1. ED Management of Alcohol Use Disorders META:PHI 2015 Educational Rounds for ED Physicians

2. 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

3. 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. Baseline Survey Please return the completed or incomplete survey face down to the facilitator when you leave the presentation. META:PHI 2015

4. OVERVIEW META:PHI 2015

5. 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 medication- assisted treatment META:PHI 2015

6. IDENTIFYING AND DIAGNOSING AN ALCOHOL USE DISORDER META:PHI 2015

7. 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

8. 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

9. 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

10. GENERAL APPROACH TO TREATING AUD IN THE ED META:PHI 2015

11. 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

12. 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

13. 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

14. 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

15. 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 anti- craving 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. MANAGING ALCOHOL INTOXICATION META:PHI 2015

24. 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

25. 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

26. 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

27. 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

28. MANAGING ALCOHOL WITHDRAWAL META:PHI 2015

29. 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

30. 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

31. Baseline Investigations for Withdrawal in the ED CBC, electrolytes, creatinine, Mg++, Ca++, phosphate GGT, AST, ALT, bilirubin, albumin, INR ECG META:PHI 2015

32. 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

33. 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

34. 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 Paroxysmal sweats 0 No sweat visible 1 Barely perceptible sweating, palms moist 2 3 4 Beads of sweat obvious on forehead 5 6 7 Drenching sweats Anxiety: “Do you feel nervous?” 0 No anxiety, at ease 1 Mildly anxious 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 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 5 Severe 6 Very severe 7 Extremely severe META:PHI 2015

35. 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 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 META:PHI 2015

36. 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

37. 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

38. 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

39. 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

40. Diazepam Vs. Lorazepam META:PHI 2015 DiazepamLorazepam Dosing Equivalents5 mg1 mg Dispensing for withdrawal 10-20 mg PO q 1-2 H2-4 mg PO, SL, IM, IV q 1- 2 H Duration of actionUp to 5 days12 hours

41. 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

42. 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

43. 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

44. 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

45. 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

46. Question What are 3 pieces of advice that you would want to give Steve? META:PHI 2015

47. 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

48. 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

49. MANAGEMENT OF CO-OCCURRING CONDITIONS AND COMPLICATIONS OF WITHDRAWAL META:PHI 2015

50. Complications of Withdrawal SeizuresGrand mal, non-focal, brief. Usually occurs 2-3 days after last drink.  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 TachyarrhythmiaIncreased risk with severe withdrawal, older age, cardiomyopathy low K +, Mg +, other substances or conditions that prolong QT interval  ECG in all patients in moderate/severe withdrawal  If QTc > 500 msec, consider monitored bed, or serial ECG measurement every 1-2 hours  Treat withdrawal aggressively: diazepam 20 mg q 1H or 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.  Continue benzodiazepine treatment per protocol  Typical and atypical antipsychotics prolong QT interval, should be avoided unless hallucinations persist post-withdrawal Electrolyte imbalance Low K+, low Mg+ common. May trigger arrhythmias.  Monitor K+, Mg+ if sweating, vomiting, tachycardia, cirrhosis. Wernicke- Korsakoff’s Encephalopathy, ataxia, ophthalmoplegia. Difficult to diagnose in patients who are intoxicated or in withdrawal.  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

51. 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

52. 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

53. Delirium Tremens More common in very heavy drinkers, hospitalized patients with acute illness, socially isolated and/or immobile patients META:PHI 2015

54. Types of Delirium Tremens Non-agitated delirium without autonomic hyperactivity Moderate delirium with autonomic hyperactivity Severe delirium with autonomic hyperactivity FeaturesDTs 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 ManagementClose observation, low-dose benzos (avoid antipsychotics) Lorazepam loadUse restraints, talk to patient, request ICU consult, lorazepam load META:PHI 2015

55. 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

56. 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

57. OTHER ALCOHOL-RELATED CONDITIONS IN THE ED META:PHI 2015

58. 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

59. Discharging the Patient with Alcohol- Induced 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

60. 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

61. Question How would you manage Gary and his request to leave the ED? META:PHI 2015

62. 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

63. 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

64. 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 non- alcoholic drinks Eat before and while drinking META:PHI 2015

65. 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

66. 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