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The social, psychological and medical management of intoxication
Joumol of Substance Abuse Treatment. Vol. Printed in the USA. All rights reserved.
ORIGINAL
1, pp. 1l-19,
0740-5472/84S3.00 + .OO Copyright o 1984Pergamon PressLtd
1984
CONTRIBUTION
The Social, Psychological and Medical Management of Intoxication ANNE GELLER, MD St. Luke’s_Roosevelt
Hospital, New York
Abstract- Intoxicated persons appear frequently in substance abuse centers and in general hospital settings. The severity of their condition mnges from mild impaimzent to coma or delirium. The prominent features of intoxication with the nqjor classes of abused drugs are described. Staff responses to intoxication are discussed. Guidelines are presented for systematic management of this condition.
Keywords-
Intoxication,
drugs, alcohol, management, treatment
CLINICAL
INTRODUCTION THE INTOXICATED PATIENT is a standard feature in hospital settings and substance abuse treatment centers. Common as this problem is, it is rare to find consistent, coherent guidelines for dealing with it. Responses to intoxicated behavior range from anxiety or amusement to rage or ridicule. Little attempt is usually made to gauge how these responses may influence subsequent treatment and disposition. Still less frequently are there systematic efforts to train staff to behave in consistent and appropriate ways towards intoxicated patients and to recognize and change their non therapeutic responses. In most texts heavy emphasis is placed on the emergency medical management of crises arising from substance abuse with little discussion of the more frequently occurring problem of dealing with the intoxicated patient whose situation is not immediately life threatening. This article will attempt to redress the balance. The clinical picture of intoxication will be presented in a continuum from mild impairment to coma and delirium. Staff responses to the intoxicated patient will be analyzed. Guidelines will be suggested for management of all stages. These will include specific medical interventions when ap propriate.
PRESENTATION
First, it is necessary to describe the signs and symp toms of intoxication with various drugs, and to do this, it is easiest to deal with broad drug categories. A word of caution is in order here. Even the most experienced observer can have difficulty determining the drug that has been used from the behavior of the user alone. The final pathways for expression of intoxication can be similar for different kinds of drugs. Many abusers are using more than one. An odor of alcohol or a pill in the pocket does not mean that this is the only culprit. Drugs purchased on the street may be anything but the name they are sold under, limited only by the ingenuity of the seller and the credulity of the buyer. Substances are used to bring about some desired changes in the nervous system, usually euphoria. At low doses the effects on function and behavior may be slight. Intoxication is reached when functioning is significantly interfered with and behavior becomes maladaptive. Depending upon the substance used, further ingestion may result in coma or delirium. The specific picture depends upon the abused substance but the most frequent changes are in judgement, emotional control, logical thinking, memory, attention, state of alertness, and coordination. How rapidly one becomes intoxicated and how long it lasts depends upon the drug, the individual and the general environment. Drug factors include the type of drug, the amount ingested, the rapidity with which it gets into the brain, and its duration of
Requests for reprints should be sent to Dr. Anne Geller, St. Luke’sRoosevelt Hospital, 428 West 59th Street, New York, NY 10019.
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A. Gelier
12 action (half life). Individual factors are weight, age, sex, state of nutrition, and tolerance to the drug. Environmental factors may influence the kind of behaviors observed and may shorten or extend the duration of these behaviors to the extent that they can be voluntarily controlled. Providing an environment that will permit maximum achievable voluntary control is one of the goals of intoxication management. With any intoxicated person, it is hard to judge during a short period of observation whether the disruption of the nervous system is getting progressively worse, has plateaued or is improving. Sedative Hypnotics Sedative hypnotics cause progressive depression of central nervous system function. After the initial increase in psychomotor activity, there is a decline in cognitive and motor efficiency. Judgement is impaired and behavior may be inappropriate. The ability to think and reason logically is impaired. Ongoing memory is also affected so that instructions may be partly or completely forgotten. Attention span is short. There are easily provoked emotional changes and irritability so that the person may be euphoric and expansive at one moment, angry and combative at the next. Excessive talking is a frequent feature, though if depression is the prevailing emotion, there may be moaning and crying. Physical signs include flushed face, general loss of coordination such as slurred speech, clumsiness or unsteady gait and nystagmus. With increasing doses there is a progressive loss of alertness with stupor, coma and finally death. A person who has acquired tolerance to a sedative hypnotic drug may not appear intoxicated at all at drug levels which would produce gross intoxication in an inexperienced user. Tolerance does not occur to all actions of the drug to the same extent. Of particular importance with the sedative hypnotics is that the center responsible for maintaining respiration does not develop the same tolerance as those serving motor coordination. A highly tolerant person appearing only slightly intoxicated may not require much more drug to affect respiration. Another phenomenon to be aware of with sedative hypnotics is the blackout. A person intoxicated with one of these drugs may be in the midst of a blackout. He may be walking and talking but not recording. If he is sent somewhere on his own he will not remember where he is supposed to go. He certainly won’t remember an appointment given for the following day. Opioids With opioid use the initial effects are usually euphoria and a calm dreamy state. With increasing dosage there is increasing lethargy with all move-
ments slowed down and with attention diminished. There may also be slurred speech and memory difficulty, though cognitive impairments are not usually as pronounced as with the sedative hypnotics. The major physical sign is constricted pupils. In severe intoxication, though, the pupils may dilate because of reduced oxygen supply to the brain. Intoxication progresses, with increasing difficulty in arousal, coma, and death. Opioid drugs produce significant respiratory depression, which constitutes the major hazard of their use. Even in doses too small to produce sleep or disturb consciousness, there is measurable slowing of respiration. This depression is at its maximum 7 minutes after intravenous morphine, 30 minutes after intramuscular and 90 minutes after subcutaneous use. Respiration begins to return to normal after 2-3 hours. In contrast to the situation with sedatives, with opioid drugs remarkable tolerance does develop to the respiratory depressant effects. Users of street drugs however do not know the dose of the drug they have received for a given amount of money. This can be quite variable. Overdoses with respiratory depression can occur in individuals who have not changed their drug use pattern but who have unexpectedly received a sample from a purer shipment. It should be noted that tolerance does not develop to the pupillary constriction effect of opioids which can thus be observed even in a tolerant user. Medical personnel who are opioid abusers have been known to use pupillary dilators to counteract this effect. Stimulants Initial effects from stimulant use are feelings of euphoria, powerfulness and self-confidence. Physical activity is usually increased. The user feels highly alert and mentally sharp. With increasing doses, the euphoria becomes elation; the self-confidence, grandiosity; the increased activity, agitation; and the alertness, hypervigilance. Rapid pressured speech is often present. There may be paranoid delusions and hallucinations. The hallucinations can be in any sphere but frequently are tactile. These can take the form of strange skin sensations such as a feeling there are small animals under the skin. With short-acting stimulants such as cocaine, these psychotic symptoms are transient; however, with longer acting drugs they may develop into delirium. In the delirious state, the mind becomes clouded, thinking is disordered, and attention wanders. The individual cannot maintain contact with another person. Speech is disjointed and irrelevant. The delusions and hallucinations persist and appear real. The accompanying physical signs are dilated
I3
