Upload
drew-reiter-rn
View
278
Download
1
Embed Size (px)
Citation preview
RECOMMENDATIONS FOR ALCOHOL WITHDRAWAL 1
Recommendations for Alcohol Withdrawal
Andrew Reiter, Steve Erikson, Kalsang Wangdu, Ken Koslowski
Bethel University
Evidenced-Based Practice
NURS 430
Kristen Sandau PhD, RN
November 29, 2015
2RECOMMENDATIONS FOR ALCOHOL WITHDRAWAL
Recommendations for Alcohol Withdrawal
Introduction
Chronic alcohol consumption and dependency has been linked to several diagnoses
requiring admission to the acute care setting including seizures, delirium, tremors, and increased
risk for myocardial infarction. “8.2 million Americans suffer from alcohol dependency and
account for twenty percent of hospital admissions contributing to a two hundred billion dollars a
year in care cost” (Perry, 2014, p. 402). The common need for this patient population is
supplementation with a chemical sedative such as a benzodiazepine to offset the symptoms of
withdrawal from alcohol dependency. Our concern for patient safety has given me the
opportunity to pose the population intervention comparison outcome (PICO) question. In adult
inpatients receiving treatment for chemical dependency withdrawal, is the Clinical Institute
Withdrawal Assessment for Alcohol (CIWA-Ar) safe and effective for basing benzodiazepine
administration in comparison to fixed rate dosing protocol?
Critique of studies
Methods
Becker and Semrow (2006) and Melson, Kane, Mooney, McWilliams, and Horton,
(2014) are performing primary studies on the implementation of the CIWA-Ar assessment
protocol. This tool is approved by the Centers for Disease Control for the treatment of alcohol
withdrawal. These are quasi-experimental studies using systematic review of patient charts.
This would be stage two evidence according to John Hopkins evidence based practice model.
The patient chart represents a legal record of the patient’s care. Recorded treatment,
3RECOMMENDATIONS FOR ALCOHOL WITHDRAWALassessments, and results are considered a valid source of data. Both studies are limited to both
short and long acting benzodiazepines as a general category of medication because there is no
specific medication due to physician preference. The third article also uses a systematic review
of charts in a quasi- experimental pre and post intervention analysis. It compared fixed rate
combined with symptom based versus just symptom based. The average dose and duration of
benzodiazepines was then compared using Mann-Whitney U test. This was also a stage two
experimental quasi-experimental study and it provided more rigorous quality assurance and
validity in the research analysis. A key flaw in the study was the vast amount of physicians
charting and placing orders (Ng, Dahri, Chow & Legal, 2011). The last article is a double blind
randomized control trial directly comparing fixed dosing to symptom based dosing using CIWA-
Ar. “The fixed-schedule regimen was determined according to the guidelines of the American
Society of Addiction Medicine (30 mg every 6 hours for 4 doses, then 15 mg every 6 hours for 8
doses” (Daeppen, et al. 2002, p.1118). See the matrix grid for more details.
Sample
All of the articles sample groups meet the criteria of the PICO question. They are all
conducted in acute care hospitals on adult patients suffering alcohol withdrawal. Becker &
Semrow (2006) limit their study groups to two participating hospitals in Wisconsin and are
generalizable to people in their area. The sample included 63 patients discharged with a
diagnosis of acute alcohol withdrawal syndrome over a period of ten months. Melson, et al.
(2014) limit their study subjects to patients receiving treatment within the Christina Health care
system of Delaware. The location of study was limited. There was a total of 1053 total charts
reviewed over a period of 21 months. The large sample size improves the weak generalizability
4RECOMMENDATIONS FOR ALCOHOL WITHDRAWALof the study. Ng et al. (2011) conducted study at the University of British Columbia Hospital in
patients 18 years of age or older and 159 patients met the inclusion criteria, and 71 charts were studied
pre-implementation and 72 post-implementations. The single location lacks diversity but an adequate
number of patients were compared. Daeppen et al. (2002) used a double blind randomized
controlled trial to select two groups. 56 were treated with benzodiazepines based on symptoms using
CIWA-Ar. The other group had 61 on fixed scheduled dosing. The study was conducted at two
university hospitals increasing the population demographic covered in their research.
