1. ED Management of Alcohol Use Disorders META:PHI 2015 Education Rounds for ED Nurses

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.

4. OVERVIEW META:PHI 2015

5. Role of the Nurse In managing alcohol use disorders in the ED, nurses play a key role: – Nurses spend more time with patients – Patients are more likely to confide in nurses than in other medical staff – Nurses are more likely to provide discharge advice – Nurses can send patients to the RAAM clinic without a formal MD referral META:PHI 2015

6. Beyond Clinical Knowledge Nurses play a significant role in a patient’s early recovery – Patients coming to the ED with an alcohol problem are often: Fearful Ashamed Wanting to change but unsure how – Nurses can play an important role in helping them change by offering: Empathy Optimism that things can improve with treatment Practical advice and suggestions (e.g. to attend the RAAM clinic) – It is important to remember that nurses can, and often do, make a big difference to patient outcomes META:PHI 2015

7. Beyond Clinical Knowledge (2) – Patients often attend the emergency department when in crisis, e.g.: Partner threatening to leave Children taken by CAS DUI Job loss – Nurse attitude toward a patient with AUD during their first treatment encounter can influence their future participation in treatment META:PHI 2015

8. Nursing 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.Give advice on avoiding alcohol-related harms 4.Provide referral to rapid access addiction medicine clinic for long term medication- assisted treatment META:PHI 2015

9. IDENTIFYING AN ALCOHOL USE DISORDER META:PHI 2015

10. Identifying 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

11. 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

12. Standard Drink Size META:PHI 2015 Image from Canadian Centre on Substance Abuse

13. Low-Risk Drinking Canada’s low-risk drinking guidelines suggest that: – Women not exceed 10 drinks a week Consume no more than 2 drinks a day most days – Men not exceed 15 drinks a week Consume no more than 3 drinks a day most days If the patient drinks in excess of these guidelines, it may indicate problematic alcohol use, and patient should be referred to Rapid Access Addiction Medicine (RAAM) Clinic META:PHI 2015

14. 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

15. GENERAL APPROACH TO MANAGING AUDS IN THE ED META:PHI 2015

16. Advice and Referral ED nurses should provide advice and referral to all patients with an alcohol-related problem – These discussions are more effective if family members are present META:PHI 2015

17. Advice on Treatment Explain the link between patient's alcohol use and their presenting condition 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 META:PHI 2015

18. 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

19. Refer All Patients to the 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

20. Anti-Craving Medications The RAAM clinic will prescribe medications that have been shown to reduce cravings and binges – None of the medications on the following slide have psychoactive effects – None of the following medications are addicting META:PHI 2015

21. MedicationWhat it DoesIs it Addictive? Does it cause nausea if you drink? Naltrexone *Frontline treatment Reduces alcohol cravings Reduces rewarding effects of alcohol No Acamprosate *Frontline treatment Reduces alcohol cravingsNo TopiramateReduces alcohol cravings Reduces rewarding effects of alcohol No GabapentinReduces alcohol cravings Improves mood Improves sleep No BaclofenReduces alcohol cravings Reduces rewarding effects of alcohol No DisulfiramMakes you sick if you drink Most effective if dispensed daily by spouse or friend NoYes

22. MANAGING ALCOHOL WITHDRAWAL IN THE ED META:PHI 2015

23. Clinical Features of Alcohol Withdrawal Signs of withdrawal begin 6-12 hours after the last drink Withdrawal symptoms 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

24. 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

25. Tremor With true tremor, patient does not fatigue Patients trying to mimic tremor will likely fatigue Best assessed with patient seated, arms fully extended Not a resting tremor Sometimes a whole body tremor (head, legs) META:PHI 2015

26. 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

27. How to assess and treat patients in alcohol withdrawal using the CIWA Protocol and SHOT Scale META:PHI 2015

28. 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

29. 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

30. Application of the CIWA In general, record your interpretation of what the patient says and what you observe – E.g. Patient says they feel very nauseated, yet they are eating and drinking normally – Should be rated as a 1 or 2 Record discrepancies between answers and observations in the nursing note META:PHI 2015

31. NAUSEA & VOMITING: Ask “do you feel sick? Have you vomited?” 0 No nausea/vomiting 1 2 3 4 Intermittent nausea with dry heaves 5 6 7 Constant nausea, frequency dry heaves & vomiting META:PHI 2015 Ask: “Are you nauseous? On a scale of 0-7, how nauseated do you feel?” Observe: Look for any evidence of vomiting (k-basin etc. at bedside). Is patient asking for something specifically for nausea?