Management of Intoxication pupils, rapid heart rate, increased blood pressure, and perspiration or chills. With higher doses there may be chest pain or seizures. Death can occur from respiratory paralysis or cardiac arrythmias. Tolerance to the euphorigenic and cardiovascular effects of stimulant drugs develops rapidly. Tolerance does not develop to the psychotic effects in chronic users. There may be a striking paucity of sympathomimetic effects accompanying a dramatic toxic psychosis. Psychedelics (Hallucinogens) This is a mixed bag of drugs that includes cannabis and lysergic acid diethylamide. Illusions, hallucinations, and delusions can also be produced on occasions by other classses of drugs, particularly stimulants (as above) and anticholinergics (see below). Hallucinogens, however, characteristically produce altered states which, if intensified can result in persistent hallucinations accompanied by anxiety, depression, paranoia and fear of losing one’s mind. The user is fully alert, Physical signs can be dilated pupils, increased heart rate, sweating, blurred vision, tremors, and loss of coordination. With cannabis, actual hallucinations are rare. Intoxication is manifested by euphoria, apathy, and altered perceptions including a slowing down. Physically, there may be reddened conjunctiva, increased appetitie, and dry mouth. Panic attacks, particularly with inexperienced users, are fairly common. In panic state due to hallucinogens, the patient is fully alert but fears that he or she is going crazy. There may be preoccupation with the possibility of brain damage or the user may be convinced that he or she is having a heart attack. Along with other symptoms of anxiety, hyperventillation may be present. Phencyclidine (PCP) This drug is considered separately because it has complex actions which include (a) sedative effects; (b) analgesic effects; (c) hallucinogenic effects; (d) adrenergic (stimulant-like effects); and (e) choline@ (vomiting and salivation) effects. There is (perhaps more so than with other drugs) individual variability. PCP is also a frequent unadvertized component mixture purporting to be other drugs (e.g., THC). In low doses the patient looks intoxicted, has ataxia, and nystagmus. He may be agitated, fearful or hostile, or may sit with a blank stare in a catatonic-like stupor. Physically, there may be vertigo, skin flushing, nausea, drooling, and vomiting. Reflexes are increased. Blood pressure is elevated. In higher doses, a
coma-like state with open eyes, decreased pain perception, waxing and waning excitation, and body rigidity may be accompanied by seizures. Over-the-Counter Drugs, Anticholinergic Antihistaminic, Non-Prescription Stimulants, Pseudo Speed These drugs have widespread use, especially among younger people. Since they are cheap and easily obtainable, they may be found masquerading as other desirable and expensive drugs. Antihistamines may be used deliberately in conjunction with another drug to produce an enhanced effect - e.g., “T’s and Blues” Pentazocine (Talwin) and Tripelannamine (Pyribenzamine). Intoxication with anticholinergics (scopolamounts of phenylpropanolamine hydrochloride, weed, deadly nightshade- produces confusion, blurred vision, headache, dry mouth, and increased heart rate. Antihistamines generally produce depression of the central nervous system with effects similar to those of sedatives hypnotics. However, stimulant effects are also seen with some antihistamines and at some doses. Over-the-counter stimulants contain varying amounts of phenylpropanolamine hydrochloride, caffeine and ephedrine. Symptoms of intoxication are similar to those from amphetamines and include a range from wild anxiety to agitation and hallucinations accompanied by increased pulse rate, blood pressure and respiration. Inhalants, Gases and Solvents This mixed group of substances includes glues, cleaning solutions, nail polish removers, paint thinners, aerosols and other petroleum products. They are generally central nervous system depressants producing lightheadedness, misperceptions, clouding of thoughts, and drowsiness. These can progress to stupor and coma. Physical effects include irritation around the eyes, nose and mouth, nausea, vomiting, double vision, ringing in the ears, and skin rashes. Dangerous cardiac arrythmias can occur. General Symptoms The common feature of most intoxication is loss of impulse control, loss of attention, and loss of the ability to behave in a socially appropriate fashion. This results in behaviors that are unpredictable, possibly dangerous and certainly are extremely frustrating. An intoxicated person may not be able to pay attention long enough to understand what is being said. He may be so preoccupied with his own disordered thoughts that he cannot be diverted from them. His state of alertness may be fluctuating so
14 that he apparently cooperates at one moment and is out of contact the next. It is difficult not to see this as willful and, indeed, sometimes it is. Very frequently, intoxication causes a severe deficit in short-term memory, so that instructions apparently received and understood are very swiftly forgotten. It is hard not to see this as willful, too. Sometimes an intense emotional state predominates and persists. When this is anger, it can result in hostility, uncooperativeness, verbal and physical violence. Particularly when the anger is directed towards oneself it is difficult not to respond to it. Response of Staff Clinical staff as a general rule do not handle intoxication well. The reasons for this are easy to understand. It is not pleasant. It is not easy. It is time consuming. It is frequently unrewarding. In some clinical settings it is taking staff time away from patients who are clearly physically sick. In drug and alcohol programs, it is often a sign of treatment failure or of violation of rules. Staff members themselves often experience intense reactions toward intoxicated patients. Sometimes these are a direct result of the patient’s behavior, for example, fear in the presence of potential violence. Sometimes, however, these reactions are due to feelings and attitudes about drug use, drug users, intoxication and being out of control. These come about as a result of the staff member’s personal experience and social attitudes. The particular behavior of a particular patient only acts as a trigger to release those complex feelings. Of course, well-trained clinical personnel do not allow themselves to express these feelings overtly. They will, however, experience strain in maintaining an appropriate therapeutic attitude. Unless the staff member has identified and recognized these feelings in himself and has a clear procedure to follow, these feelings will find expression in covert ways, not usually helpful to the patient. Feelings and Attitudes in Staff Personal Experience with Drugs. Many people working in drug and alcohol treatment have had experience of substance abuse themselves or in a close family member. Treating the sick patient in withdrawal or helping the sober patient to restructure his life can be immensely gratifying. Intoxication, though, evokes painful, fearful, sometimes even pleasurable memories of the past. Furthermore, the treatment skills that have been learned do not work for intoxicated patients. Intoxication is a stage to be passed through before treatment can begin. The staff member therefore finds himself with mixed feelings toward a patient he cannot at present help.
A. Geller
They Did It To Themselves. It is much easier to understand and empathize with compulsive drug use when it is being reconstructed in historical fashion in a therapetic session than when it is right before you with all its disagreeable manifestations. Staff in emergency rooms and general hospital wards generally have trouble dealing with self-inflicted conditions without being self-righteous or dismissive. But even substance abuse staff may have feelings of anger or disgust when a patient is intoxicated. With intoxication one sees the voluntary aspect of the drug use: “He took the drug. No one forced him. Now he is in this state and I have to deal with it.” Treatment Failure. All substance abuse staff understand intellectually that they are dealing with a relapsing condition. When an actual relapse occurs though, it is often hard to maintain the appropriate philosophical distance. An intoxicated patient who has relapsed causes a number of feelings among staff; anger that he has let them down; feelings of inadequacy that he has failed; feelings of anxiety that other patients will be affected. Intoxicated Behavior. We are accustomed to generalize about characterological traits based on observed behavior. We also make judgements about individuals based on their behavior. Intoxicated behavior is a consequence of a drug or drugs acting on the brain. It may bear little relationship to sober behavior. Even knowing this, when confronted with a person actually behaving in various nasty ways toward us, it is difficult not to apply the customary generalization procedures and conclude that this is a person with a nasty predisposition. The attitudes of hospital staff toward substance abusing patients is often derived in part from generalizations made from the behavior observed when intoxicated. Consequences of Disordered Cognitive Functions. Inability to concentrate, inability to understand and inability to remember may be seen as uncooperativeness. Euphoria, silliness, jokiness, loquacity, inability to stick to the point or to take anything seriously are very irritating if one believes that this is under conscious control, less so if one understands that it is part of a drug-induced disorder. Loss of Control. By definition an intoxicated person has lost control. Loss of control is frightening to contemplate in ourselves and alarming to see in others. Even if there is no danger of violence, the feeling that the intoxicated person cannot be fully reached and cannot be relied upon to behave reasonably makes us uneasy. All of the techniques used with sober patients don’t work here.
I5
Management of Intoxication Uncooperativeness. The relationship between health professional and patient has a number of unstated understandings. Important among them is the understanding that both are working toward improvement in the patient’s condition. Uncooperativeness on the part of the patient is a rejection of this alliance. It leaves the staff member with only unsatisfactory alternatives: coercion, in many circumstances illegal and never pleasant; persuasion, often too time consuming and of uncertain outcome; dismissal with a sense of therapeutic failure. AU animals have innate or very early acquired reactions to threats directed at themselves. Humans are no exception. Hostility provokes anger or fear and a desire to retaliate or run away. These feelings will be present as long as any personal threat is perceived. When patient behavior is completely out of control, staff behavior is often more relaxed and organized since the threat is now impersonal and, in addition, routines have been well established for dealing with these extreme circumstances.
