Search Our Scientific Publications & Authors

Crit Care Nurs Q 2019 Jan/Mar;42(1):12-29

Department of Pharmacy Services, UC Health-University of Cincinnati Medical Center, Ohio (Drs Foertsch, Winter, Droege, and Ernst); University of Cincinnati James L. Winkle College of Pharmacy, Ohio (Drs Foertsch, Winter, Rhoades, Martin, Droege, and Ernst); Department of Pharmacy Services, The Christ Hospital Health Network, Cincinnati, Ohio (Dr Rhoades); and Department of Pharmacy Services, St Elizabeth Healthcare, Edgewood, Kentucky (Dr Martin).

Alcohol withdrawal syndrome (AWS) is a complex neurologic disorder that develops after an acute reduction in or cessation of chronic alcohol consumption that alters neurotransmitter conduction. The incidence of AWS in the intensive care unit varies, but has been associated with poor outcomes. This is primarily driven by downregulation of gamma-aminobutyric acid (GABA) leading to autonomic excitability and psychomotor agitation. Read More

Am J Emerg Med 2018 Oct 11. Epub 2018 Oct 11.

School of Pharmacy, University of Sydney, Royal Prince Alfred Hospital, Pharmacy and Bank Building (A15), Camperdown Campus, Sydney, New South Wales 2006, Australia. Electronic address:

Objectives: To compare a phenobarbital-adjunct versus benzodiazepine-only approach for the management of alcohol withdrawal syndrome in the emergency department (ED) with regard to the need for intensive care unit (ICU) admission, severity of symptoms on ED discharge, and complications.

Methods: This was a retrospective cohort study conducted in two academic EDs in the United States. Adult patients seen in the ED with a diagnosis of alcohol withdrawal syndrome were included. Read More

Asian J Psychiatr 2018 Dec 24;38:29-30. Epub 2018 Oct 24.

Department of Psychiatry, National Institute of Mental Health & Neurosciences (NIMHANS), Bengaluru, India. Electronic address:

Rev Med Brux 2018;39(4):241-245

Service de Psychiatrie-Addictologie, CHU Brugmann, ULB.

This article proposes an update and summary of current knowledge in the management of alcohol withdrawal, based on a review of recent literature. The issues open to debate and the areas whith new developments will be addressed, such as: the entry into treatment, the withdrawal setting, the withdrawal medications, the various possible protocols and the introduction of relapse prevention treatments. Read More

Clin Nurse Spec 2018 Nov/Dec;32(6):307-312

Author Affiliations: Clinical Nurse Specialists (Mss Davis and Keen), Indiana University Health, University Hospital, Indianapolis; Clinical Nurse Specialist (Mr Holly), Indiana University Health, Bloomington Hospital; Clinical Nurse Specialist (Ms Balaguras), Indiana University Health, Bloomington Hospital; and Assistant Professor (Dr Miller), Indiana University School of Nursing, Indianapolis.

Purpose/aims: The purpose of this study was to validate a tool to assess alcohol withdrawal in acute care patients. Study aims included (1) establish content validity, (2) examine criterion-related validity, (3) test interrater reliability, and (4) assess nurse usability.

Design: A psychometric research study was designed to evaluate the Alcohol Withdrawal Assessment Tool. Read More

Curr Opin Support Palliat Care 2018 Dec;12(4):489-494

Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, USA.

Purpose Of Review: To provide an evidence-based synopsis on the role of benzodiazepines in patients with agitated delirium.

Recent Findings: Existing evidence supports the use of benzodiazepines in two specific delirium settings: persistent agitation in patients with terminal delirium and delirium tremens. In the setting of terminal delirium, the goal of care is to maximize comfort, recognizing that patients are unlikely to recover from their delirium. Read More

Rehabil Psychol 2018 Nov 13;63(4):588-594. Epub 2018 Sep 13.

Department of Physical Medicine and Rehabilitation.

Purpose: To compare recovery experienced during inpatient rehabilitation among individuals with traumatic brain injury (TBI) based on whether their acute care included the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol.

Design: Participants included 234 individuals with TBI who completed inpatient rehabilitation at a TBI Model Systems site. Of these, 67 patients were treated using the CIWA protocol (TBI + CIWA); 167 patients were treated for TBI alone (TBI only). Read More

Intern Emerg Med 2018 Sep 5. Epub 2018 Sep 5.