Instrument
Instrument Used
The instrument used in these articles is the Clinical Institute Withdrawal Assessment for
Alcohol Withdrawal Syndrome (CIWA-ar) is the most commonly used withdrawal assessment
tool for clinical inpatients that exhibit symptoms of acute alcohol withdrawal. The CIWA-ar
addresses ten separate symptoms that are commonly associated with acute alcohol withdrawal
symptoms. These symptoms include nausea/vomiting, tremors, anxiety, agitation, paroxysmal
sweats, orientation including clouding of the sensorium, tactile disturbances, auditory
disturbances, visual disturbances and headache. The user or care provider rate the severity of
symptoms on a one to seven or one to four-point quantified scale. Each point in the scale is
associated to a descriptor that staff will use to determine the final CIWA-ar score. The score is
then used to determine the amount and frequency of benzodiazepine administration and
frequency that which the assessment should be completed.
Reliability and Validity of Instrument
Williams, Lewis and McBride (2001) state that there were more than 30 different rating
scales for alcohol withdrawal syndrome between the years 1973 and 1997. They were able to
5RECOMMENDATIONS FOR ALCOHOL WITHDRAWALnarrow these down to 16 similar scales. Various clinical sites developed assessment tools that
tracked symptoms they believed were clinically significant indicators for medication
administration. According to Williams et al. (2001) The Clinical Institute Withdrawal
Assessment CIWA-Ar scale evolved from the Total Severity Assessment Scale (TSA) and
Selective Symptom Assessment scale. CIWA-Ar allowed the assessment to be completed more
frequently. The CIWA-Ar consisted of a fifteen-point scale designed by Sullivan, Swift, and
Lewis in 1991. This was later reduced to a ten-point scale by Metcalfe, Sobers, and Dewey in
1995. Metcalfe et al. (1995) stated that the CIWA-Ar scale could be complete accurately with
consistent inter-rater reliability in under a minute. It is regarded as a safe and consistent tool for
administration of benzodiazepines.
Statistical significance
Though Melson et al. (2014) state that there was measured improvement in the first three
months after implementation of the CIWA-Ar protocol. The p number was p = 0.5. This means
there was no significant improvement after one year. Three years after implementation of the
intervention the number of negative outcomes remained below the pre-implementation levels.
Overall improvement of patient outcomes was observed. Becker and Semrow (2006) did not
have many statistical references but they did indicate staff were surveyed post implementation.
Results showed fifty percent being comfortable with protocol and fifty percent being somewhat
comfortable. This indicates that further training regarding protocol is required. Daeppen et al.
(2002) reported average benzodiazepine dose administered in the symptom-triggered group was
37.5 mg compared with 231.4 mg in the fixed-schedule group (P<.001). They also showed
evidence of reduced duration of use compared to fixed rate dosing. Ng et al. (2011) contradicts
6RECOMMENDATIONS FOR ALCOHOL WITHDRAWALthese findings but discrepancies in pre and post protocol implementation showed increased
addiction amongst patient groups.
Discussion of researcher’s conclusions
The CIWA-Ar scale works when used properly by trained registered nurses. A
combination of scheduled and symptom based dosing of benzodiazepines as mentioned in Ng et
al. (2011) as being the preferred protocol. The article is a good alternative but not optimal since
it increased the chances of over sedation and administered unneeded doses which increases cost.
CIWA-Ar is the most widely used tool that care providers utilize for inpatient withdrawal and
according to Melson, et al. (2014) is proven to reduce inpatient transfers to intensive care unit,
related to the severity of symptoms. As a result, withdrawal has been manageable on most
medical or mental health inpatient units. Some patients who are at the upper end of the abuse
spectrum at the most risk for acute and severe withdrawal symptoms will still require ICU for
withdrawal. As Becker and Semrow (2006) stated Early detection with use of CAGE and
CIWA-ar combine with proper administration of medications reduced ICU transfers and
improved patient withdrawal experience. Care providers should be trained in proper use of the
CIWA-ar and assessing the withdrawal symptoms. For example, some patients may not be
agitated because of withdrawal, a sweaty person could be result of the room being too hot. A
combination of symptoms and the patient’s reaction to their environment must be considered by
the professional rater. There is also the possibility of patients who seek sedative medications
such as benzodiazepines and play up withdrawal symptoms. Nurses in the emergency
department as well as inpatient units should be aware of signs and symptoms of chronic alcohol
abuse related to patients whom deny alcohol dependence out of embarrassment or ignorance that
7RECOMMENDATIONS FOR ALCOHOL WITHDRAWALwithdrawal may be a problem. Patients in alcohol withdrawal do not fit any one specific
stereotypical profile men, women and young people from all ethnic backgrounds are at risk for
substandard care due to care providers not recognizing withdrawal.