Hostility.
enormously from center to center depending upon the availability of medical staff, the proximity of a general hospital and emergency room and the geographical and social setting of the center. They will also vary from unit to unit within the same center. Both policies and procedures may be different in an outpatient component than in an inpatient rehabilitation unit. The procedures should be understood by staff and transmitted to patients entering treatment. Having clear guidelines relieves much of the anxiety and uncertainty connected with intoxication. It also relieves the sense of helplessness which many staff members experience. Procedures should be as explicit and detailed as possible without putting unnecessary constraints on staff. Procedures for Dealing with Violent Behavior. The
procedures for dealing with verbal and physical violence should be written and be a part of the procedures for intoxicated behavior. The security system should be well organized and responsive. Staff who are seeing patients individually in offices should be equipped with a buzzer or equivalent to summon help when needed.
General Procedures for intoxicated Patients
Intoxicated patients will appear in substance abuse centers. There are a number of general preparations which can be made. Staff Preparation. Regular staff meetings, at least one a year, should be held around the issue of the intoxicated patient. It is important that staff members can identify their own reactions to intoxicated patients and that the universality of these responses be acknowledged. Expectations regarding staff behavior can be restated at these meetings. Policies and procedures should also be discussed. Policies for Dealing with Intoxicated Patients. Any
substance abuse center must have clear policies for the intoxicated patient in all of its units. These policies must be understood by staff and by patients. In some centers intoxication results in dismissal from the program, in some two or three instances are permitted. In other centers no penalties are attached to intoxication except that the patient cannot attend therapeutic activities until sober. In yet others, intoxicated patients are pemitted to reman in treatment provided they are not disruptive. The merits of these various approaches are not going to be discussed here. Whatever the policy, it must be clear, consistent, understood and in writing. Procedures for Dealing with Intoxicated
Patients.
Each unit of a substance abuse treatment center should have clearly written procedures for dealing with intoxicated patients. These procedures will vary
General Clinical Guidelines for Social Management
These guidelines refer to the intoxicated patient only. If the clinical picture has deteriorated to delirium, stupor or coma, then procedures for emergency medical assistance must be instituted immediately. The medical management of these states will be discussed in a later section. The patient described here as intoxicated is able to respond to questions and to remain awake even if somewhat drowsy. If the picture is one of central nervous excitation, the patient, though agitated and perhaps hallucinating, is in sufficient contact with the environment to be able to respond to questions and to follow simple instructions. The general goals are to obtain sufficient information from the patient to make an appropriate treatment plan, to ensure that the treatment plan is initiated and to do this with minimal disruption. For this to occur, it is necessary to secure the patient’s cooperation and to work toward the strongest alliance of which the patient is capable at this time. Here are some simple guidelines. 1. fl there is any potential for violence, do not interview the patient alone and do avoid any argument. Ask the patient to be seated. If you are alone with a patient showing high agitation, be alert to danger signals, sweating, talkativeness and do not hesitate to leave the room to obtain help. 2. Provide a calm reassuring atmosphere. Maintain eye contact. Maintain a relaxed posture. Don’t leave patient alone (except #I).
A. Geller
3. Provide information and structure. Give the patient your name. Explain simply what you are going to do. Use the patient’s name. 4. Communicate clearly and simply. Ask short direct questions, one at a time. Listen to responses. Be prepared to tolerate some repetition. 5. Be positive in your responses. If the patient says “I have to get into a hospital now,” don’t say, “No, you can’t just walk into a hospital.” Say “Yes, but first you have to give me some information about yourself.” 6. Establish a spec~flc contract. With patients who are already in treatment, the contract regarding intoxication will have been made. It should be repeated specifically and firmly. Again, as in number 5, if the patient is being told he cannot come to group treatment today the emphasis should be that he can come to treatment tomorrow if he is sober. With an intoxicated patient wanting to enter into treatment who is fussing about the examination, the contract might be “The faster I can get information about you the sooner you will get into treatment.” Specific Circumstances There are a number of specific circumstances in which an intoxicated person may appear in a substance abuse treatment center. When the person is already in treatment at the center a contract should have been made regarding the procedures to be followed in the case of intoxication. These procedures should also include an immediate disposition if the patient is not to be retained at the center. Ideally, a center should be equipped with a room where an intoxicated patient can be observed without disrupting staff and other patients. A period of observation is necessary to ensure that the clinical picture is not deteriorating and to gather data in order to make a disposition. All outpatient centers are likely to encounter intoxicated persons who have come in off the street without appointments whether the center operates a walk-in service or does not. These situations should be anticipated. The staff should have procedures and practiced routines to follow in the case of emergencies. In general hospital settings, substance abuse staff may be called to consult on patients who become intoxicated while in the hospital being treated for medical or surgical conditions. The clinical staff treating the patient are this point usually frustrated, angry and disgusted. They resent the time being spent on this non-medical condition which is taken from “really sick” patients elsewhere. The principles in-
volved in dealing with these patients are the same as outlined above. However, the best approach is for inservice training for the staffs on the units where this occurs and the establishment of clearly written protocols for dealing with the situation when it arises. Medical Management There are, however, situations in which medical examination is essential. 1. Where the patient’s condition is deteriorating. 2. Where the patient is semi-comatose, i.e., can be awakened and responds briefly but falls asleep when stimulus is removed. 3. Where the patient is comatose, i.e., cannot be aroused to consciousness by any stimuli. 4. Where the patient is delirious, i.e., is disoriented, incoherent, and may be delusional or hallucinating. 5. Where the patient is psychotic, i.e., is delusional or hallucinating. 6. Where the patient is extremely agitated, i.e., cannot be quieted by any of the methods outlined above. 7. Where the patient is suicidal. 8. Where the patient claims to have ingested a large quantity of drugs. 9. Where there is a history of or signs of trauma, particularly head trauma. 10. Where there is a convulsion. Physician will encounter intoxicated patients frequently in hospital settings and, more rarely, in private offices. Even physically dependent patients will, if possible, refrain from drug use prior to a physician appointment. Symptoms of withdrawal are a more common occurrence in a private office than are symptoms of intoxication. The guidelines discussed above are appropriate for all uncomplicated intoxications. Basically the patient is provided with clear, simple communication in an environment which is supportive and nonthreatening. Therapeutic interventions, especially medications, are kept to a minimum. Patients who are panicked, agitated, extremely fearful or anxious as part of their intoxication are frequently overmedicated with sedative drugs by hospital personnel. Taking the time to speak calmly and reassuringly to the patient can produce a marked improvement. Giving sedative drugs which diminish inhibition can, on the other hand, cause more problems. There should be a quiet room where the patient can be observed until his condition improves. When the drug abusing patient presents as a medical emergency (l- 10 above) it is often not possible to obtain a reliable history. The patient may be too confused or out of contact to give information. The drug or drugs used and the dosage may not be
17
Management of Intoxication known or, even worse, the patient himself may be misinformed about what he has taken. The severity of the intoxication may be assessed by determining: 1. Is patient awake and can answer questions? If not, 2. Does patient withdraw from pain? If not, 3. Are tendon reflexes present? Also, 4. Is respiration impaired? 5. Are pulse rate, blood pressure, skin color abnormal? 6. What is state of pupils? Medical management must first address any life threatening problems which might arise in a patient where intoxication has progressed to semi-coma or delirium or where there are complicating factors. Emergency care begins then by ensuring that there is an adequate airway to prevent aspiration, supporting circulation, controlling hemorrhage and dealing with life threatening behaviors. Once the physical condition is stable, a thorough evaluation should be undertaken. This should include a history from the patient and anyone accompanying him, a general physical and neurological examination, baseline laboratory tests of blood and urine, and a toxicological screen. If there is any residual of the drugs that have been taken, this should be examined also. Further management of the patient will depend upon the specific condition and upon medical problems which have been identified; however, it is important first to do no harm. Keep medications to a minimum. Avoid restraints if possible. Perform gastric lavage only when indicated. Ensure that there is an adequate period of observation after regaining full consciousness (24 hours). Do not administer respiratory stimulant drugs. Sedative Hypnotics. All the central nervous system depressants produce a similar toxic state characterized by varying levels of anesthesia and decreased central nervous system, cardiac and respiratory functions. Pupils are usually midpoint, comeal, tendon reflexes depressed. Cardiac arrythmias may be present and lungs may be congested. 1. Establish clear airway. 2. Treat shock with iv fluids and vasopressor if indicated. 3. Carry out gastic lavage only if drug was taken in the last 4-6 hours and the patient is conscious. 4. Monitor vital functions, electrolytes and blood gases if indicated. 5. Avoid central nervous system stimulants. 6. Administer slowly 0.4 mg Naloxone (Narcan) iv to rule out concomitant narcotic overdose. Barbiturates.