Regional Centre on Alcohol, Genoa, Italy.

The chronic use of alcohol can lead to the onset of an alcohol use disorder (AUD). About 50% of subjects with an AUD may develop alcohol withdrawal syndrome (AWS) when they reduce or discontinue their alcohol consumption and, in 3-5% of them, convulsions and delirium tremens (DTs), representing life-threatening complications, may occur. Unfortunately, few physicians are adequately trained in identifying and treating AWS. Read More

Eur Rev Med Pharmacol Sci 2018 Aug;22(16):5371-5376

Department of Anesthesia, Anesthesia and Chronic Pain, McMaster University, Hamilton, Ontario, Canada

Objective: Delirium Tremens (DT) is the most severe complication of alcohol withdrawal syndrome (AWS), and has a mortality rate of 1-5%. Baclofen is recommended for spasticity treatment, but it has recently been used for alcohol withdrawal symptoms reduction and alcohol abstinence.

Case Report: A cervical spinal cord injury patient was treated for two years with oral baclofen 80 mg/day for spasticity. Read More

JAMA 2018 08;320(8):825-833

British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada.

Importance: Although severe alcohol withdrawal syndrome (SAWS) is associated with substantial morbidity and mortality, most at-risk patients will not develop this syndrome. Predicting its occurrence is important because the mortality rate is high when untreated.

Objective: To assess the accuracy and predictive value of symptoms and signs for identifying hospitalized patients at risk of SAWS, defined as delirium tremens, withdrawal seizure, or clinically diagnosed severe withdrawal. Read More

JAMA 2018 08;320(8):766-768

Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts.

Adv Clin Exp Med 2018 Aug 7. Epub 2018 Aug 7.

Department of Psychiatry, Faculty of Medicine, Pomeranian Medical University, Szczecin, Poland.

Background: Numerous studies have investigated the association between the OPRM1 A118G polymorphism (rs1799971) and alcohol dependence, but the results have been inconsistent. The endogenous opioid system has been implicated in the development of alcohol dependence for its prominent role in the central rewarding mechanism.

Objectives: The aim of this study was to evaluate the role of the A118G polymorphism of the OPRM1 gene in the pathogenesis of alcohol dependence syndrome (ADS). Read More

J Formos Med Assoc 2018 Dec 19;117(12):1124-1127. Epub 2018 Jun 19.

Taipei City Psychiatric Center, Taipei City Hospital, Addiction Psychiatry Department, Taipei, Taiwan; Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan. Electronic address:

Gamma-hydroxybutyrate (GHB) is a synthetic drug used mainly for recreational purpose. Although the prevalence of GHB abuse is low in Taiwan, GHB has become increasingly popular in certain subpopulations such as clubbers and men who have sex with men (MSM). GHB dependence could be associated with severe withdrawal syndrome including hallucinations and delirium. Read More

Pharmacotherapy 2018 May 25. Epub 2018 May 25.

Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut.

Study Objective: Alcohol use disorders are prevalent and put patients at risk for developing alcohol withdrawal syndrome (AWS). Treatment of AWS with a symptom-triggered protocol standardizes management and may avoid AWS-related complications. The objective of this study was to evaluate whether implementation of a specific intensive care unit (ICU) symptom-triggered protocol for the management of AWS was associated with improved clinical outcomes and, in particular, would reduce the risk of patients with AWS requiring mechanical ventilation. Read More

J Med Toxicol 2018 Sep 10;14(3):229-236. Epub 2018 May 10.

Department of Emergency Medicine, Advocate Christ Medical Center, 4440 95th St., Oak Lawn, IL, 60453, USA.

Introduction: Benzodiazepine (BZD)-resistant alcohol withdrawal remains a challenge for most institutions due to limited evidence with available agents. One published study currently exists utilizing the N-methyl-D-aspartate antagonist, ketamine, for alcohol withdrawal.

Objective: The purpose of our study was to evaluate the effect of adjunctive ketamine continuous infusion on symptom control and lorazepam infusion requirements for BZD-resistant alcohol withdrawal patients in the intensive care unit. Read More

Crit Care Med 2018 Aug;46(8):e768-e771

Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA.

Objectives: Ketamine offers a plausible mechanism with favorable kinetics in treatment of severe ethanol withdrawal. The purpose of this study is to determine if a treatment guideline using an adjunctive ketamine infusion improves outcomes in patients suffering from severe ethanol withdrawal.

