GRACE-4

The SAEM GRACE program addresses the best practices for the care of the most common chief complaints that can be seen on the tracking board of any emergency department in the country, based upon research and expert consensus. These guidelines are designed with de-implementation as a guiding principle to reasonably reduce wasteful testing, provide explicit criteria to reduce foreseeable risk, and define sensible and prudent medical care.

SAEM GRACE-4: Alcohol Use Disorder and Cannabinoid Hyperemesis Syndrome Management in the Emergency Department

While the opioid epidemic has garnered much attention, other forms of substance use disorders (SUD) continue to have significant impacts on health and wellness. Globally, alcohol use disorder (AUD) is the most prevalent SUD with over 100 million estimated cases in 2016. Cannabis use disorder (CUD) is the third most prevalent SUD with an estimated 22 million cases worldwide (following opioid use disorder at 26 million cases).

The objective of this guideline is to provide an evidence-based, patient-centric approach for clinicians in their evaluation and management of three conditions related to nonopioid-related SUDs commonly encountered in the adult emergency department (ED) setting: alcohol withdrawal syndrome (AWS), AUD, and cannabinoid hyperemesis syndrome (CHS).

The GRACE-4 multidisciplinary panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRACE) approach to assess the certainty of evidence and strength of recommendations regarding three questions for adult ED patients coming to the ED with AWS, AUD, or CHS.

PICO Questions

1. In patients 18 years of age or older receiving pharmacologic therapy for moderate to severe alcohol withdrawal in the ED, does the use of adjunctive phenobarbital by any route compared to benzodiazepines alone lead to improvement in outcomes?

2. In patients 18 years of age or older who present to the ED with AUD who are discharged home, does the prescription of an anticraving medication, compared to no prescription, improve outcomes?

3. In adult ED patients (>18 years old) who are suspected to have CHS, does the use of dopamine antagonists (e.g., haloperidol, droperidol) or capsaicin compared to usual care (or no treatment) lead to improved outcomes?

Recommendations

1. In adult ED patients (over the age of 18) with moderate to severe alcohol withdrawal who are being admitted to hospital, we suggest using phenobarbital in addition to benzodiazepines compared to using benzodiazepines alone. (Conditional recommendation, FOR; very low to low certainty of evidence).

2. In adult ED patients (over the age of 18) with AUD, we suggest a prescription for an anticraving medication for the management of AUD for patients who desire alcohol cessation. (Conditional recommendation, FOR; very low to low certainty of evidence)

2a. In adult ED patients (over the age of 18) with AUD who are not taking opioids, we suggest naltrexone (compared to no prescription) for the management of AUD to prevent return to heavy drinking and/or reduce heavy drinking. (Conditional recommendation, FOR; low certainty of evidence)

2b. In adult ED patients (over the age of 18) with AUD, with contraindications to naltrexone, we suggest acamprosate (compared to no prescription) for the management of AUD to prevent return to heavy drinking and/or reduce heavy drinking. (Conditional recommendation, FOR; 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. (Conditional recommendation, FOR; very low certainty of evidence)

3a. In adult patients 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. (Conditional, FOR; very low certainty of evidence)

3b. In patients presenting to the ED with CHS, we suggest offering the use of topical capsaicin (in addition to usual care/serotonin antagonists, e.g. ondansetron) to help with symptom management. (Conditional, FOR; very low certainty of evidence)