Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Management of Alcohol Use Disorder and Cannabinoid Hyperemesis Syndrome
Introduction
The GRACE-4 guidelines, developed by the Society for Academic Emergency Medicine (SAEM), focus on managing non-opioid use disorders in the emergency department (ED), specifically alcohol use disorder (AUD), alcohol withdrawal syndrome (AWS), and cannabinoid hyperemesis syndrome (CHS). The guidelines aim to provide evidence-based recommendations to enhance patient care in these common but complex conditions. The writing team included emergency physicians, addiction medicine experts, and patients with lived experience, utilizing the GRADE methodology to evaluate the certainty of evidence and strength of recommendations.
3 PICO questions answered:
1) Does adding phenobarbital to benzodiazepines in AWS improve outcomes?
2) Does prescribing anti-craving medications improve outcomes in AUD?
3) Is there any benefit to treating CHS with dopamine antagonists or capsaicin?
Recommendations
1. Alcohol Withdrawal Syndrome (AWS):
- For adults with moderate to severe AWS admitted to the hospital, it is suggested to use phenobarbital in addition to benzodiazepines rather than benzodiazepines alone.
- All patients treated for alcohol withdrawal should be offered follow-up treatment where available.
2. Alcohol Use Disorder (AUD):
- For adults with AUD desiring alcohol cessation, it is recommended to prescribe an anticraving medication.
2a: Naltrexone is suggested for patients not taking opioids to prevent return to heavy drinking.
2b: For those with contraindications to naltrexone, acamprosate is suggested.
2c: Gabapentin may be considered to reduce heavy drinking days and improve withdrawal symptoms.
3. Cannabinoid Hyperemesis Syndrome (CHS):
3a: Haloperidol or droperidol, in addition to usual care, is suggested to help with symptom management.
3b: Topical capsaicin may also be offered to help with symptom management.
- Benzodiazepines and opioids should not be first-line treatments for CHS due to lack of efficacy and potential risks.
Conclusions
The GRACE-4 guidelines address the management of AUD, AWS, and CHS in the ED, emphasizing the need for appropriate pharmacologic interventions and follow-up care. Despite limited high-quality evidence, these recommendations aim to improve patient outcomes by offering practical, evidence-based guidance for ED clinicians. Future research should focus on evaluating the impact of these guidelines, refining diagnostic criteria, and developing standardized treatment protocols to enhance care for patients with non-opioid use disorders in emergency settings.
Review the full article below: