Chapter 292: Substance Use Disorders

In EDs around the world, on every shift, patients present for medical conditions related to the consequences of unhealthy drinking or drug use. Sometimes the cause of the presenting problem is obvious, but just as often, the connection of substance use with its medical consequences remains undiscovered. Emergency physicians are experts in stabilization, rapid diagnosis, and treatment of acute alcohol and drug emergencies and their secondary complications but often fail to identify and discuss drinking and drug use as a component of medical care. Factors that often accompany unhealthy alcohol and drug use, such as psychiatric illness, trauma, homelessness, low level of health literacy, inability to pay for medications, criminal justice involvement, absence of family support, and limited availability of treatment and recovery support services, make patient management and disposition difficult.

The scope of substance use disorders includes unhealthy use of alcohol, use of illicit drugs, and nonmedical use of prescription drugs. Severe substance use disorders (addictions) resemble asthma, diabetes, hypertension, and other chronic diseases in that they have genetic components and patients have problems with adherence to medication, loss to follow-up, repeat visits to the ED, and hospital admissions, yet only a small fraction of those needing alcohol or drug treatment are actually receiving indicated therapy, compared with a much higher fraction of patients with chronic medical conditions.¹

Substance use is a significant global problem. The World Health Organization reports worldwide 185 million illicit drug users, 2 billion alcohol users, and 1.3 billion smokers. In 2000, tobacco, alcohol, and illicit drugs accounted for about 12% of all deaths worldwide.²

Those who begin drinking before age 15 have a fourfold increased risk of developing dependence than those who begin drinking later.³ Underage drinking and drug use have a profound impact on the developing nervous system, so early intervention is needed to mitigate life-altering consequences.⁴

UNHEALTHY ALCOHOL USE

The term unhealthy alcohol use describes a spectrum of alcohol consumption ranging from "risky" or hazardous use (no consequences experienced), to harmful use (experience of consequences), to what was previously called alcohol dependence but is now termed alcohol use disorders.⁵ The National Institute on Alcohol Abuse and Alcoholism defines low-risk drinking as follows⁶: for men, no more than 14 drinks per week and no more than four drinks over a 2-hour occasion. Women of all ages and men >65 years old are advised to drink no more than seven drinks per week and no more than three drinks over a 2-hour occasion because of gender and age differences in volume distribution and concentrations of alcohol dehydrogenase in the liver. Binge drinking (drinking too much too fast) is alcohol consumption that results in a blood alcohol level over the U.S. legal limit of 0.08 gram/dL, which for the average male is the result of more than four drinks in 2 hours and for the average female is more than three drinks in 2 hours. Abstinence is advised for pregnant women and underage drinkers, and a lower limit or abstinence is advised for patients with chronic conditions exacerbated by alcohol or who are taking medications with an alcohol interaction.⁶

SUBSTANCE USE DISORDERS

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, groups substance abuse and dependence into categories from mild to severe substance use disorders.⁷ The diagnosis of substance use disorder requires two or more of the following 11 criteria: (1) tolerance; (2) withdrawal; (3) recurrent use in greater quantities or for a greater duration than intended; (4) failed attempts to cut back or quit substance use; (5) spending a great deal of time obtaining, using, or recovering from the substance; (6) persistent or recurrent use despite physical and or psychological consequences; (7) giving up important activities in order to use; (8) failure to fulfill responsibilities in work, school, and/or home because of recurrent use; (9) recurrent use resulting in physically hazardous behavior, such as driving under the influence; (10) persistent use despite social or interpersonal problems; and (11) craving alcohol or other drugs. Severity is based on the number of criteria: two or three of the criteria constitute mild substance use disorder, four to five constitute moderate, and six or more constitute severe.⁷

