Have you tried to use phenobarbital for your ICU patients with alcohol withdrawal syndrome?
Typically, we use benzodiazepines such as ativan to treat this.
Although the empiric data is quite compelling to make the switch.
I personally use phenobarbital more often than benzodiazepines these days.
The main question of course is the dosing.
This single-center, pre-post protocol implementation study is a great starting point for those looking for data.
Hat tip to the authors, read these data for yourself.

Phenobarbital dose/dosing for alcohol withdrawal

Here’s the dosing regimen used by the team for alcohol withdrawal: phenobarbital 260mg IV for one initial dose followed by 130mg IV every 15 to 30 minutes as needed with a max total dose of 15mg/kg of IDEAL body weight. This is aimed at achieving a CIWA-Ar score of less than 10.

What are the benefits?

This protocol shaved off almost a day in the ICU length of stay but three days in the hospital length of stay.
In addition, there was far less use of adjunctive medications such as dexmedetomidine, haloperidol, and gabapentin.
Fewer patients needed to be intubated and fewer needed restraints.

What are the adverse effects of phenobarbital for alcohol withdrawal?

Per this study, they did not find any adverse effects.

I’ve been using phenobarbital in my practice with great success. It’s time for us to consider changing our practice. If your patient has pancreatitis, this is how we should provide them with fluids.

