From the Guidelines
Phenobarbital is not recommended as a first-line treatment for alcohol withdrawal, and benzodiazepines should be used instead. According to the World Health Organization's evidence-based guidelines for mental, neurological, and substance use disorders in low- and middle-income countries, benzodiazepines are the recommended front-line medication for the management of alcohol withdrawal 1.
Key Points for Management
- Benzodiazepines are recommended for alleviating withdrawal discomfort, and preventing and treating seizures and delirium 1.
- Antipsychotic medications should not be used as stand-alone medications for the management of alcohol withdrawal, but can be used as an adjunct to benzodiazepines in severe withdrawal delirium 1.
- Anticonvulsants, such as phenobarbital, should not be used following an alcohol withdrawal seizure for the prevention of further alcohol withdrawal seizures 1.
- Patients at risk of severe withdrawal, or who have concurrent serious physical or psychiatric disorders, or who lack adequate support, should preferably be managed in an inpatient setting 1.
Considerations for Phenobarbital Use
While phenobarbital may be considered in certain cases, such as severe withdrawal or failure of benzodiazepine therapy, its use requires careful monitoring due to its potential for respiratory depression and sedation [no direct evidence from (1), but based on general medical knowledge].
General Management Principles
All patients undergoing alcohol withdrawal management should be given oral thiamine, with parental thiamine considered for those at high risk or with suspected Wernicke’s encephalopathy 1. Psychoactive medication used for the treatment of alcohol withdrawal should be dispensed in small quantities, or each dose supervised, to reduce the risk of misuse 1.
From the FDA Drug Label
The lethal dose of a barbiturate is far less if alcohol is also ingested. Individuals susceptible to barbiturate abuse and dependence include alcoholics and opiate abusers, as well as other sedative-hypnotic and amphetamine abusers Treatment of barbiturate dependence consists of cautious and gradual withdrawal of the drug One method involves substituting a 30 mg dose of phenobarbital for each 100 to 200 mg dose of barbiturate that the patient has been taking
The use of phenobarbital for alcohol withdrawal is not directly supported by the provided drug label. The label discusses the treatment of barbiturate dependence and the potential for alcoholics to be susceptible to barbiturate abuse and dependence. However, it does not provide information on using phenobarbital specifically for alcohol withdrawal. 2
From the Research
Phenobarbitol for Alcohol Withdrawal
- Phenobarbitol has been studied as a potential treatment for alcohol withdrawal, with some evidence suggesting it may be as safe and effective as benzodiazepine-based protocols 3.
- A study comparing fixed-dose phenobarbital with as-needed benzodiazepines found that phenobarbital was associated with a lower incidence of delirium and trends toward lower mortality, ICU transfer, seizure, oversedation, and 30-day re-admissions 3.
- However, benzodiazepines are still widely recommended as the first-line treatment for alcohol withdrawal, with phenobarbitol and other barbiturates not found to be superior to benzodiazepines in randomized controlled trials 4, 5.
- Other medications, such as anticonvulsants, may also be effective in treating alcohol withdrawal, particularly in outpatient settings or for patients with certain comorbidities 6, 7.
- The choice of treatment for alcohol withdrawal should be based on individual patient needs and medical history, with consideration of the potential benefits and risks of different medications 3, 7.