Expert Analysis and Professional Guidelines
Melson et al. (2014) state that initiation of the CIWA-Ar algorithm decreased symptom
progression into delirium tremens and other severe consequences of withdrawal. Using this tool
decreases risks of delirium tremens, restraints, physical assaults, and transfers to the intensive
care unit (Melson et al. 2014). In many cases it has been found that implementation of such
protocol may show minor improvement in patient outcomes though there is a definite gap in
inter-rater reliability that may stem from insufficient user training and overall lack of expertise.
Registered nurses Kathy Becker and Sue Semrow (2006) agree that standardizing the assessment
process and treatment plan would improve patient outcomes by allowing for a clear
communication pathway between the care team. “A thorough alcohol consumption history
should be recorded that includes consumption, volume, routine, preferred drink, and last drink”
(Perry, 2014, p. 402). Early assessment on admission allows for prevention and will alert the
care team to anticipate potential severity and patient need. A barrier to this assessment is that
many of the patients who do present with alcohol withdrawal are unresponsive or incoherent and
information may be skewed.
Regions Hospital, a level one trauma center in Saint Paul, Minnesota uses CIWA-Ar
protocol and order sets for patients suspected of and or admitted to the hospital for alcohol
withdrawal. Current guidelines for policy and procedure are located in the Regions Hospital
online employee competencies database. Clinical competencies are continuously managed by
8RECOMMENDATIONS FOR ALCOHOL WITHDRAWALthe Regions Hospital patient safety committee and the administrative board of directors. CIWA-
Ar scoring is followed to gauge appropriate treatment needs and treatment location. If a patient
score is 20 or above two times within two hours they will be transported to intensive care where
the patient can be closely monitored and put on a benzodiazepine drip. This is a sound protocol
and is accepted because it provides education to the user, oversight, and measures to address
emergency situations. The current protocol does not require nurses to complete a CIWA-Ar
assessment during bedside shift report. This may lead to a gap in inter-rater reliability and over
or under sedation and needs to be addressed.
The National Institute of Health subdivision of the National Institute on Alcohol Abuse
and Alcoholism is a United States government office that collects, analyzes, and disseminates
information to assist in the identification of health risks. This is a government office that does
not require membership and provides information as studies become available (National
Institutes of Health, October 14, 2015). Information on chemical dependency and treatment
protocols is given through this organization.
In our clinical judgment the nurse needs to take into account both verbal and nonverbal
indicators during the CIWA-Ar assessment. If a patient is suspected of divulging inaccurate
information. The physician should be notified for possible scheduled benzodiazepine dosing.
Facilities should also provide a specialized in-service to make sure staff nurses are using the
CIWA-Ar appropriately and congruently. Holbrook, Crowther, Lotter, Cheng, King (1999)
completed a meta-analysis of three randomized controlled trials involving the use of
benzodiazepines in conjunction with the CIWA-Ar tool. The authors stated that their analysis of
data determined that benzodiazepines are the preferred central nervous system depressant used in
9RECOMMENDATIONS FOR ALCOHOL WITHDRAWALalcohol withdrawal. Using the CIWA-Ar to score withdrawal and guide benzodiazepine
administration also showed evidence that patients had a reduced need for pharmacological
sedation within two days. This provided safe patient outcomes in addition to shorter hospital
stay. We feel that fixed scheduled dosing is potentially hazardous and in many cases unneeded
sedation hurts rapport with patients.
Patient Preferences and Values
Patients treated with benzodiazepines using the CIWA-Ar assessment tool had decreased
severity of withdrawal symptoms, including a reduction in hallucinations (Becker, & Semrow,
2006). There was also no difference in comfort and wellbeing between fixed dose group and
symptom based group (Daeppen et al., 2002). Keeping the patient alert and oriented is
something that is important to them and their family members. Reducing unnecessary doses that
can cause too much sedation is appreciated by both the patient and their loved ones as long as
they are comfortable. Being active participants in their care plan by presenting symptoms to the
nurse makes them feel like they have a voice in their treatment.
