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Ethanol in Formularies of US Teaching Hospitals
To the Editor: The care of hospitalized patients may be complicated by an alcohol withdrawal syndrome (AWS), which is sometimes treated with ethanol. The evidence supporting this practice is weak, however,1 and a recent meta-analysis concluded that benzodiazepines are the treatment of choice for AWS.2 Despite this evidence, we have personally observed residents ordering oral and intravenous (IV) ethanol for AWS, and in a 2-state survey of a convenience sample we found that ethanol was dispensed to patients in 21 (91%) of 23 hospitals.3 The present study was conducted to examine the frequency of ethanol use for patient care in major American teaching hospitals.
Methods
For each allopathic US medical school we identified the primary university-affiliated hospital of the school's principal medicine and surgery residency programs, or the community hospital used by the greatest number of residents if there was no specific university hospital. An 18-item questionnaire, developed during our preliminary study,3 was mailed to the hospital pharmacy director with a prepaid return envelope and a $1 bill. Although the survey forms contained no identifying information and no hospital identifiers were maintained in the final electronic database (SPSS v11, SPSS Inc, Chicago, Ill), each return envelope was coded with a number to allow for the distribution of follow-up questionnaires. If no response was received within 3 months, a second survey was mailed. If there was no response again, the pharmacy was telephoned up to 3 times to complete the survey. Data were collected between February and November 2001. The study was approved by the institutional review boards of the 2 universities associated with the authors.
Results
Of the 122 eligible hospitals, completed surveys were obtained from 116 (95%). The average daily patient census ranged from 71 to 1757 (mean, 398). Ethanol had been dispensed in the previous 12 months at 83 (72%) of the responding hospitals: 45 dispensed both oral and IV ethanol; 20 dispensed only IV ethanol; 18 dispensed only oral ethanol. Physicians were reported to have used ethanol to prevent or treat AWS in 62 (75%) of the 83 hospitals where ethanol was dispensed. Among the 65 sites reporting IV ethanol use, 45 (69%) indicated that physicians were permitted to order IV ethanol for AWS. Of the 63 facilities where oral ethanol was dispensed, it was used for AWS in 44 (70%). Estimates for the number of patients treated for the AWS within the prior 12 months ranged from 1 to 50 (mean, 8) with IV ethanol, and from 1 to 200 (mean, 17) with oral ethanol.
Alcoholic beverages were also used for "patient courtesy" at 38 hospitals, sedation at 10, stimulation of appetite at 6, and for other reasons at 25. Beer was dispensed at 53 hospitals, distilled spirits at 31, wine at 25, brandy at 10, and grain alcohol at 7. These were dispensed by the pharmacy at 46 sites and by food services at 15. Only 6 sites had a policy that required the pharmacy to notify food services not to dispense alcoholic beverages when patients were prescribed drugs with adverse ethanol interactions. The patient or a family member was permitted to provide alcoholic beverages to prevent AWS at 7 hospitals.
Comment
Ethanol continues to be available in the hospital formulary at more than two thirds of major US teaching hospitals, despite the lack of published evidence for its effectiveness. The availability of ethanol products for "therapeutic" purposes may send the implicit message that alcohol is an appropriate remedy for illness.
Funding/Support: This study was supported in part by grant 1R25AA011664 from the National Institute on Alcohol Abuse and Alcoholism, which provided training and consultation support, and by grant 1D12HP00093-01 from the Health Resources and Services Administration, which provided administrative and technical support.
Richard D. Blondell, MD;
Heather N. Dodds, BA;
Monica N. Blondell
Department of Family and Community Medicine
Stephen W. Looney, PhD
Department of Bioinformatics and Biostatistics
University of Louisville
Louisville, Ky
Steven H. Smoger, MD
Department of Veterans Affairs
Louisville
Leslie K. Sexton, RPh
Norton Suburban Hospital
Louisville
L. Susan Wieland, MPH
Department of Community Health
Robert M. Swift, MD, PhD
Department of Psychiatry
Brown University
Providence, RI
1. Mayo-Smith M for the American Society of Addiction Medicine Working Group on the Pharmacological Management of Alcohol Withdrawal. Pharmacological management of alcohol withdrawal: a meta-analysis and evidence-based practice guideline. JAMA. 1997;278:144-151.
ABSTRACT
2. Holbrook A, Crowther R, Lotter A, Cheng C, King D. Meta-analysis of benzodiazepine use in the treatment of acute alcohol withdrawal. CMAJ. 1999;160:649-655.
ABSTRACT
3. Smoger SH, Looney SW, Blondell RD, et al. Hospital use of ethanol survey (HUES): preliminary results. J Addict Dis. 2002;21(2):65-73.
JAMA. 2003;289:552.
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