Fewer Admissions, Shorter Stays: Phenobarbital Use for Alcohol Withdrawal in the Emergency Department.

Abstract

Alcohol withdrawal syndrome (AWS) significantly contributes to ED resource utilization. While phenobarbital is increasingly used as an alternative to benzodiazepines, data comparing their impact on ED utilization remain limited. We evaluated whether phenobarbital monotherapy improves ED operational outcomes compared to benzodiazepines or combination therapy. We conducted a single-center, retrospective cohort study of 1178 adults at a regional academic medical center from January 1, 2020, to December 31, 2023. Patients ≥ 18 years old who were treated with intravenous (IV) phenobarbital, IV benzodiazepines, or both for AWS in the ED were included. The primary outcome was hospital admission. Secondary outcomes included ED length of stay, return visits within 72 h of index visit, and 30-day hospital readmission. A formalized data abstraction process was utilized. Analyses used chi-squared or Kruskal-Wallis tests and logistic regression to estimate odds ratios with 95% confidence intervals. Of 777 eligible encounters, 459 (59.1%) resulted in admission. Admission rates were 74.0% for benzodiazepine-only encounters, followed by combination therapy (62.4%), and lowest for phenobarbital-only (52.1%; OR 0.44, 95% CI 0.30-0.66, p < 0.0001). Among discharged patients (318 encounters), median ED LOS was shortest in the phenobarbital-only group (5.8 h), versus 7.6 h for benzodiazepine-only and 10.3 h for combination therapy (p < 0.0001). Logistic regression analysis revealed treatment with phenobarbital alone was independently associated with discharge, while increasing age, increasing heart rate, and treatment with benzodiazepines alone were independently associated with hospitalization. Phenobarbital monotherapy for AWS was associated with lower admission rates, shorter ED LOS, and fewer IV medication administrations compared to benzodiazepine-based regimens. Return visit rates were similar across all groups. These findings are exploratory, underscoring the need for prospective studies to confirm these associations.