Alcohol Use Disorder and Cannabinoid Hyperemesis Syndrome Management in the Emergency Department
Summary of Recommendations
Recommendation 1
Recommendation 2
Recommendation 2a
Recommendation 2b
Recommendation 2c
Recommendation 3a
Recommendation 3b
Summary of Good Practice Statements
- All patients treated for alcohol withdrawal should be offered follow-up treatment where such treatment is available.
- Please see the anticraving medication algorithm (Figure 4) that was designed to help guide clinicians in the selection of anticraving medication based on patient-level factors and the strength of evidence for three medications. Dosage adjustments related to hepatic and renal function can be made at follow-up.
- As per American Society of Addiction Medicine Guidelines, clinicians should consider offering patients with AUD supplemental thiamine as part of their ED treatment plan and should be offered follow-up treatment where such treatment is available.
- A bridging prescription of up to 4 weeks until follow-up with an addiction medicine physician, primary care physician, or other appropriate health care provider can take place is preferred. Monitoring of liver enzymes should be at the discretion of the provider seeing the patient in follow-up. For patients not treated with long-acting benzodiazepines for AWS in the ED, patients should be advised that sudden cessation of alcohol consumption (as a result of anticraving medication) may produce acute AWS. These patients should be counseled to slowly taper consumption and seek treatment for AWS management should symptoms occur.
- A bridging prescription of up to 4 weeks until follow-up where renal function can be monitored with an addiction medicine physician, primary care physician, or other appropriate health care provider is preferred.
- Given the known misuse potential of gabapentin, a bridging prescription, for example, less than 2 weeks, is preferable to a long-term prescription. Patients should be cautioned about the sedative effects of gabapentin, and it should be prescribed with caution or avoided altogether in patients who use opioids. In patients with high self-reported withdrawal symptoms when they stop or reduce their alcohol intake, consider prescribing gabapentin in addition to naltrexone or acamprosate. Consider a weekly dispensing interval for gabapentin prescriptions longer than 2 weeks.
- IV fluids and nonopioid analgesics could be administered/offered to help with symptoms management.
- One member of the SAEM GRACE-4 Writing Team emphasized the importance of recognizing that not all patients experience relief with capsaicin, and clinicians should be prompt in escalating treatment for patients whose symptoms are not alleviated promptly. This member also emphasized that capsaicin should not be used for patients for whom it had not been effective in the past (conditional, FOR) [very low level of evidence].
- In patients presenting to the ED with CHS, benzodiazepines and opioids should not be used as first-line treatment for CHS symptom management. In balance with the lack of evidence supporting the effectiveness of benzodiazepines and opioids in this setting, and considering prior SAEM GRACE recommendations for avoiding opioids in the management of chronic abdominal pain, opioids should be reserved for patients where pain is the primary concern and in whom haloperidol/droperidol (and if attempted, capsaicin) have not provided prompt relief. we believe the potential risks associated with administration of opioids as initial treatment for CHS outweigh any potential benefit.
- These interventions should be used in conjunction with anticipatory guidance on the necessity of cannabinoid abstinence for complete symptom resolution. We found no published evidence that reduction in use will prevent CHS; however, anecdotal evidence from our representative with lived experience suggests that in some cases reducing use may reduce frequency of episodes. If the health care team suspects concurrent cannabinoid use disorder based on screening with a validated tool such as the Cannabis Use Disorder Identification Test–Revised (CUDIT-R) consider referral to psychosocial interventions and/or addiction medicine specialists if available. Hydration and other supportive treatments should not be delayed to administer either haloperidol/droperidol or capsaicin (if the patient would like to try it). Clinicians should educate patients on the rationale for the use of these medications if questioned and caution them about the intensity of burning related to capsaicin application.
Recommendation Grading
Disclaimer
Overview
Title
Alcohol Use Disorder and Cannabinoid Hyperemesis Syndrome Management in the Emergency Department
Authoring Organization
Society for Academic Emergency Medicine
Publication Month/Year
May 15, 2024
Last Updated Month/Year
June 11, 2024
Document Type
Guideline
Country of Publication
US
Document Objectives
The fourth Society for Academic Emergency Medicine (SAEM) Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4) is on the topic of the emergency department (ED) management of nonopioid use disorders and focuses on alcohol withdrawal syndrome (AWS), alcohol use disorder (AUD), and cannabinoid hyperemesis syndrome (CHS). The SAEM GRACE-4 Writing Team, composed of emergency physicians and experts in addiction medicine and patients with lived experience, applied the Grading of Recommendations Assessment Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding six priority questions for adult ED patients with AWS, AUD, and CHS. The SAEM GRACE-4 Writing Team reached the following recommendations: (1) in adult ED patients (over the age of 18) with moderate to severe AWS who are being admitted to hospital, we suggest using phenobarbital in addition to benzodiazepines compared to using benzodiazepines alone [low to very low certainty of evidence]; (2) in adult ED patients (over the age of 18) with AUD who desire alcohol cessation, we suggest a prescription for one anticraving medication [very low certainty of evidence]; (2a) in adult ED patients (over the age of 18) with AUD, we suggest naltrexone (compared to no prescription) to prevent return to heavy drinking [low certainty of evidence]; (2b) in adult ED patients (over the age of 18) with AUD and contraindications to naltrexone, we suggest acamprosate (compared to no prescription) to prevent return to heavy drinking and/or to reduce heavy drinking [low certainty of evidence]; (2c) in adult ED patients (over the age of 18) with AUD, we suggest gabapentin (compared to no prescription) for the management of AUD to reduce heavy drinking days and improve alcohol withdrawal symptoms [very low certainty of evidence]; (3a) in adult ED patients (over the age of 18) presenting to the ED with CHS we suggest the use of haloperidol or droperidol (in addition to usual care/serotonin antagonists, e.g., ondansetron) to help with symptom management [very low certainty of evidence]; and (3b) in adult ED patients (over the age of 18) presenting to the ED with CHS, we also suggest offering the use of topical capsaicin (in addition to usual care/serotonin antagonists, e.g., ondansetron) to help with symptom management [very low certainty of evidence].
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Emergency care, Hospital
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management
Diseases/Conditions (MeSH)
D019973 - Alcohol-Related Disorders, D002186 - Cannabinoids
Keywords
cannabinoids, alcohol use disorder, Cannabinoid, GRACE-4
Source Citation
Borgundvaag B, Bellolio F, Miles I, Schwarz ES, Sharif S, Su MK, Baumgartner K, Liss DB, Sheikh H, Vogel J, Austin EB, Upadhye S, Klaiman M, Vellend R, Munkley A, Carpenter CR. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department. Acad Emerg Med. 2024 May;31(5):425-455. doi: 10.1111/acem.14911. PMID: 38747203.