If done properly, the assessment of alcohol and substance use disorders in the emergency department (ED) or psychiatric emergency service can be the first step toward recovery. A proper assessment, however, can be extremely taxing for both the clinician and the patient. This article offers a paradigm for performing a rapid and comprehensive evaluation in the ED of medically stable adults with alcohol and substance use disorders.
Intoxication from alcohol and illicit substances is a frequently cited reason for ED visits. Data from the Drug Abuse Warning Network (DAWN), a national public health surveillance system that monitors trends in drug-related ED visits and medical examiner or coroner deaths, showed that there were about 627,923 drug-related ED visits in the United States in the third and fourth quarters of 2003.1
Cocaine and marijuana each were involved in about 20% of those visits; heroin, 8%; "other opioids" (some of which may have been heroin), 4%; stimulants, 7%; and benzodiazepines (nonmedical use), 17%.1 At about 0% to 2%, phencyclidine (PCP), 3,4-methylenedioxymethamphetamine (MDMA, or Ecstasy), and gamma hydroxybutyrate (GHB) were less frequently involved in ED visits.
About 23% of all drug-related ED visits also involved alcohol; because DAWN does not record events that are alcohol-related only, the actual number of alcohol-related visits is probably higher. Although it is not possible to compare the 2003 DAWN data with those of previous years because of changes in the classification criteria, a crude analysis shows that since 1995, there has been about a 40% increase in drug- and alcohol-related ED visits.1-4
Comorbidity of substance use disorders and other mental illnesses is common. About 30% of patients with a mental illness abuse either alcohol or drugs. More than 35% of alcohol abusers and 59% of drug abusers have 1 or more serious mental health disorders: mood disorders, anxiety disorders, personality disorders, and schizo-phrenia are the most common.5-9 Thus, a proper evaluation for substance use disorders and mental illness in the ED is warranted. However, evaluation of patients for these conditions is frequently fraught with difficulties and obstacles.10,11
CLINICAL FEATURES OF ACUTE DRUG INTOXICATION
Although this article does not focus on the clinical management of drug intoxication and withdrawal, some basic knowledge of their clinical picture helps in identifying the specific nature of the substance use disorder. A brief review of the main signs and symptoms of pathologic drug use is therefore appropriate. However, the clinician should remember that symptoms of drug intoxication or withdrawal may present in atypical ways because of several factors, including modality of use, combination of drugs used, purity of the substance used, and characteristics of individual drugs used.12-14
This drug class includes lorazepam, alprazolam, diazepam, clonazepam, temazepam, flurazepam, and others. A conscious person who presents to the ED with benzodiazepine intoxication usually is drowsy, unsteady, confused, disoriented, less alert, and impaired in judgment. In reality, the symptoms are not that different from those in patients with acute alcohol intoxication.
When benzodiazepine intoxication is caused by a long-acting compound (eg, clonazepam), the clinical signs of intoxication can continue for 24 hours. Abrupt discontinuation may result in tremors, anxiety, psychosis, confusion, and symptoms similar to those of delirium tremens. Discontinuation of short-acting benzodiazepines generates withdrawal symptoms within a few hours; sudden cessation of the long-acting compounds, however, may result in withdrawal effects that are delayed until the following day or even later.15,16
Alcohol intoxication and withdrawal
The effects of alcohol vary according to the level of consumption: low doses promote mild euphoria and uninhibited behavior, while substantial consumption may trigger irrational thinking, problematic behavior, psychomotor difficulties, and in rare cases, coma. The first step in evaluating a patient with a drinking problem is to identify possible predisposing factors for an episode of withdrawal.17,18 These factors include high blood alcohol levels, history of withdrawal or seizure, concurrent use of sedating agents, and co-occurrence of acute or chronic medical problems.