Design: Retrospective observational cohort study. Read More

Psychosomatics 2018 Nov 12;59(6):622. Epub 2018 Mar 12.

Icahn School of Medicine at Mount Sinai, New York, NY; Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY. Electronic address:

Asian J Psychiatr 2018 Jan 12;31:137-141. Epub 2018 Feb 12.

Postgraduate Institute of Medical Education & Research, Chandigarh, India.

Background And Aims: Delirium Tremens (DT) is the most severe form of alcohol withdrawal syndrome, with a potential risk of mortality. Search for the predictors of DT led to study of candidate genes, with inconsistent and inconclusive results. This study aimed to explore the association of various candidate gene polymorphisms and DT in a case-control design. Read More

J Intensive Care Med 2018 Jan 1:885066617754187. Epub 2018 Jan 1.

1 Orlando Health, Orlando, FL, USA.

Objective: To evaluate the efficacy and safety of lurasidone compared with quetiapine for treatment of delirium in critically ill patients.

Design: Prospective, observational cohort study.

Setting: Single-center community teaching hospital. Read More

Psychosomatics 2018 May - Jun;59(3):293-297. Epub 2017 Nov 24.

Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Department of Neuropsychiatry and Clinical Ethics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan.

Alcohol Alcohol 2018 Jan;53(1):71-77

University Hospital of Psychiatry, University of Bern, Switzerland.

Aims: As there are only a few existing experimental studies on symptom-triggered therapy for patients with alcohol withdrawal, we investigated the effectiveness of symptom-triggered detoxification regarding the use and dosage of benzodiazepine and withdrawal complications in a naturalistic clinical setting of a specialized treatment center for alcohol use disorder.

Methods: In total, 301 charts of patients who entered residential treatment for alcohol withdrawal were included in the retrospective analysis. Charts of 176 patients treated with the Alcohol Withdrawal-Scale (AWS) were compared to the charts of 125 patients treated with treatment as usual (TAU) before the implementation of AWS. Read More

Hosp Pharm 2017 Oct 17;52(9):607-616. Epub 2017 Jul 17.

University of Pittsburgh School of Pharmacy, PA, USA.

Benzodiazepines are the drug of choice for alcohol withdrawal syndrome (AWS); however, phenobarbital is an alternative agent used with or without concomitant benzodiazepine therapy. In this systematic review, we evaluate patient outcomes with phenobarbital for AWS. Medline, Cochrane Library, and Scopus were searched from 1950 through February 2017 for controlled trials and observational studies using ["phenobarbital" or "barbiturate"] and ["alcohol withdrawal" or "delirium tremens. Read More

Med Clin (Barc) 2018 Aug 21;151(3):103-108. Epub 2017 Dec 21.

Servicio de Epidemiología y Estadística, Complejo Universitario Hospitalario de A Coruña, A Coruña, España.

Background: There are no data on the incidence of admissions associated with alcohol withdrawal syndrome (AWS) or about its trend over time in Spain.

Objective: To analyze the characteristics, incidence rates and trends over time of hospital admissions associated with AWS in Spanish public hospitals.

Material And Method: Analysis from the Spanish public hospitals minimum basic data set of hospital admissions with AWS (CIE9-MC 291. Read More

Indian J Psychol Med 2017 Sep-Oct;39(5):665-667

Antara Psychiatric Centre, Sri Aurobindo Seva Kendra, Kolkata, West Bengal, India.

Opioid withdrawal is very rarely characterized by delirium unlike alcohol or benzodiazepine withdrawal. PubMed search through October 2016 reveals only two case series on delirium as feature of withdrawal in opioid dependence syndrome. We report two cases of opioid withdrawal (heroin) presenting with delirium when low-dose buprenorphine (2 mg/day) was added. Read More

J Addict Nurs 2017 Oct/Dec;28(4):E1-E2

Alcohol withdrawal syndrome (AWS) is commonly encountered in the intensive care unit population. Currently, the mainstay treatment for AWS is the use of benzodiazepines. However, some patients are refractory to benzodiazepine treatment due to heavy alcohol abuse. Read More

J Addict Nurs 2017 Oct/Dec;28(4):188-195

Tarenne A. Ferenchak, BA, BSN, MSN, RN, College of Nursing, Thomas Jefferson University, Philadelphia, Pennsylvania.