ALCOHOL WITHDRAWAL

Alcohol withdrawal symptoms develop in individuals with a history of heavy and prolonged consumption of alcohol who abruptly stop or reduce their drinking. The spectrum of alcohol withdrawal symptoms includes hand tremors, headache, loss of appetite, nausea and vomiting, diaphoresis, insomnia, tachycardia, hypertension, fever, psychomotor agitation, hyperarousal, craving, and anxiety, as well as the more serious manifestations of seizures, hallucinations, and delirium. The abrupt withdrawal of alcohol from the brain of chronic heavy drinkers is thought to reduce inhibitory neurotransmission through γ-aminobutyric acid and enhance excitatory neurotransmission through glutamate, but not all heavy drinkers experience withdrawal when stopping or cutting back their consumption.^8,9,10

Alcohol withdrawal symptoms exist on a continuum from uncomplicated to moderate and severe, may begin as early as 2 to 6 hours after reduction in alcohol consumption, and can persist for up to 2 weeks. Up to 5% of patients in withdrawal progress to delirium tremens; those with a prior history are at greatest risk. Convulsions occur in 5% to 15%, and delirium tremens occurs in less than 5%. Deaths from delirium tremens among patients receiving early and aggressive treatment have declined from 35% in the early twentieth century to 5% in the current period.^8,9,10

The first step in successful treatment is to identify alcohol withdrawal early and distinguish withdrawal from mimics. The most common mimics include toxic-metabolic abnormalities (hyponatremia, hypoglycemia, hypomagnesemia, diabetic ketoacidosis, Wernicke's encephalopathy), toxic alcohol ingestions (ethylene glycol, methanol), prescription or illicit drug ingestions (opioids, sedative-hypnotics, antihistamines), neurologic abnormalities (primary generalized seizures, withdrawal seizures), subdural or epidural hematoma, hypovolemic trauma, infection, and sepsis.

Gastritis, peptic ulcer disease, and pancreatitis are comorbidities with symptoms that often require abrupt cessation of alcohol consumption, leading to withdrawal. The gathering of collateral history, thorough serial examinations of the undressed patient, repeated monitoring of vital signs, measurement of oxygen saturation and bedside finger stick for blood glucose, laboratory assessment of metabolic conditions, and imaging as clinically indicated can detect most comorbidities.

ALCOHOL WITHDRAWAL SEIZURES

Alcohol withdrawal seizures are diffuse tonic-clonic seizures. According to the landmark observations by Victor and Brausch,¹¹ alcohol withdrawal seizures occur as early as 6 hours after the decrease in intake or the last drink, and 90% occur within 48 hours. Approximately 40% of patients have a single seizure, and 60% have multiple generalized seizures. Victor and Brausch reported that one-third of patients with alcohol withdrawal seizures develop delirium tremens, with the seizures terminating before the development of delirium. An alcohol withdrawal seizure may be brief, with a short or no postictal period.¹⁰ The diagnosis of alcohol withdrawal seizures requires the exclusion of traumatic brain injury, hypoxia, hypoglycemia, structural lesions, infections, use of illicit drugs, idiopathic epilepsy, withdrawal from other recreational drugs, and withdrawal from prescription medications. Focal seizures suggest a focal cerebral lesion. Also consider noncompliance with antiseizure medications (in those with idiopathic or posttraumatic seizures).¹²

ALCOHOL WITHDRAWAL HALLUCINATIONS (ALCOHOL-INDUCED PSYCHOTIC DISORDER)

Alcohol-induced withdrawal hallucinations or alcohol-induced psychotic disorder may develop as an isolated finding 12 to 48 hours after decreasing or abstaining from alcohol. Auditory hallucinations predominate over visual and tactile hallucinations. Psychosis, paranoia, and agitation may last from days to weeks. Alcohol-induced psychotic disorder has a high risk for suicide and co-occurs with other psychiatric diagnoses. Patients with hallucinations lasting for >6 months have the worst prognosis; however, the prognosis is more favorable if abstinence can be maintained.¹³

