CP19 - Implementation of an Outpatient Alcohol Withdrawal Protocol at an Urban Community Health Center
Poster Type: Innovation
Category: Behavioral Health Services
Issue or Challenge: The World Health Organization reports alcohol use disorder (AUD) impacts up to 5% of people worldwide. Of those with a moderate to severe alcohol use disorder, 50% will experience withdrawal symptoms which can include anxiety, sleep disturbance, tremors, seizures, delirium tremens, and death. A barrier to treatment for individuals with an AUD is the lack of detoxification services to assist in safely managing withdrawal symptoms. Outpatient treatment of mild to moderate withdrawal has been demonstrated to be safe, patient-centered, cost effective and is supported by American Society of Addiction Medicine guidelines but was not widely available in our setting.
Description of Innovation: With the intent to reduce barriers to safe treatment for lower risk patients with AUD who require medication for withdrawal, the medication assisted treatment (MAT) team in our CHC piloted an outpatient withdrawal management protocol. The protocol, which is being published elsewhere, incorporated the freely available PAWSS (Prediction of Alcohol Withdrawal Severity Scale) and CIWA (Clinical Institute Withdrawal Assessment) along with several other characteristics to risk-stratify patients who were interested in stopping drinking. Eligibility was determined for outpatient treatment (with non-benzodiazepine medications or benzodiazepine medications) versus referral to higher level of care. Providers and staff were educated about the outpatient treatment protocol at a staff meeting and patients who were identified as wanting to stop drinking were referred to our integrated addiction counselor and MAT providers for an intake visit. After initiation of the treatment protocol, daily follow up visits (either in person or telehealth) were scheduled for medication and counseling as well as a one week follow up visit to initiate maintenance treatment. Our clinic developed note templates for our electronic medical record that incorporated decision aids and we developed patient handouts and materials.
Impact or Result: Since implementing this protocol in our clinic in August of 2020 a total of 19 patients have been referred for assistance with stopping drinking. 15 of these patients were successfully able to stop drinking during the outpatient withdrawal protocol and 14 were transitioned onto maintenance medication for alcohol use disorder during follow up in our addiction clinic.Overall, we have also had a notable increase in patients receiving maintenance medication for alcohol use disorder. In the 2 quarters preceding implementation, our clinic averaged 43 patients receiving oral naltrexone, 6 receiving IM-depo naltrexone, and 7 receiving oral acamprosate. In the 2 quarters since implementation, our clinic averaged 60 patients receiving oral naltrexone, 12 receiving IM-depo naltrexone and 13 receiving acamprosate representing a 40%, 100% and 86% increase in prescriptions for maintenance medications treating alcohol use disorder.
Replicating this Innovation: The use of an algorithm and note template provides a framework to help guide treatment decisions in the outpatient setting. It has successfully been used by providers throughout our clinic and outside of the MAT clinic given the straightforward guidance. It could easily be replicated in other organizations.
Daniel White, MD, Assistant Professor, Denver Health
Jessica Cram, LAC, LPCC, Licensed Addiction Counselor, Denver Health
Jessica Bull, MD, Assistant Professor, Denver Health and Hospital Authority
Raeanna Simcoe, MD, Senior Instructor, Denver Health and Hospital Authority