Download Presentation on alcohol use disorders for

ED Management of
Alcohol Use Disorders
Educational Rounds
for ED Physicians
META:PHI 2015
About META:PHI
Mentoring, Education, and Clinical Tools for Addiction:
Primary Care–Hospital Integration
•
Goals:
– Promote evidence-based addiction medicine treatment
– Implement care pathways between the ED, hospital, WMS, primary care, and
rapid access addiction medicine clinics
•
Seven sites in Ontario are currently involved, with plans to expand the spread of
the project in the future
•
Funding and support provided by the Adopting Research to Improve Care (ARTIC)
program (Council of Academic Hospitals of Ontario & Health Quality Ontario)
https://www.porticonetwork.ca/web/meta-phi
META:PHI 2015
Baseline Survey
The baseline survey is anonymous and entirely optional. You may skip any question
that you do not wish to answer. We will not ask you for any personal information.
Please tear off and keep the front page with contact information, should you have
any questions about the survey or the META:PHI project.
Please return the completed or incomplete survey face down to the facilitator when
you leave the presentation.
META:PHI 2015
OVERVIEW
META:PHI 2015
Management Goals for
AUD Patients in the ED
1. Treat presenting problem (intoxication,
overdose, withdrawal, alcohol-related injury
etc.)
2. Screen for possible alcohol use disorder
3. Advise patient on avoiding alcohol-related
harms
4. Provide referral to rapid access addiction
medicine clinic for long term medicationassisted treatment
META:PHI 2015
IDENTIFYING AND DIAGNOSING AN
ALCOHOL USE DISORDER
META:PHI 2015
Identifying and Diagnosing an AUD
• Common alcohol-related presentations in the
ED:
– Intoxication
– Withdrawal
– Trauma
– GI (gastritis, alcoholic hepatitis, cirrhosis)
– Depression and suicidal ideation
– Failure to thrive (elderly)
META:PHI 2015
Screening for AUD
• In all patients with a possible alcohol-related
problem, ask this screening question:
– “How many times in the past year have you had 5 or
more drinks on one occasion (men) or 4 or more
drinks on one occasion (women)?”
• If they answer ‘2 or more times’ ask:
– “How many days per week do you drink? How many
drinks do you usually have per day?”
• Note: One drink = 5 oz wine, 1 bottle of beer, 1 ½ oz liquor;
– one bottle of wine = 5 drinks,
– one “mickey” of liquor (13 oz) = 9 drinks,
– one 26 oz bottle of liquor = 18 drinks
META:PHI 2015
Other Indicators of AUD in the ED
• Signs of intoxication
• High blood alcohol level
– 17 mmol/l = legal limit
– Men would need to have 4 drinks in preceding
hour or 5 in preceding 2 hours etc. to have a BAL
of 17 mmol/l
– Women would need 3 drinks in preceding hour
• Other labs: Elevated GGT, MCV; AST > ALT
META:PHI 2015
GENERAL APPROACH TO TREATING
AUD IN THE ED
META:PHI 2015
Advice and Referral
• ED physicians should provide advice and
referral to all patients with an alcohol-related
problem
 Nurse and/or social worker can provide more
specific advice about treatment options, but
physician advice is critical
• These discussions are more effective if family
members are present
META:PHI 2015
Explaining AUD
• Explain the link between patient's alcohol use
and their presenting condition
• Outline the long-term health consequences of
continued drinking
• Advise patients that they have an alcohol use
disorder, and list the treatment options
available: AA, residential, and outpatient
treatment programs
META:PHI 2015
Advice on Treatment
• Tell patients that treatment works for many
people, and they are unlikely to recover
without treatment
• Inform them that their alcohol-related
condition will improve or resolve with
abstinence, and their mood, sleep, energy
level and function will also improve
META:PHI 2015
Referral to WMS
• Refer patients to withdrawal management,
particularly if:
 They may go into withdrawal
 They do not have positive social supports
 They are in crisis (e.g., their partner has