ALCOHOL WITHDRAWAL DELIRIUM TREMENS

Alcohol withdrawal delirium tremens is characterized by acute and fluctuating disturbances in consciousness, confusion, psychomotor agitation, inattention and impairment in cognitive and perceptual function (hallucinations) unrelated to preexisting or established dementia.^8,9,10 Patients often develop life-threatening fluid, metabolic, and electrolyte imbalances. Among the risk factors associated with alcohol withdrawal delirium are past withdrawal seizure and delirium, severe dependence and prior detoxification history, high and long duration of alcohol intake, older age, use of other drugs, genetic polymorphism, and comorbidity.^8,9,10

TREATMENT OF ALCOHOL WITHDRAWAL SYNDROMES

The goals of therapy for alcohol withdrawal are to alleviate autonomic hyperactivity and agitation, halt progression to delirium tremens, and if possible, provide motivation for and access to detoxification to promote long-term abstinence.^5,8,9,10 General therapy is the substitution of a benzodiazepine for alcohol (Table 292-1).^5,8,9,10 Benzodiazepine equivalents are lorazepam 1 milligram = midazolam 2 milligrams = diazepam 5 milligrams = chlordiazepoxide 25 milligrams. Oral diazepam has a rapid onset of action, and the onset of action of IV diazepam is almost immediate. IM diazepam absorption is erratic, so do not give it IM. Duration of action of diazepam is 20 to 50 hours, and metabolism is hepatic, with the major metabolite (desmethyldiazepam) having a half-life of 20 to 50 hours. Chlordiazepoxide is only available as an oral medication, has a long half-life of up to 28 hours, and has extensive hepatic metabolism with its major active long-acting metabolite, desmethyldiazepam. Lorazepam can be given PO, IM, or IV. Onset of action when given IV is within minutes, and duration of action is 8 hours. Lorazepam is metabolized rapidly by the liver with inactive metabolites excreted by the kidneys and recognized as the benzodiazepine most tolerated by patients with advanced liver disease.^8,9,10 Midazolam can be given IV or IM, but for delirium tremens, it is typically given IV. IV onset of action is 3 to 5 minutes.

Give individualized symptom-triggered therapy rather than fixed-schedule dosing. Symptom-triggered regimens result in less drug and shorter duration of treatment than fixed-drug dosing.¹⁵ The Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA) is the most commonly used validated, structured instrument for guiding continuing treatment once a diagnosis of alcohol withdrawal is established.¹⁶ It has not been validated specifically for ED use, and comorbid conditions and medications make it difficult to score the Clinical Institute Withdrawal Assessment accurately. The CIWA score ranges from 0 to 67 and tracks 10 variables, with a 0 to 7 ranking for nine variables and a 0 to 4 ranking for the last variable (orientation and clouding of sensorium), where 0 is none and 7 (or 4) is the most severe manifestation of the variable. The variables are nausea/vomiting; tremor; paroxysmal sweats; anxiety; agitation; tactile disturbance; auditory disturbance; visual disturbance; headache; and orientation and clouding of sensorium (0 to 4 rank). A score <8 represents mild withdrawal; score of 9 to 15 moderate withdrawal, and score >15 severe withdrawal.¹⁷

Drug Therapy for Uncomplicated Alcohol Withdrawal

For patients meeting criteria for uncomplicated alcohol withdrawal without seizures, hallucination, or delirium, the recommended first-line treatment is a benzodiazepine (Table 292-1).^8,9,10 Because no specific benzodiazepine is more effective than the others, physician choice, institutional availability, cost, and patient factors are taken into consideration.¹⁰

Drug Therapy for Alcohol Withdrawal Seizures

Benzodiazepines are effective in protecting against seizures and reducing recurrent seizures in alcohol withdrawal.^18,19 A prospective randomized ED trial demonstrated a 3% seizure recurrence rate with a single dose of IV lorazepam, 2 milligrams, compared with 24% among patients receiving placebo.²⁰ Phenytoin is not recommended for prevention of further alcohol-related seizures and should not be used unless the patient has an underlying structural lesion. Repeated loading of phenytoin may, in fact, lower the seizure threshold.^20,21

