META:PHI in the Emergency Department: Implementing Best Practices for Addictions

1. META:PHI in the Emergency Department: Implementing Best Practices for Addictions Treating Alcohol Withdrawal

2. What is META:PHI? Mentoring, Education, and Clinical Tools for Addiction: Primary Care–Hospital Integration Collaborative project to implement integrated care pathways for addiction throughout Ontario Partnership between hospitals, withdrawal management services, FHTs, CHCs, and community agencies Goals: Improve care for patients with addictions Improve care provider experience Improve population health Reduce service use Provide sustainable care

3. How it works Patients presenting with addiction-related concerns receive evidence-based interventions and are referred to rapid access addiction medicine (RAAM) clinics for treatment RAAM clinics offer substance use disorder treatment on walk-in basis; no formal referral/appointment needed Patients stabilized at RAAM clinic referred back to primary care for long-term addiction treatment (with ongoing support from RAAM clinic as required) Key components: Integration of care at hospital, RAAM clinic, primary care Training, support, and mentorship from addictions specialists Capacity-building

4. Role of the ED With support from META:PHI team: Follow best practices for treating urgent alcohol-/opioid-related presentations (e.g., CIWA-Ar protocol for alcohol withdrawal, buprenorphine for opioid withdrawal) Diagnose underlying substance use disorder causing urgent presentations Refer patients to treatment at RAAM clinic

5. Alcohol withdrawal management goals Fully treat withdrawal Advise patient on avoiding alcohol-related harms Provide referral to RAAM clinic for long term medication-assisted treatment

6. Clinical features Severity increase with amount consumed; uncommon with < 6 drinks per day Predictable pattern: patients with previous withdrawal seizures are at high risk for recurrence Begins 6–12 hours after last drink Usually resolves within 2–3 days, may last up to 7 days Most reliable signs: sweating, postural or intention tremor (not resting) Other signs: tachycardia, reflexia, ataxia, disorientation Symptoms: anxiety, nausea, headache, tactile/auditory/visual disturbances

7. Initial orders ECG (prolonged QT interval in alcohol withdrawal) Electrolytes, Mg+ CBC GGT, AST, ALT, bilirubin, albumin, INR Thiamine 200 mg IM

8. Symptom-triggered treatment 10-20 mg diazepam PO q 1-2 H when CIWA-Ar ≥10 or SHOT ≥2 Use lorazepam 2-4 mg for patients at high risk for diazepam toxicity: liver dysfunction, elderly, low serum albumin, on methadone or high doses of opioids, respiratory impairment Treatment completed when CIWA-Ar < 8 and SHOT < 2 x 2, with minimal tremor Do not give outpatient bzd script

9. CIWA-Ar scale (1)

10. CIWA-Ar scale (2)

11. SHOT scale

12. Advantages of symptom-triggered treatment Higher benzodiazepine dose in shorter time: Shortens length of stay Prevents complications (e.g., seizures, DTs) Prevents return to ED for undertreated withdrawal

13. Common concerns “CIWA-Ar takes too long to complete” Takes several minutes, but SHOT scale is shorter Can shorten length of stay by administering scale hourly Adequate treatment of withdrawal shortens patient’s total length of stay and reduces chance of relapse “High doses of benzodiazepines are unsafe” Patients with AUD have high cross-tolerance No need for outpatient benzodiazepine prescriptions, reducing risk of adverse effects

14. ED discharge (1) Always refer patient to RAAM clinic Administer thiamine 200mg IM/IV Recommend thiamine 300 mg PO OD x 1 month Do not discharge patients still experiencing moderate to severe withdrawal Patients leaving the ED still in alcohol withdrawal will almost always relapse, often leading to further ED visits If patient anxious and in mild withdrawal, prescribe gabapentin 300 mg PO tid for 1 week Gabapentin reduces subacute withdrawal symptoms (anxiety, insomnia, dysphoria, craving) and relapse rates

15. ED discharge (2) Refer to withdrawal management if: Patient still has mild withdrawal symptoms • WMS staff are not medically trained and cannot dispense large doses of PRN benzodiazepines for moderate to severe withdrawal • Give prescription for diazepam 10 mg qid or lorazepam 2 mg qid for 1–2 days to be dispensed by staff, with instructions to not dispense if patient is drowsy Patient lacks positive social supports Patient is in crisis and wants/needs to start treatment right away

16. Wrap-up Treating addicted patients is our responsibility as health care providers Addiction is the same as any other chronic illness: patients need specialist referrals, medication, treatment of co-occurring conditions, and regular follow-up The ED is an opportune setting to intervene, as many patients are motivated to get help for their disorder Effective addiction treatments are available Purpose of META:PHI project is to facilitate adoption of best practices and support clinicians

17. Resources META:PHI website: www.metaphi.ca META:PHI mailing list for clinical questions and discussion (e-mail sarah.clarke@wchospital.ca to join) META:PHI contacts:Medical lead: Dr. Meldon Kahan meldon.kahan@wchospital.ca Manager: Kate Hardykate.hardy@wchospital.ca Knowledge broker: Sarah Clarke sarah.clarke@wchospital.ca