Alcohol withdrawal syndrome (AWS) is commonly encountered in the intensive care unit population. Currently, the mainstay treatment for AWS is the use of benzodiazepines. However, some patients are refractory to benzodiazepine treatment due to heavy alcohol abuse. Read More

J Arthroplasty 2018 04 13;33(4):1171-1176. Epub 2017 Nov 13.

The Rothman Institute of Orthopaedics at Thomas Jefferson University, Egg Harbor Township, New Jersey.

Background: Delirium is a common complication among elderly patients undergoing total joint arthroplasty (TJA). Its incidence has been reported from 4% to 53%. The Centers for Medicare and Medicaid Services consider delirium following TJA a "never-event. Read More

J Investig Med High Impact Case Rep 2017 Oct-Dec;5(4):2324709617742166. Epub 2017 Nov 13.

University of California Los Angeles, CA, USA.

The standard of care for alcohol withdrawal centers on the use of escalating doses of benzodiazepines until clinical improvement is achieved. However, there is no established standard in the care of patients with severe alcohol withdrawal and delirium tremens that is refractory to benzodiazepine therapy. One potential therapy that is gaining traction is the use of phenobarbital, which may be mechanistically superior to benzodiazepines in treating delirium tremens because of its effects on GABA and N-methyl-D-aspartate receptors. Read More

Alcohol Alcohol 2018 May;53(3):259-267

Betsi Cadwaladr University Health Board (BCUHB), Heddfan Unit, Wrexham Maelor Hospital, Wrexham, Wales LL13 7TD, UK.

Aims: To evaluate the effectiveness of evidence based treatments for alcohol-induced psychotic disorder (AIPD) as described by ICD-10 and DSM-5, a condition that is distinct from schizophrenia and has a close relationship with alcohol withdrawal states.

Method: Systematic review using PRISMA guidelines.

Results: Of 6205 abstracts found, fifteen studies and ten case reports met criteria and were examined. Read More

Indian J Psychiatry 2017 Jul-Sep;59(3):300-305

Department of Psychiatry, Jawaharlal Nehru Institute of Medical Sciences, Imphal, India.

Introduction: Alcohol withdrawal delirium (AWD) or delirium tremens (DT) is associated with severe complications and high mortality. Prospectively identifying patients with increased risk of developing DT would have important preventive and therapeutic implications. Thus, the present study aimed to identify clinical risk factors predicting the development of DT. Read More

Indian J Psychiatry 2017 Jul-Sep;59(3):293-299

Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India.

Background: Delirium tremens (DT) is a medical emergency. Many cases are treated and discharged from emergency services (ES), after complete or partial resolution of delirium. Few receive comprehensive inpatient addiction treatment (CIAT) after the initial emergency management. Read More

JAMA 2017 Oct;318(15):1441-1442

Oregon Health & Science University, Division of General Internal Medicine, Portland, Oregon.

BMJ Case Rep 2017 Oct 15;2017. Epub 2017 Oct 15.

Department of Internal Medicine, Hurley Medical Center, Flint, Michigan, USA.

A 60-year-old African-American man with a medical history significant for heavy alcohol abuse, hypertension, delirium tremens, nephrolithiasis and seizure disorder was brought to the hospital with altered mental status. He was found to have high anion gap metabolic acidosis with significantly elevated lactate along with an elevated osmolal gap and calcium oxalate crystals in his urine. With this combination of findings, ethylene glycol poisoning was high in the differential. Read More

Am J Emerg Med 2017 Dec 29;35(12):1956-1957. Epub 2017 Sep 29.

The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas 75390, TX, United States.

Am J Emerg Med 2017 Dec 29;35(12):1956. Epub 2017 Sep 29.

Alcohol treatment unit, University hospital, 80000 Amiens, France. Electronic address:

Turk Psikiyatri Derg 2017 ;28(3):217-220

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological entity characterized by headache, altered mental status, epileptic seizures, visual disturbances and typically transient changes in posterior cerebral circulation areas. In this article, we present a case of alcohol withdrawal accompanied by PRES.

Case Presentation: A 53-year-old male patient presented to the emergency department with visual hallucinations and meaningless speech. Read More

Can Fam Physician 2017 09;63(9):691-695

Medical Lead for Addiction Medicine, Mental Health and Substance Use for the Interior Health Authority in British Columbia and a clinical instructor in the Department of Family Medicine at the University of British Columbia in Vancouver. At the time of this case she was an addiction medicine physician at St Paul's Hospital in Vancouver.

