Alcohol and Other Drug Emergencies EMC SDMH 2015

Objectives Recognise and manage alcohol and opioid overdose Recognise and manage stimulant toxicity Become familiar with dealing with severe alcohol withdrawal and acute complications of alcohol addiction Recognise and manage opioid withdrawal Develop an approach to ED assessment of less acute alcohol related and appropriate referral

AOD and the ED Data lacking for amount of presentations to ED Point estimates 13.8% pt’s in ED relating to alcohol during high demand times 8% average rate of alcohol related presentations Drug reporting absent – anecdotally increasing Frequent crisis presentations – interventions?

Alcohol overdose Occasionally seen Possible cardio-respiratory depression with sudden elevations to high levels BAL 0.4-0.5 in naïve individuals Risk of aspiration with drop in GCS Typically young males ‘sculling’ spirits Watch for hypoglycaemia

Opioid overdose Uncommon to get to ED – ASNSW Changing patterns of opioids Death from respiratory depression Resp. depression, miosis and hx of drug exposure suggest diagnosis Naloxone 0.4 -2 mg IV/IM/IN reverses effects for 20-90 mins. May provoke withdrawal ! Larger doses may be required for SR formulations, fentanyl and methadone May require infusion in above situation

Stimulant overdose Amphetamine, cocaine, MDMA, methamphetamine Toxic usage - may only be 1-2 x ‘normal’ use Sympathomimetic toxidrome Methamphetamine – CNS excitation, paranoia, psychosis common IV benzodiazepines to sedate +/- fluids. Hyperthermia indicates severe toxicity and requires aggressive management IM/IV droperidol for behavioural disturbance may also be useful

Alcohol withdrawal Crisis presentations (unplanned abstinence) Occurrence during intercurrent illness/admission Request for ‘detox’ after bingeing Onset 6-24 from last drink. Withdrawal possible with positive BAL Withdrawal seizure may be presenting complaint Symptoms/Signs of alcohol withdrawal

Severe withdrawal Seizures – 2-9%; occur within first 48 hrs Anticonvulsants ineffective for acute alcoholic seizures – use benzodiazepines. Alcohol withdrawal delirium (‘delirium tremens’) – 5% Hallucinations Requires inpatient supervision and management to prevent mortality

Management Benzodiazepines mainstay of therapy Diazepam standard agent Oxazepam if concerns regarding age, hepatic function Dosing by differing approaches ‘Loading dose’ – 20mg q 2-4 hr until 80mg reached, then cease and observe ‘Tapered’ 10-20mg qid, reducing on daily basis ‘Symptom triggered’ – PRN dosing basis upon an AWS NB – What does a febrile rigoring pneumonia pt score on the AWS?

Wernickes encephalopathy Classic triad rarely present ~12.5% heavy drinkers (by autopsy studies) Nonspecific confusion and STM loss often only signs. Confabulation = classic feature of Dx Failure to diagnose leads to irreversible neurological changes (Korsakoff’s syndrome) In malnourished/severe alcoholism parenteral thiamine required (bioavailability 1.5%!) IMI Thiamine 300mg daily for 3-5 days, then PO for further 1-2 weeks

Other problems Malnourishment Dehydration Electrolytes – K, Mg Hypoglycemia/Ketosis Arrhythmias' – AF Infection Trauma - falls

Opioid Withdrawal Uncommon (currently) May present with drug–seeking behaviour ‘Acute abdomen’ – cramps, pains, vomiting Loud ! Presence track marks; yawning; goosebumps typical features Pt may disclose hx of drug use and request withdrawal assistance

Opioid Withdrawal Onset time dependent upon drug of abuse Aim to reduce symptoms whilst attempting to engage in controlled withdrawal Illegal to knowingly prescribe opioids to known addicts for purposes of withdrawal management without specific authority Permitted to prescribe for pain for medical illness

Opioid withdrawal Buprenorphine SL is preferred agent of choice 4-8 mg SL daily Binds m receptors, long acting, higher affinity than other opioid Partial agonist so lower risk overdose If unable to prescribe buprenorphine, then symptomatic management undertaken 

Ongoing management Detailed assessment of drug habit(s) Engagement with family and social supports Counselling services AOD community services

Questions

Summary Patterns of opioid use changing dramatically; be aware of novel opioid overdoses Stimulant overdose potentially fatal but uncommon. Psychosis common Alcohol withdrawal mortality virtually zero with early decisive care. Wernicke's encephalopathy under-recognized. Give all alcoholic pt.'s parenteral thiamine Ensure other health issues have been attended to and that correct diagnosis applied Acute opioid withdrawal less common than previously – can be problematic to control in ED without authorized prescribers All AOD presentations will benefit from brief interventions to try and engage with withdrawal management in community