Robert E. Gwyther

Pharmacokinetic dosing of phenobarbital in the treatment of alcohol withdrawal syndrome.

We used a pharmacokinetically derived phenobarbital dosing protocol to treat alcohol withdrawal syndrome in patients admitted to a family medicine inpatient service. We describe the protocol and include two case reports documenting its efficacy. Although benzodiazepine agents are considered by many to be the primary agents of choice, based upon our experience and its ease of administration, relative safety, therapeutic efficacy, and lower cost, phenobarbital should be reconsidered as a promising alternative. Comparative trials between these two therapeutic classes will clarify their roles in the treatment of alcohol withdrawal syndrome.

Alcohol Use Disorder Treatment: The Association of Pretreatment Use and the Role of Drinking Goal

Background: In a recent study conducted in a family medicine setting, the medication acamprosate was found not to be efficacious in the treatment of alcohol dependence, but a drinking goal of abstinence was found to have positive effects on alcohol use outcomes. The purpose of this secondary analysis was to further understand which patients with an alcohol use disorder may be most successfully treated in a primary care setting. Methods: The study was exploratory and used a trajectory-based approach based on data from the acamprosate treatment trial of 100 participants (recruited mostly by advertisement) who were randomly assigned to receive either acamprosate or a matching placebo. Post hoc trajectories of alcohol use before treatment were identified to examine whether trajectory classes and their interactions with treatment arm (acamprosate or placebo), pretreatment drinking goal (abstinence or a reduction), and time predicted alcohol use outcomes. Results: Three distinct trajectory classes were identified: frequent drinkers, nearly daily drinkers, and consistent daily drinkers. Consistent daily drinkers with a goal of abstinence significantly improved over time on the primary outcome measure of percent days abstinent when compared with frequent and nearly daily drinkers. In addition, all participants with a goal of abstinence, regardless of trajectory class, significantly reduced their percentage of heavy drinking days over time. Conclusions: Patients with an alcohol use disorder who have a drinking goal of abstinence, in particular consistent daily drinkers, may maximally benefit from alcohol use disorder treatment, including the use of medication, in a primary care setting.

Medical Legal Challenges

Physicians commonly encounter legal issues related to their practice of medicine, their role as supervising physicians for learners, and their administrative roles as leaders in healthcare settings. While malpractice concerns are the most notorious in the litigious society of the United States, there are several other areas in which legal issues may arise, including requirements for billing medical services; federal and state regulations on the prescription of controlled substances; federal, state and local employment laws; and oversight by state medical boards. Hospitals generally have risk managers who are charged to work with physicians when unexpected and/or adverse patient outcomes occur. Other administrators or legal counsel may advise academic physicians on promotion and tenure regulations, hiring and firing regulations, and requirements for maintaining hospital certification and licensure. Medical faculty members benefit from good relations with risk managers and lawyers who work in training hospitals.