Drug Therapy for Alcohol Withdrawal Hallucinosis (Alcohol-Induced Psychotic Disorder)

Antipsychotic therapy with alcohol abstinence is the recommended treatment. There is no long-term need for antipsychotic medication for abstinent patients once symptoms remit. Because patients with alcohol-induced psychotic disorder could be at risk for suicide, admission is recommended.¹³

Drug Therapy for Alcohol Withdrawal Delirium

Alcohol withdrawal delirium develops within 3 to 5 days of the last drink and generally lasts 48 to 72 hours, but may last longer. The current practice guideline published by the American Society of Addiction Medicine recommends the use of sedative-hypnotics in high enough doses to quickly control agitation, minimize adverse events, and achieve light somnolence with arousal when stimulated.⁹ A benzodiazepine is the initial treatment of choice (Table 292-1). If symptoms are unresponsive to adequate doses of benzodiazepines, additional agents include phenobarbital, propofol, or haloperidol.^22,23,24 Phenobarbital or propofol typically requires intubation. Propofol's central nervous system mechanism of action is thought to be similar to that of ethanol. Adverse effects of propofol include hypotension, and prolonged use >48 h and >5 milligrams/kg/h can cause propofol infusion syndrome,^25,26 with dysrhythmias, heart failure, hyperkalemia, lipemia, metabolic acidosis, and rhabdomyolysis. Antipsychotics such as haloperidol, droperidol, or ziprasidone should be reserved for psychosis or continued agitation (see chapter 287, "Acute Agitation") only after adequate benzodiazepines are administered.

Patients with delirium require thorough diagnostic assessment, aggressive treatment of co-occurring illnesses, supportive care, prevention of aspiration, and treatment of hyperthermia, dehydration, hypoglycemia, and electrolyte imbalance. Thiamine, 100 milligrams, and folate, 1 milligram, should be considered. Treat hypomagnesemia with IV magnesium. A benefit from magnesium therapy in the absence of hypomagnesemia is not established.²⁷ Physical restraints may be temporarily needed until chemical restraint is achieved; a quiet, calm, supportive environment with low stimuli contributes to successful management.^8,9,10

DISPOSITION

Patients with mild or moderate uncomplicated alcohol withdrawal that responds well to initial ED treatment, without trauma or major medical comorbidities, with no suicidal or homicidal ideation, and without a seizure disorder can be managed successfully in a detoxification unit or discharged to a supportive family with referral to an outpatient program. Indications for admission include advanced age, mild or moderate withdrawal that does not respond well to ED treatment, the presence of active medical comorbidities, a prior history of delirium tremens, and alcohol withdrawal seizures. Consider intensive care unit admission for moderate withdrawal with comorbid conditions or severe withdrawal in which sedative requirements necessitate intubation or close monitoring to prevent respiratory compromise.

Symptoms of opioid withdrawal include dilated pupils and tearing, sneezing and running nose, nausea, vomiting, diarrhea and abdominal cramps, yawning, piloerection (goose bumps), and myalgias. Heroin or short-acting opioid withdrawal symptoms appear within 36 to 72 hours after decreasing or stopping the agent and may last for 7 to 10 days.⁸ Of the opioids, withdrawal symptoms are most severe with heroin but most prolonged with methadone.⁹ Oxycodone or crushed and injected OxyContin^® withdrawal resembles heroin in this regard. OxyContin^® (long-acting oxycodone) and buprenorphine are intermediate-acting opioids, and peak withdrawal symptoms occur in a time frame between heroin and methadone. Methadone is used for pain control and also to transition patients from other narcotics as medication-assisted treatment for opioid addiction. Methadone has been associated with QT prolongation on the ECG and possibly torsade de pointes, so review the ECG prior to initiating the medication.^28,29 However, methadone withdrawal symptoms can be protracted, because methadone is firmly bound to tissue protein and there is slow release over time from tissue-binding sites. Methadone withdrawal symptoms appear at 72 to 96 hours and may last for 2 weeks or more. For methadone cessation, typically 10% of the maintenance dose is reduced every 2 weeks.

