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?