Barriers to the Use of Phenobarbital For Acute Alcohol Withdrawal: A QI Project

Document Type

Conference Proceeding

Publication Date

10-2025

Publication Title

Chest

Abstract

PURPOSE: Our project assessed the barriers to the use of phenobarbital for treatment of alcohol withdrawal syndrome (AWS). Despite recent literature supporting phenobarbital’s benefits over benzodiazepines (BZD), phenobarbital remains underutilized in the treatment of AWS. Our survey identified gaps in knowledge, familiarity, and comfort with phenobarbital. We later developed and implemented an evidence-based treatment protocol and now seek to assess its effectiveness in addressing those same gaps. METHODS: We developed a standardized survey and polled emergency medicine, internal medicine, family medicine and critical care teams. Questions started by assessing knowledge/familiarity of phenobarbital itself as well as prior perceptions and experiences regarding phenobarbital use. There was a brief educational section outlining mechanisms and benefits of phenobarbital in the middle. At the end, we re-assessed comfort with use of phenobarbital to treat AWS. After the survey results, we partnered with pharmacy colleagues to harness the feedback and develop a standardized AWS treatment algorithm. Initial risk for severe alcohol withdrawal is assessed using the validated prediction of alcohol withdrawal severity scale (PAWSS). Guidance for the use of differing phenobarbital formulations and doses is then provided based on clinical institute for withdrawal assessment (CIWA) scores. We are currently in the process of re-distributing the survey to re-assess attitudes and perceptions of phenobarbital use and to evaluate the clinical utility and impact of the treatment algorithm itself. RESULTS: The initial survey garnered 57 responses, most of which came from attending physicians and residents with the major specialties being EM and FM. There was a wide range of years in practice for attendings and diverse distribution of residents from PGY1 to PGY4. The most common barriers to use of phenobarbital were prior training which emphasized use of bzd over phenobarbital (53%) and current practice pattern not inclusive of phenobarbital (32%). A minority of respondents felt comfortable using phenobarbital to treat AWS before the educational section of the survey with 21/57 (37%) rated 4 or 5 on 5 point scale and 24/57 (42%) rated 1 or 2 on 5 point scale. There was a significant increase in comfort using phenobarbital to treat AWS after the educational section of the survey with 42/57 (74%) rated 4 or 5 and 2/57 (4%) rated 1 or 2. CONCLUSIONS: The survey results revealed that while there was initial lack of comfort with use of phenobarbital for AWS, a relatively simple educational intervention was sufficient to achieve significant self-reported improvement. The largest barriers to phenobarbital use were lack of knowledge/exposure during medical training and contemporary practice patterns at our institution. CLINICAL IMPLICATIONS: There is a general lack of knowledge regarding phenobarbital use for AWS which originates in medical training and is perpetuated by contemporary practice patterns. By increasing medical education regarding phenobarbital and developing decision making algorithms such as ours, both the efficacy and safety of phenobarbital treatment for AWS can be improved.

Volume

168

Issue

4S

First Page

4606A

Last Page

4607A

Comments

American College of Chest Physicians CHEST Annual Meeting, October 19-22, 2025, Chicago, IL

DOI

10.1016/j.chest.2025.07.2581

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