Journal Article

Alcohol Withdrawal Syndrome (AWS) is a frequent occurrence in the emergency room, with patients often presenting for treatment. Generally, benzodiazepines are used to treat AWS and prevent any of its complications. There is a suggestion that phenobarbital, a barbiturate, may produce similar effects. Both drugs act on the GABA receptors, but have different mechanisms of action. Benzodiazepines facilitate more frequent opening of the channels, whereas barbiturates prolong the channels’ opening. Due to this similar action on GABA, phenobarbital is accepted to be beneficial as well.

This study’s goal was to assess whether adding a one-time dose of phenobarbital to the established regimen of symptomatic lorazepam administration could yield improved outcomes, such as reduced ICU admissions. This is a retrospective chart review which analyzed the records of patients presenting to the emergency department with AWS. Inclusion criteria required patients to have received lorazepam via the institution’s Alcohol Withdrawal Order Set. Those with severe AWS (CIWA over 15) received 4 mg of lorazepam, while those with moderate symptoms (CIWA 9-15) received 2 mg. The comparison group consisted of patients who received a single dose of phenobarbital in addition to lorazepam. The primary outcome measure was the total lorazepam dosage required. Patients receiving a different benzodiazepine were excluded from the analysis.

This study had multiple limitations including its small sample size and possible author bias. However, they found that pts who received 1 dose of phenobarbital were more likely to be discharged from the hospital by day 3 than pts who only received lorazepam. This can be attributed to the longer half life of phenobarbital. In their discussion, they bring a previous study and discuss those findings. That study was a randomized control trial where some pts received phenobarbital and some received normal saline. The dosage of phenobarbital was weight based. That study also found phenobarbital along with the benzodiazepine to be beneficial. This study lacks some of the credibility that the study they discuss has because it is not a randomized control trial and because the dose of the phenobarbital was not standardized. However, this study does concur with the finding of the previous cited study and lends itself towards saying that using phenobarbital can be beneficial for the pt. Additionally, the study did not note any extra adverse effects in the pts who received phenobarbital as well. Further studies must be done to assess the efficacy and risk of adverse effects with concurrent use of benzodiazepines and barbiturates for AWS, but it seems like together the two seem to prevent worsening of AWS.