Change Theory and Quality Improvement
After reviewing evidence based practice on alcohol withdrawal. Symptom based dosing
of benzodiazepines using CIWA-Ar assessment tool has been found to be an effective change
agent compared to previous fixed scheduled dosing. Kurt Lewin identified three stages of
implementing a change agent into practice. To implement a change agent into practice the
protocol requires unfreezing, change or moving, and refreezing (Dulaney, & Stanley, 2005).
During the unfreezing stage the fixed scheduled dosing causing unnecessary sedation is
identified as a protocol that has flaws. This may adversely affect attitudes of staff members who
10RECOMMENDATIONS FOR ALCOHOL WITHDRAWALimplemented the fixed scheduled dosing. A comprehensive analysis of staff members affected
by the change should be evaluated during the unfreezing stage as it can be detrimental to
introducing the CIWA-Ar assessment tool into practice. During the change stage training and
support for staff members on CIWA-Ar is important so that staff members feel confident and
comfortable in their ability to properly administer on their patients. The refreezing stage
includes providing data on effectiveness of CIWA-Ar with outcomes conveyed to all staff. As
this becomes common practice re-education should be provided for any regression or
inconsistencies to help cement this change agent into practice.
To improve the quality of this change agent adverse events of alcohol withdrawal patients
should be conducted on facility charts quarterly by a quality improvement specialist. The data
should include seizures, physical harm to staff or self, restraint use, over sedation requiring
intervention, tremors, and other complications associated with alcohol withdrawal. Once data is
collected information should be given to the unit nursing director and results posted in work area.
This will let staff know the effectiveness of the CIWA-Ar protocol and areas needing
improvement. The safety coordinator and quality specialist should identify any facility gaps in
patient outcomes and education and training provided to units of concern. It is important that
these units are not chastised for negative outcome results. Becker and Semrow (2006) indicate
creating a safety interdisciplinary group that meets bi-weekly would provide other staff members
support that is needed. A collaborative educational in-service with interdisciplinary involvement
should encourage concerns of staff members to identify any barriers in quality improvement.
11RECOMMENDATIONS FOR ALCOHOL WITHDRAWAL
Conclusion
After systematic review of the use of the CIWA-Ar for acute alcohol withdrawal in the
acute care setting. We were able to determine that when used consistently the CIWA-Ar is a safe
and effective tool for administering benzodiazepines to the adult population. The protocol
reduced the amount of benzodiazepines given and the duration of use compared to fixed rate
protocol. The duration of hospitalization also decreased. Reducing length of stay and
medication cost using this symptom based protocol is beneficial to the healthcare system and the
patient. However, facilities with a high volume of patients and untrained staff members may
want to implement fixed rate dosing in addition to CIWA-Ar protocol until staff are familiar with
the tool. Education and regular audits should be performed on staff members to assess inter-rater
reliability and the need for additional training. Studies reveal an overall improvement in patient
outcomes as a total reduction in severity of symptoms.
12RECOMMENDATIONS FOR ALCOHOL WITHDRAWAL
EVIDENCE-BASED MATRIX GRID
PICO Question: In adult inpatients receiving treatment for chemical dependency withdrawal, is the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) safe and effective for basing benzodiazepine administration in comparison to fixed rate dosing protocol?
Student Name, Citation in APA
Purpose of Study
Sample/Setting Design Results Recommendations for Practice Change
Methodology
Instruments (include
reliability& validity)
#1 Kalsung Wangdu
Becker, K., & Semrow, S., (2006). Standardizing the care of detox patients to achieve quality outcomes: professionals from many disciplines come together to focus on the patient and improve care. Journal of Psychosocial Nursing & Mental Health Services, 44(3), 33 - 38.
Using a multidisciplinary performance improvement team to review evidence based practice and initiate the AWA protocol for safe administration of sedatives for improved patient outcomes.
This study occurred at two hospitals. The first was Waukesha Memorial Hospital, a 300-bed tertiary community hospital. The second was Oconomowoc Memorial Hospital, a 72-bed community hospital. The sample reviewed 45 patients of unknown race or gender with alcohol withdrawal.
Retrospective review of the literature with a multidisciplinary team.
