From the Guidelines
The priority in management at today's visit is instructing the patient to stop driving (D). This patient with a seizure disorder is experiencing daily seizures, which poses an immediate safety risk to herself and others while operating a vehicle, as highlighted in the recent clinical policy by the American College of Emergency Physicians 1. The fact that she is currently driving children to school and a neighbor to hospital appointments makes this intervention particularly urgent. Most states have laws prohibiting driving for individuals with uncontrolled seizures until they have been seizure-free for a specific period (typically 3-12 months). While addressing her alcohol consumption (which may be contributing to her seizure breakthrough by interfering with phenobarbital metabolism) and evaluating for depression are important, the immediate safety concern of preventing potential harm from a seizure while driving takes precedence. The physician should explain this restriction compassionately, acknowledging the financial impact, but emphasizing that it's temporary until seizure control is reestablished. Alternative transportation options should be discussed, and documentation of this counseling should be included in the medical record.
Some key points to consider in this case include:
- The patient's daily seizures pose a significant risk to herself and others while driving
- The patient's alcohol consumption may be contributing to her seizure breakthrough
- Evaluating for depression and addressing alcohol consumption are important, but secondary to the immediate safety concern of driving
- The physician should emphasize the temporary nature of the driving restriction and discuss alternative transportation options.
Given the recent clinical policy by the American College of Emergency Physicians 1, the focus should be on prioritizing the patient's safety and the safety of others, making instructing the patient to stop driving (D) the most appropriate course of action.
From the FDA Drug Label
DRUG ABUSE AND DEPENDENCE Phenobarbital Sodium Injection is a Schedule IV controlled substance. Barbiturates may be habit forming. Tolerance and psychological dependence and physical dependence may occur especially following prolonged use of high doses of barbiturates The lethal dose of a barbiturate is far less if alcohol is also ingested.
The patient is taking phenobarbital and has been drinking two beers daily. The priority in management at today's visit is to instruct the patient to stop driving, as the combination of phenobarbital and alcohol can increase the risk of accidents and harm to herself and others. 2
From the Research
Patient Management
The patient's history of seizure disorder, borderline hypertension, and alcohol abuse, as well as her current medication regimen, must be considered when determining the priority in management at today's visit.
- The patient's daily seizures for the past 3 weeks, despite adhering to her medication regimen, suggest that her current treatment may not be effective.
- Her history of alcohol abuse and recent increase in alcohol consumption may be contributing to her seizures.
- The patient's occupation as a driver for her neighbors' children and another neighbor to hospital appointments raises concerns about her ability to safely operate a vehicle.
Priority in Management
Given the patient's complex medical history and current situation, the priority in management at today's visit is:
- Instructing the patient to stop driving, as her seizures and alcohol consumption pose a significant risk to herself and others on the road 3.
- Evaluating the patient's ability/desire to stop drinking alcoholic beverages, as alcohol abuse is a significant contributor to her seizures and overall health 4, 5, 6.
- Discussing a new treatment regimen for the patient's seizure disorders may be necessary, but it is not the priority at this visit.
- Evaluating the patient for depressive disorder may be relevant, given her history of phenobarbital use and the potential for depression associated with this medication 7.