Management of the intoxicated
patient in the ER
February 21, 2013
Dr. Paul Sobey
Dr. Karen Nordahl
Dr. Roy Morton
Overview
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Determination of competency
Kindling effect
Intervention and treatment options
When to consult other experts
Who requires admission?
Statistics
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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
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More violent method
50% suicides recent EtOH
25% BAL > 25 mmol
Substance Abuse issues are responsible for a
minimum 20-25% of ER visits
Suicidality and competency-CMPA
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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
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Not Black and White re: admit / discharge
“…reasonable to assume..”
“…impairment severe enough…”
“…not based on 17mmol…”
Judgement
Judgement
JUDGEMENT
? Decision ?
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History – Physical – Lab - Collateral
presentation
previous suicidality
driving
ER visits
Comorbidities
Axis 1 / 11
? Decision ?
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Admit / Discharge?
“share the grief ”
Suicide risks / withdrawal risks
Options:
inpatient / outpatient
Get help…. Family / SW / others
Contraindications to discharge
! Decision !
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If suicidal AND intoxicated
Few Options
Admit / Hold
“Thinking Room” overnight
 Medical
admission
Kindling effect
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Alcohol Withdrawal severity, complications and
cravings are correlated to number of withdrawal
cycles
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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.
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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
Outpatient Alcohol 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
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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
Problem Drinking Guideline
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Everyone is an outpatient withdrawal candidate
unless contraindicated
Contraindications to Outpatient
Withdrawal
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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, gammahydroxy 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.
Screening and Brief Intervention
and Referral to Treatment (SBIRT)
Effectiveness
What constitutes a Brief Intervention?
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Effectiveness
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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
What is a Brief Intervention
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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
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Match treatment options with risk
SBIRT
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Brief Intervention
 Process
of taking history and feed back
 Judging
 To
stage of change
reduce substance use and harms
 What
can we do to make this work for you?
Treatment Options
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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
Case I - Mr. J
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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
Case I - Mr. J - Options
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Risk of kindling and cognitive decline
Assessing motivation to change
Some wait and self referral
Facility MD can facilitate “next available bed”
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Abuse potential…
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
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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
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other labs done
Drowsy but rouses, says “dope sick” again
VVS, pupils 4mm, not sweating, ambulatory
Case II Mr. L
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SW saw at 15:00h next day – “got bed at Creekside
for tomorrow afternoon”
Case II – Management Options
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Does this patient need admission?
 What
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is the diagnosis?
What are the treatment options?
 Bridging
medications for detox
 Referral to community resources
Articles and Resources
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CMPA: Managing intoxicated patient in the
emergency department
Problem Drinking Guideline:
http://www.bcguidelines.ca/guideline_problem_drin
king.html