GRACE-4 Guidelines: Navigating Alcohol Abuse, Withdrawals, and Cannabinoid Hyperemesis Syndrome

As a young nursing student, I can remember delivering my elderly patient his dinner tray, complete with his evening beer. He was recovering from surgery, and due to his history of heavy drinking, his doctor had ordered an ice-cold beer with each meal to prevent him from developing withdrawals.

Years later, I found myself working on a medical detox unit caught in a debate about alcohol withdrawal treatment. A new protocol was proposed using phenobarbital.

Some nurses were adamant that we should just continue giving the patients their mealtime beer taper, as it seemed to make them feel less anxious and more at home while on the unit. Others were starting to see the benefits of patients who had arisen from their phenobarbital-induced hibernation, ready to begin their journey of sobriety. Others wanted to move away from beer as well but argued that benzodiazepines were the better option.

On the physician side, there was also no clear consensus, which resulted in patients being on differing protocols, causing significant frustration for the patients who had their own opinions on which detox protocol they preferred. Eventually, a protocol was developed that saw all alcohol withdrawal patients admitted on a phenobarbital taper. The beer fridge was removed from the unit, and the staff slowly learned to embrace this new age of alcohol withdrawal treatment.

The Problem With Multiple-Choice Medicine

Medicine rarely offers just one treatment option.

Penicillin allergy? No problem—there are alternatives. Need a muscle relaxer? Take your pick from half a dozen.

But more choices can lead to more confusion. Without evidence-based guidelines, clinicians may rely on anecdotal experience, comfort-based practices, or personal biases.

This may seem trivial when deciding between ibuprofen or naproxen, but for more complex issues like alcohol withdrawal, there can be very real downstream consequences. 

GRACE-4 Guidelines: Evidence-Based Clarity

To bring clarity to the treatment of alcohol withdrawal syndrome (AWS), alcohol use disorder (AUD), and cannabinoid hyperemesis syndrome (CHS), the Society for Academic Emergency Medicine (SAEM) recently released the GRACE-4 guidelines.

These guidelines offer specific pharmacological recommendations, strength of evidence evaluations, and practical advice for managing these common, challenging conditions.

Recommendation 1: Alcohol Withdrawal Syndrome (AWS)

For adult patients with moderate to severe alcohol withdrawal, they recommend using phenobarbital in addition to benzodiazepines instead of using benzodiazepines alone. 

• • • This is a conditional recommendation with a very low/low certainty of evidence. 

It is also recommended that all patients treated for AWS should be offered follow-up treatment where available.

Recommendation 2: Alcohol Use Disorder (AUD)

For adults with AUD seeking sobriety:

Medication options:

• Naltrexone for patients not taking opioids

• Acamprosate if naltrexone is contraindicated

• Gabapentin to help reduce heavy drinking days and manage AWS symptoms

Good practice statements also address bridge prescriptions, therapy duration, and medication selection algorithms.

Recommendation 3: Cannabinoid Hyperemesis Syndrome (CHS)

For adults presenting to the ED with CHS:

• Use haloperidol or droperidol for symptom management

• Offer topical capsaicin for symptomatic relief

  (Both are conditional recommendations with very low certainty of evidence)

Additional recommendations:

• Provide IV fluids and non-opioid analgesics

• Avoid opioids

Remember: while not evidence-supported, abstinence likely contributes to symptom resolution.

Why Guidelines Matter

AWS, AUD, and CHS are common presentations in emergency departments worldwide. Having evidence-based protocols to fall back on can be useful when deciding between a handful of options. Whether you are working in a large academic medical center or a small critical access facility, guidelines like these help provide us with the most up-to-date information to make the best-informed decisions to help our patients.

Want to dive deeper? Check out the May 2025 ERcast segment, "Grace-4 Guidelines: Alcohol and Cannabinoids," for more on the GRACE-4 recommendations.