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Management of the Intoxicated Patient in the ER

Explore the complexities of handling intoxicated patients in the ER, covering competency evaluation, kindling effect, treatment options, and consultation protocols. Learn about statistics, suicidality, and strategies for managing Substance Abuse issues. Discover the duty of attendance, diagnosis, and treatment, including the assessment of capacity. Make informed decisions on admit/discharge, suicide risks, and withdrawal complications. Gain insights into the Kindling effect in Alcohol Withdrawal and outpatient detoxification protocols, and understand the SBIRT effectiveness in reducing substance use harms.

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Management of the Intoxicated Patient in the ER

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  1. Management of the intoxicated patient in the ER February 21, 2013 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 - 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

  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. 375-380, 1996 • Possibly as little as 2 detoxes per year can increase the risk for significant complications of withdrawal

  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. 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

  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 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.

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

  14. 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

  15. 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

  16. 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?

  17. 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

  18. 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

  19. 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…

  20. 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

  21. 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

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

  23. 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

  24. 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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