Buprenorphine is a partial opioid agonist and a weak antagonist. It has a high affinity for μ-receptors, displacing other opioids from the receptor, causing acute withdrawal in patients who have recently used opioids. The antagonist effects of buprenorphine block respiratory depression and provide a good margin of safety to treat withdrawal or to provide opioid substitution therapy. The U.S. Food and Drug Administration approved two sublingual formulations of buprenorphine in 2002 for the treatment of opioid dependence. The preferred preparation is a combination of buprenorphine combined with naloxone in a ratio of 4:1, as a sublingual tablet or film (brand name Suboxone^® or Zubsolv^®) to prevent diversion and overdoses.^30,31 The naloxone component is rapidly bioavailable and will precipitate withdrawal symptoms in opioid users. Overdoses can be managed with naloxone.³⁰

OPIOID WITHDRAWAL TREATMENT

There are few options for treating opioid withdrawal. Clonidine in doses of 0.2 milligram three times a day can reduce autonomic symptoms to some degree, but it is not very effective with other symptoms. Patients who stop clonidine abruptly may develop severe rebound hypertension. Symptomatic relief of anxiety and muscle spasms can be achieved with muscle relaxants or benzodiazepines, and GI symptoms can be managed with antispasmodics, antiemetics, and antidiarrheals.⁸

Buprenorphine/naloxone can be used to treat mild withdrawal, but when symptoms are moderate or severe, the high affinity of the drug for the μ-receptor will displace the other opioid and precipitate severe withdrawal. It can be given approximately 12 hours after short-acting opioid use, 24 hours after long-acting opioid use, and up to 48 to 96 hours after high-dose methadone use (30 to 60 milligrams/d). Patient on methadone ideally should be tapered to <30 milligrams/d, and at this low dose, patients can be transitioned to buprenorphine/naloxone in 24 hours.

The starting dose for treatment of opioid withdrawal is sublingual buprenorphine/naloxone, 4 to 8 milligrams buprenorphine/2 milligrams naloxone, with a first-day maximum of 8 milligrams.³² In an outpatient setting, the dose is titrated to control symptoms, usually 16 to 32 milligrams/d. Buprenorphine withdrawal is slower in onset and milder than withdrawal from opioids.³¹ Patients taking buprenorphine who develop conditions associated with severe pain, may require large doses of potent opioids such as fentanyl to override buprenorphine's antagonist properties, with close observation for respiratory depression.

OPIOID ADDICTION MANAGEMENT

The Drug Addiction Treatment Act of 2000 established office-based opioid treatment in an effort to integrate treatment options into comprehensive clinical care practice and reduce stigmatization of medication-assisted treatment. The prescription of methadone for treatment of addiction is limited by the Federal Narcotics Act to inpatient units or outpatient facilities licensed by the U.S. Drug Enforcement Administration, and buprenorphine is limited to certified clinicians in office- or clinic-based practices. However, there is a "3-day rule" (Title 21, Code of Federal Regulations, Part 1306.07b) that allows a practitioner who is not separately registered as a narcotic treatment program or certified as a "waivered Drug Addiction Treatment Act of 2000" physician to administer (but not prescribe) narcotic drugs to a patient to relieve acute withdrawal symptoms while arranging for referral to treatment (http://www.buprenorphine.samhsa.gov/faq.html). Only one day's supply may be administered or given to a patient, and this may be done for 72 hours only, which cannot be extended. The intent of Title 21, Code of Federal Regulations, Part 1306.07b is to provide flexibility in emergency situations and is especially relevant to emergency physicians. This offers patients options for relief of withdrawal symptoms to bridge the patient for follow-up to either a specialized treatment program or an office-based physician program in the community.