Short-acting
barbiturates
may cause
cardiac arrythmias. Diuresis and alkalinization urine are helpful. Dialysis may be useful.
of the
Methaquafone. Methaqualone does not depress brain stem function to the same extent as other sedative hypnotics. For this reason intubation may be difficult as the gag reflex is intact. Methaqualone overdose may be present as delirium, hypertonia, and convulsions. Glutethimide and Ethehlorvynof. Both are fat soluble drugs and coma may be both protracted and fluctuating in intensity. Gastric lavage and dialysis are therefore more effective if performed with oil. Alcohol. Because of the large volume of alcohol required to produce coma in a tolerant user, people usually pass out before attaining sufficiently high blood concentration. Exceptions are inexperienced users, drinking for bets or hepatic damage. In a comatose patient smelling of alcohol, look for other causes such as: (a) other depressant drugs; (b) hypoglycemia or hyperlycemia; (c) trauma, skull fracture, subdural hematoma; (d) septicemia; (e) cardiac arrythmias; and/or (f) Wernickes encephaIopathy. The use of fructose solutions to speed the metabolism of alcohol carries risks of disturbed sugar metabolism, electrolytes, and’acid base balance that outweigh its benefits. Opioids. Depression of the central nervous system with constricted pupils is the classical picture of opioid overdose. (Constricted pupils can also be seen in barbiturate, ethanol and phenothiazine overdose.) As has been noted above dilation can occur in hypoxic states. Meperidine (Demerol) overdose can produce dilated pupils. Pulmonary edema may be present. Cardiac arrythmias and convulsions may be seen with codeine, propoxyphene (Darvon) and meperidine (Demerol). The basic procedures are as for the sedative hyp notic (l-6) 1. The administration of the narcotic antagonist naloxone 0.4 mg iv should result in rapid and dramatic response. If this does not occur, other causes for the patient’s condition should be investigated. 2. Antagonists are effective for about 2 hours and repeat doses may be necessary. (Heroin may remain active for 6 hours, methadone for 24. hours.) 3. The patient must be observed for at least 24 hours. Stimulants. Excessive doses of stimulants produce a clinical picture of a toxic agitated psychosis with
18 sympathetic nervous system overactivity. Increased heart rate, blood pressure and temperature can lead to cardiovascular or respiratory collapse. Convulsions and cerebrovascular accidents can occur. Treatment will depend on the symptomatology and may include respiratory and cardiac support. 1. Elevated body temperature must be treated aggressively with hypothermia. 2. Repeated seizures should be treated with iv diazepam (Valium) 5-20 mg injected very slowly and repeated in 15 minutes if indicated. 3. The urine may be acidified with ammonium chloride to promote excretion of the stimulant. 4. Marked agitation may be treated with haloperidol (Haldol). Phenothiazines should be avoided as they may retard the excretion of amphetamines. Panic reactions, flashbacks, and toxic reactions occur with these drugs and patients present in a frightened, agitated and hallucinated state. Physiologically there are signs of sympathetic stimulation. The toxic psychosis is often labile with the patient fluctuating from rationality to confusion. 1. The most important therapeutic intervention is to provide calm, support, and reassurance. 2. Sensory stimulation should be kept low. 3. Medications are usually not needed. If agitation is severe and persistent, chlordiazepoxide or diazepam may be used. Phenothiazines should be avoided because of possible additive anticholinergic effects.
A. Geller
heroin. Hypoxia from drug overdose may also cause seizures. In addition as the level of sedative hypnotic drugs falls following intoxication, there may be withdrawal seizures. Seizures attributed to drugs should be generalized. Focal seizures suggest other etiologies. A single seizure does not require anticonvulsant treatment. However, if seizures are multiple treatment should be instituted. 1. Maintain ventilation 2. Establish iv line 3. Loosen tight clothing 4. Do not restrain or attempt to wedge objects in the mouth 5. Begin diazepam slowly 5-20 mg iv with careful monitoring every 20 minutes until seizures are under control
Hallucinogens.
Phencyclidine has cholinergic, sympathomimetic, anesthetic and analgesic properties. The toxic picture is one of a fluctuating confusional state, often with catatonic-like features accompanied by increase in heart rate, blood pressure and respiration (sympathomimetic), sweating, flushing, drooling, pupil constriction (cholinergic), ataxia, nystagmus (anesthetic), and insensitivity to pain (analgesic). High doses may cause seizures, opisteotonus and Cheyne-Stokes respiration. 1. General cardiovascular and respiratory support if indicated with close monitoring. Intubation may require muscle relaxants. 2. Diazepam iv for repeated seizures. 3. Gastric lavage. 4. Severe hypertension may be treatd with agents like phentolamine (Regitine) in an iv drip 2-5 mg over 5 minutes. Phencyclidine.
General Medical Situations Convulsions. Convulsions may occur in intoxicated states with stimulants, phencyclidine, lysergic acid diethylamide, methaqualone, meperidine or rarely
Orally Ingested Drugs. Gastric lavage can be considered if a drug has been taken by mouth within 3 hours or longer if the drug is known to cause delayed gastric emptying. It can only be carried out with safety in a hospital or emergency room setting. Contraindications to gas lavage are: (a) Ingestion of corrosive substances; (b) Ingestion of petroleum distillates; and (c) Presence of coma with depression of the cough reflex. If the drug has been taken within one hour, induction of vomiting may be obtained with apomorphine O-l mg/kg subcutaneously. It should not be used if the patient is comatose or has a depressed cough reflex.
CONCLUSIONS The management of the intoxicated patient should take place according to well established and practiced routines. This reduces stress on both staff and patients and permits optimal care to be delivered. Anticipation that there will be occasions when an intoxicated patient in a non-medical setting will require emergency medical care should result in procedures for transfer that are swift and efficient. Staff training, education and discussion around recognition of and responses to the intoxicated patient must be regular and repeated. BIBLIOGRAPHY Cox, Ann. (1979) The management of intoxicated and disruptive patients. (Emergency Department Training Manual.) Addiction Research Foundation, Toronto, Canada. Giannini. A.J., & Slaby, A.E. (1982). In M.C. Giannini. (Ed.), Handbook of Overdaw and Detoxifiation Emergencies. New York: Medical Examination Publishing Company. Jaffe, J.H. (1980). Drug addiction and drug abuse. In A. Goodman Gilman, L.S. Goodman, & A. Gilman (Eds.) The pharmacological basis of therapeutics (6th ed.). New York: Macmillan.
Management
of Intoxication
Jaffe, J.H., & Martin, W.R. (1980). Opioid analgesics and antagonists. In A. Goodman Gilman, L.S. Goodman, & A. Gilman (Eds.). The pharmacological basis of therapeutics (6th ed.). New York: Macmillan. Schuckit, M.A. (1979). Drug and alcohol abuse: A clinical guide to
19 diagnosis and treatment. New York: Plenum. Senay, E.C., Raynes, A.E., Becker, C.E., &Schnoll, S.H. (1979). Theprimaryphysician’s guide to drug abuse treatment. (NMTS Medical Monograph Series 1, 7).
