The last time I had seen “beer” on someone’s medication list was during my third year of medical school. The patient was scheduled to receive one can of beer with each meal. The patient, a upper class fellow whose wife had curtly reported, “He drinks two highballs before dinner each night and a glass or two of wine with dinner—he’s not an alcoholic!”, underwent some sort of facial surgery. His surgical team wanted to prevent any alcohol withdrawal and hence ordered alcohol for him.
I found this rather odd at the time.
This time, I saw two alcoholic beverages on the patient’s medication list:
beer 1 application by mouth at each meal (1 application = 2 cans of beer)
vodka 60mL by mouth every four hours for tremors
“What?” I exclaimed out loud. “Vodka and beer?”
This man had also undergone facial surgery and reported at the time of admission that he regularly consumed large quantities of alcohol. To prevent withdrawal, the team prescribed alcohol. However, they also prescribed the CIWA-A protocol, which utilizes Ativan, a sedative used in preventing alcohol withdrawal.
“He’s getting alcohol and Ativan? What’s the point?” I further commented.
I scanned the sheet for further information: Overnight, he had received a total of 90mL of vodka (60mL at 10:30pm and 30mL at 4:15am). He had also received two cans of beer with breakfast.
I defied the urge to tip over in resignation.
When I spoke with the patient, I spied the can of Budweiser sitting next to the tray of mostly uneaten food. I picked up the can. It was empty.
“I’d like to stop drinking,” the man spontaneously said to me. “I’d save a ton of money if I didn’t drink anymore. Alcohol doesn’t help me with anything. Man.”
I asked the nurse about the alcohol. She smiled at me—the sort of smile you give when you’ve forfeited emotional investment—and shrugged her shoulders. “Yeah, we use it all the time on this unit.”
The primary medical team offered a succinct reply, “The surgeons worry that Ativan will interfere with their exam. They won’t let us prescribe it. They always use alcohol instead.”
“What?” I said. “What” was rapidly becoming the only word in my vocabulary.
After I explained my increasingly agitated rationale, the medical team remarked, “Yeah—you’re right. It doesn’t make a lot of sense, especially if he wants to stop. I guess we’re not really reinforcing a sound decision, are we.”
My mind boggled.
“What if,” I commented, “the local papers got a hold of this? ‘Hospital prescribes alcohol to alcoholics.’ This is absurd.”
Questions:
- Why beer and vodka? Why not just beer? Why not just vodka?
- Why choose vodka? What about rum? gin? whiskey?
- If we’re thinking about cost containment, why not just use malt liquor?
- Does the pharmacy purchase the alcohol? Which supplier do they use? How much do they order? How do they keep it in stock?
- How about boxes of wine?
- Who decides the dosing strategies? Why does “one application” mean two cans of beer?
- And why dose vodka at 60mL units? One shot is about 44mL.
- Is it easier to titrate volumes of alcohol rather than milligrams of medication?
- How does one justify that Ativan will interfere with an exam but alcohol won’t?
I can’t be the only one who finds this practice odd and disturbing. I cannot find any evidence to support this practice. To whom do I express my astonishment and umbrage?
9 Sep 2007 |
It’s not like your hospital is alone: over 70% of US teaching hospitals have hooch on formulary:
http://www.ncbi.nlm.nih.gov/sites/entrez?db=PubMed&cmd=Retrieve&list_uids=12578486
But some ideas:
1) Binge-drinking adults generally drink beer.
http://www.sciencedaily.com/releases/2007/08/070831143158.htm
2) It’s hard to get enough ETOH volume into someone who isn’t all that thirsty with beer alone. Vodka gives you a 10:1 reduction in fluid volume. Good for people with CHF!
3) Vodka is good with hospital OJ. Gin is polarizing - you either like it or hate it - no middle ground. Whiskey has congeners, and trying to find a diet Coke at the same time as the bourbon is nigh-on impossible. Tequila causes clothes to fall off.