The rise in opioid overdose hospitalizations and deaths has contributed to the White House Office of National Drug Control Policy³³ partnering with the Substance Abuse and Mental Health Services Administration and Centers for Disease Control and Prevention to address the epidemic. The four pillars of their national strategy are to (1) educate prescribers about opioid painkiller prescribing³⁴; (2) expand prescription drug monitoring programs and promote links among state systems and to electronic health records³⁵; (3) increase prescription return/take-back and disposal programs; and (4) assist states to address doctor shopping and pill mills via law enforcement. Additional national strategies include reducing social stigma and expanding access to medication-assisted treatment,^33,36 and implementing innovative policies to increase availability of naloxone to first responders and the lay public together with ED and community-based programs to train the public in overdose prevention education, calling 911, rescue breathing, and the proper use of bystander naloxone.^33,37,38

Symptoms of withdrawal may develop up to 7 to 10 days after stopping chronic benzodiazepine use. Patients may develop withdrawal seizures. The clinical picture resembles alcohol withdrawal with symptoms of hypertension, tachycardia and tachypnea, tremulousness, anxiety, agoraphobia, insomnia, altered mental status, delirium, and hallucinations. Mild withdrawal can be managed by a gradual taper over 10 weeks of the benzodiazepine that has been abused.³⁹

Stimulant withdrawal can produce symptoms often associated with depression such as disturbances in sleep, appetite, and mood. The duration is from 8 to 48 hours. Co-occurring opioid and sedative dependency may complicate withdrawal. There is no effective evidence-supported treatment currently available for cocaine and stimulant withdrawal.

Marijuana dependence has been associated with low energy, sleep and memory disturbances, deterioration in job and family function, and financial difficulties, but dependence is less likely than for other drugs. Marijuana withdrawal begins after 24 to 48 hours, usually lasts for 1 to 3 weeks after abstinence, and peaks within 4 to 6 days. Among the symptoms associated with withdrawal are difficulty sleeping, cravings, mood swings, depression and irritability, and decreased appetite. Withdrawal symptoms are considerably less severe than for heroin or alcohol, but nevertheless, like other drugs, withdrawal symptoms can interfere with efforts to quit or seriously cut back on use.⁴⁰

Screening, brief intervention, and referral to treatment were established in 2003 by the U.S. Substance Abuse and Mental Health Services Administration to address the gap in preventive services for unhealthy alcohol and drug use, to stem the progression to addiction by early intervention, and to address the treatment gap by promoting help seeking and facilitating access to addiction treatment and recovery support services. Screening, brief intervention, and referral to treatment in the ED setting may have short-term benefits.^{41, 42, 43, 44, 45, 46, 47, 48, 49}

SCREENING FOR UNHEALTHY DRINKING AND DRUG USE

Brief standardized screening questions have a higher sensitivity for identifying heavy and dependent drinkers and illicit drug–using patients than smell of alcohol on breath, patient self-report, or profiling based on demographics or presenting complaint. Brief screening instruments are easy to administer and may help match an individual to the most appropriate treatment resource. Validated brief screening questions useful for ED providers include the National Institute on Alcohol Abuse and Alcoholism Quantity/Frequency/Questions⁶ and the Single Screening Questions for Alcohol⁵⁰ and Drug Use (Table 292-2).⁵¹ Questions can be integrated into the triage electronic medical record.⁵² Screening for heavy smoking is also important since there is an association between heavy smoking and poly drug use.⁵²

As part of the social history, physicians can integrate questions that reflect their concern for the patient's overall health and safety. Substance use disorder screening questions could be embedded among other preventive health issues to reduce stigma and patient resistance and encourage veracity and trust. Questions asked in a nonjudgmental, matter-of-fact fashion are well accepted by patients.⁵³

Patients who are above the "low-risk" drinking guidelines could benefit from a brief intervention and primary care referral to motivate reducing consumption. For moderate to severe alcohol use, provide referral to a specialized treatment center.

