Management of the intoxicated patient in the ER
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Management of the intoxicated patient in the ER
February 21, 2013 Dr. Paul Sobey
Dr. Karen Nordahl
Dr. Roy Morton
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Overview
Determination of competency Kindling effect Intervention and treatment options When to consult other experts Who requires admission?
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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
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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?
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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
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? Decision ?
History – Physical – Lab - Collateral presentation previous suicidality driving ER visits Comorbidities Axis 1 / 11
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? Decision ?
Admit / Discharge?
“share the grief” Suicide risks / withdrawal risks Options: inpatient / outpatient Get help…. Family / SW / others Contraindications to discharge
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! Decision !
If suicidal AND intoxicated Few Options Admit / Hold “Thinking Room” overnight
Medical admission
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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
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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
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Problem Drinking Guideline
Everyone is an outpatient withdrawal candidate unless contraindicated
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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.
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Effectiveness What constitutes a Brief Intervention?
Screening and Brief Intervention and Referral to Treatment (SBIRT)
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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
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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
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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?
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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
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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
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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…
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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
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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
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Case II Mr. L
SW saw at 15:00h next day – “got bed at Creekside for tomorrow afternoon”
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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
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Articles and Resources
CMPA: Managing intoxicated patient in the emergency department
Problem Drinking Guideline: http://www.bcguidelines.ca/guideline_problem_drinking.html
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