Practice Variation in the Pharmacologic Management of Severe Alcohol Withdrawal: a Survey of Medical Toxicology and Critical Care Physicians.

BACKGROUND

Severe alcohol withdrawal is associated with substantial morbidity, mortality, and resource utilization, yet evidence guiding optimal pharmacologic management remains limited. Although benzodiazepines have traditionally been recommended as first-line therapy, current professional guidelines vary. The overall aim is to determine if treatment heterogeneity or practice patterns exist for severe alcohol withdrawal.

METHODS

A scenario-based, self-administered survey of attending physicians who regularly treat severe alcohol withdrawal was performed. Survey invitations were distributed to members of the American College of Medical Toxicology and the University of Pittsburgh Medical Center ICU Service Center. Questions assessed initial medication choice, dosing, drug changes after inadequate response, assessment tools, strategies, physician demographics, and willingness to participate in future clinical trials.

RESULTS

Among 787 physicians invited, 252 responded. Respondents most commonly selected phenobarbital as initial therapy (53.0%), followed by benzodiazepines (41.4%). Phenobarbital was also the most frequently continued drug when selected initially and the most common alternative when initial therapy failed. However, practice patterns varied by specialty. Most respondents preferred symptom-triggered dosing guided by an alcohol withdrawal assessment scale, CIWA-Ar.

CONCLUSIONS

This survey demonstrates that phenobarbital and benzodiazepines are the reported preferred treatments for severe alcohol withdrawal among medical toxicologists and critical care medicine physicians, with a slight overall preference for phenobarbital. Respondents also favored symptom-triggered dosing guided by a withdrawal-specific assessment scale, such as the CIWA-Ar. Importantly, these findings underscore substantial variability in clinical practice and clinician interest in randomized trials to identify optimal treatment strategies for severe alcohol withdrawal.