The Centers for Disease Control and Prevention recommends screening for illicit drug use or nonmedical use of prescription drugs before writing an opioid prescription.⁵⁴ Screening may not detect all patients with an abuse problem. As an additional tool, nearly all states have implemented prescription drug monitoring programs,⁵⁵ which track the prescribing and dispensing of controlled substances at the retail pharmacy level. States with prescription drug monitoring programs appear to have lower rates of substance abuse treatment admission and lower rates of increase in abuse/misuse compared to states that do not have them.⁵⁶ Prescription drug monitoring program data can change prescribing behavior, because providers do not have a very good sensitivity (63%) or positive predictive value (41%) in determining drug-seeking behavior without the aid of a prescription drug monitoring programs.^57,58 There are still no evidence-based consensus guidelines for identifying possible drug-seeking activity or patients at risk for prescription drug abuse. Prescription drug monitoring programs do not detect medications that are diverted or purchased illegally, report prescriptions filled in another state (unless there is a data-sharing program in place), or identify residents writing prescriptions under a hospital's Drug Enforcement Administration number. Use prescription drug monitoring program data along with history, physical examination, and clinical impression. Do not use prescription drug monitoring program data as a reason to withhold adequate and necessary analgesia. Several factors from prescription drug monitoring program data may suggest concerning substance abuse risk (Table 292-3).

The brief negotiated interview^{41,43,48,49,66,67} has four key elements: establish rapport, provide feedback, enhance motivation, and negotiate plan of action. The first principle of promoting health behavior change is that the argument for change needs to come from the patient, not the healthcare provider. Begin a respectful, nonjudgmental conversation by recognizing the patient as the decision maker and asking the patient's permission to talk about alcohol or drug use and health concerns. The best time for early intervention may be during a medical, social, or criminal justice crisis.⁶⁹ The entire interaction often can be accomplished in 5 to 7 minutes,⁶⁶ and the conversation can take place at any point in care, such as at discharge or while suturing or casting or performing an incision and drainage of an abscess.

The brief negotiated interview algorithm incorporates key elements of motivational interviewing: open-ended questions, affirmations, reflective listening, and summaries (Figure 292-1) (see SBIRT for drug use).

Establish rapport and ask the patient's permission to discuss his or her use of alcohol and drugs. Establish an atmosphere of trust through respect. The patient is not the problem but is a person who has a problem.

Provide feedback. Elicit patient's thoughts on low-risk or safe alcohol and drug use. Provide information by reviewing current drinking and drug use and guidelines. Express concern that by drinking in excess of safe limits, the patient is at risk for injury or illness. Elicit/solicit the reaction to the guidelines. Ask patients to make a connection between alcohol and/or drug use and quality of life; possible negative consequences related to health, family, legal system, and employment; and, if applicable, the current ED visit or injury. If appropriate, discuss physical dependence, withdrawal, and the cycle of behaviors to obtain more alcohol and/or drugs.

Enhance motivation. Assess readiness to change on a readiness ruler. Ask patients to mark on a drawing of a ruler, with a scale of 1 to 10, how ready they are to change, cut back, or quit their alcohol and/or drug use. If they say 5, give affirmation and say that "You are 50% on the way," and ask, "Tell me why you didn't mark a 2 or 3, a lesser number?" Here is when we try to elicit change talk/reasons and motivation for change. Repeat what the patient has shared with you and follow up with, "It sounds like you have some important reasons to change, so what small steps can you take to stay healthy and safe?" If the patient shows resistance to the readiness ruler or the score is <2, then explore the pros and cons of current use. A discussion of the pros and cons promotes self-questioning and draws attention to the patient's own reasons for tipping the scale toward change. Use open-ended questions such as, "Help me to understand (or see it through your eyes) what you like and dislike about your use of alcohol?" Explore the importance to the patient of the issues that emerge. Use reflective listening to summarize what you think the patient said to verify your interpretation, for example: "On the one hand, you like the taste, how it helps you to loosen up and forget your problems, and it is something to do when you're bored. On the other hand, you said you don't like how you feel the next day and that wrecking your car in a crash and ending up in the ED is no fun. You also told me you are spending a lot of money on drinking and are concerned about not meeting some responsibilities. So then, in the balance, where does that leave you?"