Most persons with alcohol dependence will experience mild signs and symptoms of withdrawal within 24 hours after the last drinking episode. These usually include restlessness, anxiety, tremors, tachycardia, GI discomfort, and insomnia. Symptoms may last for about a day and usually remit without major consequences. More rarely--but especially when predisposing factors are present--a mild withdrawal state may develop into (1) an episode of generalized seizure, typically within 24 to 72 hours or (2) delirium tremens, usually within 5 days of the last drink. Delirium tremens is characterized by a magnification of the symptoms of withdrawal and by the development of disorientation, visual hallu- cinations, high blood pressure, and in some cases, fever.17,18
Stimulants: cocaine and amphetamines
Initial signs of cocaine intoxication are restlessness, anxiety, hyperactivity, euphoria, dysphoria, elevated blood pressure levels, and increased heart rate. If the patient has taken high doses of cocaine, hallucinations and paranoid delusions may predominate the clinical picture. Overdose may lead to cardiac arrhythmias and extremely elevated blood pressure levels, which may be life-threatening. The euphoria related to cocaine use is sometimes followed by feelings of discomfort and depression and a craving that is usually defined as withdrawal.19,20
Classified under "amphetamines" are stimulant drugs, such as methamphetamine and methylphenidate. Symptoms of acute amphetamine-related intoxication include decreased appetite, increased stamina and physical energy, irritability, aggressiveness, psychotic features, increased sexual drive, involuntary bodily movements, increased perspiration, hyperactivity, jitteriness, nausea, increased and irregular heart rate, and rarely, seizure. Withdrawal from amphetamines is usually characterized by depression, fatigue, withdrawn behavior, lack of motivation, and possibly, abdominal discomfort and headache, all of which can continue for several days.21,22
The euphoric effects of opioids contribute to their widespread abuse. Heroin, morphine, codeine, oxycodone, and fentanyl are among the most commonly abused opioids. The most salient signs of intoxication include sedation, psychomotor difficulties, confusion, pinpoint pupils and, in more extreme cases, respiratory depression. If the opioid is discontinued, the withdrawal usually appears within a few hours for most of the drugs in this class and may last up to 1 week. The only exception is methadone, the withdrawal from which may appear the day after its discontinuation and tends to be milder and longer-lasting. Generally, the withdrawal for short-acting opioids peaks on about the second or third day. The most common signs and symptoms of opioid withdrawal include diarrhea, abdominal cramping, generalized pain, piloerection, and rhinorrhea. Although opioid withdrawal is usually very uncomfortable, it is not life-threatening.23,24
These agents are among a loosely defined category of recreational drugs popular at dance clubs, parties, and rock concerts. They may have stimulating or psychedelic properties and include MDMA, GHB, ketamine, and lysergic acid diethylamide (LSD).25-28
MDMA. Commonly known as Ecstasy, this drug produces effects similar to those of amphetamines and hallucinogens. The major effect is usually described as a state of pleasant euphoria characterized by sensory-altering experiences. Intoxication typically causes anxiety, depression, and a mild form of paranoia; increased blood pressure and heart rate; and muscle tension with teeth clenching. Chills and sweating, when present, result from a sustained increase in body temperature.
GHB. Known as liquid Ecstasy, GHB simultaneously produces effects of euphoria and sedation. High doses can cause a rapid deep sleep and in rare cases, coma.
Ketamine. Nicknamed vitamin K, ketamine produces pleasure through inducing dreamlike states, altered perceptions, and at times, hallucinations. Intoxication can also cause symptoms varying from mild confusion to impairment of motor functions, mood swings, increased blood pressure, and difficulty in breathing.
LSD. Commonly referred to as acid, LSD is a hallucinogen used for its abnormal perception-inducing properties. Psychosis and flashbacks (recurrent disorder of perception)--although rare--may occur. The most commonly reported adverse effects are tremors, nausea, and sweating. Blood pressure and heart rate may be elevated. Usually, no withdrawal symptoms are reported after this drug or other hallucinogens are discontinued.
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