32. TREMOR: Arms extended and fingers spread apart 0 No tremor 1 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 META:PHI 2015 Ask: “Can you reach for this coffee cup/pen?” Ask: “Can you please extend your arms in front of you, with your palms at a ninety degree angle?” Observe: Look out for any evidence of tremor. How severe is the tremor? Is the tremor typical (high frequency, visible with movement/action, does not fatigue)? If you cannot see a tremor, you can consider putting your fingertips in contact with the patient. If you can feel a tremor that you cannot see, it is a 1/7.

33. 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 META:PHI 2015 Observe: Observe patients for sweat, and feel their palms.

34. ANXIETY: Ask “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 Acute panic as seen in severe delirium or acute schizophrenic reactions META:PHI 2015 Ask: “How anxious are you feeling right now on a scale of 0-7, with 0 being at ease, and 7 being the most anxious you have ever been?” If a patient answers with “7” (acute panic), but they are clearly able to concentrate and are not fidgety, they are probably not a true 7.

35. AGITATION: Observation 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 interview, or constantly thrashes about META:PHI 2015 Observe: Observe the patient to look for signs of agitation. Signs may be obvious, or subtle. E.g. patients may not want to sit down, may continuously readjust the way they are sitting, may play with hospital bands or pace constantly etc. Agitation is more accurately rated through observation rather than by asking.

36. TACTILE DISTURBANCES: Ask “Have you had any itching, pins and needle sensations, any burning, any numbness or do you feel bugs crawling on or under your skin?” 0 None 1 Very mild itching, pins and needles, burning or numbness 2 Mild itching, pins and needs, burning or numbness 3 Moderate pins and needles, burning or numbness 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations META:PHI 2015 Ask: “Sometimes people in alcohol withdrawal feel weird sensations in their skin – have you had any feelings like that?” Let the patient explain what they are feeling.

37. AUDITORY DISTURBANCES: Ask “Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing 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 mild harshness or ability to frighten 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations META:PHI 2015 Ask: “Do you feel that you are more aware of sounds around you?” Ask: “Do you ever think that you are hearing things that maybe not everyone else hears?”

38. VISUAL DISTURBANCES: Ask “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 hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations META:PHI 2015 Ask: “Does the light appear to be too bright?” Sometimes people in withdrawal are much more sensitive to light. In general, patients who have light sensitivity but no hallucinations could rate up to a 3 on the scale, so if patient responds that they are sensitive to light, ask them to rate it on a scale of 0-3. Ask: “Are you seeing anything that you think other people might not see?” Sometimes people in alcohol withdrawal see things that other people do not seem to see or feel. In general, people who are having visual hallucinations would rate 4 or more. If patient has hallucinations, score rate as 4 for occasional hallucinations and up to 7 for continuous hallucinations.

39. HEADACHE, FULLNESS IN HEAD: Ask “Does your head feel different? Does it feel like there is a band around your head?” Do not rate for dizziness or lightheadedness. 0 Not present 1 Very mild 2 Mild 3 Moderate 4 Moderately severe 5 Severe 6 Very severe 7 Extremely severe META:PHI 2015 Ask: “Do you have a headache?” If patient reports that they do, ask them to rate it on a scale of 0-7. Make sure to only rate for pain, and not dizziness or lightheadedness.

40. ORIENTATION & CLOUDING OF SENSORIUM: Ask “What day is this? Where are you? Who am I?” 0 Orientation and can do serial additions 1 Cannot do serial additions or is uncertain about the date 2 Disorientated for date by no more than 2 calendar days 3 Disoriented for date by more than 2 calendar days 4 Disoriented to place and/or person META:PHI 2015 Ask: “What is today’s date (day of the week, month, year)?” Ask: “Where are you right now?” Orientation is critical to assess. If a patient is disoriented, it may indicate that they are suffering from delirium, which may be related to alcohol withdrawal. All patients with delirium should be admitted to hospital until the cause is determined and appropriately managed. Remember that responses are contextual. E.g. if a business person has come from place of employment, you would expect them to know the exact date. A homeless person, might be expected to know place and season.