Negotiate and advise. Negotiate an action plan. Explore with patients what life might be like if they made these changes. What would be the benefits of change, and what would be the challenges? Add the steps they would need to take to address challenges and explore and support confidence in ability to make a change. Offer a menu of options and resources to assist with the change plan, including, if appropriate, referrals to primary care providers and substance use disorder treatment. Document the plan. Ask the patient to state in her or his own words the agreed-on steps and document them on a piece of paper or discharge instructions as a reminder of goals (a prescription for change). Reflect back to the patient and reinforce reasons for, and steps toward, change. End the conversation by thanking the patient for being honest and spending time talking with you.

Afterward, take a minute for self-assessment. To what degree did you provide feedback? Did you listen carefully? Did you ask open-ended questions? Did you offer affirmations and alternatives? (FLOAT) Did the patient have enough time to talk, or did you do the majority of talking? Did you negotiate a concrete action plan?

Train ED staff in screening, brief intervention, and referral to treatment. Develop an ED collaborative team with staff such as social workers, care managers, psychologists, nurse specialists, peer alcohol and drug counselors, volunteers from Alcoholics Anonymous or Narcotics Anonymous, or health promotion advocates to enhance the efforts of existing staff and motivate and assist patients with identifying and accessing treatment options.^45,67,68

Build and maintain a referral/resource service network.^45,67,68 Current practice in most EDs is to provide patient and family members with a list of detoxification or treatment resources in the community (see "Useful Web Resources" below). The Center for Substance Abuse Treatment at the U.S. Department of Health and Human Services also has an online resource locator (http://dasis3.samhsa.gov). The resource list includes specialized treatment facilities for patients with co-occurring medical, traumatic, and psychiatric illnesses; inpatient and outpatient detoxification, acupuncture, and medication-assisted treatment such as methadone maintenance programs, buprenorphine, and naltrexone for opioid and alcohol addiction; outpatient individual and group counseling; intensive outpatient or partial hospitalization; recovery residents; residential communities; Alcoholics and Narcotics Anonymous meetings; and programs focused on the needs of women, culture-specific programs, and programs designed for gay, lesbian, and transgender clients.

If patients are not ready to enter specialized treatment or attend Alcoholics Anonymous or Narcotics Anonymous, then try to provide information and negotiate a safety plan such as the identification of a designated driver or use of a taxicab when drinking heavily, or avoiding drinking while taking medications. The injecting drug user who is not ready to accept a treatment referral may accept a referral to a syringe exchange program or overdose education, a nasal naloxone rescue kit program, or a prescription for naloxone.

THE MEDICAL CLEARANCE EXAMINATION

EDs often function as sources for the medical clearance examination before patient transfer to a substance or psychiatric treatment facility. There is considerable variability in the levels of medical care provided in such facilities, ranging from facilities that manage an array of chronic health problems to those with minimal nursing support only for very sTable patients. Medical clearance does not mean that the patient has no medical problems, but it does mean that "within reasonable medical certainty there is no medical emergency."⁷¹ Criteria include the following: patients are sTable for transfer (in the short term rather than long term), are ambulatory, can take oral medications, and are not suicidal or likely to seize. Patients on medications should bring them to the treatment facility or be given prescriptions or provided with several doses. Psychiatrically sTable patients with dual diagnoses who are not suicidal or acutely psychotic can be medically cleared for transfer, as long as they have a supply of necessary nonpsychiatric medications and can be expected to be reliable in taking their medications correctly.