Alcohol and Drug Problems in the Emergency Department

1
Alcohol and Drug Problems in the Emergency
Department

• A Project CREATE Module

2
Outline

• Screening and early identification of alcohol and
  drug (A D) problems
• Management of withdrawal
• Intoxication and overdose - alcohol and opioids
• Advice and referral
• Drug seeking

3
Alcohol and Drug Problems in the Emergency
Department SCREENING AND IDENTIFICATION
4
A D Problems in the EDCommon and Commonly
Missed

• High burden/prevalence 10 of 1000 patients
  presented to ED with alcohol-related problems
• Only 10 of these were identified
• Only 1 were given advice or referral

Cherpitel (1996)
5
Unique Position of Emergency Physicians

• To intervene on the front-line in crisis
  situations
• To decrease burden of illness and the impact of A
  D problems on society

6
Identification of A D ProblemsWhy Bother?

• If AD problems are not identified
• Treatment may be inappropriate or incomplete
• Complications may be missed
• Missed opportunities for referral and treatment
  of A D problems with impact on
• individuals, e.g., GI bleed
• society, e.g., drinking and driving

7
CASE 1

• A 45-year-old school teacher presents to the ED
  with chest pain. Work-up is negative for MI, but
  his blood pressure is elevated. He is sent home
  with a prescription for beta-blockers and
  follow-up with the cardiology clinic.
• What the MD missed He smokes crack cocaine.

8
CASE 2

• An 18-year-old university student presents to the
  ED with episodes of chest pain, palpitations and
  severe anxiety. Exam and ECG are normal. He is
  diagnosed with panic disorder, given alprazolam
  and referred to the mental health clinic.
• What the MD missed He smokes cannabis daily.

9
CASE 3

• A 60-year-old woman presents to the ED with
  epigastric burning and vomiting. Exam and CBC
  are normal. She is given an H2 blocker (Zantac)
  and referred to the GI clinic.
• What the MD missed She drinks 8 oz. of vodka per
  day.

10
CASE 4

• A 25-year-old law student had a grand mal seizure
  earlier today, her third in the past month.
  Neurological exam is negative. An outpatient CT
  scan, EEG and neurology referral is booked, and
  she is sent home on phenytoin.
• What the MD missed All seizures occurred within
  30 minutes of smoking cocaine.

11
CASE 5

• A 70-year-old woman presents in the ED with
  facial lacerations. She is sutured and sent home
  with a one week prescription for lorazepam 1 mg
  tid and naproxyn 250 mg qid.
• What the MD missed She is alcohol-dependent, and
  her husband had assaulted her when both of them
  were intoxicated.

12
CASE 6

• An elderly patient presents to the ED with
  confusion and falls. On exam, he is mildly
  tremulous. He is sent home with a referral to
  the geriatric consult service for the following
  week.
• What the MD missed The patient was in alcohol
  withdrawal.

13
Common A D Presentations

• Intoxication, overdose
• Withdrawal
• Trauma
• GI gastritis, varices, pancreatitis
• Infectious hepatitis B and C, HIV,
  cellulitis/abscess, STD

1
14
Common A D Presentations

• Respiratory pneumonia, TB
• Psychiatric depression, suicidal ideation,
  psychosis
• Cardiac arrhythmias, heart failure
• Geriatric confusion, failure to thrive, falls

2
15
Identification of A D Problemsin the ED

• A D problems can mimic or complicate many
  conditions!
• Always think about A D problems in any of the
  presentations listed in first slide
• Women, elderly most likely missed

16
Identification of A D Problems Alcohol History

• Ask daily or weekly amount
• Ask about MAXIMUM consumption on any one day in
  past month
• Convert responses to standard drinks 12 oz.
  beer, 5 oz. glass of wine, 1 1/2 oz. liquor

17
Identification of AD ProblemsCAGE

• Have you ever felt you needed to Cut down on your
  drinking?
• Have you every felt Annoyed by others telling you
  to cut down?
• Have you ever felt Guilty about your drinking?
• Have you ever need an Eye-opener in the morning
  to settle your nerves or relieve a hangover?
• Positive if 2 yes for men, 1 for women

