepine as one of the two medication regimens for detox, the other being benzodiazepines (BZDs). One systematic review cast doubt on the role of anticonvulsants as primary agents in alcohol detox:

Jesse, S., Bråthen, G., Ferrara, M., Keindl, M., Ben-Menachem, E., Tanasescu, R., Brodtkorb, E., Hillbom, M., Leone, M. A. and Ludolph, A. C. (2017), Alcohol withdrawal syndrome: mechanisms, manifestations, and management. Acta Neurologica Scandinavica, 135: 416.

Jesse and colleagues frankly say: “In summary, besides BZD, anticonvulsants seem to be widely used for the treatment of AWS. Nevertheless, a Cochrane review investigating 56 studies with a total of 4076 participants found no sufficient evidence in favor of any antiepileptic agent for therapy of AWS.” Moreover, carbamazepine can cause pancytopenia. This is a rare problem but it’s something to be aware of in patients who struggle with alcohol use disorder because chronic alcoholism itself can lead to bone marrow suppression. It might be risky to expose them to an agent which can also cause that.

This CPCP led to stimulating discussion on the psychiatry consult service and I hope some of you have comments as well. I believe the proper way to ensure clinical competence is to pursue excellence, which Dr. Toprani is demonstrating every day on the service. It’s much more appropriate for busy doctors than the Maintenance of Certification (MOC), of which she was not aware. It will be very important for her, especially as she pursues a Faculty Development Fellowship. MOC actually takes time away from patient care and slows down the pursuit of excellence; in fact, it interferes with it. The recent Mayo Clinic Proceedings study of physicians’ attitudes about MOC was telling:

Physician Attitudes About Maintenance of Certification. Cook, David A. et al. Mayo Clinic Proceedings , Volume 91 , Issue 10 , 1336 – 1345.

Abstract

Objectives

To determine physicians’ perceptions of current maintenance of certification (MOC) activities and to explore how perceptions vary across specialties, practice characteristics, and physician characteristics, including burnout.

Patients and Methods

We conducted an Internet and paper survey among a national cross-specialty random sample of licensed US physicians from September 23, 2015, through April 18, 2016. The questionnaire included 13 MOC items, 2 burnout items, and demographic variables.

Results

Of 4583 potential respondents, we received 988 responses (response rate 21.6%) closely reflecting the distribution of US physician specialties. Twenty-four percent of physicians (200 of 842) agreed that MOC activities are relevant to their patients, and 15% (122 of 824) felt they are worth the time and effort. Although 27% (223 of 834) perceived adequate support for MOC activities, only 12% (101 of 832) perceived that they are well-integrated in their daily routine and 81% (673 of 835) believed they are a burden. Nine percent (76 of 834) believed that patients care about their MOC status. Forty percent or fewer agreed that various MOC activities contribute to their professional development. Attitudes varied statistically significantly (P<.001) across specialties, but reflected low perceived relevance and value in nearly all specialties. Thirty-eight percent of respondents met criteria for being burned out. We found no association of attitudes toward MOC with burnout, certification status, practice size, rural or urban practice location, compensation model, or time since completion of training.

Conclusion

Dissatisfaction with current MOC programs is pervasive and not localized to specific sectors or specialties. Unresolved negative perceptions will impede optimal physician engagement in MOC.

You can also see the recent Medscape article about the American Board of Internal Medicine (ABIM) MOC and the continuing problems with it. The reader comments are just as interesting as the brief article itself. Will the MOC change with the retirement of the American Board of Medical Specialties (ABMS) current President and CEO, Dr. Lois Nora?

Only time will tell. Rank and file doctors seem to have little influence over the process. I’ve got my fingers crossed for Dr. Toprani. Medicine needs to move on and she has the drive, tenacity, and brains to help make that happen.

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Comments

  1. Great topic Jim,

    Inadequate detoxification is a huge problem and I think it is driven by managed care rather than inadequate medical knowledge. There are very few medically oriented detox facilities these days and like psychiatric disorders – detox has moved from hospitals to much less optimal country run facilities. There is no way that anyone should expect that a person who is consuming moderate to high amounts of alcohol will be able to manage their own detox at home. In my experience many of these folks are given benzodiazepines from their primary care physician or the ED and told to do that. Loss of control over alcohol is the equivalent of loss of control over benzodiazepines.

    The other issue is what we are trying to prevent and that is basically alcohol withdrawal seizures and delirium tremens. The genetics of alcohol metabolism and susceptibility to both conditions is complex making it difficult to predict who will get the complications. I think the general rule of total daily alcohol consumption, duration, and associated medical complications from alcohol can be kept in mind when deciding on withdrawal protocols. Previous withdrawal seizures and other risk factors in this context should rule out prn short acting benzodiazepines in favor of scheduled long acting benzodiazepines. Anticonvulsants may have a place in that setting but the concern raised in your presentation about bone marrow suppression as well as alcoholic liver disease both merit consideration.

    George

    George Dawson, MD, DFAPA

    Liked by 1 person

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