threatened to leave them) and they want to start
treatment right away
META:PHI 2015
Refer All Patients to the Rapid Access
Addiction Medicine (RAAM) Clinic
• Advantages of RAAM clinic:
– Located near the ED
– Patient can be seen within a few days without an
appointment
– RAAM clinic provides both counselling and anticraving medication
– Addiction specialist provides shared care with the
patient’s family physician
• Refer patients to withdrawal management until
next RAAM clinic day if support would be helpful
META:PHI 2015
Anti-Craving Medications (1)
• Consider prescribing anti-craving medications
in hospitalized patients
• Initiation in hospital will delay relapse and
increase chances of attending treatment
• Prescriptions should only last for 1-2 weeks,
until patient can be seen in RAAM clinic
META:PHI 2015
Anti-Craving Medications (2)
• Naltrexone and acamprosate
 Strong evidence of benefit, should be offered routinely
 ODB only covers through the Exceptional Access Program
(EAP)
• Topiramate, gabapentin, and baclofen
 Small controlled trials found good evidence of benefit
 Covered under ODB
 Baclofen is safe in patients with cirrhosis
• Disulfiram
 Available as a compounded medication at individual
pharmacies
META:PHI 2015
Naltrexone
• Competitive opioid antagonist
• Blunts euphoric effect of alcohol
• Has been shown to reduce frequency and
intensity of alcohol binges
• Contraindicated in patients on regular opioid
medications
– Will trigger severe withdrawal
• Caution in patients with alcoholic liver disease
META:PHI 2015
Naltrexone (2)
•
•
•
•
Minor side effects – nausea, dizziness
Initial dose 25mg OD x 3 days
Then 50mg OD
Increase to 100mg or 150mg OD if cravings
and drinking persist
META:PHI 2015
Acamprosate
• Glutamate antagonist
• Relieves subacute withdrawal symptoms
– insomnia, dysphoria, craving
• Has been shown to improve abstinence rates
• Start after at least 2-4 days of abstinence
• Dose: 666mg tid
– Reduced dose in renal insufficiency
• Minor side effects: diarrhea
META:PHI 2015
Disulfiram
• Blocks acetaldehyde hydrogenase, causing build
up of acetaldehyde when alcohol consumed
• If patient drinks, will experience severe
headache, flushed face, vomiting, possible
hypotension
• Shown to be effective when dispensed by partner
or companion
• Caution in alcoholic liver disease, cardiovascular
disease
• Contraindicated in pregnancy
META:PHI 2015
Disulfiram (2)
• Do not start until patient abstinent from
alcohol for 48 hours
• Patient must wait 7 days after last dose before
resuming drinking
• Dose: 125mg – 250mg per day
META:PHI 2015
MANAGING ALCOHOL INTOXICATION
META:PHI 2015
Initial Assessment
• Examine patient for signs of trauma
• Document typical signs of intoxication: odour
of alcohol, slurred speech, etc.
• Check finger stick glucose
• If blood work is drawn, add blood alcohol level
(BAL)
• If BAL < 20 mmol/L, consider alternative
diagnosis to explain ataxia, slurred speech or
altered level of consciousness
META:PHI 2015
Thiamine
• Give thiamine routinely
– Wernicke’s encephalopathy difficult to diagnose in
an intoxicated patient
• Dose: 100mg IM
• Discharge prescription: 100mg PO OD x 1
month
META:PHI 2015
Discharge
• Discharge when the patient is alert and
responsive, and not in withdrawal
• Provide discharge advice and referral
• Refer to Rapid Access Addiction Medicine
Clinic
• Consider referral to WMS
• Consider reporting to the Ministry of
Transport
META:PHI 2015
Reporting to Ministry of
Transportation
• Report to MTO if:





Patient drove to ED intoxicated
Estimated BAL > 17 mmol/l at time of driving
Patient/family reports drinking and driving
Patient has had a seizure and drives
Patient has hepatic encephalopathy, cerebellar
ataxia, alcohol-induced dementia, etc., and drives
 Patient drinks throughout the day and regularly
drives
META:PHI 2015
MANAGING ALCOHOL WITHDRAWAL
META:PHI 2015
Risk Factors
• Risk and severity increase with amount
consumed; uncommon with < 6 drinks per day
