Original Title: Administration de benzodiazépines ou de gabapentine prescrites dans le cadre d’une ordonnance individuelle pour le sevrage d’alcool : Rapport en soutien au protocole médical national

Authors' objectives: Stopping or significantly reducing alcohol consumption after prolonged and heavy use can lead to the development of alcohol withdrawal syndrome. The associated signs and symptoms may be mild, such as tremor and insomnia, but can also progress to major complications, such as delirium tremens and even death in the absence of appropriate pharmacological treatment. In 2014, the Ministère de la Santé et des Services sociaux (MSSS) tasked the Institut national d'excellence en santé et en services sociaux (INESSS) with developing, updating, and hosting the current national medical protocols (NMPs) and prescription templates. In connection with the implementation of the Plan d’action interministériel en dépendance 2018-2028 (2018-2028 Interministerial Addiction Action Plan), and considering that a large portion of the clinical procedures performed in the context of alcohol withdrawal are handled by nurses, the MSSS’s Direction nationale des soins et services infirmiers asked the INESSS to develop an NMP that would provide a framework for administering drugs prescribed via an individual prescription to treat alcohol withdrawal syndrome, with the aim of optimizing primary care management of alcohol use disorder (AUD).

Authors' results and conclusions: The information search yielded 4941 items, of which 10 CPGs were selected. These guidelines were deemed of sufficient methodological quality for use, based on the AGREE II instrument. From a review of the best clinical practice guidelines, the contextual information and the experiential knowledge provided by the advisory committee members, it was determined that the preferred first-line treatments for alcohol withdrawal involve either gabapentin or a benzodiazepine. These treatments can be prescribed according to two general dosing regimens: symptom-triggered or fixed-schedule. In fixed-schedule therapy, dosing can be started as soon as the person stops drinking alcohol, while in symptom-triggered therapy, dosing is started when the person has reduced or stopped his or her drinking and is showing signs or symptoms of withdrawal. The clinical situation for applying the protocol has been defined to take this into account. Also, given the risks associated with the concomitant use of benzodiazepines or gabapentin and other central nervous system depressants, restrictions concerning this matter have also been set out for withdrawal in an outpatient setting. The NMP development process also provided the opportunity to emphasize the importance of using an objective, validated scale to assess, in the case of inpatient withdrawal, the severity of signs and symptoms of alcohol withdrawal, which serves to guide both the administration of drugs in a symptom-triggered regimen and the patient’s follow-up. For this, the CIWA-Ar assessment scale should be used for all in-person withdrawal assessments. However, based on the stakeholders’ experiential knowledge, there are certain limitations in using the CIWA-Ar, particularly in emergency departments, where a shorter, validated version of this scale, the Modified CIWA, could be used. However, these scales cannot be used to guide dosing in individuals undergoing alcohol withdrawal in an outpatient setting. Since they are at low risk for complications and are, so to speak, in the driver’s seat when it comes to their medication use, they simply take their medication when there is at least one withdrawal symptom. Lastly, the importance of monitoring and looking for signs and symptoms pointing to an unfavourable change in the clinical situation, such as the occurrence of convulsions, fever or signs and symptoms suggestive of delirium tremens, or for signs and symptoms of over-sedation, is emphasized in the protocol. In addition, the stakeholders’ experiential knowledge helped clarify the minimum frequency of follow-up based on the severity of the observed withdrawal signs and symptoms and what this follow-up should cover, there being a certain amount of flexibility, depending on the care setting, the availability of health-care staff, and changes in the individual’s status. Conclusion This NMP was developed based on the best practice recommendations, which were enhanced with the experiential knowledge provided by different experts and clinicians, and with contextual information. With an analysis involving the triangulation of data from these different sources having been carried out, the protocol should promote better management of individuals treated pharmacologically for alcohol withdrawal and support the interdisciplinary approach to this management as well as the standardization of practice across the different clinical care settings. An assessment of the pertinence of updating the NMP will be carried out at least every four years in order for the protocol to be revised within a five-year period

Authors' methods: A systematic review of clinical practice guidelines (CPGs), expert consensus statements, consensus conference reports, guidance documents, and any other types of publications containing clinical recommendations was conducted in several databases in accordance with the INESSS’s standards and processes. The literature search was limited to items published between January 2015 and May 2020. The selected items focused on individuals with AUD for whom pharmacotherapy for alcohol withdrawal syndrome is used. The information sought was the criteria for assessing health status, the pharmacological treatments used, the clinical situations in which the administration of drugs is indicated or contraindicated, the necessary follow-up based on the care setting, and the specific clinical situations requiring further investigation or a reassessment with the prescriber. In addition, a manual literature search was carried out by consulting the websites of health technology agencies and bodies, as well as those of government and paragovernmental bodies, and professional associations and bodies dealing with the topic of interest. The bibliographies of the selected publications were searched for other relevant items. The data were analyzed from the perspective of contextualizing the practice in Québec, using mainly legislative, regulatory and organizational contextual information specific to Québec, and the experiential knowledge provided by the different stakeholders consulted.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/thematiques/medicaments/protocoles-medicaux-nationaux-et-ordonnances-associees/protocoles-medicaux-nationaux-et-ordonnances-associees/trouble-lie-a-lusage-dalcool.html

Year Published: 2021

URL for published report: https://www.inesss.qc.ca/fileadmin/doc/INESSS/Ordonnances_collectives/Sevrage/INESSS_Sevrage_alcool_GN.pdf

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)