To the Editor.
—The recent article entitled "Individualized Treatment for Alcohol Withdrawal" by Dr Saitz and colleagues1 compared "fixed-schedule therapy" (substitution) with "symptom-triggered therapy" (suppression). The conclusions are open to misinterpretation for the following reasons. The dosage chosen for the fixed schedule (400 mg of chlordiazepoxide) may be high for groups of subjects with little evidence of alcohol withdrawal (selection bias). A Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) median score of 9 is barely recognizable as alcohol withdrawal (and some subjects had scores of 0). No entry criterion for alcohol withdrawal was used (presumably it was the expectation of withdrawal). Previous studies using a predominantly white male veteran population have demonstrated that only 13% of these subjects required drug treatment.2 Other general hospital studies have revealed that a median dose of 50 mg of diazepam (200 mg of chlordiazepoxide) was required using similar criteria for treatment
Sullivan JT. Individualized Treatment of Alcohol Withdrawal. JAMA. 1995;273(3):183. doi:10.1001/jama.1995.03520270017011