Benzo free inpatient hospital?

[PeacockMaiden]

I work as a RN charge nurse at a small 16 bed county managed acute inpatient psychiatric facility. The psychiatrist says she "doesn't believe in benzos" and has declared us a benzo free facility.

She won't prescribe them, no matter how agitated or violent the patient is. She refuses to prescribe benzos for patients who come in after long term ETOH use because she said "we are not a detox facility".

When a patient arrives who has been taking benzos prescribed by an outside provider, she will taper them off in a matter or 1-2 days, no matter how long they have been taking them.

I know that the prescription of benzos must be done with caution, but this psychiatrist's prescribing behavior is dangerous in my opinion and not beneficial for patients in an acute psychiatric crisis.

Does anyone else work at a benzo free facility?

[greenbeanio]

OP: When you have a long-term heavy drinker, does she do anything to prevent seizures, even if it's not a benzo? Because I think that would be important.

One of our docs sometimes used scheduled Depakote for seizure protection instead of putting someone on an Ativan CIWA. And this link is to an article that includes using Tegretol for alcohol detox. http://www.jfponline.com/index.php?id=22143&tx_ttnews[tt_news]=178826

[Jules A, MSN]

OP: When you have a long-term heavy drinker, does she do anything to prevent seizures, even if it's not a benzo? Because I think that would be important.

One of our docs sometimes used scheduled Depakote for seizure protection instead of putting someone on an Ativan CIWA. And this link is to an article that includes using Tegretol for alcohol detox. http://www.jfponline.com/index.php?id=22143&tx_ttnews[tt_news]=178826

It was my understanding that anticonvulsant medications medications are not supported as an ideal option for alcohol withdrawal. If the OPs provider isn't willing to use benzodiazpines for patients at risk of DTs my suggestion would be they aren't admitted to their unit.

From UptoDate:

Alternative and contraindicated agents — Drugs other than phenobarbital and propofol have been used with benzodiazepines or, rarely, alone to treat alcohol withdrawal. These agents are less well studied than benzodiazepines and may mask the hemodynamic signs of withdrawal, which can precede seizures. We believe they should not be used routinely in the treatment of moderate or severe alcohol withdrawal. Such drugs include:

●Ethanol

●Antipsychotics (eg, haloperidol)

●Anticonvulsants (eg, carbamazepine)

●Centrally acting alpha-2 agonists (eg, clonidine)

●Beta blockers (eg, propranolol)

●Baclofen

All of these agents can reduce the frequency and intensity of minor withdrawal symptoms, but more data support the efficacy and safety of benzodiazepines in reducing the risk of seizures and delirium tremens.

●Ethanol – Ethanol should not be used as therapy in the setting of acute alcohol withdrawal. It is difficult to titrate, associated with many adverse metabolic and end-organ effects, and clearly inferior to benzodiazepines [50]. Of note, the metabolism and kinetics of ethanol have not been well studied in the critically ill.

●Antipsychotics – Phenothiazines and butyrophenones (including haloperidol) lower the seizure threshold and should not be used routinely in the withdrawing alcoholic [51]. These drugs may also interfere with heat dissipation and do not exhibit cross-tolerance with ethanol.

Treatment with antipsychotics would only be appropriate when a decompensated thought disorder (such as schizophrenia) coexists with ethanol withdrawal and any symptoms associated with ethanol withdrawal have been definitively treated with benzodiazepines. In our experience, such occurrences are rare, even in patients with known thought disorders.

If a clinician determines that antipsychotic therapy is indicated, we recommend an ECG to screen for QT prolongation (a contraindication to many antipsychotic medications) and the correction of electrolyte abnormalities (such as hypokalemia and hypomagnesemia, which are common in alcoholics) before any medication is administered.

●Anticonvulsants – Sustained anticonvulsant therapy has no role in patients with isolated alcohol withdrawal seizures. The overwhelming majority of seizures from withdrawal are self-limited and do not require treatment with anticonvulsants. If status epilepticus ensues, phenobarbital or propofol may be used for short-term management in conjunction with benzodiazepines, while an underlying cause is investigated. (See 'Withdrawal seizures' above.)