18
Identification of A D Problems Laboratory
Markers

• Poor screening method due to low sensitivity and
  specificity
• Most sensitive is elevated GGT (35-50)
• other causes microsomal inducing agents
  (phenobarbital, phenytoin), obstructive liver
  disease, hepatitis, diabetes, obesity
• average half-life of 26 days can take 4 months
  to return to normal
• Elevated MCV less sensitive (35-40)

19
Identification of A D Problems Physical Exam

• Smell of alcohol on breath
• Drowsy
• Needle marks antecubital fossa
• Hepatomegaly

20
Alcohol and Drug Problems in the Emergency
Department ALCOHOL INTOXICATION
21
Alcohol Intoxication in the ED

• Conditions that cause impaired consciousness or
  ataxia can mimic or complicate alcohol
  intoxication, e.g.
• Subdural hematoma
• Encephalopathies Wernickes, hepatic
• Metabolic, e.g., nonketotic hyperosmolar coma
• Hypoxia from any cause
• Intoxication from other drugs
• Infections meningitis, sepsis

1
22
Alcohol Intoxication in the ED

• Easy to miss serious problems in intoxicated
  patients
• Intoxicated patients ignore symptoms, give a poor
  history, are harder to examine and are often
  non-compliant

2
23
Alcohol Intoxication in the ED

• History
• Listen to patients even if theyre drunk
• Past health, medication list
• Physical exam
• General observation, vital signs, hydration,
  heart, lungs, abdo, screening neuro (level of
  consciousness, gait), signs of trauma

3
24
Alcohol Intoxication in the ED
KEY QUESTION Is their clinical presentation
consistent with their reported alcohol
consumption or BAL?

• If in doubt, observe for two to three hours
• Avoid giving sedatives

4
BAL Blood Alcohol Level
25
Alcohol and Drug Problems in the Emergency
Department ALCOHOL WITHDRAWAL
26
Alcohol Withdrawal

• Classified as minor, intermediate or major
• Undetected, under-treated withdrawal is a barrier
  to recovery
• Ask all patients about withdrawal symptoms
• Past history predicts future episodes

1
27
Alcohol Withdrawal

• Minor
• Starts 6-12 hours after last drink, lasts up to 7
  days
• Tremor, sweating, tachycardia, vomiting
• Intermediate
• Seizures, dysrhythmias, hallucinosis

2
28
Major Withdrawal(Delirium Tremens)

• Starts day 3-5 of severe, untreated withdrawal
• More common in medically ill alcoholics
• Confusion, fluctuating level of consciousness,
  hallucinations, marked autonomic hyperactivity
• Can be fatal

29
Diazepam Loading Technique

• Diazepam 20 mg PO every one to two hours until
  symptoms abate
• Long half-life covers duration of withdrawal - no
  need for take-home doses
• If history of withdrawal seizures 20 mg PO per
  hour for at least three doses

30
Diazepam Loading Precautions

• Do not give diazepam if BAC gt 0.15 g
• Will not prevent seizures in patients taking
  daily high-dose sedatives
• Give lorazepam if severe liver disease,
  respiratory failure, severe asthma, elderly,
  debilitated, low serum albumin
• If unable to tolerate oral meds, give lorazepam
  SL or diazepam IV 2-5 mg/minute maximum - up to
  10-20 mg/hour do not give IM

1
31
Diazepam Loading Precautions

• If intoxicated patient has history of
  intermediate or major withdrawal, observe in ED
  overnight, treat withdrawal promptly
• Diazepam loading will not prevent withdrawal from
  high doses of benzodiazepines or barbiturates

2
32
Prevention of Wernickes Encephalopathy

• Clinical Features
• Triad of confusion, ataxia, ophthalmoplegia
• Difficult to diagnose
• Related to thiamine deficiency
• Prevention
• Do not rehydrate patients in alcohol withdrawal
  with glucose solutions until thiamine given
• Administer thiamine 100 mg IM first 2 to 3 days
  to ALL patients in withdrawal

33
Alcohol Withdrawal Indications for Admission

• Major withdrawal (DTs)
• Recurrent seizures, arrhythmias despite diazepam
• Severe minor withdrawal despite 60-80 mg diazepam
• Associated medical illness (e.g., pancreatitis,
  Wernickes)
• Physical dependence on other drugs such as
  benzodiazepines or barbiturates