ORIGINAL
1, pp. 1l-19,
0740-5472/84S3.00 + .OO Copyright o 1984Pergamon PressLtd
1984
CONTRIBUTION
The Social, Psychological and Medical Management of Intoxication ANNE GELLER, MD St. Luke’s_Roosevelt
Hospital, New York
Abstract- Intoxicated persons appear frequently in substance abuse centers and in general hospital settings. The severity of their condition mnges from mild impaimzent to coma or delirium. The prominent features of intoxication with the nqjor classes of abused drugs are described. Staff responses to intoxication are discussed. Guidelines are presented for systematic management of this condition.
Keywords-
Intoxication,
drugs, alcohol, management, treatment
CLINICAL
INTRODUCTION THE INTOXICATED PATIENT is a standard feature in hospital settings and substance abuse treatment centers. Common as this problem is, it is rare to find consistent, coherent guidelines for dealing with it. Responses to intoxicated behavior range from anxiety or amusement to rage or ridicule. Little attempt is usually made to gauge how these responses may influence subsequent treatment and disposition. Still less frequently are there systematic efforts to train staff to behave in consistent and appropriate ways towards intoxicated patients and to recognize and change their non therapeutic responses. In most texts heavy emphasis is placed on the emergency medical management of crises arising from substance abuse with little discussion of the more frequently occurring problem of dealing with the intoxicated patient whose situation is not immediately life threatening. This article will attempt to redress the balance. The clinical picture of intoxication will be presented in a continuum from mild impairment to coma and delirium. Staff responses to the intoxicated patient will be analyzed. Guidelines will be suggested for management of all stages. These will include specific medical interventions when ap propriate.
PRESENTATION
First, it is necessary to describe the signs and symp toms of intoxication with various drugs, and to do this, it is easiest to deal with broad drug categories. A word of caution is in order here. Even the most experienced observer can have difficulty determining the drug that has been used from the behavior of the user alone. The final pathways for expression of intoxication can be similar for different kinds of drugs. Many abusers are using more than one. An odor of alcohol or a pill in the pocket does not mean that this is the only culprit. Drugs purchased on the street may be anything but the name they are sold under, limited only by the ingenuity of the seller and the credulity of the buyer. Substances are used to bring about some desired changes in the nervous system, usually euphoria. At low doses the effects on function and behavior may be slight. Intoxication is reached when functioning is significantly interfered with and behavior becomes maladaptive. Depending upon the substance used, further ingestion may result in coma or delirium. The specific picture depends upon the abused substance but the most frequent changes are in judgement, emotional control, logical thinking, memory, attention, state of alertness, and coordination. How rapidly one becomes intoxicated and how long it lasts depends upon the drug, the individual and the general environment. Drug factors include the type of drug, the amount ingested, the rapidity with which it gets into the brain, and its duration of
Requests for reprints should be sent to Dr. Anne Geller, St. Luke’sRoosevelt Hospital, 428 West 59th Street, New York, NY 10019.
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12 action (half life). Individual factors are weight, age, sex, state of nutrition, and tolerance to the drug. Environmental factors may influence the kind of behaviors observed and may shorten or extend the duration of these behaviors to the extent that they can be voluntarily controlled. Providing an environment that will permit maximum achievable voluntary control is one of the goals of intoxication management. With any intoxicated person, it is hard to judge during a short period of observation whether the disruption of the nervous system is getting progressively worse, has plateaued or is improving. Sedative Hypnotics Sedative hypnotics cause progressive depression of central nervous system function. After the initial increase in psychomotor activity, there is a decline in cognitive and motor efficiency. Judgement is impaired and behavior may be inappropriate. The ability to think and reason logically is impaired. Ongoing memory is also affected so that instructions may be partly or completely forgotten. Attention span is short. There are easily provoked emotional changes and irritability so that the person may be euphoric and expansive at one moment, angry and combative at the next. Excessive talking is a frequent feature, though if depression is the prevailing emotion, there may be moaning and crying. Physical signs include flushed face, general loss of coordination such as slurred speech, clumsiness or unsteady gait and nystagmus. With increasing doses there is a progressive loss of alertness with stupor, coma and finally death. A person who has acquired tolerance to a sedative hypnotic drug may not appear intoxicated at all at drug levels which would produce gross intoxication in an inexperienced user. Tolerance does not occur to all actions of the drug to the same extent. Of particular importance with the sedative hypnotics is that the center responsible for maintaining respiration does not develop the same tolerance as those serving motor coordination. A highly tolerant person appearing only slightly intoxicated may not require much more drug to affect respiration. Another phenomenon to be aware of with sedative hypnotics is the blackout. A person intoxicated with one of these drugs may be in the midst of a blackout. He may be walking and talking but not recording. If he is sent somewhere on his own he will not remember where he is supposed to go. He certainly won’t remember an appointment given for the following day. Opioids With opioid use the initial effects are usually euphoria and a calm dreamy state. With increasing dosage there is increasing lethargy with all move-
ments slowed down and with attention diminished. There may also be slurred speech and memory difficulty, though cognitive impairments are not usually as pronounced as with the sedative hypnotics. The major physical sign is constricted pupils. In severe intoxication, though, the pupils may dilate because of reduced oxygen supply to the brain. Intoxication progresses, with increasing difficulty in arousal, coma, and death. Opioid drugs produce significant respiratory depression, which constitutes the major hazard of their use. Even in doses too small to produce sleep or disturb consciousness, there is measurable slowing of respiration. This depression is at its maximum 7 minutes after intravenous morphine, 30 minutes after intramuscular and 90 minutes after subcutaneous use. Respiration begins to return to normal after 2-3 hours. In contrast to the situation with sedatives, with opioid drugs remarkable tolerance does develop to the respiratory depressant effects. Users of street drugs however do not know the dose of the drug they have received for a given amount of money. This can be quite variable. Overdoses with respiratory depression can occur in individuals who have not changed their drug use pattern but who have unexpectedly received a sample from a purer shipment. It should be noted that tolerance does not develop to the pupillary constriction effect of opioids which can thus be observed even in a tolerant user. Medical personnel who are opioid abusers have been known to use pupillary dilators to counteract this effect. Stimulants Initial effects from stimulant use are feelings of euphoria, powerfulness and self-confidence. Physical activity is usually increased. The user feels highly alert and mentally sharp. With increasing doses, the euphoria becomes elation; the self-confidence, grandiosity; the increased activity, agitation; and the alertness, hypervigilance. Rapid pressured speech is often present. There may be paranoid delusions and hallucinations. The hallucinations can be in any sphere but frequently are tactile. These can take the form of strange skin sensations such as a feeling there are small animals under the skin. With short-acting stimulants such as cocaine, these psychotic symptoms are transient; however, with longer acting drugs they may develop into delirium. In the delirious state, the mind becomes clouded, thinking is disordered, and attention wanders. The individual cannot maintain contact with another person. Speech is disjointed and irrelevant. The delusions and hallucinations persist and appear real. The accompanying physical signs are dilated