1. Symptom triggered administration
2. scheduled administration
3. combination of 1&2
1 -3 using CIWA-Ar AWA protocol. And early detection using CAGE tool. When used correctly these scales are considered valid assessment tools. A core group of nurses received hands-on training at ProHealth Care’s inpatient/outpatient substance abuse treatment facility. This would facilitate other nurses on best protocol.
Improved staff education and comfortable and consistent use of AWA tool between staff members along with early detection resulted and improved patient outcomes. Overall reduction in DT, MI and seizure. Increased referrals for outpatient management.
1. A well-organized protocol to manage ETOH dependent patients in acute care setting.2. Standardized protocol for identifying and treating patients at risk for ETOH withdrawal.3. Special project team to review literature, provide education to support consistent use of AWA tool.
13RECOMMENDATIONS FOR ALCOHOL WITHDRAWAL
#2 Andrew Reiter
Melson, J., Kane, M., Mooney, R., McWilliams, J., & Horton, T. (2014). Improving Alcohol Withdrawal Outcomes in Acute Care. The Permanente Journal, 18(2), 141 - 145
CIWA implementation study for the reduction in incidents of ETOH withdrawal advancing to DT use of restraints and subsequent patient transfer from acute care to intensive care.
Retrospective review of existing data sets of patients of the Christiana Care Health System of Delaware. for a period of 21 months in the acute care and intensive care setting.
Quarterly retrospective data analysis of information extracted from existing data sources of patients discharged with a dx of acute alcohol withdrawal. 9 months prior to implementation and quarterly for 12 months after. Screening of all inpatients for risk of AWS and using symptom triggered management using CIWA-ar and AUDIT-PC for patient that score at treatable.
There was a measurable reduction in patients experiencing DT, requiring restraint or transfer to ICU in the first quarter after implementation. Though over the course of the study r = 0.5 and finding were not significant. Though results remained below reimplementation levels by conclusion of the study.
Recommend repeating the study with a control group. Recommend that physicians be able to track patients detox history starting in the ED in order to better gage dosages by implementing patient tracking including previous visits and CIWA-Ar scores.
#3 Steve Erikson
Ng, K., Dahri, K., Chow, I., & Legal, M. (2011). Evaluation of an Alcohol Withdrawal Protocol and a Preprinted Order Set at a Tertiary Care Hospital. The Canadian Journal of Hospital Pharmacy, 64(6), 436–445.
To evaluate efficiency and safety of a combination fixed-scheduledosing and symptom-triggered benzodiazepine dosing protocol for alcohol withdrawal.
This study took place at the University of British Columbia Hospital in patients 18 years of age or older. 159 patients met the inclusion criteria. 71 charts were studied pre-implementation and 72 post-implementations. Anyone with seizures unrelated to alcohol withdrawal and
Patients were placed on 1 of 4 scheduled benzodiazepine protocols in addition to symptom based administration using CIWA-Ar. Nurses had specialized educational course in CIWA-Ar tool. Data collection was entered in Microsoft Excel using SPSS and Predictive Analytic SoftwareWare to analyze data. The average length of benzodiazepine treatment and the average total benzodiazepine dose for withdrawal were
Average length of stay was 5.6 days pre-implementation and 3.5 days post-implementation. The patients receiving both protocols had higher doses for decreased duration.
Using a fixed schedule dosing as well as symptom related dosing with the CIWA-Ar tool may lead to additional doses that are not required causing oversedation. However, this may be beneficial in a high volume work environment where assessments may not be accurate and staff are not thoroughly trained using the CIWA-Ar tool for symptom based dosing..
14RECOMMENDATIONS FOR ALCOHOL WITHDRAWAL
current benzodiazepine use were excluded.
compared using the Mann–Whitney U test.
#4 Ken Koslowski
Daeppen, J., Gache, P., Landry, U., Sekera, E., Schweizer, V., Gloor, S., Yersin, B. (2002). Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: A randomized treatment trial. Archives of Internal Medicine, 162(10), 1117-1121
Fixed doses of benzodiazepines primary course of action in alcohol withdrawal. This article explores benefits of symptom specific benzodiazepine administration using CIWA-Ar assessment tool and the length of its use after initiation of treatment.
