Grace-4 Guidelines: Alcohol and Cannabinoids

Alcohol withdrawal is not just a benzodiazepine problem; admitted patients with moderate to severe withdrawal appear to do better when phenobarbital is added. Separately, emergency care for alcohol use disorder now includes anti-craving medications, and cannabinoid hyperemesis syndrome responds better to dopamine antagonists than to typical antiemetics alone.

Alcohol Withdrawal and Alcohol Use Disorder

• Phenobarbital adjunct therapy: For admitted adults with moderate to severe alcohol withdrawal, adding phenobarbital to benzodiazepines is associated with less intubation, fewer ICU admissions, and shorter hospital stay.
• Delirium and restraint reduction: The signal with phenobarbital is broader than symptom control alone, with lower rates of delirium, less continuous-infusion sedation, and less need for physical restraints.
• Follow-up after withdrawal care: Alcohol withdrawal treatment should not end at discharge; patients treated in the ED should be offered follow-up addiction care whenever that pathway exists, and we get into the practical handoff in the episode.
• Naltrexone first-line option: For patients with alcohol use disorder who want to stop drinking, naltrexone is a recommended anti-craving option that can reduce heavy drinking and can be started as an ED bridge when opioids are not on board.
• Alternatives to naltrexone: Acamprosate is a useful alternative when naltrexone is contraindicated, especially when opioid exposure rules naltrexone out or hepatic issues push you toward another agent.
• Gabapentin selected use: Gabapentin can reduce heavy drinking days and may help patients with prominent self-reported withdrawal symptoms, but misuse risk and opioid co-use matter when choosing it.

Cannabinoid Hyperemesis Syndrome Treatment

• Dopamine antagonist preference: Cannabinoid hyperemesis syndrome often responds poorly to ondansetron, metoclopramide, or promethazine; haloperidol or droperidol may be more effective for symptom control.
• Capsaicin as low-risk adjunct: Topical capsaicin has weak efficacy data but a very low risk profile, making it a reasonable adjunct for CHS when usual antiemetics are not getting traction.
• Usual care still matters: Haloperidol or droperidol are used in addition to usual care rather than instead of it, and the bedside sequencing nuances are worth hearing in the chapter.
• Outpatient symptom bridge: Olanzapine is a consideration for short-term outpatient symptom relief in selected CHS patients when there is no contraindication, with a few caveats we cover on the show.

References:

1. Borgundvaag B, Bellolio F, Miles I, et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department. Acad Emerg Med. 2024;31(5):425-455. PMID: 38747203