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Management of Intoxication pupils, rapid heart rate, increased blood pressure, and perspiration or chills. With higher doses there may be chest pain or seizures. Death can occur from respiratory paralysis or cardiac arrythmias. Tolerance to the euphorigenic and cardiovascular effects of stimulant drugs develops rapidly. Tolerance does not develop to the psychotic effects in chronic users. There may be a striking paucity of sympathomimetic effects accompanying a dramatic toxic psychosis. Psychedelics (Hallucinogens) This is a mixed bag of drugs that includes cannabis and lysergic acid diethylamide. Illusions, hallucinations, and delusions can also be produced on occasions by other classses of drugs, particularly stimulants (as above) and anticholinergics (see below). Hallucinogens, however, characteristically produce altered states which, if intensified can result in persistent hallucinations accompanied by anxiety, depression, paranoia and fear of losing one’s mind. The user is fully alert, Physical signs can be dilated pupils, increased heart rate, sweating, blurred vision, tremors, and loss of coordination. With cannabis, actual hallucinations are rare. Intoxication is manifested by euphoria, apathy, and altered perceptions including a slowing down. Physically, there may be reddened conjunctiva, increased appetitie, and dry mouth. Panic attacks, particularly with inexperienced users, are fairly common. In panic state due to hallucinogens, the patient is fully alert but fears that he or she is going crazy. There may be preoccupation with the possibility of brain damage or the user may be convinced that he or she is having a heart attack. Along with other symptoms of anxiety, hyperventillation may be present. Phencyclidine (PCP) This drug is considered separately because it has complex actions which include (a) sedative effects; (b) analgesic effects; (c) hallucinogenic effects; (d) adrenergic (stimulant-like effects); and (e) choline@ (vomiting and salivation) effects. There is (perhaps more so than with other drugs) individual variability. PCP is also a frequent unadvertized component mixture purporting to be other drugs (e.g., THC). In low doses the patient looks intoxicted, has ataxia, and nystagmus. He may be agitated, fearful or hostile, or may sit with a blank stare in a catatonic-like stupor. Physically, there may be vertigo, skin flushing, nausea, drooling, and vomiting. Reflexes are increased. Blood pressure is elevated. In higher doses, a
coma-like state with open eyes, decreased pain perception, waxing and waning excitation, and body rigidity may be accompanied by seizures. Over-the-Counter Drugs, Anticholinergic Antihistaminic, Non-Prescription Stimulants, Pseudo Speed These drugs have widespread use, especially among younger people. Since they are cheap and easily obtainable, they may be found masquerading as other desirable and expensive drugs. Antihistamines may be used deliberately in conjunction with another drug to produce an enhanced effect - e.g., “T’s and Blues” Pentazocine (Talwin) and Tripelannamine (Pyribenzamine). Intoxication with anticholinergics (scopolamounts of phenylpropanolamine hydrochloride, weed, deadly nightshade- produces confusion, blurred vision, headache, dry mouth, and increased heart rate. Antihistamines generally produce depression of the central nervous system with effects similar to those of sedatives hypnotics. However, stimulant effects are also seen with some antihistamines and at some doses. Over-the-counter stimulants contain varying amounts of phenylpropanolamine hydrochloride, caffeine and ephedrine. Symptoms of intoxication are similar to those from amphetamines and include a range from wild anxiety to agitation and hallucinations accompanied by increased pulse rate, blood pressure and respiration. Inhalants, Gases and Solvents This mixed group of substances includes glues, cleaning solutions, nail polish removers, paint thinners, aerosols and other petroleum products. They are generally central nervous system depressants producing lightheadedness, misperceptions, clouding of thoughts, and drowsiness. These can progress to stupor and coma. Physical effects include irritation around the eyes, nose and mouth, nausea, vomiting, double vision, ringing in the ears, and skin rashes. Dangerous cardiac arrythmias can occur. General Symptoms The common feature of most intoxication is loss of impulse control, loss of attention, and loss of the ability to behave in a socially appropriate fashion. This results in behaviors that are unpredictable, possibly dangerous and certainly are extremely frustrating. An intoxicated person may not be able to pay attention long enough to understand what is being said. He may be so preoccupied with his own disordered thoughts that he cannot be diverted from them. His state of alertness may be fluctuating so
14 that he apparently cooperates at one moment and is out of contact the next. It is difficult not to see this as willful and, indeed, sometimes it is. Very frequently, intoxication causes a severe deficit in short-term memory, so that instructions apparently received and understood are very swiftly forgotten. It is hard not to see this as willful, too. Sometimes an intense emotional state predominates and persists. When this is anger, it can result in hostility, uncooperativeness, verbal and physical violence. Particularly when the anger is directed towards oneself it is difficult not to respond to it. Response of Staff Clinical staff as a general rule do not handle intoxication well. The reasons for this are easy to understand. It is not pleasant. It is not easy. It is time consuming. It is frequently unrewarding. In some clinical settings it is taking staff time away from patients who are clearly physically sick. In drug and alcohol programs, it is often a sign of treatment failure or of violation of rules. Staff members themselves often experience intense reactions toward intoxicated patients. Sometimes these are a direct result of the patient’s behavior, for example, fear in the presence of potential violence. Sometimes, however, these reactions are due to feelings and attitudes about drug use, drug users, intoxication and being out of control. These come about as a result of the staff member’s personal experience and social attitudes. The particular behavior of a particular patient only acts as a trigger to release those complex feelings. Of course, well-trained clinical personnel do not allow themselves to express these feelings overtly. They will, however, experience strain in maintaining an appropriate therapeutic attitude. Unless the staff member has identified and recognized these feelings in himself and has a clear procedure to follow, these feelings will find expression in covert ways, not usually helpful to the patient. Feelings and Attitudes in Staff Personal Experience with Drugs. Many people working in drug and alcohol treatment have had experience of substance abuse themselves or in a close family member. Treating the sick patient in withdrawal or helping the sober patient to restructure his life can be immensely gratifying. Intoxication, though, evokes painful, fearful, sometimes even pleasurable memories of the past. Furthermore, the treatment skills that have been learned do not work for intoxicated patients. Intoxication is a stage to be passed through before treatment can begin. The staff member therefore finds himself with mixed feelings toward a patient he cannot at present help.
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They Did It To Themselves. It is much easier to understand and empathize with compulsive drug use when it is being reconstructed in historical fashion in a therapetic session than when it is right before you with all its disagreeable manifestations. Staff in emergency rooms and general hospital wards generally have trouble dealing with self-inflicted conditions without being self-righteous or dismissive. But even substance abuse staff may have feelings of anger or disgust when a patient is intoxicated. With intoxication one sees the voluntary aspect of the drug use: “He took the drug. No one forced him. Now he is in this state and I have to deal with it.” Treatment Failure. All substance abuse staff understand intellectually that they are dealing with a relapsing condition. When an actual relapse occurs though, it is often hard to maintain the appropriate philosophical distance. An intoxicated patient who has relapsed causes a number of feelings among staff; anger that he has let them down; feelings of inadequacy that he has failed; feelings of anxiety that other patients will be affected. Intoxicated Behavior. We are accustomed to generalize about characterological traits based on observed behavior. We also make judgements about individuals based on their behavior. Intoxicated behavior is a consequence of a drug or drugs acting on the brain. It may bear little relationship to sober behavior. Even knowing this, when confronted with a person actually behaving in various nasty ways toward us, it is difficult not to apply the customary generalization procedures and conclude that this is a person with a nasty predisposition. The attitudes of hospital staff toward substance abusing patients is often derived in part from generalizations made from the behavior observed when intoxicated. Consequences of Disordered Cognitive Functions. Inability to concentrate, inability to understand and inability to remember may be seen as uncooperativeness. Euphoria, silliness, jokiness, loquacity, inability to stick to the point or to take anything seriously are very irritating if one believes that this is under conscious control, less so if one understands that it is part of a drug-induced disorder. Loss of Control. By definition an intoxicated person has lost control. Loss of control is frightening to contemplate in ourselves and alarming to see in others. Even if there is no danger of violence, the feeling that the intoxicated person cannot be fully reached and cannot be relied upon to behave reasonably makes us uneasy. All of the techniques used with sober patients don’t work here.
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Management of Intoxication Uncooperativeness. The relationship between health professional and patient has a number of unstated understandings. Important among them is the understanding that both are working toward improvement in the patient’s condition. Uncooperativeness on the part of the patient is a rejection of this alliance. It leaves the staff member with only unsatisfactory alternatives: coercion, in many circumstances illegal and never pleasant; persuasion, often too time consuming and of uncertain outcome; dismissal with a sense of therapeutic failure. AU animals have innate or very early acquired reactions to threats directed at themselves. Humans are no exception. Hostility provokes anger or fear and a desire to retaliate or run away. These feelings will be present as long as any personal threat is perceived. When patient behavior is completely out of control, staff behavior is often more relaxed and organized since the threat is now impersonal and, in addition, routines have been well established for dealing with these extreme circumstances.