Citations Evaluating Phenobarbital for Alcohol Withdrawal

Alwakeel M, Alayan D, Saleem T, Afzal S, Immler E, Wang X, Akbik B, Duggal A. Phenobarbital-Based Protocol for Alcohol Withdrawal Syndrome in a Medical ICU: Pre-Post Implementation Study. Crit Care Explor. 2023 Apr 18;5(4):e0898. doi: 10.1097/CCE.0000000000000898. PMID: 37091477; PMCID: PMC10115550.
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Wolpaw BJ, Oren H, Quinnan-Hostein L, Bradley KA, Johnson NJ, Hallgren KA, Gupta A, Kim HN, Granich MA, Steel TL. Hospital-Wide Implementation, Clinical Outcomes, and Safety of Phenobarbital for Alcohol Withdrawal. JAMA Netw Open. 2025 Aug 1;8(8):e2528694. doi: 10.1001/jamanetworkopen.2025.28694. Erratum in: JAMA Netw Open. 2025 Sep 2;8(9):e2538977. doi: 10.1001/jamanetworkopen.2025.38977. PMID: 40853658; PMCID: PMC12379078.
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The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management. J Addict Med. 2020 May/Jun;14(3S Suppl 1):1-72. doi: 10.1097/ADM.0000000000000668. Erratum in: J Addict Med. 2020 Sep/Oct;14(5):e280. doi: 10.1097/ADM.0000000000000731. PMID: 32511109.
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Borgundvaag B, Bellolio F, Miles I, Schwarz ES, Sharif S, Su MK, Baumgartner K, Liss DB, Sheikh H, Vogel J, Austin EB, Upadhye S, Klaiman M, Vellend R, Munkley A, Carpenter CR. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department. Acad Emerg Med. 2024 May;31(5):425-455. doi: 10.1111/acem.14911. PMID: 38747203.
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Seshadri A, Appelbaum R, Carmichael SP 2nd, Farrell MS, Filiberto DM, Jawa R, Kodadek L, Mandell S, Miles MVP, Paul J, Robinson B, Michetti CP. Prevention of alcohol withdrawal syndrome in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open. 2022 Nov 21;7(1):e001010. doi: 10.1136/tsaco-2022-001010. PMID: 36425749; PMCID: PMC9680182.
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Pourmand A, AlRemeithi R, Kartiko S, Bronstein D, Tran QK. Evaluation of phenobarbital based approach in treating patient with alcohol withdrawal syndrome: A systematic review and meta-analysis. Am J Emerg Med. 2023 Jul;69:65-75. doi: 10.1016/j.ajem.2023.04.002. Epub 2023 Apr 5. PMID: 37060631.
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Murphy JA, Curran BM, Gibbons WA 3rd, Harnica HM. Adjunctive Phenobarbital for Alcohol Withdrawal Syndrome: A Focused Literature Review. Ann Pharmacother. 2021 Dec;55(12):1515-1524. doi: 10.1177/1060028021999821. Epub 2021 Mar 7. PMID: 33678057.
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Kessel KM, Olson LM, Kruse DA, Lyden ER, Whiston KE, Blodgett MM, Balasanova AA. Phenobarbital Versus Benzodiazepines for the Treatment of Severe Alcohol Withdrawal. Ann Pharmacother. 2024 Sep;58(9):877-885. doi: 10.1177/10600280231221241. Epub 2024 Jan 21. PMID: 38247044.
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Fleenor LM, Beavers JR, Tidwell WP, Atchison L, Woo E, Medvecz AJ, Beyene RT, Kast K, Marcovitz D, Dennis BM, Guillamondegui OD, Smith MC. Comparison of phenobarbital monotherapy to a benzodiazepine-based regimen for management of alcohol withdrawal syndrome in trauma patients. J Trauma Acute Care Surg. 2024 Mar 1;96(3):493-498. doi: 10.1097/TA.0000000000004116. Epub 2023 Aug 21. PMID: 37599414.
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Ronan MV, Ganatra RB, Saukkonen J. Establishing the safety of phenobarbital treatment of alcohol withdrawal syndrome on general medical wards: A retrospective cohort study. Alcohol. 2024 May;116:29-34. doi: 10.1016/j.alcohol.2023.10.005. Epub 2023 Nov 17. PMID: 37979844.
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Abrams TE, Ronan MV. Clinical progress note: Phenobarbital in the treatment of alcohol withdrawal syndrome. J Hosp Med. 2025 Oct;20(10):1094-1098. doi: 10.1002/jhm.70088. Epub 2025 May 29. PMID: 40443022.
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Suhotliv A, Blinder V, Mohamed A, Fein DG, Moskowitz A. An Exploration of Alcohol Withdrawal Protocols, with a Focus on the Use of Phenobarbital. South Med J. 2026 Mar;119(3):152-154. doi: 10.14423/SMJ.0000000000001938. PMID: 42000195.
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Lee CM, Dillon DG, Tahir PM, Murphy CE 4th. Phenobarbital treatment of alcohol withdrawal in the emergency department: A systematic review and meta-analysis. Acad Emerg Med. 2024 May;31(5):515-524. doi: 10.1111/acem.14825. Epub 2024 Jan 8. PMID: 37923363; PMCID: PMC11065966.
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Ware LR, Schuler BR, Goodberlet MZ, Marino KK, Lupi KE, DeGrado JR. Evaluation of Dexmedetomidine as an Adjunct to Phenobarbital for Alcohol Withdrawal in Critically Ill Patients. J Intensive Care Med. 2023 Jun;38(6):553-561. doi: 10.1177/08850666231152837. Epub 2023 Jan 26. PMID: 36703284.
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Matecki M, Noureldin A, Akkari R, Cohen Z, McMullan M, Hawkins K, Williams J, Nwude A, Yamane D, Sarani B, Lee SM, Kartiko S. Phenobarbital Addition to Alcohol Withdrawal Treatment Offers Better Outcomes than Dexmedetomidine in Hospitalized Patients. J Intensive Care Med. 2025 Sep;40(9):948-955. doi: 10.1177/08850666251328881. Epub 2025 Mar 28. PMID: 40152196.
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Brooks L, Reinert JP. Phenobarbital Dosing for the Treatment of Alcohol Withdrawal Syndrome: A Review of the Literature. J Pharm Technol. 2024 Aug;40(4):186-193. doi: 10.1177/87551225241249407. Epub 2024 Apr 29. PMID: 39157637; PMCID: PMC11325683.
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Umar Z, Haseeb Ul Rasool M, Muhammad S, Yousaf S, Nassar M, Ilyas U, Hosna AU, Parikh A, Bhangal R, Ahmed N, Ariyaratnam J, Trandafirescu T. Phenobarbital and Alcohol Withdrawal Syndrome: A Systematic Review and Meta-Analysis. Cureus. 2023 Jan 12;15(1):e33695. doi: 10.7759/cureus.33695. PMID: 36788902; PMCID: PMC9922035.
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Govalan R, Hao S, Kenes MT, McSparron JI, Tapper EB. Safety and effectiveness of phenobarbital vs. benzodiazepines for severe alcohol withdrawal in alcohol-associated liver disease in the ICU. JHEP Rep. 2026 Apr;8(4):101769. doi: 10.1016/j.jhepr.2026.101769. Epub 2026 Feb 4. PMID: 41861676; PMCID: PMC13019541.
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Hernandez K, Kang C, Allison-Aipa T, Qi C, Haycock K, Choi M. High-dose Phenobarbital for Severe Alcohol Withdrawal in the Emergency Department. JACP. 2025;1(1):22-29.
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Kast KA, Sidelnik SA, Nejad SH, Suzuki J. Management of alcohol withdrawal syndromes in general hospital settings. BMJ. 2025 Jan 8;388:e080461. doi: 10.1136/bmj-2024-080461. PMID: 39778965.
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Fujimoto J, Lou JJ, Pessegueiro AM. Use of Phenobarbital in Delirium Tremens. J Investig Med High Impact Case Rep. 2017 Nov 13;5(4):2324709617742166. doi: 10.1177/2324709617742166. PMID: 29164160; PMCID: PMC5686878.
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Parthvi R, Agne P. Update on Phenobarbital for Alcohol Withdrawal Syndrome in Intensive Care. J Clin Intensive Care Med. 2019; 4: 036-039. doi:10.29328/journal.jcicm.1001023
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Punia K, Scott W, Manuja K, Campbell K, Balodis IM, MacKillop J. SAEM GRACE: Phenobarbital for alcohol withdrawal management in the emergency department: A systematic review of direct evidence. Acad Emerg Med. 2024 May;31(5):481-492. doi: 10.1111/acem.14788. Epub 2023 Sep 2. PMID: 37589203.
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Young GP, Rores C, Murphy C, Dailey RH. Intravenous phenobarbital for alcohol withdrawal and convulsions. Ann Emerg Med. 1987 Aug;16(8):847-50. doi: 10.1016/s0196-0644(87)80520-6. PMID: 3619162.
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