Rapid Clinical Updates: Inpatient AUD Pearls and Adulterants in the Unregulated Supply-Slides

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The "Rapid Clinical Updates" session addressed two key topics: inpatient alcohol use disorder (AUD) management pearls and challenges related to xylazine—a veterinary sedative increasingly found as an adulterant in the unregulated drug supply.<br /><br />Dr. Melissa Bregger reviewed essential AUD concepts for hospitalists, emphasizing differentiating unhealthy alcohol use from AUD and employing non-stigmatizing language in patient documentation. She introduced validated screening tools like PAWSS to identify patients at high risk for complicated alcohol withdrawal syndromes (AWS) and presented newer symptom monitoring tools such as mMINDS that are less labor-intensive and more objective than the traditional CIWA-Ar scale. Phenobarbital’s role as an off-label rescue medication for severe AWS was discussed, alongside first-line long-acting benzodiazepines. Importantly, hospital initiation of medications for AUD (MAUD) such as naltrexone and acamprosate improves outcomes by reducing mortality, ED visits, and readmissions. Safe prescribing practices and patient-centered goal setting were highlighted, with advice to avoid unnecessary supplements on discharge and instead focus on MAUD and harm reduction strategies (e.g., safer drinking practices, alternating alcohol with water).<br /><br />Dr. Raagini Jawa focused on xylazine’s emergence in the illicit drug supply, particularly fentanyl-xylazine mixtures considered an emerging threat by the US government. Xylazine is a full α-2 adrenergic and kappa opioid receptor agonist causing profound CNS depression, prolonged sedation, and distinctive wounds. Challenges include under-recognition due to lack of standard urine drug screens, limited testing options (GC/MS testing, community drug-checking), and difficulty managing xylazine withdrawal (overlapping with opioid withdrawal but requiring adjunctive treatments like clonidine). Harm reduction measures include wound care protocols, early pain and withdrawal management, and patient education. Provider stigma and inadequate care for wounds were noted barriers. Naloxone remains effective for overdose despite myths about xylazine resistance.<br /><br />Overall, the updates emphasized evidence-based inpatient AUD care and emerging clinical challenges related to potent adulterants like xylazine, underscoring the importance of screening, tailored treatment, harm reduction, and compassionate non-stigmatizing care.

Keywords

inpatient alcohol use disorder

AUD management

PAWSS screening tool

mMINDS symptom monitoring

phenobarbital for AWS

medications for AUD (MAUD)

xylazine adulterant

fentanyl-xylazine mixtures

xylazine withdrawal management

harm reduction strategies