• Large inter-individual variation in risk and
severity
• Predictable pattern: patients with previous
withdrawal seizures at high risk for recurrence
META:PHI 2015
Clinical Features
• Signs of withdrawal begin 6-12 hours after the
last drink
• Usually resolve in 2-3 days, but can last up to 7
days
• Most reliable signs: sweating and tremor
• Other signs: tachycardia, hyper-reflexia, ataxia
• Symptoms: anxiety, nausea
META:PHI 2015
Baseline Investigations for
Withdrawal in the ED
• CBC, electrolytes, creatinine, Mg++, Ca++,
phosphate
• GGT, AST, ALT, bilirubin, albumin, INR
• ECG
META:PHI 2015
IV Fluids and Thiamine
• IV if sweating, vomiting, and/or severe
withdrawal
• If glucose used, always give thiamine first
• Thiamine 100mg IM
• Discharge prescription: 100mg PO OD x 1
month
META:PHI 2015
Withdrawal Severity Scales
Clinical Institute Withdrawal
Assessment for Alcohol (CIWA-A)
• Validated, reliable
• Administered by nurse every
1-2 hours; takes 3-5 minutes
• 10 questions, each rated on
scale from 1 to 7
• Questions include symptoms
(anxiety, nausea, headache)
and signs (tremor, sweating)
• False positives: Other causes
of vomiting, headache,
anxiety, etc.
• False negatives: Language
barrier
Sweating, Hallucinations,
Orientation, Tremor (SHOT)
• 4 items scored on a scale from
2-4
• Administered by nurse every
1-2 hours; takes 1-2 minutes
• Takes less time to administer
• Less likely to give false positive
• Less evidence on validity and
reliability
META:PHI 2015
CIWA-Ar scale
Nausea/vomiting: “Do you feel sick to your stomach? Have you vomited?”
0 No nausea or vomiting
1
2
3
4 Intermittent nausea with dry heaves
5
6
7 constant nausea, frequent dry heaves and
vomiting
Tremor: Arms extended and fingers spread apart
0 No tremor
1 Tremor not visible but can be felt fingertip
to fingertip
2
3
4 Moderate with patient’s arms extended
5
6
7 Severe, even with arms not extended
2
3
4 Beads of sweat obvious on forehead
5
6
7 Drenching sweats
2
3
4 Moderately anxious, or guarded, so
anxiety is inferred
5
6
7 Equivalent to acute panic states as seen in
severe delirium or acute schizophrenic
reactions
Paroxysmal sweats
0 No sweat visible
1 Barely perceptible sweating, palms moist
Anxiety: “Do you feel nervous?”
0 No anxiety, at ease
1 Mildly anxious
Headache, fullness in head: “Does your head feel different? Does it feel like there is a band around your head?” Do not
rate for dizziness or light-headedness. Otherwise, rate severity.
0 Not present
1 Very mild
2 Mild
3 Moderate
4 Moderately severe
META:PHI 2015
5 Severe
6 Very severe
7 Extremely severe
Agitation
0 Normal activity
1 Somewhat more than normal activity
META:PHI 2015
2
3
4 Moderately fidgety and restless
5
6
7 Paces back and forth during most of the
interview, or constantly thrashes about
Tactile disturbances: “Have you had any itching, pins and needles sensations, any burning or numbness, or do you feel
bugs crawling on your skin?”
0 None
1 Very mild itching, pins and needles,
burning, or numbness
2 Mild itching, pins and needles, burning, or
numbness
3 Moderate itching, pins and needles,
burning, or numbness
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations
Auditory disturbances: “Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you
hearing anything that is disturbing to you? Are you hearing things you know are not there?”
0 Not present
1 Very mild harshness or ability to frighten
2 Mild harshness or ability to frighten
3 Moderate harshness or ability to frighten
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations
Visual disturbances: “Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you
seeing anything that is disturbing to you? Are you seeing things you know are not there?”
0 Not present
1 Very mild sensitivity
2 Mild sensitivity
3 Moderate sensitivity
4 Moderately severe sensitivity
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations
Orientation and clouding of sensorium: “What day is this? Where are you? Who am I?”
