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

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

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

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

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

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

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

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

CIWA-Ar scale (1) 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 4 Moderate with arms extended 7 Severe, even with arms not extended Paroxysmal sweats 0 No sweat visible 1 Barely perceptible sweating, palms moist 4 Beads of sweat obvious on forehead 7 Drenching sweats Anxiety: “Do you feel nervous?” 0 No anxiety, at ease 1 Mildly anxious 4 Moderately anxious, or guarded, so anxiety is inferred 7 Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions 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. 0 Not present 1 Very mild 2 Mild 3 Moderate 4 Moderately severe 5 Severe 6 Very severe 7 Extremely severe

CIWA-Ar scale (2) Agitation 0 Normal activity 1 Somewhat more than normal activity 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, 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 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? 1 Very mild sensitivity 2 Mild sensitivity 3 Moderate sensitivity 4 Moderately severe sensitivity 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 two calendar days 3 Disoriented for date by more than two calendar days 4 Disoriented for place and/or person

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 False positives: Interpret SHOT with caution if patient has a febrile illness, cerebellar disease or benign essential tremor, psychosis, dementia, impaired consciousness, or delirium not related to alcohol. Positive H or O: If either H or O is greater than zero, assess and treat for delirium, encephalopathy, and/or psychosis.

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

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

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

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

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

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 Hardy kate.hardy@wchospital.ca Knowledge broker: Sarah Clarke sarah.clarke@wchospital.ca