Hostility.
enormously from center to center depending upon the availability of medical staff, the proximity of a general hospital and emergency room and the geographical and social setting of the center. They will also vary from unit to unit within the same center. Both policies and procedures may be different in an outpatient component than in an inpatient rehabilitation unit. The procedures should be understood by staff and transmitted to patients entering treatment. Having clear guidelines relieves much of the anxiety and uncertainty connected with intoxication. It also relieves the sense of helplessness which many staff members experience. Procedures should be as explicit and detailed as possible without putting unnecessary constraints on staff. Procedures for Dealing with Violent Behavior. The
procedures for dealing with verbal and physical violence should be written and be a part of the procedures for intoxicated behavior. The security system should be well organized and responsive. Staff who are seeing patients individually in offices should be equipped with a buzzer or equivalent to summon help when needed.
General Procedures for intoxicated Patients
Intoxicated patients will appear in substance abuse centers. There are a number of general preparations which can be made. Staff Preparation. Regular staff meetings, at least one a year, should be held around the issue of the intoxicated patient. It is important that staff members can identify their own reactions to intoxicated patients and that the universality of these responses be acknowledged. Expectations regarding staff behavior can be restated at these meetings. Policies and procedures should also be discussed. Policies for Dealing with Intoxicated Patients. Any
substance abuse center must have clear policies for the intoxicated patient in all of its units. These policies must be understood by staff and by patients. In some centers intoxication results in dismissal from the program, in some two or three instances are permitted. In other centers no penalties are attached to intoxication except that the patient cannot attend therapeutic activities until sober. In yet others, intoxicated patients are pemitted to reman in treatment provided they are not disruptive. The merits of these various approaches are not going to be discussed here. Whatever the policy, it must be clear, consistent, understood and in writing. Procedures for Dealing with Intoxicated
Patients.
Each unit of a substance abuse treatment center should have clearly written procedures for dealing with intoxicated patients. These procedures will vary
General Clinical Guidelines for Social Management
These guidelines refer to the intoxicated patient only. If the clinical picture has deteriorated to delirium, stupor or coma, then procedures for emergency medical assistance must be instituted immediately. The medical management of these states will be discussed in a later section. The patient described here as intoxicated is able to respond to questions and to remain awake even if somewhat drowsy. If the picture is one of central nervous excitation, the patient, though agitated and perhaps hallucinating, is in sufficient contact with the environment to be able to respond to questions and to follow simple instructions. The general goals are to obtain sufficient information from the patient to make an appropriate treatment plan, to ensure that the treatment plan is initiated and to do this with minimal disruption. For this to occur, it is necessary to secure the patient’s cooperation and to work toward the strongest alliance of which the patient is capable at this time. Here are some simple guidelines. 1. fl there is any potential for violence, do not interview the patient alone and do avoid any argument. Ask the patient to be seated. If you are alone with a patient showing high agitation, be alert to danger signals, sweating, talkativeness and do not hesitate to leave the room to obtain help. 2. Provide a calm reassuring atmosphere. Maintain eye contact. Maintain a relaxed posture. Don’t leave patient alone (except #I).
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3. Provide information and structure. Give the patient your name. Explain simply what you are going to do. Use the patient’s name. 4. Communicate clearly and simply. Ask short direct questions, one at a time. Listen to responses. Be prepared to tolerate some repetition. 5. Be positive in your responses. If the patient says “I have to get into a hospital now,” don’t say, “No, you can’t just walk into a hospital.” Say “Yes, but first you have to give me some information about yourself.” 6. Establish a spec~flc contract. With patients who are already in treatment, the contract regarding intoxication will have been made. It should be repeated specifically and firmly. Again, as in number 5, if the patient is being told he cannot come to group treatment today the emphasis should be that he can come to treatment tomorrow if he is sober. With an intoxicated patient wanting to enter into treatment who is fussing about the examination, the contract might be “The faster I can get information about you the sooner you will get into treatment.” Specific Circumstances There are a number of specific circumstances in which an intoxicated person may appear in a substance abuse treatment center. When the person is already in treatment at the center a contract should have been made regarding the procedures to be followed in the case of intoxication. These procedures should also include an immediate disposition if the patient is not to be retained at the center. Ideally, a center should be equipped with a room where an intoxicated patient can be observed without disrupting staff and other patients. A period of observation is necessary to ensure that the clinical picture is not deteriorating and to gather data in order to make a disposition. All outpatient centers are likely to encounter intoxicated persons who have come in off the street without appointments whether the center operates a walk-in service or does not. These situations should be anticipated. The staff should have procedures and practiced routines to follow in the case of emergencies. In general hospital settings, substance abuse staff may be called to consult on patients who become intoxicated while in the hospital being treated for medical or surgical conditions. The clinical staff treating the patient are this point usually frustrated, angry and disgusted. They resent the time being spent on this non-medical condition which is taken from “really sick” patients elsewhere. The principles in-
volved in dealing with these patients are the same as outlined above. However, the best approach is for inservice training for the staffs on the units where this occurs and the establishment of clearly written protocols for dealing with the situation when it arises. Medical Management There are, however, situations in which medical examination is essential. 1. Where the patient’s condition is deteriorating. 2. Where the patient is semi-comatose, i.e., can be awakened and responds briefly but falls asleep when stimulus is removed. 3. Where the patient is comatose, i.e., cannot be aroused to consciousness by any stimuli. 4. Where the patient is delirious, i.e., is disoriented, incoherent, and may be delusional or hallucinating. 5. Where the patient is psychotic, i.e., is delusional or hallucinating. 6. Where the patient is extremely agitated, i.e., cannot be quieted by any of the methods outlined above. 7. Where the patient is suicidal. 8. Where the patient claims to have ingested a large quantity of drugs. 9. Where there is a history of or signs of trauma, particularly head trauma. 10. Where there is a convulsion. Physician will encounter intoxicated patients frequently in hospital settings and, more rarely, in private offices. Even physically dependent patients will, if possible, refrain from drug use prior to a physician appointment. Symptoms of withdrawal are a more common occurrence in a private office than are symptoms of intoxication. The guidelines discussed above are appropriate for all uncomplicated intoxications. Basically the patient is provided with clear, simple communication in an environment which is supportive and nonthreatening. Therapeutic interventions, especially medications, are kept to a minimum. Patients who are panicked, agitated, extremely fearful or anxious as part of their intoxication are frequently overmedicated with sedative drugs by hospital personnel. Taking the time to speak calmly and reassuringly to the patient can produce a marked improvement. Giving sedative drugs which diminish inhibition can, on the other hand, cause more problems. There should be a quiet room where the patient can be observed until his condition improves. When the drug abusing patient presents as a medical emergency (l- 10 above) it is often not possible to obtain a reliable history. The patient may be too confused or out of contact to give information. The drug or drugs used and the dosage may not be
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Management of Intoxication known or, even worse, the patient himself may be misinformed about what he has taken. The severity of the intoxication may be assessed by determining: 1. Is patient awake and can answer questions? If not, 2. Does patient withdraw from pain? If not, 3. Are tendon reflexes present? Also, 4. Is respiration impaired? 5. Are pulse rate, blood pressure, skin color abnormal? 6. What is state of pupils? Medical management must first address any life threatening problems which might arise in a patient where intoxication has progressed to semi-coma or delirium or where there are complicating factors. Emergency care begins then by ensuring that there is an adequate airway to prevent aspiration, supporting circulation, controlling hemorrhage and dealing with life threatening behaviors. Once the physical condition is stable, a thorough evaluation should be undertaken. This should include a history from the patient and anyone accompanying him, a general physical and neurological examination, baseline laboratory tests of blood and urine, and a toxicological screen. If there is any residual of the drugs that have been taken, this should be examined also. Further management of the patient will depend upon the specific condition and upon medical problems which have been identified; however, it is important first to do no harm. Keep medications to a minimum. Avoid restraints if possible. Perform gastric lavage only when indicated. Ensure that there is an adequate period of observation after regaining full consciousness (24 hours). Do not administer respiratory stimulant drugs. Sedative Hypnotics. All the central nervous system depressants produce a similar toxic state characterized by varying levels of anesthesia and decreased central nervous system, cardiac and respiratory functions. Pupils are usually midpoint, comeal, tendon reflexes depressed. Cardiac arrythmias may be present and lungs may be congested. 1. Establish clear airway. 2. Treat shock with iv fluids and vasopressor if indicated. 3. Carry out gastic lavage only if drug was taken in the last 4-6 hours and the patient is conscious. 4. Monitor vital functions, electrolytes and blood gases if indicated. 5. Avoid central nervous system stimulants. 6. Administer slowly 0.4 mg Naloxone (Narcan) iv to rule out concomitant narcotic overdose. Barbiturates.
