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Alcohol and drug withdrawal

Copyright © 2006 Society of Hospital Medicine

Alcohol and drug withdrawal is a set of signs and symptoms that develop in association with a sudden cessation or taper in alcohol intake or use of prescription (particularly narcotic medications), over‐the‐counter (OTC), or illicit drugs. Withdrawal may occur prior to hospitalization or during the course of hospitalization. The Healthcare Cost and Utilization Project (HCUP) estimates 195,000 discharges for alcohol/drug abuse or dependency in 2002. These patients were hospitalized for a mean of 3.9 days with mean charges of $7,266 per patient. Hospitalists can lead their institutions in evidence based treatment protocols that improve care, reduce costs and length of stay, and facilitate better overall outcomes in patients with substance related withdrawal syndromes.

KNOWLEDGE

Hospitalists should be able to:

  • Describe the effects of drug and alcohol withdrawal on medical illness and the effects of medical illness on substance withdrawal.

  • Recognize the complications from substance use and dependency.

  • Distinguish alcohol or drug withdrawal from other causes of delirium.

  • Describe the indicated tests required to evaluate alcohol or drug withdrawal.

  • Identify patients at increased risk for drug and alcohol withdrawal using current diagnostic criteria for withdrawal.

  • Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat acute alcohol and drug withdrawal.

  • Identify local trends in illicit drug use.

  • Determine the best setting within the hospital to initiate, monitor, evaluate and treat patients with drug or alcohol withdrawal.

  • Explain patient characteristics that on admission portend poor prognosis.

  • Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

  • Elicit a thorough and relevant history, with emphasis on substance use.

  • Recognize the symptoms and signs of alcohol and drug withdrawal, including prescription and OTC drugs.

  • Differentiate delirium tremens from other alcohol withdrawal syndromes.

  • Assess for common co‐morbidities in patients with a history of alcohol and drug use.

  • Perform a rapid, efficient and targeted physical examination to assess alcohol or drug withdrawal and determine life‐threatening co‐morbidities.

  • Apply DSM‐IV Diagnostic Criteria for Alcohol Withdrawal.

  • Formulate a treatment plan, tailored to the individual patient, which may include appropriate pharmacologic agents and dosing, route of administration, and nutritional supplementation.

  • Integrate existing literature and federal regulations into the management of patients with opioid withdrawal syndromes. for patients who are undergoing existing treatment for opioid dependency, communicate with outpatient treatment centers and integrate dosing regimens into care management.

  • Manage withdrawal syndromes in patients with concomitant medical or surgical issues.

  • Determine need for the use of restraints to ensure patient safety.

  • Reassure, reorient, and frequently monitor the patient in a calm environment.

  • Assess patients with suspected alcohol or drug withdrawal in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.

ATTITUDES

Hospitalists should be able to:

  • Use the acute hospitalization as an opportunity to counsel patients about abstinence, recovery and the medical risks of drug and alcohol use.

  • Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.

  • Appreciate the indications for specialty consultations.

  • Initiate prevention measures prior to discharge, including alcohol and drug cessation measures.

  • Manage the hospitalized patient with substance use in a non‐judgmental manner.

  • Employ a multidisciplinary approach, which may include psychiatry, pharmacy, nursing and social services, in the treatment of patients with substance use or dependency.

  • Establish and maintain an open dialogue with patients and families regarding care goals and limitations.

  • Appreciate and document the value of appropriate treatment in reducing mortality, duration of delirium, time required to control agitation, adequate control of delirium, treatment of complications, and cost.

  • Facilitate discharge planning early in the hospitalization, including communicating with the primary care provider and presenting the patient with contact information for follow‐up care, support and rehabilitation.

  • Utilize evidence based national recommendations to guide diagnosis, monitoring and treatment of withdrawal symptoms.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, Hospitalists should:

  • Lead, coordinate or participate in the development and promotion of guidelines and/or pathways that facilitate efficient and timely evaluation and treatment of patients with alcohol and drug withdrawal.

  • Promote the development and use of evidence based guidelines and protocols for the treatment of withdrawal syndromes.

  • Advocate for hospital resources to improve the care of patients with substance withdrawal, and the environment in which the care is delivered.

  • Lead, coordinate or participate in multidisciplinary teams, which may include psychiatry, to improve patient safety and management strategies for patients with substance abuse.

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