Suicidal thoughts are unassailable grounds for comprehensive evaluation and treatment—regardless of the suicide evaluation’s outcome. The addict who even hints at suicide should undergo a thorough medical and psychiatric evaluation and then engage in whatever treatment is indicated.
Emphasize the seriousness of suicidal thoughts to the patient, his family, third-party payers, and whomever else has influence in bringing the patient to treatment. Suicidal behaviors or intentions remain one of the few legal justifications for involuntary hospitalization.
Accidental overdose
An accidental overdose provides another teachable moment to convince the addict to enter treatment. Patients who try to make a statement by overdosing on a substance they consider benign, such as oxycodone with acetaminophen, can inadvertently kill or badly injure themselves. Conversely, patients who clearly intend to harm themselves may misconstrue a substance’s lethality and ingest a large amount of a relatively nonlethal substance such as clonazepam. Either case:
- is a true psychiatric emergency
- bodes poorly for the patient’s future
- provides a strong rationale for addiction treatment.
Whether the means or the intent were deadly or benign, the overdose can be used as a convincing argument for treatment.
Intoxication
Intoxication with any addictive substance impairs judgment and increases the danger of injury. Specific medical dangers include alcohol’s powerful CNS depression in the nontolerant individual and the possibility for heart attack and stroke in the cocaine-intoxicated patient.
Attempts to convince an intoxicated person of the need for addiction treatment are usually futile. But the acute treatment represents a golden opportunity to reach out to friends and family members, who often escort the intoxicated addict to the emergency room. A medical record documenting the patient’s impaired behavior serves as evidence for (later) convincing the addict to go into treatment or for legal coercion of that treatment.
Table 2
MANAGING SYMPTOMS OF ALCOHOL WITHDRAWAL AND DELIRIUM TREMENS
| Alcohol withdrawal | Delirium tremens |
|---|---|
| Begins 4 hours to 2 days after cessation of alcohol or precipitous drop in blood alcohol level | Begins 1 to 2 days after cessation of alcohol or precipitous drop in blood alcohol level |
| Symptoms | Symptoms |
| Anxiety Agitation Tremor Autonomic instability Insomnia Confusion | Agitation Severe autonomic instability Seizure Severe confusion Hallucinations |
| Treatment Treatment of co-occurring medical illness Parenteral thiamine Tapering doses of CNS depressants, most often benzodiazepines | |
Withdrawal
Withdrawal, like intoxication, presents emergency conditions specific to the abused substance. Unlike the intoxicated patient, however, a patient experiencing the unpleasant symptoms of withdrawal may understand the need for addiction treatment. Because alcohol withdrawal often requires sedative/hypnotic treatment, the wise clinician can design a treatment plan that combines the anti-withdrawal medication with:
- attending Alcoholics Anonymous meetings
- taking disulfiram 12 hours after the last alcohol use and then daily
- and participation in relapse prevention psychotherapy.
Emergency treatments
Psychiatrists often have close contact with addicted patients in the hospital, clinic, or emergency department and therefore need to be familiar with basic techniques for managing addiction emergencies. Although addiction-trained psychiatrists manage emergencies at many institutions, general psychiatrists who have learned the following guidelines can form quick and solid therapeutic alliances with their addicted patients in the emergency department.
Alcohol
People live dangerously when intoxicated; about 40% of fatal U.S. car accidents involve a drunken driver.9 Alcohol also can incite physical violence and self-damaging sexual behavior and cause respiratory depression and death.
Acute effects of alcohol intoxication must be treated while guarding against potentially lethal withdrawal. Dangerous intoxication states with respiratory compromise may require aggressive supportive care, including intubation and mechanical ventilation. For agitated, intoxicated persons who represent a threat to themselves or others, chemical sedation with benzodiazepines—as opposed to physical restraint—is the preferred treatment.
Alcohol withdrawal requires immediate, definitive treatment (Table 2). Although mild withdrawal is common among alcoholics who cut back on or abruptly stop drinking, it can devolve quickly into delirium tremens (DTs). Serious medical problems—including severe autonomic instability and seizures—occur with DTs, which are associated with mortality rates of 5 to 15%.10 The adroit emergency department clinician can use the alcohol withdrawal/delirium episode to encourage the patient to begin addiction treatment (Box 2).11
Cocaine
Stimulants—most commonly cocaine and smoked methamphetamine—can cause myocardial infarction, cardiac arrhythmia, cerebral hemorrhage, hyperpyrexia, and status epilepticus.12 These emergencies occurring in a young person indicate the need to screen for cocaine use. Because no antidote exists for stimulant intoxication, we can only deliver supportive care while remaining vigilant for other sequelae of stimulant use, such as agitation and hypertension.13
Opiates
Overdoses leading to coma and death are the most devastating physical consequence of opiate abuse. Contrary to popular belief, orally ingested and inhaled opiates can depress respiration enough to cause death, just as injected opiates can. Because even appropriately prescribed opioid medications can lead to overdose or addiction, emergency treaters should be prepared to refer patients for pain management.