34
Blood Alcohol Level

• 80 mg (17 mmol/L)
• Legal limit
• 4 drinks/hour for men 2-3 for women
• Non-tolerant drinkers may be tipsy
• Tolerant drinkers may be in withdrawal!
• 240 mg (51 mmol/L)
• If patient alert and talking clearly, is very
  tolerant, may go into withdrawal

1
35
Blood Alcohol Level

• Can be used to determine when patient will go
  into withdrawal
• Declines by 4-7 mmol/L/hour patients go into
  withdrawal at levels lt 20
• Can help determine whether ataxia, impaired level
  of consciousness is due to alcohol or not
• Low BAL rules out alcohol as a cause
• Has legal implications

2
36
Alcohol and Drug Problems in the Emergency
Department ADVICE AND REFERRAL

• Problem Drinking
• Alcohol Dependence

37
Advice and Referral in the ED

• Reasons for negative attitudes
• Intoxicated patients can be loud and abusive
• Self-inflicted illness
• Multiple visits - the regulars
• Poor historian
• Often non-compliant
• Yet ED patients are often very receptive to
  advice and interventions from MDs

38
Problem Drinking

• Drink above low-risk levels
• 2/day for men and women
• 14/week for men, 9/week for women
• Not severely alcohol-dependent
• Usually less than 40 drinks/week
• No withdrawal symptoms
• Socially stable, few serious social or physical
  problems

39
Effectiveness of MD Advice toProblem Drinkers

• Randomized trials confirm the effectiveness of
  brief physician advice
• Reduced drinking in problem drinkers
• Reduced ED visits and admissions
• Patients in ED may be receptive to MD advice -
  fear, guilt, pressure from family

40
Brief Advice for the Problem Drinker

• Express concern about the patients drinking
• Explain how their drinking caused their
  presentation to the ED
• Emphasize that the problem will get better if
  they reduce or abstain

1
41
Brief Advice for the Problem Drinker

• Advise patient of low-risk drinking guidelines
• Recommend a daily drinking diary
• Give advice on avoiding intoxication, e.g.,
• One drink per hour
• Alternate alcoholic with non-alcoholic drinks
• Dont drink on empty stomach
• Follow-up with family physician

2
42
Alcohol Dependence

• Compared to problem drinkers
• Higher consumption (gt40/week)
• Often withdrawal symptoms
• Severe social or physical consequences

43
Alcohol Dependence Management

• Express concern about alcohol use
• Explain how their use caused their presentation
  to the ED
• Recommend abstinence
• Have a plan for treating withdrawal

1
44
Alcohol Dependence Management

• Suggest treatment options
• Inpatient or outpatient treatment programs
• Pharmacotherapy
• Refer patients who are intoxicated or in
  withdrawal to a detoxification centre
• Recommend attendance at AA or other mutual aid
  group
• Give at least one practical way for the patient
  to access treatment
• Arrange medical follow-up

2
45
Alcohol and Drug Problems in the Emergency
Department DRUG WITHDRAWAL

• Benzodiazepines
• Barbituates
• Opioids

46
Benzodiazepine Withdrawal

• Presents to ED with acute anxiety, seizures or
  other complications
• Withdrawal can occur even with therapeutic doses
• Onset 1 - 4 days, may last weeks or months
• Two groups of symptoms
• Anxiety-related symptoms (e.g., irritability)
• Neurologic (tinnitus, blurry vision,
  dysperceptions, depersonalization)

47
Complications of Withdrawal

• Withdrawal worse with short-acting drugs, large
  doses, long duration of use
• Abrupt cessation of doses above 50 mg
  diazepam/day or equivalent can cause seizures,
  psychosis, delirium, arrhythmias
• Patients with mixed anxiety/depression may become
  suicidal

48
ManagementEquivalent dose lt 50-80 mg
diazepam/day

• Refer to family doctor, addiction medicine
  clinic, etc., for outpatient tapering
• Switch to diazepam
• Taper by 2-5 mg/week over 6-12 weeks