0 Oriented and can do serial additions
1 Cannot do serial additions or is uncertain
about date
2 Disoriented for date by no more than 2
calendar days
3 Disoriented for place by more than 2
calendar days
4 Disoriented for place and/or person
• Score of 10+ indicates need for benzodiazepines
• Discontinue treatment when score < 8 on two consecutive occasions
SHOT Scale
Sweating
0 – No visible sweating
1 – Palms moderately moist
2 – Visible beads of sweat on forehead
Hallucinations
“Are you feeling, seeing, or hearing anything that
is disturbing to you? Are you seeing or hearing
things you know are not there?”
0 – No hallucinations
1 – Tactile hallucinations only
2 – Visual and/or auditory hallucinations
Orientation
“What is the date, month, and year?
Where are you? Who am I?”
0 – Oriented
1 – Disoriented to date by one month or more
2 – Disoriented to place or person
Tremor
Extend arms and reach for object.
Walk across hall (optional).
0 – No tremor
1 – Minimally visible tremor
2 – Mild tremor
3 – Moderate tremor
4 – Severe tremor
• Score of 2+ indicates need for benzodiazepines
• Discontinue treatment when score < 2 on two consecutive occasions
META:PHI 2015
Protocol: Symptom-Triggered
Treatment of Alcohol Withdrawal (1)
1. Diazepam treatment
• 10-20 mg PO q 1-2 H when CIWA ≥10 or SHOT
≥2
• If cannot take diazepam orally, use lorazepam,
or give IV diazepam at a rate of no more than
2-5 mg/min
META:PHI 2015
Diazepam: Precautions
• Can cause sedation if:
–
–
–
–
–
Patient intoxicated (estimated BAL > 30-40 mmol/l)
Liver dysfunction
Elderly patients
Low serum albumin
On methadone or high doses of opioids
• Can trigger encephalopathy in patients with
decompensated cirrhosis
• Can cause respiratory depression in patients with
severe COPD, asthma or pneumonia
META:PHI 2015
Symptom-Triggered Treatment of
Alcohol Withdrawal (2)
2. Lorazepam
• 2-4 mg PO, SL, IM, IV q 1-2 H
• Shorter duration of action than diazepam
• Safer in patients at high risk for diazepam
toxicity:
– Liver dysfunction, elderly, low serum albumin, on
methadone or high dose opioids, decompensated
cirrhosis, respiratory impairment
META:PHI 2015
Diazepam Vs. Lorazepam
Diazepam
Lorazepam
Dosing Equivalents
5 mg
1 mg
Dispensing for
withdrawal
10-20 mg PO q 1-2 H
2-4 mg PO, SL, IM, IV q 12H
Duration of action
Up to 5 days
12 hours
META:PHI 2015
Discharge to WMS
• Benzodiazepines are dispensed by staff
• MD should give written note with directions
• Max. dose diazepam 10 mg qid or lorazepam
2 mg qid for 1-2 days
 Scheduled treatment, not PRN
 Instruct WMS not to dispense if client is sleepy or
no longer in withdrawal
META:PHI 2015
Discharge Home
• Partner should dispense benzodiazepines if
possible
• Patient should agree not to drink while taking
lorazepam or diazepam
• Don’t dispense more than 10-12 tabs
• Maximum dose diazepam 10 mg or lorazepam 2
mg q6H PRN for tremor
• Prescribe thiamine 100mg PO OD x one month
• Follow up with family physician in 1-2 days
META:PHI 2015
Discharge Advice and Referral
• Alcohol withdrawal is a serious complication
of AUD
• You are unlikely to recover on your own, but
treatment works for many people
• A number of treatment options available:
– AA
– Outpatient, day and residential programs
– Anti-craving medications
META:PHI 2015
Discharge Referrals
 Always refer patient to the Rapid Access Addiction
Medicine clinic using RAAM clinic referral card
 Refer to WMS if:
 Withdrawal has not fully resolved
 Patient lacks positive social supports
 Patient is in crisis and wants/needs to start treatment
right away
META:PHI 2015
Case Scenario
Steve is a 21-year-old man who fell in a bar
parking lot. He sustained a Colles’ fracture of the
wrist. On presentation to the emergency
department the nurses noted a strong odor of
alcohol. The patient was somewhat boisterous
but cooperative. Several hours later his fracture
has been casted and he is ready for discharge.
