What is the best approach for managing a patient with alcohol use disorder in the emergency room?

Emergency Department Management of Alcohol Use Disorder

Immediately screen for alcohol withdrawal syndrome and treat with benzodiazepines if present, provide thiamine supplementation, then implement brief motivational intervention and initiate pharmacotherapy with naltrexone before discharge, while arranging outpatient addiction specialist follow-up. 1, 2

Immediate Assessment Priorities

Screen for Alcohol Withdrawal Syndrome

• Assess for withdrawal symptoms within 6-24 hours of last drink: elevated blood pressure and pulse, tremors, hyperreflexia, irritability, anxiety, headache, nausea, and vomiting. 1
• Recognize that symptoms can progress to severe forms including delirium tremens, seizures, coma, cardiac arrest, and death. 1
• Monitor vital signs continuously in patients showing any withdrawal symptoms. 3

Administer Thiamine Immediately

• Provide thiamine 100-300 mg/day before any glucose-containing IV fluids to prevent Wernicke encephalopathy. 2, 4
• This is mandatory and must precede glucose administration. 4

Treat Withdrawal with Benzodiazepines

• Benzodiazepines are the gold standard treatment for alcohol withdrawal syndrome, reducing both withdrawal symptoms and risk of seizures and delirium tremens. 1, 2
• Use short or intermediate-acting benzodiazepines (lorazepam, oxazepam) as they are safer in patients with potential hepatic dysfunction. 1
• Long-acting benzodiazepines (diazepam, chlordiazepoxide) provide more protection against seizures but should be avoided if liver disease is suspected. 1

Screening for Alcohol Use Disorder Severity

Use Validated Screening Tools

• Administer the AUDIT (Alcohol Use Disorders Identification Test) as the gold standard screening tool. 1, 2, 5
• Scores ≥8 for men or ≥4 for women indicate positive screening requiring intervention. 1, 5
• The AUDIT-C is a suitable shorter alternative for rapid ED screening. 6

Assess for Psychiatric Comorbidities

• Screen for anxiety disorders, affective disorders, depression, and PTSD, as up to 50% of patients with alcohol use disorder have concurrent psychiatric conditions. 1, 5
• Distinguish between independent disorders (requiring specific treatment) and concurrent disorders (may resolve with abstinence). 1
• Screen for intimate partner violence, as rates exceed 50% in patients with alcohol use disorders in some settings. 1
• Assess for nicotine dependence, as up to 80% of patients with alcohol use disorder are heavy smokers. 1, 5

Brief Intervention in the Emergency Department

Implement FRAMES Model

Deliver a brief motivational intervention using the FRAMES model (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy), which has proven efficacy in reducing alcohol consumption and related morbidity and mortality. 2, 5

Key components:

• Provide feedback about drinking dangers and health risks. 2
• Emphasize patient responsibility and autonomy in decision-making. 2
• Give clear advice about reducing or stopping alcohol use. 2
• Offer a menu of treatment options. 2
• Express empathy and create a destigmatizing environment. 2, 7
• Enhance self-efficacy and confidence in ability to change. 2

Address Barriers to Treatment Acceptance

• Rapidly manage withdrawal symptoms, as this facilitates treatment acceptance. 7
• Create positive, non-judgmental interactions that destigmatize the patient's condition. 7
• Acknowledge if patient uses alcohol as self-treatment for psychiatric trauma or physical pain, and address these concerns. 7

Pharmacotherapy Initiation in the Emergency Department

For Patients WITHOUT Advanced Liver Disease

Initiate naltrexone 50 mg daily before discharge, as it reduces relapse to heavy drinking and drinking frequency. 1, 2, 5

• Naltrexone reduces the likelihood of return to any drinking by 5% and binge-drinking risk by 10%. 2
• Offer choice between intramuscular and oral formulations, as patient preference improves acceptance. 7
• Avoid naltrexone in patients with suspected or confirmed alcoholic liver disease due to hepatotoxicity risk. 4, 5

For Patients WITH Advanced Liver Disease

Use baclofen instead of naltrexone, titrated up to 80 mg/day over 12 weeks, as it is safe and effective for preventing alcohol relapse in advanced alcoholic liver disease. 2, 4, 5

• Baclofen does not carry hepatotoxicity risk. 2, 4
• Avoid naltrexone and acamprosate in patients with advanced liver disease due to potential side effects. 2

Assess Liver Function

• Obtain baseline liver function tests to determine medication safety. 4
• Look for signs of hepatic dysfunction: jaundice, ascites, hepatomegaly, spider angiomata. 1

Critical Medication Contraindications

Avoid Acetaminophen

Never use acetaminophen or combination opioid-acetaminophen products in patients with alcohol use disorder due to significant hepatotoxicity risk. 4

Avoid NSAIDs

NSAIDs must be avoided or used with extreme caution due to multiple high-risk factors including GI bleeding, renal dysfunction, and hepatotoxicity. 4

Discharge Planning and Follow-Up

Arrange Addiction Specialist Referral

• Connect patients to outpatient addiction specialists (psychiatrists, psychologists, social workers) for continued treatment. 1
• Provide information about local treatment resources using SAMHSA Treatment Locator. 1
• Arrange follow-up within 1-3 months to assess progress. 4, 5

Encourage Mutual Help Groups

Actively encourage engagement with Alcoholics Anonymous or SMART Recovery, which have demonstrated 50% abstinence rates at one year. 2, 5, 6

• Peer-led support programs are effective at maintaining abstinence or reductions in drinking. 6

Provide Treatment Options Information

• Outpatient treatment for patients with stable living environments includes group and individual counseling plus pharmacotherapy. 1
• Residential treatment for patients needing stable environment or with severe addiction and comorbidities. 1

Special Considerations

Pain Management

• Prioritize nonpharmacologic interventions for pain management. 4
• Opioid analgesics are safe alternatives to NSAIDs in this population if pain medication is necessary. 4

Observation Unit Utilization

• Patients with acute alcohol intoxication are ideal candidates for ED observation units, as clinical course is often completed within 24 hours with favorable outcomes. 3
• This approach reduces unnecessary hospitalizations while ensuring safe monitoring. 3

Common Pitfalls to Avoid

• Never give glucose-containing IV fluids before thiamine administration. 4
• Never rely on pharmacotherapy alone; psychosocial interventions are equally essential. 2, 4
• Never use disulfiram in the ED setting; it should only be used in supervised settings with highly motivated patients. 2
• Ensure ED providers are knowledgeable about naltrexone and treatment options, as lack of provider knowledge is a significant barrier to treatment acceptance. 7