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

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

3. Statistics
11.2% of Canadians aged 15 years and older reported past-year use of at least one substance of abuse
males vs females % 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

4. 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?

5. 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

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

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

8. ! Decision ! If suicidal AND intoxicated Few Options Admit / Hold
“Thinking Room” overnight
Medical admission

9. 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 , 1996
Possibly as little as 2 detoxes per year can increase the risk for significant complications of withdrawal
Kindling is a process in which weak electrical or chemical stimulus, which initially causes no overt behavioral responses, results in the appearance of behavioral effects, such as seizures, when it is administered repeatedly (Becker, 2004) Repeated withdrawal experiences (in some research, anything greater than twice per year) can cause a neurochemical imbalance in the brains of alcoholics who suddenly cease or reduce their drinking.
These imbalances can cause a lowering of the seizure threshold, with a patient suddenly experiencing withdrawal seizures, even when the previous withdrawal attempts have been less severe.

10. Outpatient Alcohol 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 , 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

11. Problem Drinking Guideline
Everyone is an outpatient withdrawal candidate unless contraindicated

12. 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 hours.
Pregnancy.
Advanced withdrawal state (delirium, hallucinations, temperature > 38.5
Lack of a safe, stable, substance-free setting and care giver to dispense medications.

14. Screening and Brief Intervention and Referral to Treatment (SBIRT)
Effectiveness
What constitutes a Brief Intervention?

15. 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

16. 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

17. 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?

18. 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

19. 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

20. 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…

21. 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

22. 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

23. Case II Mr. L
SW saw at 15:00h next day – “got bed at Creekside for tomorrow afternoon”

24. 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

25. Articles and Resources
CMPA: Managing intoxicated patient in the emergency department
Problem Drinking Guideline: king.html