2. Unit. We have had anecdotal success with this protocol
and undertook this study to formally investigate its safety
and effectiveness.
2. Materials and methods
Through our electronic medical record, information
technology specialists identified patients who had received
phenobarbital over a 5-year period, and the electronic
records of each were reviewed to identify those who had
received it for benzodiazepine detoxification. We reviewed
electronic records to see if they received concurrent
treatment for opioid dependence or if they were on
methadone maintenance at the time of admission. We
looked at previous discharge summaries on each patient to
determine if they had been treated at our institution for
benzodiazepine withdrawal in the past. We also recorded
whether a history of seizures or delirium was documented in
the admission database or previous admissions.
The phenobarbital taper is a 3-day schedule that begins
with a one-time dose of 200 mg, followed by 100 mg every 4
hours for five doses, this is followed by 60 mg every 4 hours
for four doses, then 60 mg every 8 hours for three doses.
Using each patient's electronic medication administration
record, we verified that each patient received the taper, if
they had received extra doses, and what, if any, doses were
missed and why. We also looked at physician and nursing
assessments to see if there were any adverse events. Patients
who required concurrent opioid detoxification were given
sublingual buprenorphine on a schedule of 8 mg the first
2 days, then 6 mg on Day 3, followed by 2 mg on Day 4
(usually the morning of discharge).
We reviewed the medical records of 310 admissions over
a 5-year period between April 2004 and May 2009. We
calculated the incidence of seizures, falls, and delirium as
markers for safety; we also recorded how many patients had
doses held because of sedation. Finally, we reviewed
emergency department visit and admission records to see if
any had returned to the hospital for either an emergency
room visit or a hospital admission within 30 days and
recorded the reason. We compared demographic and clinical
factors between subjects who had doses held because of
sedation and those who did not; chi-square tests were used
for categorical variables and t test for continuous variables.
A p value less than .05 was considered significant. Statistical
analysis was performed using PASW software version 18
(SPSS Inc., Chicago, IL). This study was approved by the
Johns Hopkins Institutional Review Board.
3. Results
Table 1 provides data on the subjects. The median age
was 36 years (range = 19–62 years), and 55% were men. The
median length of stay was 3 days, and the range was 0 (left
against medical advice on the day of admission) to 9 days.
Eighty-seven (28.1%) had previously been admitted to our
institution for benzodiazepine detoxification. One hundred
seventy-seven (57.1%) of the patients received concurrent
opiate detoxification with buprenorphine, and 78 (25.2%)
were on methadone maintenance. Twelve (3.9%) had a
history of delirium in their medical record, and 43 (13.9%)
reported a history of seizures. Most (89.0%) of the patients
were treated on the chemical dependence unit, and 9.7%
were treated on the general medical service.
At least one dose of the taper was held because of
sedation in 80 (25.8%) of the admissions. Table 2 provides
more detailed information on which doses were held. As
shown on Table 3, female patients and those on methadone
maintenance or receiving concurrent buprenorphine for
opioid detoxification were somewhat more likely to have
doses held, but these differences were not statistically
significant. Thirty-six (11.6%) of the patients received at
least one extra dose of phenobarbital, most of these (58.3%)
receiving one or two extra doses; there were 10 patients who
received five or more additional doses.
Table 4 provides a summary of the outcomes and adverse
events among the subjects. No one had a seizure during
detoxification, and only 3 (1.0%) had delirium. Fifty-three
(17.1%) of the patients left early against medical advice, 22
(7.1%) had an emergency department visit within 30 days of
discharge, and 19 (6.1%) were readmitted within 30 days to
our medical or psychiatry service. Of these patients,
Table 1
Characteristics of the 310 admissions
Median age (range) 36 (19–62)
Male gender 171 (55.2%)
Prior benzodiazepine detoxification 87 (28.1%)
Concurrent opioid detoxification 177 (57.1%)
Methadone maintenance 78 (25.2%)
Prior seizures 43 (13.9%)
Prior delirium 12 (3.9%)
Median length of stay in days (range) 3 (0–9 days)
Treatment setting
Chemical dependence unit 276 (89.0%)
General medical service 29 (9.4%)
Psychiatry 4 (1.3%)
Obstetrics/Gynecology 1 (0.3%)
Table 2
Phenobarbital protocol and percentage of doses held
Dose/Interval
No. of doses
in protocol
Percentage
who received
all doses a
Percentage of
doses held
because of
sedation a
200 mg once 1 86 14
100 mg every 4 hours 5 58 17
60 mg every 4 hours 4 70 14
60 mg every 8 hours 3 56 25
a
Patients who were discharged against medical advice were not
included.
332 S.S. Kawasaki et al. / Journal of Substance Abuse Treatment 43 (2012) 331–334
3. ID Title Pages
329844 Safety and effectiveness of a fixed-dose phenobarbital protocol for inpatient benzodiazepine detoxification 4
http://fulltext.study/article/329844
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