4) Cheap vodka is usually more cost-effective per proof-gallon. Also, it’s not inconceivable that pharmacy can procure untaxed ETOH since it’s not strictly for beverage purchases
It’s not uncommon in some areas that hospitals have wine available through dietary; my mom was hospitalized for several weeks and found an amusing little merlot on her menu after her doctor OKed it. I thought the Chardonnay was crap, but I’m a snob that way.
At a major teaching hospital in Seattle, my ENT was *completely* OK with me bringing a blender and Pina Colada fixin’s post-tonsillectomy, as I don’t tolerate opiates and needed an effective analgesia strategy. Fortunately, my advanced powers of denial have managed to keep me out of the OR on that count.
As for the Ativan, c’mon, who doesn’t like an Ativan and a margarita together? It saves money - let the synergy work for you in this, the age of the $7 ‘Rita.
E
Comment by Eric | 10 Sep 2007 @ 2:42am
It seems to me that there is something very wrong with prescribing alcohol, especially to someone who “wants to quit”. When my husband’s 96 year old grandfather was admitted to a VA hospital/nursing home (he lived to 104), the doctor prescribed a shot of brandy and a cigar daily because that was his routine. That was 20 years ago. You’d think we’d get smarter.
Comment by donnalee | 10 Sep 2007 @ 5:15am
The beer is for patients that might suffer from hops withdrawal. ;)
Comment by Terry | 10 Sep 2007 @ 7:16am
This isn’t unusual at all. It’s much easier to give EtOH via IV, though, which is what we do around here. And yes, hospital pharmacies usually have a metric buttload on hand. At least around here, they do. (Boston)
What I find unusual is that it’s being given PO in a hospital setting. I’ve never heard of that being done in recent years. Y’all must be backwards out there on the west coast. ;)
And why dose vodka at 60mL units? One shot is about 44mL.
Most of my personal shot glasses are actually shot-and-a-half glasses.
How does one justify that Ativan will interfere with an exam but alcohol won’t?
Well presumably s/he’s an alcoholic, no? Returning the BAC to what’s baseline for that particular patient? Then a benzo on top for anxiety?
Can’t apply normal standards to abnormal folks, and all that. I’ve known people who regularly combined Klonopin and EtOH. Or EtOH and Antabuse just because they could.
Yes, I knew some really… interesting… people in college. :o
Comment by RJS | 10 Sep 2007 @ 11:39am
Remember what else IV ETOH is good for… methanol toxicity. ETOH is competitive with methanol. We’ve got a guy at our hospital who loves to regularly huff carburator fluid, and that usually buys him an ER—>ICU visit. Lately tho, cause he is such a health care abuser, he has been stable enough to stay in the ER and just mellow out with a ETOH drip. I’m not certain if any of the other interns have been brave enough to just try PO beer, but if he was concious enough to take it without aspirating I would like to try. Morons
Comment by Glyph | 11 Sep 2007 @ 9:11pm
Curtseys to Eric and RJS—thank you for the links and information!
Comment by Maria | 11 Sep 2007 @ 9:14pm
Yes, it may be distressing to see in some settings but post surgery it makes sense.
If you are an alcoholic not drinking is dangerous.I understand we all have judgments about patient behavior but when a patient comes to hospital for a surgical procedure we are responsible for their recovery..from the surgery.
I don’t care if you drink or shoot up or snort. It’s not my job to police my patients about their personal lifestyle choices. It’s my job to assess the very best plan of care that will help my patient recover with minimal risk.
If that means maintaining their regular alcohol levels so be it.
When they have recovered then we can talk about making some different lifestyle choices, that is if the patient wants to change.
Despite the moral outrage you feel prescribing alcohol to alcoholics it prevents some very bad health risks in the post op setting.
More importantly when we prescribe we have some control over consumption. Alcoholics drink and they have people around them that facilitate their drinking. Better it’s me pouring the drinks then the patients wife.
Comment by mo | 11 Sep 2007 @ 11:10pm
This doesn’t really surprise me at all. I recall reading about coffee drinkers being given caffeine via IV post op when they couldn’t take anything by mouth. Prevents those withdrawal headaches.
Comment by Shauna | 13 Sep 2007 @ 9:55am