Anaesthesist 2017 Nov 8;66(11):858-861. Epub 2017 Sep 8.

Klinik für Anästhesie und Intensivtherapie, Integriertes Forschungs- und Behandlungszentrum Sepsis und Sepsisfolgen, Universitätsklinikum Jena, Paul-Schneider-Str. 2, 07747, Jena, Deutschland.

A previously healthy 60-year-old patient presented to the emergency department with severe headache, altered personality and fever. He was treated for bacterial meningitis with delirium of unknown cause but presumed to be due to alcohol withdrawal. Despite receiving the antibiotic therapy regimen recommended for bacterial meningitis the patient's condition rapidly deteriorated with profound delirium and tachypnea. Read More

Indian J Psychol Med 2017 Jul-Aug;39(4):441-444

Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Navi Mumbai, Maharashtra, India.

Aims: This study aimed to evaluate the patterns of platelet counts during the course of alcohol withdrawal and its relationship if any with liver enzymes.

Methodology: Forty consecutive patients, with alcohol dependence according to the Diagnostic and Statistical Manual of Mental Disorders-fourth edition, Text Revision criteria, willing for a 10-day inpatient detoxification program and presenting within 12 h of the last consumption of alcohol were recruited in the study. Details about the diagnosis and alcohol consumption patterns were assessed with a detailed psychiatric interview. Read More

Asian J Psychiatr 2017 Dec 12;30:98-99. Epub 2017 Aug 12.

Department of Psychiatry, JSS Medical College, JSS University, Mysore, Karnataka, 570004, India.

Am J Addict 2017 Oct 24;26(7):722-730. Epub 2017 Aug 24.

Department of Psychiatry, Yale University, New Haven, Connecticut, 06511.

Background And Objectives: Alcohol withdrawal-especially delirium tremens (DT)-is a potentially life-threatening condition. While short-term treatment regimens and factors that predispose to more severe symptomatology have been extensively studied, little attention has been paid to the clinical epidemiology and long-term care of the chronic medical, addictive, psychiatric, and psychosocial problems faced by these patients.

Methods: National Veterans Health Administration data from fiscal year 2012 were examined to identify veterans diagnosed with DT; with withdrawal but not DT (WNDT); and with Alcohol Use Disorder (AUD) but neither DT nor WNDT. Read More

Case Rep Psychiatry 2017 24;2017:2598973. Epub 2017 Jul 24.

Department of Psychiatry, Patan Academy of Health Sciences, Lalitpur, Nepal.

Autoscopic phenomenon, a psychic illusionary duplication of one's own self, has been the subject of interest in the literature and science for years. It has been reported in various diseases of the central nervous system but with an unknown mechanism. Hallucinations are a common presentation in alcohol dependence syndrome during delirium tremens and as induced disorder. Read More

Subst Abus 2017 Oct-Dec;38(4):394-400. Epub 2017 Jul 12.

e Division of Pulmonary and Critical Care Medicine , Johns Hopkins University School of Medicine , Baltimore , Maryland , USA.

Background: The standard of care for management of alcohol withdrawal is symptom-triggered treatment using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar). Many items of this 10-question scale rely on subjective assessments of withdrawal symptoms, making it time-consuming and cumbersome to use. Therefore, there is interest in shorter and more objective methods to assess alcohol withdrawal symptoms. Read More

Rev Clin Esp 2017 Oct 21;217(7):381-386. Epub 2017 Jun 21.

Medicina Interna, Hospital Universitario Lucus Augusti, Lugo, España.

Objectives: To analyse the influence of epidemiological and sociodemographic factors in complicated alcohol withdrawal syndrome (AWS).

Material And Methods: A multicentre, observational prospective study was conducted on consecutively added patients with AWS hospitalised in internal medicine departments. We recorded sociodemographic, epidemiological, clinical and progression data. Read More

Clin Neuropharmacol 2017 Jul/Aug;40(4):183-184

*Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, and †Department of Anaesthesiology and Critical Care Medicine, Medical Faculty Mannheim, Heidelberg University, Germany.

Objective: Alcohol withdrawal delirium (AWD) is a notorious complication in alcohol withdrawal. Usually, the symptomatic treatment is efficacious; however, some patients show treatment resistance or a prolonged course of AWD.

Method: We report the case of a patient with a prolonged and severest form of AWD. Read More