Substance Use Disorders in the Emergency Setting

Proper evaluation of patients for alcohol and substance use disorders is usually time-consuming. When done in a busy emergency department (ED), assessment is often rushed, increasing the likelihood of misdiagnosis and, therefore, mismanagement. Because the evaluation is a patient's first step to effective therapy, it should be conducted as efficiently and effectively as possible.

The following case presentations illustrate the concepts discussed in the article "Alcohol and Drug Abuse Intervention in the Emergency Department: A Step Toward Recovery" that appears on page 11 of this issue. Although the reader can examine the case presentations separately, he or she may gain more insight into their meaning and significance after reviewing the article, which provides a theoretic framework for the clinical cases.

CASE 1: SCREENING AND CULTURAL SENSITIVITY

Jerry is an 18-year-old American Indian originally from a Southwestern US tribe. He presented in the psychiatric emergency service (PES) with his aunt, who has been worried for the past 2 months about his intermittent moodiness, withdrawn behavior, and episodic staring. During the assessment interview, which does not involve the aunt at length, the patient denies any drug use but reports mood swings, depression, and lack of motivation. No other psychiatric symptoms are present. Results from the CAGE questionnaire,^1,2 a breathalyzer test, and drug screening do not show any evidence of a drug problem. Preliminary questions about psychiatric conditions reveal a possible depressive disorder.

The interview was extremely brief because of overcrowding and the long waiting list in the ED. Moreover, the questions were asked without considering the patient's level of comfort and communication style. The CAGE questionnaire was introduced in the evaluation process rather brusquely, without any prologue or transitional statements (eg, asking the patient whether he is concerned about his alcohol or drug use). The ED physician discharged Jerry with a referral to a psychiatric outpatient clinic for follow-up.

Discussion

This case illustrates some common pitfalls in assessing ethnic and minority patients for substance use disorders. The psychiatric interview of ethnic minority patients--and of American Indians in particular--should take into account specific cultural and social issues that tend to influence its outcome, such as whether family is included, the communication style of the patient, how culture may influence the patient's responses, and the age of the patient.

Inclusion of family. Whenever possible, family members of the patient should be included in the interview. Although patients from every background can benefit from it, American Indians usually perceive the presence of family as crucial, because their sense of identity often stems from their family and community ties. Furthermore, the presence of an aunt, uncle, or cousin in the ED may indicate that those persons are assuming parental duties, since American Indian cultures are flexible in assigning and shifting family roles and responsibilities. Therefore, any family member or close family friend constitutes a valid source of support for the patient and the physician. Neglecting these aspects could contribute to an incorrect referral for Jerry, who may need dual-diagnosis services.

Communication style.The ED professional also needs to take into account that American Indians usually have a less hurried, methodical communication style, which is in conflict with the swift and quick interactions of the dominant culture. Respecting patients' moments of silence and accepting a somewhat circumstantial narrative style rather than demanding a concise report of a patient's feelings and symptoms are 2 essential elements for a successful intervention with American Indian patients.

Cultural variance in test response. Because the CAGE questionnaire may not be culturally sensitive with this patient, the mental health professional needs to interpret both positive and negative results with extreme caution.

Age-related issues. In addition, the age of the patient may require screening questions focused on the social consequences of drug abuse and, ideally, the consultation of an adolescent psychiatrist. If this specialist is not available, a more sensitive approach focuses on social behavior (ie, episodes of acting out, drop in school grades) instead of possible drug and alcohol use.

Other considerations. It is also important to stress that a negative drug test result does not exclude the use of "club drugs" (3,4-methylenedioxymethamphetamine [MDMA, or Ecstasy], flunitrazepam [Rohypnol], gamma hydroxybutyrate, or ketamine) or recent use of cocaine, opioids, and other legal and illicit drugs with short half-lives. Club drugs are popular with teens and young adults, especially those who are part of the nightclub and rave scene. Furthermore, because MDMA has hallucinogenic properties and the use of hallucinogens is an integral part of some American Indian tribal rituals, the mental health professional should consider the possibility of inappropriate use by this young patient as a behavior deviating from the traditional ritual norms of his culture.

CASE 2: CONSEQUENCES OF IGNORING POLYSUBSTANCE ABUSE

Angie is a 45-year-old woman who presented to the PES with a chief complaint of mild withdrawal symptoms from heroin and opioids. She reported anxiety, generalized aches, and GI upset. She claimed to have been snorting heroin and taking painkillers for the past 6 months. For the past 2 days, she has not been using either kind of drug; she is trying to stop "cold turkey and tough it out." However, the attempt is proving intolerable, and she would like "some help" for her withdrawal symptoms.

Her vital signs are within normal limits, and results of drug screening and breathalyzer tests are negative. Routine blood test results are still pending. The examining physician focuses primarily on the possibility of opioid dependence without exploring other addictions. The physician confirms the possibility of mild opioid withdrawal and discharges the patient with a referral to an ambulatory detoxification center before receiving the results of the blood tests.

Alcohol dependence. Angie returns to PES the following day. This time, her presentation is characterized by elevated vital signs (pulse rate, 125 beats per minute; blood pressure, 189/105 mm Hg; temperature, 37.1ºC [98.8ºF]). The complaints that she reported during her previous evaluation are still causing her discomfort.

