Presentation on theme: "Management of the intoxicated patient in the ER"— Presentation transcript:
1 Management of the intoxicated patient in the ER February 21, Dr. Paul SobeyDr. Karen NordahlDr. Roy Morton
2 Overview Determination of competency Kindling effect Intervention and treatment optionsWhen to consult other expertsWho requires admission?
3 Statistics11.2% of Canadians aged 15 years and older reported past-year use of at least one substance of abusemales vs females % vs 7.5%7% lifetime risk of suicide attemptMore violent method50% suicides recent EtOH25% BAL > 25 mmolSubstance Abuse issues are responsible for a minimum 20-25% of ER visits
4 Suicidality and competency-CMPA Duty to attendDuty to diagnoseDuty to treatAssessment of capacity is a clinical decisionNot based on Blood Alcohol LevelManagement of Concurrent Medical IssuesCertification?
5 CMPA position Not Black and White re: admit / discharge “…reasonable to assume..”“…impairment severe enough…”“…not based on 17mmol…”JudgementJ u d g e m e n tJ U D G E M E N T
7 ? Decision ? Admit / Discharge? “share the grief” Suicide risks / withdrawal risksOptions:inpatient / outpatientGet help…. Family / SW / othersContraindications to discharge
8 ! Decision ! If suicidal AND intoxicated Few Options Admit / Hold “Thinking Room” overnightMedical admission
9 Kindling effectAlcohol Withdrawal severity, complications and cravings are correlated to number of withdrawal cyclesRecurrent detoxification may elevate alcohol craving as measured by the Obsessive Compulsive Drinking scale - Alcohol 20 (2000) 181–185Kindling in Alcohol Withdrawal - Howard C. Becker, Ph.D.Relative kindling effect of readmissions in alcoholics Alcohol & Alcoholism Vol. 31, No. 4, pp , 1996Possibly as little as 2 detoxes per year can increase the risk for significant complications of withdrawalKindling 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 consequencesHome detoxification from alcohol Its safety and efficacy in comparison with inpatient care – Alcohol and Alcoholism, Vol. 26. No 5/6. pp , 1991Outpatient Detoxification of the Addicted or Alcoholic Patient - Christopher D. PraterLower risk of over sedationReduced total benzo useReduced incidence seizure and deliriumImproved access for marginalized populationsWomen 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 > 38.5Lack of a safe, stable, substance-free setting and care giver to dispense medications.
14 Screening and Brief Intervention and Referral to Treatment (SBIRT) EffectivenessWhat constitutes a Brief Intervention?
15 Effectiveness Alcohol Reduce hospitalization costs by $1000/person screenedSave $4 for each $1 invested in ER and trauma center screeningSingle intervention and 6 month follow up40-50% consumption reduction42% reduction in ER visits55% reduced MVAs100% reduced arrests
16 What is a Brief Intervention MD questioning re: frequency and quantity of useTreatment hx, social determinantsBiological markers – Urine drug screen, EtOH level, liver enzymes, CBC, E7 and PharmaNetTo determine risk for self harmConsequences – emotional, thought, physical, home, relationships, legal, financial/occupational5/7 = severeMatch treatment options with risk
17 SBIRT Brief Intervention Process of taking history and feed back Judging stage of changeTo reduce substance use and harmsWhat can we do to make this work for you?
18 Treatment Options Detox Inpatient (I/P) or Outpatient (O/P) Home and Mobile detoxOutpatient Options12-step/SMART RecoveryAlcohol and Drug Programs - localSobering Assessment CentreDaytoxInpatient programsRecovery houses: low to high intensityPublic and private treatment settingsMedications
19 Case I - Mr. J52 yo male, fell, simple facial lacn, neuro exam negative, no hx complicated AWBrought to ER by distraught family, long hx EtOH misuseER x 4 in last 12 months, detox x 2Longest sober 4 weeksGGT 85, all else normalEtOH level 26, last drink 4 hours agoNo other med/psych issues. Major social issuesWants to stay to detoxWife refusing to take him home
20 Case I - Mr. J - Options Risk of kindling and cognitive decline Assessing motivation to changeSome wait and self referralFacility 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 resourcesMeets criteria for Outpatient ProtocolHow not to enable
22 Case II Mr. LPresent 23:00 h “dope sick”, “thinking about getting clean”No other underlying medical issuesPMHx: similar presentation to LMH 10 days agoCBC normalNo other labs doneDrowsy but rouses, says “dope sick” againVVS, pupils 4mm, not sweating, ambulatory
23 Case II Mr. LSW 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 detoxReferral to community resources
25 Articles and Resources CMPA: Managing intoxicated patient in the emergency departmentProblem Drinking Guideline: king.html