Fixed Dosing vs Symptom-triggered Dosing of Benzodiazepines
A fixed dosage scheme suffers from the lack of individualized treatment, lack of monitoring and documentation of symptoms and a paternalistic view hampering the patients’ motivation for continued adherence to treatment. (Elholm et al, 2011)
Symptom-triggered therapy individualizes treatment, decreases both treatment duration and the amount of benzodiazepine used, and is as efficacious as standard fixed-schedule therapy for alcohol withdrawal. (JAMA. 1994;272:519-523)
We favor a symptom-triggered approach to the treatment of alcohol withdrawal that involves providing medication only when a patient has symptoms. To use this approach, a regular systematic assessment should be made of the patient's status... (Hoffman & Weinhouse, 2013).
Recently, START provided care for a 41-year old male with a 24-year history of alcohol abuse. “Fred” had initially gone to the ER with alcohol withdrawal syndrome (AWS) and received 30 Ativan with a taper schedule and instructions to see his Primary Provider with-in 3 days. Fred reported taking the entire 30 Ativan over the following 72-hour period. He did make a follow-up appointment with his Provider and received another 30 Ativan at that time with the intention of doing a proper ambulatory detox with daily check-ins at the Provider’s office. However, after picking up the prescription, the reality altered radically from the plan. Fred, having taken enough Ativan to control his AWS symptoms, knew he was not safe to drive. He was staying in a friend’s spare room while going through a divorce and did not have a support system in place to provide safe medication oversight nor transportation. His inability to get in to see his Provider became a reminder of the loss of control in his life and the shame quickly led him to START drinking again. He took the entire 30 Ativan with-in a 48 hour period while drinking.
Five days later, Fred still needed to detox so he could go back to work. Fred called a START RN who helped him arrange to stay at a hotel and receive 24-hour caregiving support including medication administration based on symptom-triggered dosing, regular monitoring of AWS symptoms with a CIWA-based tool, transportation, meal preparation and around-the-clock nursing support. The START RN faxed Fred’s Provider the template orders and the Provider approved the Assisted Ambulatory Alcohol Detox. Fred did not score on the CIWA-based tool for medication during the first 24 hours and he wasn’t experiencing any AWS. The protocol includes a breathalyzer with each monitoring and Fred’s blood alcohol level was 0.00. A urine drug screen was performed and results were positive for Ativan leading us to believe his body was still clearing the Ativan from his previous detox. Fred only needed two doses of Ativan on day 2 of his detox and some additional prn medications for nausea. Fred successfully completed his detox and during the Transition Visit the START RN made a follow-up appointment with the Provider, destroyed the unused Ativan, and faxed a report with the Success Plan (from the Counselor) to the Provider.