The blood test results from the day before reveal a 2-fold increase in liver function and an elevated mean corpuscular volume. Results of a new drug screen are negative, but the breathalyzer test reveals a blood alcohol level of 0.03. Angie now discloses a history of alcohol dependence and a previous episode of delirium tremens. She is admitted to the dual inpatient service for detoxification.

Discussion

Highlighted here is one of the difficulties physicians face when evaluating polysubstance abusers: omission of relevant history. In this case, the physician neglected to ask about polysubstance use, despite its high frequency in clinical practice; heroin abuse is often concomitant with alcohol and cocaine abuse. However, health care providers tend to focus more on heroin and cocaine abuse than on alcohol misuse. This bias may result in haphazard evaluations, such as the one just described.

The pathologic use of alcohol in opioid-dependent patients is common and often resistant to management with methadone and buprenorphine maintenance therapy. Nevertheless, patients who have such a dual addiction may benefit from psychotherapeutic and pharmacologic therapies that target both opioid and alcohol dependence.

Cognitive-behavioral therapies, such as motivational intervention and building relapse-prevention skills, may be indicated to address the coexisting addictions. Frequent urine and blood alcohol level tests are useful tools for the implementation of a contingency approach to management (a milieu in which patients are rewarded for progressing toward sobriety), which is effective in positively shaping behaviors. Pharmacotherapy for heroin addiction could include methadone or buprenorphine maintenance, and for alcohol withdrawal, disulfiram or acamprosate; the use of naltrexone would be contraindicated in this patient because it would induce methadone withdrawal. Ideally, these therapies should be offered at a single setting, such as a methadone clinic, to allow for coordinated imple- mentation of the treatment plan.

The PES physician did not consider the possibility of a life-threatening event, such as alcohol withdrawal. This oversight originated both from the disregard for the blood test results and from clinical bias. To prevent this kind of oversight, the physician should inquire into possible polysubstance abuse and dependence during the initial evaluation.

CASE 3: OVERLOOKING THE MANAGEMENT GUIDELINES

Ron, a 54-year-old man with a long-standing history of cocaine and heroin dependence, presented to the PES with complaints of chronic generalized aches (more intense in the low back), depression, and anxiety. The cause of his physical symptoms is difficult to identify, because they are compatible with various conditions, including a degenerative disorder (eg, osteoarthritis), insufficient vitamin D and calcium intake, low-grade withdrawal from opioids, anxiety, and depression.

Independent from his physical symptoms, he claims a high degree of distress. He reports recurrent use of cocaine and heroin for several years and claims abstinence from any substance for the past 4 days. He does not disclose any medical problems and states that the last visit with his physician took place more than 3 years ago and did not uncover any health problems. His vital signs are normal, and results of a drug screen and routine blood tests are unremarkable. After administering the CAGE questionnaire to the patient, the physician confirms a diagnosis of polydrug dependence and mild withdrawal. The patient is discharged without medications and referred to an outpatient detoxification program.

Discussion

Screening for comorbidities. Although it was right to assess for a substance use disorder, the examining physician overlooked screening for psychiatric comorbidities. Depression and anxiety often are comorbid with stimulant abuse; this relationship should guide both treatment and prognosis. If the depression and anxiety are primary, then the prognosis for the substance use disorder is usually more favorable, because managing the depression generally resolves the substance use disorder. Also, if the PES physician had considered the chronic pain, the discharge plans might have included a referral to a pain clinic. Viewing the chronic pain as separate from the withdrawal syndromes would have been justified because the patient reported that the pain intensified at the low back; this location is consistent with a degenerative process, such as osteoarthritis.

The patient's cocaine and heroin use may be his way of dealing with the depression and the chronic pain. If so, managing one or both problems (depression and chronic pain) could substantially improve his drug use habits. Neglecting the depression and chronic pain, however, could generate a vicious circle of symptoms and behaviors that contribute to the persistence of drug abuse.

Attention to the American Society of Addiction Medicine Patient Placement Criteria (ASAM PPC)^3,4 could have prompted the physician to address eventual medical and psychiatric comorbid conditions (eg, chronic pain and depression). The ASAM PPC are guidelines for the assessment and placement of patients with substance use disorders. They prompt the clinician to assess the detoxification need, biomedical complications, psychiatric conditions, resistance to treatment, potential for relapse, and social problems. The clinician can then assign patients to the appropriate level of care by choosing among outpatient, partial hospitalization, residential, and inpatient treatment approaches.

Had the clinician in this case followed the ASAM PPC, he might have considered a variety of referrals, including dual-diagnosis services, a primary care physician, a pain clinic, and a methadone program. This last option would have addressed both the heroin dependence and the chronic pain. Because it can take up to 24 hours for people to enroll in a detoxification program, the physician could have prescribed nonaddictive medications, such as clonidine, an antihistamine, or an NSAID, to allow for a smoother transition. Unfortunately, a referral as deficient as this one will delay the recognition of these issues and even prevent the engagement of the patient in treatment, since he may find it easier and quicker to resort to using street drugs.

SUMMARY

These 3 cases show the complexity of evaluating and treating patients with drug problems in the ED. Their respective focus on cultural issues, comorbidity, and the development of a comprehensive treatment plan unveils some of the most common mistakes in clinical practice, especially when the health care professional conducting the evaluation is pressed for time. Paying attention to these matters will most likely translate into better outcomes and a reduction in the number of subsequent visits to the ED. *

References:

REFERENCES

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