1. Alcohol and Other Drug Emergencies
EMC SDMH 2015

2. 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

3. 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?

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

5. 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 mg IV/IM/IN reverses effects for mins.
May provoke withdrawal !
Larger doses may be required for SR formulations, fentanyl and methadone
May require infusion in above situation

6. 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

7. 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

8. 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

9. 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?

10. 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

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

12. 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

13. 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

14. 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 

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

16. Questions

17. 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