Management of the intoxicated patient in the ER February 21, 2013 Dr. Paul Sobey Dr. Karen Nordahl Dr. Roy Morton.

Management of the intoxicated patient in the ER

February 21, 2013 Dr. Paul Sobey

Dr. Karen Nordahl

Dr. Roy Morton

Overview

Determination of competency Kindling effect Intervention and treatment options When to consult other experts Who requires admission?

Statistics

11.2% of Canadians aged 15 years and older reported past-year use of at least one substance of abuse

males vs females - 15.3% vs 7.5% 7% lifetime risk of suicide attempt

More violent method 50% suicides recent EtOH 25% BAL > 25 mmol

Substance Abuse issues are responsible for a minimum 20-25% of ER visits

Suicidality and competency-CMPA

Duty to attend Duty to diagnose Duty to treat

Assessment of capacity is a clinical decision Not based on Blood Alcohol Level Management of Concurrent Medical Issues Certification?

CMPA position

Not Black and White re: admit / discharge

“…reasonable to assume..” “…impairment severe enough…” “…not based on 17mmol…” Judgement J u d g e m e n t J U D G E M E N T

? Decision ?

History – Physical – Lab - Collateral presentation previous suicidality driving ER visits Comorbidities Axis 1 / 11

? Decision ?

Admit / Discharge?

“share the grief” Suicide risks / withdrawal risks Options: inpatient / outpatient Get help…. Family / SW / others Contraindications to discharge

! Decision !

If suicidal AND intoxicated Few Options Admit / Hold “Thinking Room” overnight

Medical admission

Kindling effect

Alcohol Withdrawal severity, complications and cravings are correlated to number of withdrawal cycles Recurrent detoxification may elevate alcohol craving as measured by the

Obsessive Compulsive Drinking scale - Alcohol 20 (2000) 181–185 Kindling in Alcohol Withdrawal - Howard C. Becker, Ph.D. Relative kindling effect of readmissions in alcoholics Alcohol & Alcoholism Vol.

31, No. 4, pp. 375-380, 1996

Possibly as little as 2 detoxes per year can increase the risk for significant complications of withdrawal

Outpatient withdrawal has fewer negative consequences

Home detoxification from alcohol Its safety and efficacy in comparison with inpatient care – Alcohol and Alcoholism, Vol. 26. No 5/6. pp. 645-650, 1991

Outpatient Detoxification of the Addicted or Alcoholic Patient - Christopher D. Prater

Lower risk of over sedation Reduced total benzo use Reduced incidence seizure and delirium Improved access for marginalized

populations Women with children/FN/HIV/psych

comorbidities

Outpatient Alcohol Withdrawal

Problem Drinking Guideline

Everyone is an outpatient withdrawal candidate unless contraindicated

Contraindications to Outpatient Withdrawal History of withdrawal seizure or withdrawal delirium. Multiple failed attempts at outpatient withdrawal. Unstable associated medical conditions: Coronary Artery

Disease (CAD), Insulin-Dependent Diabetes Mellitus (IDDM). Unstable psychiatric disorders: psychosis, suicidal ideation,

cognitive deficits, delusions or hallucinations. Additional sedative dependence syndromes

(benzodiazepines, gamma-hydroxy butyric acid, barbiturates and opiates).

Signs of liver compromise (e.g., jaundice, ascites). Failure to respond to medications after 24-48 hours. Pregnancy. Advanced withdrawal state (delirium, hallucinations,

temperature > 38.5 Lack of a safe, stable, substance-free setting and care giver

to dispense medications.

Effectiveness What constitutes a Brief Intervention?

Screening and Brief Intervention and Referral to Treatment (SBIRT)

Effectiveness

Alcohol Reduce hospitalization costs by

$1000/person screened Save $4 for each $1 invested in ER and

trauma center screening Single intervention and 6 month follow up

40-50% consumption reduction 42% reduction in ER visits 55% reduced MVAs 100% reduced arrests

What is a Brief Intervention

• MD questioning re: frequency and quantity of use

• Treatment hx, social determinants • Biological markers – Urine drug screen, EtOH

level, liver enzymes, CBC, E7 and PharmaNet• To determine risk for self harm

Consequences – emotional, thought, physical, home, relationships, legal, financial/occupational

5/7 = severe• Match treatment options with risk

SBIRT

Brief Intervention Process of taking history and feed back

Judging stage of change To reduce substance use and harms

What can we do to make this work for you?

Treatment Options

• Detox Inpatient (I/P) or Outpatient (O/P)• Home and Mobile detox

• Outpatient Options• 12-step/SMART Recovery• Alcohol and Drug Programs - local• Sobering Assessment Centre• Daytox

• Inpatient programs• Recovery houses: low to high intensity• Public and private treatment settings

• Medications

Case I - Mr. J

52 yo male, fell, simple facial lacn, neuro exam negative, no hx complicated AW

Brought to ER by distraught family, long hx EtOH misuse

ER x 4 in last 12 months, detox x 2 Longest sober 4 weeks GGT 85, all else normal EtOH level 26, last drink 4 hours ago No other med/psych issues. Major social issues Wants to stay to detox Wife refusing to take him home

Case I - Mr. J - Options

Risk of kindling and cognitive decline Assessing motivation to change Some wait and self referral Facility MD can facilitate “next available

bed” Abuse potential…

Case I - Mr. J - Management

Creekside Detox - medically monitored with daily intervention, engage in and disposition to treatment resources

Meets criteria for Outpatient Protocol

How not to enable

Case II Mr. L

Present 23:00 h “dope sick”, “thinking about getting clean”

No other underlying medical issues PMHx: similar presentation to LMH 10

days ago CBC normal

No other labs done Drowsy but rouses, says “dope sick” again VVS, pupils 4mm, not sweating, ambulatory

Case II Mr. L

SW saw at 15:00h next day – “got bed at Creekside for tomorrow afternoon”

Case II – Management Options Does this patient need admission?

What is the diagnosis? What are the treatment options?

Bridging medications for detox Referral to community resources

Articles and Resources

CMPA: Managing intoxicated patient in the emergency department

Problem Drinking Guideline: http://www.bcguidelines.ca/guideline_problem_drinking.html