In this rapid review, we adapted traditional systematic review methods to generate evidence within an accelerated time frame [21,22,23]. Rapid reviews are a pragmatic and resource-efficient approach to knowledge synthesis that remains scientific, transparent and reproducible . The utility and importance of rapid reviews is recognized by the Cochrane Rapid Review Methods Group , and health policy institutions such as the World Health Organization and the Canadian Agency for Drugs and Technologies in Health [26, 27].
We prepared this paper in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist . Our adaptations to allow rapid review were that one reviewer performed title/abstract screening and quality assessments rather than two independent reviewers performing these steps in duplicate. Our search strategy utilized focused search terms in the most highly relevant databases to prioritize yielding citations with greatest relevance.
Protocol and registration
In line with our goal of producing this evidence summary expeditiously, we did not publish a review protocol or register this review prior to study initiation.
Adult patients (18 years and older) who presented to the ED with any clinical feature of alcohol withdrawal syndrome, as determined by criteria specified by study authors, e.g., Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score.
Any clinical intervention aimed at treating alcohol withdrawal symptoms, signs, or complications; and administered via any route. We excluded studies that examined psychosocial interventions alone, or supportive interventions alone.
Any clinical or patient-oriented outcome related to alcohol withdrawal.
Interventional studies with or without a comparator group, including randomized controlled trials (RCT) and non-randomized trials, as well as observational cohort studies that evaluated an intervention. We excluded review articles and case reports, studies published prior to 1980, non-English publications, and non-human studies.
We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) from 1980 to 2020 through Ovid. All three databases were last searched on May 11, 2020.
A professional health sciences librarian (MDW) developed our search strategy. We searched MEDLINE and CENTRAL using concepts emergency department AND alcohol withdrawal AND (drugs OR drug subheadings). We searched EMBASE using concepts emergency department AND alcohol withdrawal (focused) AND (drugs OR drug subheadings), as well as concepts emergency department AND alcohol withdrawal AND drugs AND drug subheadings. Subheadings and keywords were included in the searches to increase sensitivity.
We performed the grey literature search using the search engine Google using combinations of terms [“emergency department”, “emergency room”, “emergency” or “accident and emergency”] and [“alcohol withdrawal”] and [“treatment” or “intervention” or “management”]. The first 50 search results were opened and reviewed for relevant materials. We also hand-searched the most recent conference abstracts (2015 to 2020) of the Canadian Society of Addiction Medicine, American Society of Addiction Medicine, Canadian Association of Emergency Physicians, and American College of Emergency Physicians.
We report our full electronic search strategy for MEDLINE (Ovid) in Appendix 1.
A single reviewer (MM) performed title and abstract screening. Before full-text screening, articles were flagged for secondary review by the principal investigator (JM) as needed. Inclusion and exclusion decisions for full-text articles were performed in duplicate by two trained reviewers (MM and JK).
Data collection process
Data extraction was performed independently and in duplicate by two extractors (MM and JK). The principal investigator (JM) arbitrated and resolved any issues that arose during data extraction.
We extracted information relating to the study design and characteristics, and results as follows:
authors, year of publication, study design, study location, study time period (start and end dates), follow-up period (if applicable), data sources.
inclusion and exclusion criteria, age, sex, ethnicity, alcohol withdrawal severity at presentation, method of determining alcohol withdrawal, comorbidities, number of participants in main analysis, losses to follow-up.
method of allocation, method of determining eligibility for intervention, description of intervention (type, duration, dose, and timing), person administering intervention, other components of the intervention, method of determining end-point, components of the intervention after ED visit, follow-up after ED visit.
person ascertaining outcomes, primary outcomes, secondary and tertiary outcomes, adverse events.
Risk of bias in individual studies
We used the Cochrane risk-of-bias tool for randomized trials Version 2 (RoB 2) to assess the risk of bias in the RCTs included in this study . For non-randomized studies, we used the Cochrane risk of bias in non-randomized studies of interventions (ROBINS-I) tool . Risk of bias assessments were performed by one trained reviewer (JK) and verified by the principal investigator (JM).
Synthesis of results
Due to clinical and methodological heterogeneity of included RCTs, we did not meta-analyze their results. Instead, we present a narrative summary of the results of all included studies.