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Management of the intoxicated patient in the ER

Management of the intoxicated patient in the ER. February 21, 2013 Dr. Paul Sobey Dr. Karen Nordahl Dr. Roy Morton. Overview . Determination of competency Kindling effect Intervention and treatment options When to consult other experts Who requires admission?. Statistics.

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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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