In millions of households across the country, bottles containing multivitamin tablets sit next to the toaster, on a cabinet shelf next to the sugar or some other handy location. They’re a staple for people who want daily diet supplements. Among the familiar substances in those bottles is a secret weapon that also helps people ravaged by alcohol use.
It’s vitamin B1, or thiamine, a substance that plays a key role in converting the foods we eat into energy. Most people get plenty of it through their diet or those multivitamin supplements. But thiamine has a small number of enemies. One of them is chronic alcohol consumption, which often leads people to poor nourishment. That means that the body gets less thiamine and also has greater difficulty absorbing and utilizing what it gets of the vitamin.
Thiamine deficiency, in turn, can lead to acute Wernicke encephalopathy, a form of brain damage that causes confusion, vision problems and difficulty moving. The good news is there is a quick, inexpensive treatment for it: intravenous infusion of thiamine as soon as possible after the symptoms appear. Screening alcohol-use patients for Wernicke encephalopathy and treating those at risk with IV thiamine is now an established protocol at the UCHealth Center for Dependency, Addiction and Rehabilitation (CeDAR) on the Anschutz Medical Campus, thanks in large part to the work of CeDAR nurse Gene Shiling.
Thiamine time
Shiling developed the protocol as a credentialing project for UEXCEL, the professional development ladder for nurses at UCHealth University of Colorado Hospital. It began when he looked at gaps between the time CeDAR admits patients and the time physicians enter orders that initiate treatment. He wanted to be sure that all patients admitted for alcohol use who could benefit from Vitamin B1 received it as quickly as possible.
Shiling was eager to work on the problem because Wernicke encephalopathy is completely reversible once patients receive IV thiamine. In the past, providers often looked for all three of the main symptoms – loss of control of bodily movements, confusion and vision problems like nystagmus (rapid, uncontrolled eye movements) – before giving patients treatments. New research shows treatment is beneficial even if patients have just one symptom. Most importantly, the treatment saves brain function and can help to stave off the even more serious Wernicke-Korsakoff syndrome, which permanently damages the brain.
“Thiamine is easy to get and it’s relatively inexpensive,” said Dr. Daniel Bebo, an addiction medicine specialist at CeDAR. “But the effect of Wernicke encephalopathy and Wernicke-Korsakoff is brain damage. The end result is patients can become non-functional.”
High-risk population
To illustrate the significance of thiamine treatment in CeDAR’s patient population, Bebo noted that Wernicke encephalopathy appears on autopsy – the only way to definitely diagnose it – in between .4 percent and 2.8 percent the general population. For heavy alcohol users, it’s about 12.5 percent, and in those who die alcohol-related deaths, it ranges from 25 percent to 59 percent. Given those numbers, Bebo said, “It’s curious that thiamine deficiency is still undertreated.”
Indeed, Shiling said in his research for the UEXCEL project that he couldn’t find another substance use disorder facility anywhere in the country that follows an IV thiamine protocol like the one that he helped to put in place at CeDAR. It includes screening all alcohol-use patients for Wernicke encephalopathy and administering IV thiamine within the 72-hour window to all who exhibit at least one of the three indicators or who are too intoxicated to be screened.
In addition, Shiling designed training in recognizing Wernicke encephalopathy for all CeDAR nurses and physicians and a tool for assessing the condition that is now in the Epic electronic health record. He also successfully advocated for adding thiamine to the initial order set for physicians.
Payoff for patients
The results of the work were significant. After implementing the protocol, Shiling analyzed three months of data and found that of 57 patients admitted to CeDAR for alcohol use disorder, 22 received IV thiamine. Another five met the screening standard but did not receive the therapy for a variety of reasons, he said.
It’s difficult to identify definitively the benefits of the treatment, but for Shiling the “probable consequences” of thiamine deficiency have been on display during his seven years as a CeDAR nurse. “We frequently see patients after detox, inpatient care, counseling and multiple modalities of treatment who still have cognitive deficits, but we can’t figure out what they are,” he said.
In the wider world, Shiling added, the damage caused by Wernicke encephalopathy ranges from increased difficulties for individuals working in fields like accounting and law that require high-level cognitive ability to a complete loss of executive function in the most serious cases.
Shiling and Bebo pointed to the case of a patient who arrived at CeDAR severely intoxicated and exhibited “the classic triad of symptoms” of Wernicke encephalopathy, as Bebo put it. The patient received IV thiamine treatment within one hour, helping to lead to a positive outcome.
“Our concern was that he would lose cognitive ability, but he walked out just fine,” Bebo said.
What if the Wernicke encephalopathy diagnosis is wrong but providers initiate treatment? Well, nothing. If a person gets too much thiamine, the body simply gets rid of it through the call of nature.
“If we give thiamine to a whole bunch of people who don’t really need it, there is no harm done,” Shiling said. It’s also inexpensive, he noted. The total cost of the thiamine and supplies to administer it is $89 for a total of six 500-milligram treatments delivered three times a day for two days.
“At CeDAR, we’ve said, let’s go ahead and be aggressive,” Bebo said. “Gene’s role was to recognize the need and implement a policy that we have adopted. He has also opened up the view to others at CeDAR of research being really important.”
Professional and personal interest
The project seems to have opened an avenue of interest beyond CeDAR. Shiling presented his work in early October to the annual conference of the International Nurses Society on Addictions and said he received a good response. He’s also submitted it to the American Society of Addiction Medicine and to the UCHealth-sponsored Rocky Mountain Interprofessional Research and Evidence-based Practice Symposium, which will be held next spring.
The commitment Shiling has made to patient care also has a personal component. He was a patient at CeDAR in 2009 for treatment of a heroin addiction. In July 2019 he looks forward to celebrating a decade of sobriety.
“I feel like I can relate to our patients on a personal level,” he said. “I know what it feels like to be in their shoes, what it feels like to have to give up control and surrender, to take advice from strangers and have people tell you how to live your life and how difficult that is.”
His commitment has not gone unnoticed at UCHealth. “It’s very exciting to see the impact our clinical nurses are making with patient outcomes when they lead quality improvement work,” said Danielle Schloffman, director of the Magnet Program for nursing at UCH. “One goal of the UEXCEL credentialing program is to support direct care nurses to improve care delivery. Gene’s dedication to evidenced-based practice and his passion for improving lives for this vulnerable patient population is exemplary. Due to his efforts, patients are receiving preventative treatment that may have lasting positive effects on their overall health and wellbeing.”
Those words sum up Shiling’s primary motivation as a nurse at CeDAR. “We’re trying to give people better quality of life,” he said. “If we save just one person, I’ve done my job.”