Patients who end up in ER for severe dependence on alcohol need medications: doctors

A group of Canadian and American experts is urging emergency room doctors to prescribe specific medications to help curb cravings and alleviate withdrawal from heavy use of alcohol, which leads to more hospitalizations than any other substance.

Guidelines on prescribing by the Society for Academic Emergency Medicine include input from ER physicians, specialists in addiction and patients who experienced harms due to dependence on alcohol.

Dr. Bjug Borgundvaag, lead author of the guidelines published recently in the journal Academic Emergency Medicine, said people who suddenly stop drinking after consuming high amounts of booze can end up with severe withdrawal symptoms, especially seizures and delirium tremens, which include confusion among other symptoms.

"Withdrawal can be very dangerous, and in fact it can be fatal. We see it's very common in the emergency department," said Borgundvaag, director of the Schwartz/Reisman Emergency Medicine Institute at the Sinai Health System in Toronto.

The usual medication for moderate to severe alcohol withdrawal syndrome is diazepam, which is sold under the brand name Valium. Instead, the experts recommended phenobarbital along with benzodiazepines, compared to benzodiazepines alone.

Some doctors are not familiar with phenobarbital because it's an older drug, but it should be prescribed to patients who will likely be hospitalized, sometimes in an intensive care unit, for symptoms associated with withdrawal, Borgundvaag said.

"We think that if people are treated with phenobarbital we can reduce ICU admissions, we can reduce intubation, so having to really, really sedate people, basically to the point where they're completely unconscious and have machines breathing for them," he said.

The experts suggested gabapentin, rather than no prescription, for ER patients with ongoing sleep disturbances and anxiety related to alcohol withdrawal. And for patients who need help to prevent heavy drinking or to significantly reduce how much they consume, they recommended the anti-craving medication naltrexone, compared to no prescription.

Borgundvaag, who will present the guidelines in Saskatoon at next month's conference of the Canadian Association of Emergency Physicians, said ER care providers have the perfect opportunity to treat alcohol dependence but that like most medical professionals they lack the education to do so.

"Less than five per cent of patients who have alcohol use disorder ever get treated with these medications."

Anna Kemp of Almonte, Ont., near Ottawa, said she began drinking daily to the point of becoming "a train wreck" as she tried to numb the stress of caring for her mentally ill teenage son.

Kemp became suicidal and ended up in the emergency department in 2011, when she was prescribed antidepressants and told her symptoms were due to menopause, she said.

"It's really, really sad," said Kemp, adding that ER health professionals seem to be focused on treating physical wounds without addressing alcohol dependence.

Kemp said she now drinks socially but her relationship with alcohol is "a constant challenge."

The need to manage alcohol addiction with medication is slowly being recognized, said nurse practitioner Katie Dunham.

Dunham, who works in an addiction medicine clinic in Guelph, Ont., said she is educating rural and remote ER nurses to recognize alcohol use disorder and withdrawal because they spend more time with patients and can start conversations about consumption before medications may be prescribed.

She will also be holding an education session next week at the National Emergency Nurses Association conference in Gatineau, Que.

Dunham said that as a former ER nurse in London, Ont., she saw plenty of university students come in for alcohol-related reasons.

"Typically, after a night of drinking they would come in intoxicated, sometimes unconscious, unfortunately," said Dunham, adding some were suffering from hypothermia or had been injured in a fall.

At most, treatment involved some blood work and intravenous fluids for rehydration before they were discharged, she said.

"That falls short of best practices and standards in terms of having conversations about what brought them to the emergency department and brief interviews to let them know that there are treatments and resources available."

Dunham said new education resources, which are co-authored by Borgundvaag and funded by the Ontario government, are aimed at helping ER health-care providers learn about interviewing patients enduring alcohol-related harms and the most effective medications to help manage their condition.

They come as the province is also set to expand sales of beer, wine, cider and ready-to-drink cocktails in convenience stores by 2026, and as advocacy groups call for a comprehensive strategy to reduce harms from booze.

Data from the Canadian Institute on Substance Use Research at the University of Victoria shows that alcohol accounted for about 652,000 emergency room visits in Canada in 2020, compared to about 166,000 for tobacco and 37,000 for cannabis.

This report by The Canadian Press was first published May 29, 2024.

Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.

Camille Bains, The Canadian Press