Alcohol and drug withdrawal is a set of signs and symptoms that develops in association with sudden cessation or reduction in the use of alcohol or a number of prescription (particularly opioids and benzodiazepines), over-the-counter (OTC), or illicit drugs. Withdrawal syndromes encompass a broad range of symptoms from mild anxiety and tremulousness to more serious manifestations such as delirium tremens, which occurs in up to 5% of alcohol-dependent persons who undergo withdrawal.1 Withdrawal may occur before hospitalization or during the course of hospitalization. Alcohol- and substance-related disorders account for more than 400,000 hospital discharges each year and are associated with a mean length of stay of approximately 4.6 days.2 Alcohol and drug dependence is often an end product of a combination of biopsychosocial influences, and in most cases, a multidisciplinary approach is necessary to successfully treat affected individuals. 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.
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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 symptoms and signs of alcohol and drug withdrawal, including withdrawal from prescription and OTC drugs.
Recognize the medical complications from substance use and dependence.
Determine when consultation with a medical toxicologist or expert is necessary.
Distinguish alcohol or drug withdrawal from other causes of delirium.
Differentiate delirium tremens from other alcohol withdrawal syndromes.
Differentiate the clinical manifestations of alcohol or drug intoxication from those of withdrawal.
Recognize different characteristic withdrawal syndromes, such as abstinence syndrome of opioid withdrawal and delirium tremens of alcohol withdrawal.
Describe the tests indicated to evaluate alcohol or drug withdrawal.
Identify patients at increased risk for drug and alcohol withdrawal according to current diagnostic criteria.
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 portend a poor prognosis.
Explain patient characteristics that indicate a requirement for a higher level of care and/or monitoring.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transitions.
Hospitalists should be able to:
Elicit a thorough and relevant medical history, with emphasis on substance use.
Assess patients with suspected alcohol or drug withdrawal in a timely manner, identify the level of care required, and manage or comanage the patient with the primary requesting service.
Perform a rapid, efficient, and targeted physical examination to assess for alcohol or drug withdrawal and determine whether life-threatening comorbidities are present.
Assess for common comorbidities in patients with a history of alcohol and drug use.
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.
Diagnose oversedation and other complications associated with withdrawal therapies.
Recommend the use of restraints and direct observation to ensure patient safety when appropriate.
Reassure, reorient, and frequently monitor patients in a calm environment.
Use the acute hospitalization as an opportunity to counsel patients about abstinence, recovery, and the medical risks of drug and alcohol use.
Initiate preventive measures before discharge, including alcohol and drug cessation measures.
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.
Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transition of care.
Hospitalists should be able to:
Employ a multidisciplinary approach, which may include psychiatry, pharmacy, nursing, and social services, in the treatment of patients with substance use or dependency.
Follow evidence-based national recommendations to guide diagnosis, monitoring, and treatment of withdrawal symptoms.
Act in a nonjudgmental manner when managing the hospitalized patient with substance use.
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.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Lead, coordinate, and/or participate in multidisciplinary teams, which may include psychiatry and toxicology, to improve patient safety and management strategies for patients with substance abuse.
Lead, coordinate, and/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.
Establish relationships with and develop knowledge of community-based organizations that provide support to patients with substance use disorders.
Promote awareness of substance use disorders and screening for them.
Coordinate initiatives to address the increased risk of readmissions associated with substance and polysubstance abuse.