49
ManagementEquivalent dose gt 80-100 mg
diazepam/day

• Admit and obtain internal medicine or addiction
  medicine consult
• Switch patient to 1/2 to 2/3 equivalent dose of
  long-acting benzodiazepine (diazepam)
• Taper by 5-15 mg/day (maximum 10/day)
• If on alprazolam or triazolam taper with these
  agents
• If elderly, severe liver disease or low serum
  albumin use lower dose of diazepam or
  shorter-acting benzodiazepine

50
Barbiturate Withdrawal

• Like alcohol withdrawal, except more severe,
  later onset, longer duration
• Sudden cessation of 500 mg of intermediate-acting
  barbiturate daily puts patients at risk for
  severe withdrawal
• seizures, delirium, psychosis, arrhythmias

51
Treatment of Barbiturate Withdrawal

• Consider internal medicine or addiction medicine
  consult
• Phenobarbital loading requires admission
• Phenobarb 120 mg PO Q1H until patient intoxicated
  with 3 or more of
• drowsiness
• nystagmus
• ataxia
• slurred speech
• emotional lability

52
Opioid Withdrawal

• Anxiety, insomnia, drug-craving, myalgia,
  flu-like symptoms
• Lasts 5 days - several weeks
• Safe except in pregnancy - premature labour
• Assess for suicidal ideation
• Consider referral to a methadone program,
  especially if pregnant

53
Clonidine Protocol

• 0.1 mg tid-qid for 5-7 days can increase to 0.2
  mg tid-qid (but greater risk of hypotension)
• Can give test dose hold if BP lt 90/60
• Warn about postural hypotension, drowsiness,
  caution with driving
• Combine with antinauseants, antidiarrheals,
  analgesics, HS sedation

54
Alcohol and Drug Problems in the Emergency
Department OVERDOSE

• Opioids
• Benzodiazepines

55
Overdose in the Physically Addicted Patient
Principles

• General management airway, breathing,
  circulation, universal antidotes
• Avoid triggering severe withdrawal with naloxone,
  flumazenil
• Dont discharge patient until overdose has fully
  worn off
• Watch for and treat withdrawal
• Refer patient for drug treatment

56
Opioid Overdose

• Drowsiness, mioisis, slow respirations
• Naloxone competitive opioid antagonist
• Peak effect 5-15 minutes, duration 60 minutes
• Duration of action much shorter than that of
  opioids
• Patients need naloxone drip or intubation, up to
  48-72 hrs with long-acting opioids

57
Naloxone for Opioid Overdose

• Titrate to effect
• 0.01 mg/kg if no response, 0.1 mg/kg
• Infuse at 2/3 effective dose/hour
• Naloxone will put addicted patients in severe
  withdrawal
• Can trigger arrhythmias
• Intubation avoids adverse effects

58
Flumazenil for Benzodiazepine Overdose

• May trigger seizures in patients who are
  dependent on benzodiazepines
• Only use for iatrogenic benzodiazepine overdose

59
OverdoseOnce patient stabilized...

• Patient may go into withdrawal once OD treated
• take an alcohol drug history once patient
  alert polydrug abuse is common
• treat withdrawal according to standard protocols
• Refer patient for alcohol and drug treatment
• Refer to psychiatry if indicated

60
Alcohol and Drug Problems in the Emergency
Department DRUG SEEKING
61
Drug Seeking
Drug seekers will

• Make false claims of pain or distress
• Gravitate towards clinical services with a high
  volume of new patients
• Often be dependent on licit or illicit opiates
• May be dependent on cocaine or other drugs
• May be trafficking in narcotics

Note A subset may have true organic pain
62
Clinical Features of Drug Seekers

• Ask for drug of choice by name
• Refuse other therapeutic options
• Difficult to confirm story
• Pressure physician through anger, tears,
  bargaining

63
Drug Seeking Management

• Use general policy statements
• Only prescribe if you believe the patient might
  be on the level
• Don't make decisions based on stereotypes
• Try to confirm the patients story

1
64
Drug Seeking Management

• Ask if they have received a narcotic within the
  past 30 days
• Offer alternative treatment
• Guard your prescription pad carefully

2
65
Drug Seeking Management

• Ask if they feel they have a drug problem
• If they admit to a drug problem
• Refer them for treatment
• Offer non-narcotic treatment of withdrawal
• Dont taper with opioids

3