META:PHI 2015
Question
• What are 3 pieces of advice that you would
want to give Steve?
META:PHI 2015
Three Pieces of Discharge Advice
1) Avoid intoxication
2) If drinking, avoid risky situations and
activities (e.g., driving, boating)
3) If your drinking is interfering with your life,
you should consider attending treatment
(e.g. RAAM Clinic)
META:PHI 2015
Indications for Admission to Hospital
• Marked tremor, sweating not improving or
getting worse despite at least 80 mg diazepam or
16 mg lorazepam
• Complications:
 Two or more seizures
 QT interval > 500 msec, not resolving
 Repeated vomiting, dehydration, electrolyte
imbalance
 Impending or early DTs: confusion, disorientation,
delusions, agitation
META:PHI 2015
MANAGEMENT OF CO-OCCURRING
CONDITIONS AND COMPLICATIONS OF
WITHDRAWAL
META:PHI 2015
Complications of Withdrawal
 If withdrawal seizure hx: diazepam 20 mg PO q 1-2 H or
lorazepam 2-4 mg SL/PO/IM/IV for at least 3 doses, regardless of
CIWA or SHOT score
Seizures
Grand mal, non-focal, brief.
Usually occurs 2-3 days after
last drink.
Tachyarrhythmia
Increased risk with severe
 ECG in all patients in moderate/severe withdrawal
withdrawal, older age,
 If QTc > 500 msec, consider monitored bed, or serial ECG
+
+
cardiomyopathy low K , Mg ,
measurement every 1-2 hours
other substances or conditions  Treat withdrawal aggressively: diazepam 20 mg q 1H or
that prolong QT interval
lorazepam 4 mg q 1H until tremor/QT prolongation have
resolved.
 Correct electrolyte imbalance
Hallucinations
without delirium
Usually tactile but may be
auditory or visual.
Patient is oriented, knows
hallucinations are not real.
Low K+, low Mg+ common.
May trigger arrhythmias.
Encephalopathy, ataxia,
ophthalmoplegia.
Difficult to diagnose in patients
who are intoxicated or in
withdrawal.
Electrolyte
imbalance
WernickeKorsakoff’s
 Continue benzodiazepine treatment per protocol
 Typical and atypical antipsychotics prolong QT interval, should be
avoided unless hallucinations persist post-withdrawal
 Monitor K+, Mg+ if sweating, vomiting, tachycardia, cirrhosis.
 Thiamine 100 mg IM routinely in all patients who are intoxicated
or in withdrawal.
 If Wernicke’s suspected, give thiamine 300 mg IV daily x 3 days.
 Do not give IV dextrose solutions until IM thiamine administered.
 Discharge prescription for thiamine 300 mg PO OD x 1 month,
especially if malnourished or cirrhosis.
META:PHI 2015
Co-occurring Conditions (1)
Decompensated cirrhosis
• Firm liver, spider naevi
• Ascites, portal hypertension, esophageal varices
• High bilirubin, low albumin, high INR
• Do not treat mild withdrawal with benzos
• Use lorazepam 0.5-1 mg for moderate withdrawal
• Discontinue benzodiazepines as soon as tremor
improves
• May require hospital admission
META:PHI 2015
Co-occurring Conditions (2)
Patient on methadone or opioids
• Benzodiazepines can cause sedation and
respiratory depression, even if dose is stable
• Use lorazepam 0.5-1 mg
• Discontinue benzodiazepines as soon as
tremor improves
META:PHI 2015
Delirium Tremens
• More common in very heavy drinkers,
hospitalized patients with acute illness,
socially isolated and/or immobile patients
META:PHI 2015
Types of Delirium Tremens
Non-agitated delirium Moderate delirium
without autonomic
with autonomic
hyperactivity
hyperactivity
Severe delirium with
autonomic
hyperactivity
Features
DTs that are resolving,
delirium unrelated to
alcohol, or delirium
superimposed on
dementia
Patient tremulous,
delusional but
relatively calm, but
may suddenly
become agitated
and violent
Patient muttering
incoherently, thrashing
about, grabbing at
things in the air,
diaphoretic,
tachycardic, tremulous,
febrile
Management
Close observation,
low-dose benzos
(avoid antipsychotics)
Lorazepam load
Use restraints, talk to
patient, request ICU
consult, lorazepam
load
META:PHI 2015
Lorazepam Load for DTs
Investigations and monitoring
• Telemetry or serial ECGs, especially if QT
interval prolonged
• Daily lytes, magnesium
• O2 sat monitoring
• Restraints, sitter as needed
META:PHI 2015
Medication Orders
• CIWA not helpful if experiencing DTs
• Lorazepam 4 mg SL/PO q ½ H x 4
• Patients at high risk for benzodiazepine toxicity should
have a more gradual load, e.g., 2-4 mg q 1 H.