41. Application of the SHOT In general, record your interpretation of what the patient says and what you observe – Be careful of 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 META:PHI 2015

42. 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

43. Treatment of Alcohol Withdrawal Benzodiazepines treat alcohol withdrawal Mimic ethanol’s effect on GABA receptors Diazepam is the preferred benzodiazepine unless there is liver failure (cirrhosis, jaundice, ascites) Then Lorazepam should be used Not unusual to give large total amounts (over 100 mg diazepam) as heavy drinkers will be very tolerant Once fully treated, patients can be safely discharged to home/detox META:PHI 2015

44. 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, lorazepam is best alternative, or IV diazepam at a rate of no more than 2-5 mg/min META:PHI 2015

45. Diazepam: Precautions Can cause sedation if: – Patient intoxicated (estimated BAL > 30-40 mmol/l) – Liver dysfunction – Patient is elderly – 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

46. 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

47. 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 Diazepam’s long half life reduces the number of additional doses required

48. Discharge Home Ideally, patients who have had withdrawal treated DO NOT require a prescription but there may be times when this is necessary If prescription required: – Coach patient’s partner/support person on dispensing medication at home if present – Coach patient not to drink – Direct patient to follow up with family physician in 1-2 days META:PHI 2015

49. Case Scenario - Gary Gary is a 46-year-old street-involved man with a short but severe history of 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 2013

50. Question How would you manage Gary and his request to leave the ED? META:PHI 2013

51. Managing Gary Ensure that Gary’s CIWA score is less than 8 on two consecutive occasions and he has minimal or no tremor before being discharged from the ED Refer Gary to RAAM clinic and emphasize that alcohol use disorder is treatable and that effective medications exist Refer Gary to WMS until next open RAAM clinic, for psychosocial support and safe shelter META:PHI 2013

52. MANAGEMENT OF CO-OCCURRING CONDITIONS AND COMPLICATIONS OF ALCOHOL USE META:PHI 2015

53. 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, patient should be seen by psychiatrist if: – Has recently attempted suicide – Remains severely depressed – Has frequent binges – Has other major risk factors for suicide META:PHI 2015

54. 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

55. Alcohol and Trauma Risk of trauma dramatically increases with each drink Even if you suspect patient is just young, reckless weekend binge drinker without AUD, they are still at high risk of trauma and need treatment – Refer to RAAM clinic META:PHI 2015

56. Harm Reduction Strategies to Avoid Intoxication Strategies: – No more than one drink per hour – Sip rather than gulp – Switch to non-favourite drink – Avoid unmeasured drinks (especially vodka) – Alternate alcoholic drinks with non-alcoholic drinks – Eat before and while drinking If patient has serious AUD (e.g., recurrent visits to ED for intoxication and withdrawal) harm reduction advice is unlikely to work – Patient must remain abstinent – Refer them to RAAM clinic META:PHI 2015

57. Ways to Avoid Trauma if Drinking Strategies: – 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 lots of strangers begin to arrive, or if it starts to get chaotic – Have a non-drinking friend accompany you and take you home META:PHI 2015

58. Case Scenario - Steve 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 2013

59. Question What are 3 pieces of advice that you would want to give Steve? META:PHI 2013

60. Three Pieces of Discharge Advice 1)Avoid severe intoxication using the harm reduction strategies above 2)If drinking, avoid risky situations and activities (e.g., driving, boating) 3)If your drinking is interfering with your life (e.g., you’re getting injured) you should consider attending treatment (e.g. RAAM Clinic) META:PHI 2013

61. Other Conditions Decompensated cirrhosis, GI conditions, cardiac, elderly (e.g. failure to thrive) In any condition where AUD suspected: – Ask patient about alcohol consumption – Talk to patient’s family – Advise patients that alcohol cessation or reduction is essential for successful treatment – Advise patient to attend treatment and RAAM META:PHI 2015