Short-acting
barbiturates
may cause
cardiac arrythmias. Diuresis and alkalinization urine are helpful. Dialysis may be useful.
of the
Methaquafone. Methaqualone does not depress brain stem function to the same extent as other sedative hypnotics. For this reason intubation may be difficult as the gag reflex is intact. Methaqualone overdose may be present as delirium, hypertonia, and convulsions. Glutethimide and Ethehlorvynof. Both are fat soluble drugs and coma may be both protracted and fluctuating in intensity. Gastric lavage and dialysis are therefore more effective if performed with oil. Alcohol. Because of the large volume of alcohol required to produce coma in a tolerant user, people usually pass out before attaining sufficiently high blood concentration. Exceptions are inexperienced users, drinking for bets or hepatic damage. In a comatose patient smelling of alcohol, look for other causes such as: (a) other depressant drugs; (b) hypoglycemia or hyperlycemia; (c) trauma, skull fracture, subdural hematoma; (d) septicemia; (e) cardiac arrythmias; and/or (f) Wernickes encephaIopathy. The use of fructose solutions to speed the metabolism of alcohol carries risks of disturbed sugar metabolism, electrolytes, and’acid base balance that outweigh its benefits. Opioids. Depression of the central nervous system with constricted pupils is the classical picture of opioid overdose. (Constricted pupils can also be seen in barbiturate, ethanol and phenothiazine overdose.) As has been noted above dilation can occur in hypoxic states. Meperidine (Demerol) overdose can produce dilated pupils. Pulmonary edema may be present. Cardiac arrythmias and convulsions may be seen with codeine, propoxyphene (Darvon) and meperidine (Demerol). The basic procedures are as for the sedative hyp notic (l-6) 1. The administration of the narcotic antagonist naloxone 0.4 mg iv should result in rapid and dramatic response. If this does not occur, other causes for the patient’s condition should be investigated. 2. Antagonists are effective for about 2 hours and repeat doses may be necessary. (Heroin may remain active for 6 hours, methadone for 24. hours.) 3. The patient must be observed for at least 24 hours. Stimulants. Excessive doses of stimulants produce a clinical picture of a toxic agitated psychosis with
18 sympathetic nervous system overactivity. Increased heart rate, blood pressure and temperature can lead to cardiovascular or respiratory collapse. Convulsions and cerebrovascular accidents can occur. Treatment will depend on the symptomatology and may include respiratory and cardiac support. 1. Elevated body temperature must be treated aggressively with hypothermia. 2. Repeated seizures should be treated with iv diazepam (Valium) 5-20 mg injected very slowly and repeated in 15 minutes if indicated. 3. The urine may be acidified with ammonium chloride to promote excretion of the stimulant. 4. Marked agitation may be treated with haloperidol (Haldol). Phenothiazines should be avoided as they may retard the excretion of amphetamines. Panic reactions, flashbacks, and toxic reactions occur with these drugs and patients present in a frightened, agitated and hallucinated state. Physiologically there are signs of sympathetic stimulation. The toxic psychosis is often labile with the patient fluctuating from rationality to confusion. 1. The most important therapeutic intervention is to provide calm, support, and reassurance. 2. Sensory stimulation should be kept low. 3. Medications are usually not needed. If agitation is severe and persistent, chlordiazepoxide or diazepam may be used. Phenothiazines should be avoided because of possible additive anticholinergic effects.
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heroin. Hypoxia from drug overdose may also cause seizures. In addition as the level of sedative hypnotic drugs falls following intoxication, there may be withdrawal seizures. Seizures attributed to drugs should be generalized. Focal seizures suggest other etiologies. A single seizure does not require anticonvulsant treatment. However, if seizures are multiple treatment should be instituted. 1. Maintain ventilation 2. Establish iv line 3. Loosen tight clothing 4. Do not restrain or attempt to wedge objects in the mouth 5. Begin diazepam slowly 5-20 mg iv with careful monitoring every 20 minutes until seizures are under control
Hallucinogens.
Phencyclidine has cholinergic, sympathomimetic, anesthetic and analgesic properties. The toxic picture is one of a fluctuating confusional state, often with catatonic-like features accompanied by increase in heart rate, blood pressure and respiration (sympathomimetic), sweating, flushing, drooling, pupil constriction (cholinergic), ataxia, nystagmus (anesthetic), and insensitivity to pain (analgesic). High doses may cause seizures, opisteotonus and Cheyne-Stokes respiration. 1. General cardiovascular and respiratory support if indicated with close monitoring. Intubation may require muscle relaxants. 2. Diazepam iv for repeated seizures. 3. Gastric lavage. 4. Severe hypertension may be treatd with agents like phentolamine (Regitine) in an iv drip 2-5 mg over 5 minutes. Phencyclidine.
General Medical Situations Convulsions. Convulsions may occur in intoxicated states with stimulants, phencyclidine, lysergic acid diethylamide, methaqualone, meperidine or rarely
Orally Ingested Drugs. Gastric lavage can be considered if a drug has been taken by mouth within 3 hours or longer if the drug is known to cause delayed gastric emptying. It can only be carried out with safety in a hospital or emergency room setting. Contraindications to gas lavage are: (a) Ingestion of corrosive substances; (b) Ingestion of petroleum distillates; and (c) Presence of coma with depression of the cough reflex. If the drug has been taken within one hour, induction of vomiting may be obtained with apomorphine O-l mg/kg subcutaneously. It should not be used if the patient is comatose or has a depressed cough reflex.
CONCLUSIONS The management of the intoxicated patient should take place according to well established and practiced routines. This reduces stress on both staff and patients and permits optimal care to be delivered. Anticipation that there will be occasions when an intoxicated patient in a non-medical setting will require emergency medical care should result in procedures for transfer that are swift and efficient. Staff training, education and discussion around recognition of and responses to the intoxicated patient must be regular and repeated. BIBLIOGRAPHY Cox, Ann. (1979) The management of intoxicated and disruptive patients. (Emergency Department Training Manual.) Addiction Research Foundation, Toronto, Canada. Giannini. A.J., & Slaby, A.E. (1982). In M.C. Giannini. (Ed.), Handbook of Overdaw and Detoxifiation Emergencies. New York: Medical Examination Publishing Company. Jaffe, J.H. (1980). Drug addiction and drug abuse. In A. Goodman Gilman, L.S. Goodman, & A. Gilman (Eds.) The pharmacological basis of therapeutics (6th ed.). New York: Macmillan.
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of Intoxication
Jaffe, J.H., & Martin, W.R. (1980). Opioid analgesics and antagonists. In A. Goodman Gilman, L.S. Goodman, & A. Gilman (Eds.). The pharmacological basis of therapeutics (6th ed.). New York: Macmillan. Schuckit, M.A. (1979). Drug and alcohol abuse: A clinical guide to
19 diagnosis and treatment. New York: Plenum. Senay, E.C., Raynes, A.E., Becker, C.E., &Schnoll, S.H. (1979). Theprimaryphysician’s guide to drug abuse treatment. (NMTS Medical Monograph Series 1, 7).