Hey NEJM, where’s the beef?

By  |  November 30, 2014 | 

 

I opened the most recent copy of NEJM with anticipation.  At last, a review on severe alcohol withdrawal.  Perhaps a solution to the age old conflict between psychiatry (start benzo on Monday, decrease by 20-25% daily and discharge on Thursday or Friday) versus medicine (start benzo on Monday, and if they look like a rose on Tuesday, send them home).  No such luck.

I did find this though:

“The doses needed to control agitation and insomnia vary dramatically among patients and can be prodigious (e.g., >2000 mg of diazepam in the first 2 days in some patients); this underscores the advisability of providing treatment in a hospital, preferably in an ICU.”

UM.  You think?  

The management of alcohol withdrawal dangles out there.  Not since the CIWA scale (>10 years) has anything new crossed our path.  Not a lick.  The treatment sits at an intersection between medical, psychiatric, and social domains–and defies our uniform ability to categorize discharge readiness or safety.  We use our best judgment and hope to mirror each other’s practice within 2 SD’s.

I am waiting for the SHM plenary in which a resourceful group presents some compelling, new data–and moves the evidence base further down field toward the goal line.  Its’ been a long time since we’ve altered practice or learned something new.

Here’s a handy little table.  And yes, it still looks the same:

 

etoh

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About the Author:

Brad Flansbaum
Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education. Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates. Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University. He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.

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