• MD to reassess every 4 doses; repeat for 4 more doses
if withdrawal still severe
• If delirium worsens despite two or more loads,
consider ICU admission
• If agitation resolves, continue lorazepam 2 mg q 2 H as
standing order, taper dose over next few days
• Adjunctive sedation e.g. phenobarbital may be helpful
META:PHI 2015
OTHER ALCOHOL-RELATED
CONDITIONS IN THE ED
META:PHI 2015
Anxiety, Depression, and Suicidal
Ideation
• If patient is intoxicated and suicidal, observe
patient in ED until intoxication resolves
• Even if suicidal ideation resolves when sober,
refer to psychiatry if patient:
– has recently attempted suicide
– remains severely depressed
– has frequent binges
– Has other major risk factors for suicide
META:PHI 2015
Discharging the Patient with AlcoholInduced Depression
• Upon discharge, explain that:
 Alcohol causes short-lived relief of
depression/anxiety but overall it can cause or
dramatically worsen mood or anxiety
 Abstinence/reduced drinking improves mood
within days or weeks
 Patient needs treatment urgently
 Refer to RAAM clinic and other community
treatment
META:PHI 2015
Case Scenario - Gary
• Gary is a 46-year-old street-involved man with
a two year history of severe alcohol use. Gary
frequently presents to the ED, usually
intoxicated, occasionally in withdrawal. Gary
arrived at the ED last night severely
intoxicated and was given an IV and kept
overnight. He is now in mild withdrawal and
wants to leave.
META:PHI 2015
Question
• How would you manage Gary and his request
to leave the ED?
META:PHI 2015
Managing Gary
• Ensure that Gary’s withdrawal has completely
resolved before leaving the ED
• Send patient to withdrawal management with
a benzodiazepine prescription if necessary (no
more than 10mg q4h total of 12 tabs over two
days)
• Refer Gary to RAAM clinic and emphasize that
alcohol use disorder is treatable and that
effective medications exist
META:PHI 2015
Alcohol and Trauma
• Risk of trauma dramatically increases with
each drink
• Refer to RAAM clinic:
– Young, weekend heavy binge drinkers are at
high risk of trauma and need treatment even if
not daily drinkers, don’t have withdrawal etc.
META:PHI 2015
Strategies to Avoid Intoxication
•
•
•
•
No more than one drink per hour
Sip rather than gulp
Switch to non-favourite drink
Avoid unmeasured drinks (especially
vodka and other liquors)
• Alternate alcoholic drinks with nonalcoholic drinks
• Eat before and while drinking
META:PHI 2015
Ways to Avoid Trauma if Drinking
• Do not drive a car or boat after drinking
• Do not get in a car or boat with people who
have been drinking
• Do not engage in arguments with intoxicated
people
• Leave a party if strangers arrive and it
becomes chaotic
• Have a non-drinking friend accompany you
and take you home
META:PHI 2015
Other Conditions
• Decompensated cirrhosis, GI conditions,
cardiac, elderly (e.g. failure to thrive)
• In any condition where AUD suspected:
– Ask about alcohol consumption
– Look for BAL, GGT, MCV, other lab signs
– Talk to family
– Advise patients that alcohol cessation or reduction
is essential for successful
– Advise them to attend treatment and RAAM
META:PHI 2015