This study evaluated 117 patients with alcohol withdrawal. Participants were enrolled in treatment programs at both the Lausanne and Geneva University Hospitals, in Switzerland. Patients were randomized into 2 groups: 56 were treated with benzodiazepines based on symptoms using CIWA-Ar. 61 were treated with benzodiazepines every 6 hours with additional doses as needed (fixed-schedule).
This was a randomized control trial of 117 chemically dependent patients. A full medical history and exam with blood tests for γ-glutamyltransferase, red blood cell volume, and blood alcohol concentration were obtained at admission. Patients were interviewed by trained research assistants to assess their demographic characteristics and medical comorbidities using the Charlson Scale. Those with withdrawal medication use in the last 30 days, illegal drug use, and mental disorders were excluded. Comfort and well-being were evaluated day three using the Medical Outcomes Study 36-Item Short-Form Health Survey (MOS-SF-36) questionnaire.
The average dose given in the symptom-triggered group was 37.5 mg compared with 231.4 mg in the fixed-schedule group (P<.001). The average duration of treatment was 20.0 hours in the symptom-triggered group vs 62.7 hours in the fixed-schedule group (P<.001). Withdrawal reactions consisted of a single episode of seizures in the symptom-triggered group.
Following the CIWA-Ar assessment tool in the treatment of alcohol withdrawal provided decreased benzodiazepine dosages and reduced duration of treatment. This had no effect on the patient's’ comfort or well-being. This also improved cost of care due to the reduction in pharmaceutical interventions.
References
15RECOMMENDATIONS FOR ALCOHOL WITHDRAWALBecker, K., & Semrow, S. (March 26, 2006). Standardizing the care of detox patients to achieve
quality outcomes: professionals from many disciplines come together to focus on the
patient and improve care. Journal of Psychosocial Nursing & Mental Health Services,
44(3), 33 - 38. Retrieved from http://web.a.ebscohost.com.ezproxy.bethel.edu
/ehost/detail/detail?sid=ec64312a-f3d8-4f84-a243-d05e9c59b73a%40sessionmgr4005&
vid=0&hid=4209&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#AN=106444
870&db=ccm
Daeppen, J., Gache, P., Landry, U., Sekera, E., Schweizer, V., Gloor, S., Yersin, B. (2002).
Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: A
randomized treatment trial. Archives of Internal Medicine, 162(10), 1117-1121.
Dulaney, P., & Stanley, K. (2005). Accomplishing change in treatment strategies. Journal Of
Addictions Nursing (Taylor & Francis Ltd), 16(4), 163-167 5p.
Holbrook, A. M., Crowther, R., Lotter, A., Cheng, C., & King, D. (1999). Meta‐analysis of
benzodiazepine use in the treatment of acute alcohol withdrawal (structured abstract).
Canadian Medical Association Journal, 160, 649-655.
Melson, J., Kane, M., Mooney, R., McWilliams, J., & Horton, T. (2014). Improving alcohol
withdrawal outcomes in acute care. The Permanente Journal, 18(2), 141-145.
http://dx.doi.org/doi: 10.7812/TPP/13-099
Metcalfe, P., Sobers, M., & Dewey, M. (1995). The windsor clinic alcohol withdrawal
assessment scale (wcawas): Investigation of factors associated with complicated
withdrawals. Alcohol & Alcoholism, 30, 367-372.
16RECOMMENDATIONS FOR ALCOHOL WITHDRAWALNational Institute on Alcohol Abuse and Alcoholism (NIAAA). (October 14, 2015). Retrieved
November 2, 2015, from
http://www.nih.gov/about-nih/what-we-do/nih-almanac/national-institute-alcohol-abuse-
alcoholism-niaaa#mission
Ng, K., Dahri, K., Chow, I., & Legal, M. (2011). Evaluation of an alcohol withdrawal protocol
and a preprinted order set at a tertiary care hospital. The Canadian Journal Hospital
Pharmacy, 64(6), 436–445.
Perry, E. C. (April 30, 2014). Inpatient management of acute alcohol withdrawal syndrome. CNS
Drugs , 28, 401 -410. http://dx.doi.org/DOI 10.1007/s40263-014-0163-5
Williams, D., Lewis, J., & McBride, A. (2001). A comparison of rating scales for the alcohol-
withdrawal syndrome. Alcohol & Alcoholism, 36, 104-108. http://dx.doi.org/doi:
10.1093/alcalc/36.2.104