While carbamazepine may have a role in the outpatient management of mild alcohol withdrawal, convincing evidence that the drug effectively treats patients with delirium tremens or other severe symptoms is lacking [52]. (See "Medically supervised alcohol withdrawal in the ambulatory setting".)

●Centrally acting alpha-2 agonists ‒ Some clinicians report using centrally acting alpha-2 agonists (eg, dexmedetomidine) as adjunct therapy for alcohol withdrawal, and these agents may reduce some symptoms of withdrawal. However, there are no controlled trials showing that they prevent the development of seizures or DT. Pending more convincing studies, we believe centrally acting alpha-2 agonists should not be used as a primary treatment for acute severe alcohol withdrawal.

●Beta blockers – Beta blockers may reduce minor symptoms of withdrawal, but they have not been shown to prevent the development of seizures or DT. We believe they should not be used for the treatment of acute severe alcohol withdrawal. However, patients with known cardiovascular disease should be given their maintenance medications after sedation and volume resuscitation, as sustained tachycardia and hypertension may contribute to cardiovascular morbidity especially in the elderly.

●Baclofen – Baclofen, a selective agonist of the gamma-aminobutyric acid (GABA)-B receptor used to treat reversible spasticity, has been studied as a therapy for acute alcohol withdrawal, but its effectiveness in controlling severe symptoms remains unproven [53-56]. We believe baclofen should not be used for the treatment of acute severe alcohol withdrawal.

From: http://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes

[greenbeanio]

Thanks, Jules. What do you think of the use of anticonvulsants in mild alcohol detox in a patient with no hx and low risk of seizures or DTs? You know, the patients who have no objective symptoms and whose only detox symptoms are "really bad anxiety, I'm jumping out of skin, I NEED some Ativan right now"?

[Jules A, MSN]

Thanks, Jules. What do you think of the use of anticonvulsants in mild alcohol detox in a patient with no hx and low risk of seizures or DTs? You know, the patients who have no objective symptoms and whose only detox symptoms are "really bad anxiety, I'm jumping out of skin, I NEED some Ativan right now"?

As antibenzo as I tend to be except in cases of severe anxiety with no substance abuse history or paranoid schizophrenia I am rather generous in an effort to prevent benzo or alcohol withdrawal seizures. With acute alcohol withdrawal, even fairly mild, I almost always use a standing order benzo taper in addition to the CIWA monitoring with additional prn benzos. I prefer Valium but will use Ativan if their LFTs are jacked up. It is my objective to avoid full blown DTs, take the burden off my nurses for administering round the clock prns and make the patient as comfortable as possible during the first few days of withdrawal. You can get behind the 8ball fairly quickly with DTs and I don't even want to dip my toes in that cesspool. I do not send them out on benzodiazepines and when I work OP patients with substance abuse, especially alcohol, they would not get benzos from me.

I'm not sure where the benefit would be to order an anticonvulsant vs a brief benzo taper early on in an inpatient setting. Out patient is different because of the chances of them drinking and taking the benzodiazepines so I would probably trial SSRI with Vistaril prn and add Buspar down the road if needed in the early weeks with therapy and 12 step attendance. Mood stabilizers can be helpful and indicated in the early months of alcohol cessation if the above isn't effective or only provide partial relief of ongoing anxiety and mood symptoms. I would go more with Lamictal or Trileptal rather than Depakote or Tegretol for the lowered side effect profile. Are you thinking of a situation in mind where anticonvulsants early on might be beneficial? I'm always up for exploring different ideas.

[macfar28]

But in some cases I feel like a joke throwing Atarax at someone who's had to depend on Klonopin to be low-functioning at best for the past twenty years.

I honestly can't imagine NEVER using Ativan in a cocktail. Sometimes it's the only thing that stands between a patient and constant violence. I love when providers make decisions like that...because they don't have to deal with the consequences.

Absolutely agree. As you said, sometimes ativan is the only thing that's going to help a violent patient. There are also providers who truly aren't thinking about the safety of the patient, staff and overall milieu for whatever reason (inexperience, own personal recovery, etc). This, too, has been my experience.

[OwlNation]

She needs to ensure detoxers are not admitted. And Benzo tapering should be done properly!